8.3 Late postpartum haemorrhage


Excessive vaginal bleeding from 24 hours to 6 weeks postpartum.

8.3.1 Diagnosis


A combination of the following signs: foul-smelling vaginal bleeding, fever, a uterus that is soft and larger than expected, general deterioration, anaemia.

8.3.2 Possible causes

– Retained placenta or blood clots with secondary infection (endometritis).
– Rarely, persistent trophoblastic disease or choriocarcinoma.

8.3.3 Management

– Admit to inpatient department.

– Administer immediately:
amoxicillin/clavulanic acid IV (dose expressed in amoxicillin): 3 g/day divided into 3 injections administered 8 hours apart
+ gentamicin IM: 3 to 5 mg/kg once daily
Continue until the fever disappears (at least for 48 hours), then change to:
amoxicillin/clavulanic acid PO (dose expressed in amoxicillin) to complete 5 days of treatment

Using the 8:1 ratio: 3000 mg daily, i.e. 2 tablets of 500/62.5 mg 3 times daily
Using the 7:1 ratio: 2625 mg daily, i.e. 1 tablet of 875/125 mg 3 times daily

or
ampicillin IV: 6 g/day divided into 3 injections administered 8 hours apart
+ metronidazole IV: 1.5 g/day divided into 3 injections administered 8 hours apart
+ gentamicin IM: 3 to 5 mg/kg once daily
Continue until the fever disappears (at least for 48 hours), then change to amoxicillin PO: 3 g/day in 3 divided doses + metronidazole PO: 1.5 g/day in 3 divided doses, to complete 5 days of treatment.

– Manually explore the uterus when cervical dilation permits, otherwise perform digital curettage (Chapter 9, Section 9.4) or instrumental curettage with the widest curette available (Chapter 9, Section 9.6) and administer a uterotonic agent (oxytocin IM or slow IV: 5 to 10 UI, or, if not available, methylergometrine IM: 0.2 mg or misoprostol sublingually: 800 micrograms).