# Secondary Postpartum Haemorrhage > NEET-PG OBG notes on secondary postpartum haemorrhage covering retained products, sepsis, choriocarcinoma workup, cautious evacuation and embolisation. - Canonical URL: https://prepelephant.com/topics/neet-pg/obstetrics-and-gynaecology/secondary-postpartum-haemorrhage - Exam / course: NEET-PG · Subject: Obstetrics and Gynaecology - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Secondary Postpartum Haemorrhage", PrepElephant, https://prepelephant.com/topics/neet-pg/obstetrics-and-gynaecology/secondary-postpartum-haemorrhage ## Direct answer Bleeding that is abnormal in amount or duration from 24 hours after delivery until 12 weeks postpartum is secondary (delayed) postpartum haemorrhage, and the commonest cause is retained products of conception with puerperal sepsis causing an atonic, subinvoluted uterus. Evaluation must always include an ultrasound for retained tissue, infection assessment, and a beta-hCG where trophoblastic disease is possible — late bleeding can be the first sign of choriocarcinoma. Management ranges from antibiotics with uterotonics for a settled uterus, to careful evacuation of retained products in theatre, to uterine artery embolisation for intractable bleeding, with histopathology of all evacuated material mandatory to exclude trophoblastic neoplasia. ## What you must remember - Definition — bleeding that is abnormal in amount or duration between 24 hours and 12 weeks after delivery; lighter than primary PPH as a rule but can be severe. - Causes in exam order — retained products of conception with endometritis (commonest), uterine subinvolution with delayed involution of the placental site (classically cited for bleeding at 2-6 weeks), puerperal sepsis, unrecognised cervical tears, and the must-not-miss trio of choriocarcinoma, uterine artery pseudoaneurysm and arteriovenous malformation. - Retained cotyledon or membrane fragments maintain a boggy, large, tender uterus with foul lochia; a succenturiate lobe retained after delivery is a classic MCQ cause. - Every woman gets — haemoglobin, infection markers, ultrasound for retained products, and beta-hCG if bleeding persists or histology is suspicious; a pregnancy test also excludes a new conception. - Management of the stable patient — resuscitation as needed, broad-spectrum antibiotics plus a uterotonic (oxytocin, ergometrine or misoprostol), and evacuation of the uterus if retained products persist; retained tissue will keep the bleeding going until removed. - Evacuation is performed cautiously — the septic soft puerperal uterus perforates easily and aggressive curettage causes synechiae (Asherman syndrome), so suction evacuation under ultrasound guidance in theatre is preferred. - Histopathology of evacuated tissue is compulsory — to confirm retained trophoblast and to exclude choriocarcinoma; persistent beta-hCG after evacuation follows the gestational trophoblastic neoplasia pathway. - Refractory bleeding — uterine artery embolisation is the preferred uterus-sparing intervention for pseudoaneurysm, AVM or uncontrolled bleeding; hysterectomy is the last resort. ## A case from bleed to biopsy A 24-year-old contacts the clinic on day 18 after a vaginal delivery with a gush of fresh bleeding, clots, mild fever and foul-smelling lochia for four days. First questions: how soaked, any dizziness, and has the bleeding been continuous or episodic. She is haemodynamically stable with a haemoglobin of 9 g/dL; the uterus is slightly tender and larger than expected for day 18. Ultrasound shows echogenic material within the cavity with increased vascularity — retained products with endometritis. She is started on broad-spectrum antibiotics (amoxicillin-clavulanate plus metronidazole, or gentamicin with clindamycin if febrile) and given a uterotonic; because tissue persists, suction evacuation is arranged in theatre with cross-matched blood — the soft puerperal uterus is treated with respect. Histopathology shows degenerate decidua and chorionic villi with acute inflammation: retained products confirmed, choriocarcinoma excluded, with a six-week review to confirm involution. Change one detail and the pathway changes. Had she been afebrile with a focal highly vascular lesion on Doppler, pseudoaneurysm or AVM enters, and the answer becomes uterine artery embolisation rather than curettage — blind instrumentation of a vascular lesion is dangerous. Had her bleeding followed a molar pregnancy or come with an enlarged uterus and high beta-hCG, the working diagnosis is gestational trophoblastic neoplasia, and chemotherapy under the GTN protocol replaces mechanical evacuation. Each fork is decided by three tools: ultrasound, beta-hCG and histology. ## Where students slip The classic slip is managing secondary PPH exactly like primary PPH — heavy uterotonic escalation while ignoring infection and tissue; the driver here is retained products plus sepsis, so antibiotics and evacuation are the answer, and examining the placenta at birth (the succenturiate lobe) was the missed opportunity. The second slip is curetting vigorously: perforation and Asherman syndrome in a young woman are real costs, so suction under ultrasound cover is the taught technique. The third is forgetting the beta-hCG — a woman who keeps bleeding after any pregnancy earns that test until proven otherwise. Ergometrine is withheld when sepsis dominates; antibiotics plus oxytocin or misoprostol are preferred, since the problem is not simple atony. ## Frequently asked questions ### What is the commonest cause of secondary postpartum haemorrhage? Retained products of conception complicated by puerperal sepsis, producing a subinvoluted, atonic, tender uterus with persistent bleeding. ### Until when can secondary PPH occur? Up to 12 weeks (about 90 days) after delivery; bleeding beyond that is investigated as abnormal uterine bleeding or a new pregnancy-related cause. ### Which placental anomaly causes delayed bleeding when retained? A succenturiate (accessory) lobe left in situ after the main placenta delivers, keeping the placental site open and bleeding. ### When is uterine artery embolisation chosen? For refractory bleeding, uterine artery pseudoaneurysm or arteriovenous malformation — it stops the bleeding while preserving the uterus in women of reproductive age.