Information
Editors
Postpartum Haemorrhage and Endometritis
Essentials
- Suspect abnormal bleeding or endometritis if
- lochia returns to bright red colour
- lochia has foul odour or
- the patient has lower abdominal pain or fever.
- Endometritis with severe symptoms requires i.v. antimicrobials.
Normal lochia
- Postpartum discharge typically lasts for 4-6(-8) weeks. The initial blood-stained discharge (lochia rubra) lasts for 3-4 days after which it becomes reddish brown (lochia serosa) for about one week. This is followed by whitish discharge (lochia alba) for 3-4 weeks.
- About 25% of women have lochia for more than six weeks, particularly when breast feeding.
- The amount of lochia will vary from day to day. Vaginal or cervical lacerations sustained during delivery will increase the amount of lochia, as will breast feeding.
Bleeding complications
- The majority of cases involve primary postpartum haemorrhage (< 24 hours after delivery); these cases are not discussed in the present article.
- The frequency of secondary postpartum haemorrhage (> 24 hours and up to 6 weeks after delivery) is about 1%.
- Primary postpartum haemorrhage and manual extraction of the placenta are the principal factors responsible for secondary haemorrhage.
- The majority of cases occur during the second postpartum week.
- Clinical examination must aim to determine the site of bleeding.
Causes of excessive bleeding
- Retained placental products or foetal membranes
- Endometritis
- Episiotomy dehiscence
- Vaginal or cervical laceration
- Choriocarcinoma following term pregnancy is rare and its presenting symptoms vary. However, it must be suspected where vaginal bleeding increases progressively and/or the patient presents with chest pain, dyspnoea, haemoptysis, headache or an episode of unconsciousness Gestational Trophoblastic Disease.
Recent obstetric history
- Course of pregnancy
- Delivery and recovery
- Check essential information concerning delivery from locally relevant source(s) (e.g. health record).
- The risk of vaginal and cervical lacerations is increased by the following: vacuum extraction, forceps delivery, breech delivery, precipitate delivery, shoulder dystocia and delivery of a macrosomic infant.
- If caesarean section was performed, what were the indications, possible complications and recovery. The risk of endometritis after caesarean section is 4-10%.
- The patient's records will indicate whether the placenta and foetal membranes were delivered complete or whether some parts were retained in the uterus.
- Establish the amount of blood loss.
- Ask the patient about her general health status and symptoms suggestive of an infection.
Gynaecological examination
- Establish the site of bleeding!
- Inspect the episiotomy. Have the sutures given way and the wound reopened? Is there a palpable haematoma? Is wound infection evident?
- Inspect and palpate the vaginal walls
- Inspect the cervix. Is the blood flowing from the uterus? Is the blood bright red? Anything suggestive of an infection?
- Internal examination: the size and tenderness of the uterus.
- If required, digital rectal examination
Laboratory investigations as appropriate
- CRP, basic blood count with platelets
- Human chorionic gonadotrophin (hcG) tests
- Decided according to findings
- Empirical antimicrobial therapy is usually used in the treatment of slight bleeding from an episiotomy wound or from a laceration on the vaginal or cervical mucous membranes, even though infection is the cause of bleeding only in the minority of cases. The antimicrobial treatment of choice is either a first-generation cephalosporin combined with metronidazole or amoxicillin 500 mg combined with clavulanic acid thrice daily for 7 days.
- Early surgical intervention is warranted in a haematoma of the episiotomy wound or vagina.
- Symptomless haematoma initially only needs to be observed. Antimicrobial therapy should be initiated as soon as healing appears to be delayed or the haematoma becomes infected.
- The cause of excessive blood flow from the uterus must be investigated with ultrasound examination.
- Retained products of conception must be evacuated .
- If the bleeding is scant and there are no signs of retained products, the treatment should consist of antimicrobials and monitoring.
- Choriocarcinoma is rare but its possibility should be borne in mind Gestational Trophoblastic Disease.
Endometritis
- Endometritis is an infection of the inner lining of the uterus (endometrium) and it often extends to involve the myometrium, leading to endomyometritis.
Risk factors
- Prolonged delivery
- Frequent procedures and internal examinations during delivery
- Premature rupture of foetal membranes
- Retained products of conception
- Vacuum extraction and forceps delivery
- Caesarean section - prolonged procedure, use of instruments and sutures, accumulation of blood or tissue fluid in the pelvis or tissues are predisposing factors.
Aetiology
- Pathogenic bacteria ascend, via cervix, from the vagina to the uterus where the placental bed and gestational endometrium provide an ideal growth medium. As the infection progresses, local myometrium becomes involved. The bacteria will then spread, via circulation, to infect the rest of the myometrium.
- The most common aerobic causative agents are beta-haemolytic streptococci, Escherichia coli, enterococci and chlamydia. Bacteroides species and B. fragilis are the most common anaerobic pathogens. The infection is usually polymicrobial.
- Tissue viability, and the circulation within the tissues, is diminished after caesarean delivery, leading to reduced resistance particularly against anaerobic bacteria.
Clinical signs and symptoms
- Symptoms usually start 4-10 days after delivery but they may also present later.
- Fever
- Lower abdominal pain, which may radiate to involve the entire abdomen
- Tender lower abdomen, uterus and possibly adjacent tissues
- Foul smelling lochia
- Purulent discharge at the cervix
Laboratory investigations as appropriate
- CRP, increased up to 100-150 mg/l
- Midstream urine to exclude concurrent urinary tract infection, including as necessary bacterial culture
- Blood cultures, if severe general symptoms occur
- Samples for chlamydia infection and gonorrhoea if these are suspected
Treatment
- Mild endometritis: cefalexine 500 mg thrice daily combined with metronidazole 400 mg thrice daily p.o. Antibiotic Regimens for Endometritis after Delivery for 7-10 days
- Severe endometritis (severe and generalised symptoms, high fever, CRP > 100 mg/l) requires hospitalisation and treatment with intravenous antimicrobials.
- Initially, for example, cefuroxime 1.5 mg thrice daily combined with metronidazole 500 mg thrice daily. Subsequent treatment in accordance with the results of bacterial cultures.
- If the disease is severe and the treatment response is poor to cephalosporin+metronidazole therapy before the bacterial culture is ready, or if the patient has endometritis together with a wound infection (section, episiotomy): alternatively the combination of clindamycin and the aminoglycoside gentamicin.
- Endometritis after caesarean delivery warrants early treatment with i.v. antimicrobials which should continue for up to 2 weeks.
- Breast feeding is allowed during the combination therapy of cephalosporin and metronidazole.
- Treatment of chlamydia infection Chlamydial Urethritis and Cervicitis
Treatment response
- Over 90% respond to treatment within 2-3 days.
- If treatment response is poor or fever persists
- bacterial resistance is rare
- the infection may have spread to the tissues adjacent to the uterus, or there may be lumbar peritonitis, an abscess, septic thrombophlebitis in the lumbar region or an infected haematoma
- the patient will need further investigations in a hospital (ultrasound examination, CT/MRI scan).