Increased incidence of secondary postpartum hemorrhage due to subinvolution of the placental site and effectiveness of interventional radiology

Background

Secondary postpartum hemorrhage (PPH), which occurs between 24 h and 12 weeks postpartum, is a rare but potentially severe complication. The primary causes include retained products of conception (RPOC), subinvolution of the placental site (SIPS), and endometritis. SIPS, historically diagnosed histopathologically, is increasingly being identified using ultrasonography and angiography. However, this condition remains underrecognized in Japan. Uterine artery embolization (UAE) is an effective and minimally invasive treatment for PPH. This study aimed to evaluate the increasing incidence of secondary PPH, particularly due to SIPS, and the effectiveness of UAE.

Methods

In this retrospective review, we analyzed cases of PPH requiring blood transfusion or embolization at a regional perinatal medical center between December 2014 and November 2024. Patients with placenta previa or accreta were excluded. Maternal characteristics, use of assisted reproductive technology, delivery mode, bleeding onset, hemostatic intervention, and transfusion status were evaluated. Imaging diagnoses were confirmed by radiologists and interventional radiology-certified emergency physicians.

Results

Among the 8107 deliveries, 37 cases (0.46%) of PPH were identified. 10 patients had secondary PPH. UAE was performed in 9 of the 10 cases (90%), with a 100% success rate. SIPS was the most common cause of secondary PPH (70%). Major complications were not observed.

Conclusion

The incidence of secondary PPH, particularly due to SIPS, has been increasing. UAE is considered a safe and effective intervention. Strategies for improved recognition and further research on PPH are needed to optimize the diagnosis and management of PPH due to SIPS in Japan.