8.3 Late postpartum haemorrhage

Excessive vaginal bleeding from 24 hours to 6 weeks after delivery.

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 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 an antibiotherapy:
amoxicillin/clavulanic acid IV (dose expressed in amoxicillin): 1 g every 8 hours + gentamicin IM: 5 mg/kg once daily
ampicillin IV: 2 g every 8 hours + metronidazole IV: 500 mg every 8 hours + gentamicin IM: 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
Ratio 8:1: 3000 mg daily (2 tablets of 500/62.5 mg 3 times daily)
Ratio 7:1: 2625 mg daily (1 tablet of 875/125 mg 3 times daily)
amoxicillin PO: 1 g 3 times daily + metronidazole PO: 500 mg 3 times daily, 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).