What are the symptoms and management of delayed postpartum hemorrhage?

From the Guidelines

Delayed postpartum hemorrhage is a life-threatening condition that requires immediate attention, and the most recent guidelines suggest that tranexamic acid should be administered within 1 to 3 hours of bleeding onset to reduce maternal morbidity and mortality 1. The symptoms of delayed postpartum hemorrhage include excessive vaginal bleeding, passing large clots, pelvic pain, fever, foul-smelling discharge, and signs of hypovolemic shock such as dizziness, tachycardia, and hypotension. Management begins with rapid assessment of vital signs and blood loss, followed by IV access establishment and fluid resuscitation. Laboratory tests including complete blood count, coagulation studies, and crossmatching for potential transfusion should be ordered. The most common cause is subinvolution of the placental site or retained placental fragments, which may require uterotonic medications like oxytocin (10-40 units IV infusion), methylergonovine (0.2 mg IM every 2-4 hours), or misoprostol (800-1000 mcg rectally) 1. Antibiotics are indicated if infection is suspected, typically a broad-spectrum regimen such as ampicillin 2g IV every 6 hours plus gentamicin 5mg/kg IV daily. Surgical interventions may include dilation and curettage to remove retained tissue, uterine artery embolization, or hysterectomy in severe cases. Patients should be monitored closely for ongoing bleeding, vital sign stability, and response to treatment. Prevention strategies include thorough placental examination at delivery, proper uterine massage, and patient education about normal postpartum bleeding patterns and when to seek medical attention. Some key points to consider in the management of delayed postpartum hemorrhage include:

• The use of tranexamic acid to reduce bleeding-related morbidity and mortality 1
• The importance of rapid assessment and intervention to prevent shock and other complications
• The need for careful monitoring and management of potential coagulopathy and hemorrhage
• The role of imaging studies, such as ultrasound and CT, in diagnosing and managing delayed postpartum hemorrhage 1
• The importance of patient education and prevention strategies to reduce the risk of delayed postpartum hemorrhage. In terms of specific management, the guidelines suggest that tranexamic acid should be administered at a dose of 1g IV, with a second dose of 1g IV if bleeding continues after 30 minutes, or if bleeding restarts within 24 hours of completing the first dose 1. Additionally, the guidelines recommend that patients with delayed postpartum hemorrhage should be managed in a multidisciplinary setting, with involvement of obstetricians, anesthesiologists, and other specialists as needed. Overall, the management of delayed postpartum hemorrhage requires a comprehensive and multidisciplinary approach, with a focus on rapid assessment, intervention, and prevention of complications.

From the FDA Drug Label

Carboprost tromethamine injection is indicated for the treatment of postpartum hemorrhage due to uterine atony which has not responded to conventional methods of management. The symptoms of delayed postpartum hemorrhage are not directly mentioned in the provided drug labels.

• Postpartum hemorrhage is mentioned as an indication for carboprost tromethamine injection, but the specific symptoms of delayed postpartum hemorrhage are not described.
• The management of postpartum hemorrhage due to uterine atony is discussed, including the use of carboprost tromethamine injection and oxytocin.
• Key points in the management of postpartum hemorrhage include:
  • Use of intravenously administered oxytocin
  • Manipulative techniques such as uterine massage
  • Intramuscular ergot preparations (unless contraindicated)
  • Carboprost tromethamine injection as a treatment option for postpartum hemorrhage due to uterine atony that has not responded to conventional methods of management 2 However, the specific symptoms of delayed postpartum hemorrhage are not addressed.

From the Research

Symptoms of Delayed Postpartum Hemorrhage

• Severe vaginal bleeding that can occur between 24 hours to 12 weeks postdelivery 3
• The bleeding can be profuse and intermittent 4
• Hemodynamic instability, such as hypovolemic shock, can occur due to excessive blood loss 5

Management of Delayed Postpartum Hemorrhage

• Active management of the third stage of labor can help reduce the incidence of postpartum hemorrhage 6
• Use of oxytocin after delivery of the anterior shoulder is an effective component of active management 6
• Combined therapy with oxytocin and other uterotonics, such as methylergonovine, misoprostol, and carboprost, may be more effective than oxytocin alone in preventing postpartum hemorrhage 7
• Tranexamic acid may be effective in decreasing maternal mortality in women with postpartum hemorrhage and may decrease the need for packed red blood cell transfusions and/or uterotonics 7
• Uterine angiography and embolization may be used to treat rare etiologies of delayed postpartum hemorrhage, such as uterine artery pseudoaneurysm 4
• Massive transfusion protocols can help minimize morbidity and mortality associated with postpartum hemorrhage 6

Differential Diagnoses

• Uterine atony is a common cause of primary postpartum hemorrhage, but is rare in secondary postpartum hemorrhage 3
• Retained products of conception, infection, and subinvolution of the placental implantation site are common etiologies of delayed postpartum hemorrhage 4
• The Four T's mnemonic can be used to identify and address the four most common causes of postpartum hemorrhage: tone (uterine atony), trauma (laceration, hematoma, inversion, rupture), tissue (retained tissue or invasive placenta), and thrombin (coagulopathy) 6