Secondary Postpartum Haemorrhage

(PPH) following partial uterine

dehiscence after caesarean delivery
 Definition
PPH : Blood loss greater than or equal to 500 ml
within 24 hours after birth

Severe primary PPH : Blood loss greater than or

equal to 1000 ml within 24 hours.
(The World Health Organization, 2014)

Uterine Dehiscence : Asymptomatic disruption of

the uterine muscle complete or incomplete (with
intact uterine serosa).
 Postpartum
hemorrhage

Primary Secondary
Loss of 500 ml or more of blood from the Heavy vaginal
genital tract within 24 hours of the birth of a bleeding
baby. between 24
PPH can be minor (500–1000 ml) or major hours and 12
(more than 1000 ml). weeks after the
Major could be divided to moderate (1000– birth.
2000 ml) or severe (more than 2000 ml). 
RCOG 2019
Primary and secondary post caesarean section hemorrhage

53.81%

Secondary
postpartum 1. Retained products of conception
haemorrhage after 2. Subinvolution of the placental site.
Pana et al, 2014
caesarean occurs in 3. Partial or complete dehiscence of
about 1 : 365 cases the lower uterine segment incision
 Risk factors for primary PPH
Before the birth
• Known placenta previa – when the placenta is located lower down near the neck
of the womb
• Suspected or proven placental abruption – when the placenta separates from the
womb early
• Carrying twins or triplets
• Pre-eclampsia and/or high blood pressure
• Having had a PPH in a previous pregnancy
• Having a BMI (body mass index) of more than 35
• Anemia
• Fibroids
• Blood clotting problems
• Taking blood-thinning medication
 Risk factors for primary PPH
In labor
• Delivery by caesarean section
• Induction of labour
• Delay in delivery of placenta (retained after birth)
• Perineal tear or episiotomy
• Forceps or ventouse delivery
• Having a long labour (more than 12 hours)
• Having a large baby (more than 4 kg or 9 lb)
• Having first baby more than 40 years old
• Having a raised temperature (fever) during labor
• Needing a general anesthetic during delivery
 Risk factors for secondary PPH
• Nulliparity
• Diabetes mellitus WBC 24.100/ mm
3

• Emergency surgery
• Infection
• Incision placed too low in the uterine segment
 Risk factors for uterine dehiscence
1 2
Ischemia and Mal-Apposition Patient Specific Factors
Hypothesis for CS Niche Impairing Uterine Wound
(Techniques of Closure of the Healing
Uterine Incision)

1. Diabetes
1. Recommended double mellitus
layer closure 2. Infection
2. Type of suture material
is much importance
(tensile strenght 2 -3
week)

1. Ischemic necrosis
2. Inappropriate
apposition of
myometrial layers
 Cesarean scar Niche
The presence of a
hypoechoic area within
the myometrium in the
isthmus (lower uterine
segment) with
discontinuation of
myometrium at the site
of previous CS

Indentation of
myometrium of at least
2 mm Formation and retraction of adhesions
between uterine isthmus (cesarean scar)
and anterior abdominal wall combined
with retroversion of uterus
 Conservative Treatment of PPH
2
1 External compression uterine
Uterotonic drugs vascular sutures (B-Lynch, Hayman,
4 Cho)
Intrauterine packing
3
In situ hemostasis by
5
electrocoagulation of bleeding
Baloon tamponade sites per hysteroscopy
6
Selective devascularization by
ligation or embolization uterine
artery ligation
There are various balloons available
including the Bakri, Foley,
Sengstaken-Blakemore, Rusch
and condom catheter

In this case, the patient using Foley

catheter for managing PPH
 Prognosis for next pregnancy
NK
ce
ll HIF-1 (Hypoxia
Inducible Factor-
1

Induce angiogenic
growth factor MMP
r
ch of
ye
bu c t
La

UNDERLYING
ta fe
Ni De

MECHANISM OF
PLACENTA ACCRETA
 Conclusion
• Severe PPH due to partial or complete
dehiscence of uterine wound is unusual and the
bleeding is probably due to eroded vessels on
the uterine margin
• The dehiscence of a caesarean section may be
associated with an infection
• Conservative treatment was the first intention
in all cases before the decision for
hysterectomy.
Thank you