Severe Delayed Postpartum Hemorrhage after Cesarean Section

Severe secondary or delayed postpartum hemorrhage (PPH) is rare and affects 0.23-3% of all pregnancies. It happens between 24 hours to 12 weeks postdelivery. These PPHs occur more often during normal vaginal delivery; only a small subset of these PPHs occur after cesarean section. The top differential diagnoses of both primary and secondary PPH are different, and as a result, the management may be different. Although uterine atony causes 80% of primary PPHs, extensive literature review exposed the rarity of it in the setting of secondary PPH.

A 27-year-old woman presented to the emergency department 1 week after a cesarean section for severe vaginal bleeding that started an hour earlier. The patient required rigorous uterine massage for approximately 30 min along with oxytocin, carboprost, methergine, and misopristol before bleeding subsided. She required 1 unit of O^- blood transfusion during resuscitation and still had a hemoglobin drop of 2.7 g/dL from arrival to after bleeding subsided. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: PPH is a life-threatening condition that emergency physicians rarely encounter and may be uncomfortable managing. It is important to be familiar with the differential diagnosis of both primary and secondary PPH and the management of each of the causes.