Postpartum hemorrhage is a condition of excessive blood loss exceeding 1000 ml after the placenta has been delivered. It is divided into 2 types:
- Acute hemorrhage within 24 hours after delivery
- Delayed hemorrhage refers to bleeding that occurs after 24 hours up to 12 weeks postpartum
If postpartum hemorrhage is detected while the patient is still in the hospital, the obstetrician will manage the treatment. However, delayed postpartum hemorrhage after discharge is a condition that patients should monitor themselves for symptoms and abnormalities.
Causes of Delayed Hemorrhage
Delayed hemorrhage usually shows symptoms within 1-2 weeks after delivery. The cause is due to the uterus being unable to contract properly to return to its normal state, accompanied by abnormal bleeding, or in other words, the uterus fails to involute. The causes include:
- Infection inside the uterine cavity
- Retained placental fragments inside the uterine cavity
- Dilated blood vessels inside the uterine cavity
Symptoms of Delayed Hemorrhage
1. Abnormal lochia characteristics
Normally, after delivery, lochia occurs in 3 stages:
Stage 1: During the first 3-4 days postpartum, lochia is red, called Lochia rubra.
Stage 2: From 4-10 days postpartum, lochia becomes light red, resembling diluted blood, called lochia serosa.
Stage 3: From 10 days onward, lochia turns yellow-white, called Lochia alba. Generally, lochia lasts up to an average of 36 days after delivery.
Therefore, after returning home, if the patient notices abnormal lochia such as persistent red color without fading or blood clots after 10 days postpartum, it is considered a symptom of delayed hemorrhage.
2. Uterine subinvolution
Normally, after delivery, the uterus contracts to prevent blood loss and immediately reduces in size to slightly below the level of the navel, then gradually decreases. Two days postpartum, the uterus size is equivalent to a 4-month pregnancy (uterine length by ultrasound is 16-18 cm). At 7 days postpartum, the uterus size reduces to above the pubic bone or equivalent to a 3-month pregnancy (uterine length by ultrasound is 12-13 cm) and returns to normal size within 6-8 weeks postpartum. Uterine subinvolution is often accompanied by bleeding. Therefore, if these symptoms occur, the patient should see a doctor promptly.
3. Symptoms of uterine cavity infection
Patients will have severe tenderness over the uterus, fever, or foul-smelling lochia. The cause is bacterial infection. Common bacteria reported to cause infection include GBS, Chlamydia spp., Mycoplasma spp., and Gardnerella vaginalis.
Risk factors for infection include
- Cesarean section
- History of bacterial infection causing disease in the pregnant woman’s vagina
- History of premature rupture of membranes or intra-amniotic infection before delivery
- Meconium-stained amniotic fluid
- Prolonged labor induction
- Pregnant women under 20 years old
- Pregnant with twins
- Mother with overweight (BMI ≥ 25 kg/m2)
Pregnant women with abnormal symptoms after delivery as mentioned above should see a doctor for examination and treatment. Generally, treatment involves antibiotics. The doctor may consider hospitalization for intravenous antibiotics if the patient has a fever or does not improve with oral antibiotics.
Treatment
Treatment of delayed hemorrhage depends on the identified cause
- Uterine infection: Treatment involves antibiotics.
- Retained placental fragments inside the uterine cavity: Treatment includes medication to induce uterine contraction and antibiotics to prevent uterine infection. If ultrasound shows blood clots or medication is ineffective, curettage or suction of blood clots from the uterine cavity may be considered.
- Dilated blood vessels inside the uterine cavity: This is a very rare but dangerous condition because if the blood vessel ruptures, bleeding may be uncontrollable and fatal. If suspected, diagnosis is by CT-angiogram, and treatment is uterine artery embolization to stop the bleeding.
Reference: F. Gary Cunningham, MD, Kenneth J. Leveno, MD et al. Williams Obstetrics. 25th edition; chapters 35-36. New York: McGraw Hill Education; 2018
Sheehan’s Syndrome: Pituitary gland necrosis due to ischemia
What is Sheehan’s Syndrome?
Sheehan’s syndrome is a condition where the pituitary gland dies due to lack of blood supply caused by massive acute postpartum hemorrhage. This is a rare condition but can be dangerous because the pituitary gland cannot produce hormones normally.
How much blood loss increases the risk of Sheehan’s syndrome?
Research data shows that postpartum hemorrhage of 1000-2000 ml combined with low blood pressure due to blood loss can cause this condition in 1-2% of cases. Blood loss exceeding 3000 ml increases the risk further.
Symptoms of Sheehan’s syndrome
Symptoms can appear immediately after delivery or several years later. If symptoms occur within 6 weeks postpartum, it is called Acute-onset Sheehan’s Syndrome. If symptoms appear after 6 weeks postpartum, it is called Late-onset Sheehan’s syndrome.
Symptoms depend on the area of pituitary gland dysfunction. Patients may present with one or more of the following:
- No milk production
- Absence of menstruation even after stopping breastfeeding
- Dry skin, weight gain, leg swelling
- Low blood sugar
- Frequent thirst, frequent urination, large urine volume, chronic electrolyte imbalance
- Low red blood cells, white blood cells, and platelets below normal levels
Diagnosis
Diagnosis is made by brain MRI along with hormone tests of the pituitary gland suspected to be abnormal.
Treatment
Endocrinologists will manage the treatment, which varies depending on the hormone abnormalities found. Treatment mostly involves hormone replacement therapy.
Dr. Linlada Wichakunururoj
Obstetrician and Gynecologist specializing in Maternal-Fetal Medicine
Phayathai 3 Hospital
