Postpartum Complications

Educational Objectives

The goal of this program is to improve outcomes of common postpartum complications. After hearing and assimilating this program, the clinician will be better able to:

1. Diagnose and manage common postpartum complications.

Summary

Introduction: Batra et al (2017) showed that, of 1,000,000 postpartum women, 8.3% visited the emergency department ≤90 days of delivery or pregnancy termination; Say et al (2014) showed that the leading causes of pregnancy-associated death include abortion, miscarriage, and ectopic pregnancy, embolism, hemorrhage, hypertensive emergencies, sepsis, and direct obstetric causes, eg, obstructed labor, childbirth complications; indirect causes are often exacerbations of underlying medical conditions or external factors, eg, accidents, HIV complications, maternal suicide, amniotic fluid embolism

Postpartum hemorrhage (PPH): defined as the loss of ≥500 mL of blood or a “concerning amount” of bleeding after childbirth

Tone: the most common cause of PPH is uterine atony; external fundal massage — both hands are placed on the uterus and firm pressure is applied to encourage contractions; internal fundal massage — one hand is inserted into the vagina to support the uterus from below, while the other hand applies external pressure to the fundus; medications — oxytocin reduces risk for significant blood loss by ≈40%; administer with caution, as rapid intravenous (IV) administration can lead to cardiovascular collapse; administer oxytocin after the delivery of the anterior shoulder to avoid potential complications, eg, shoulder dystocia; other uterotonics include carboprost, methylergonovine, and misoprostol; carboprost is contraindicated in asthma and severe renal or hepatic disease; methylergonovine is contraindicated in hypertension

Trauma: the clinician must examine the entire vaginal canal to identify and address any bleeding; second-degree tears are the most common type of vaginal laceration; third-degree lacerations involve the anal sphincter and require specialized repair by an obstetrician or surgeon; if necessary, a synthetic absorbable suture, eg, 3-0 polyglactin 910 (Vicryl), is used for suturing; trauma can lead to serious complications, eg, uterine scar dehiscence, uterine rupture, particularly following CD or vaginal birth after CD

Tissue: in the case of retained placental tissue, a gentle uterine sweep can help remove the remaining tissue and promote uterine contraction, thereby reducing bleeding; patients with incomplete miscarriage may retain products of conception

Thrombin: contributes to <1% of PPH; for hemophiliac patients scheduled for delivery, standard protocols for managing blood loss (eg, factor replacement, massive transfusion protocols) should be implemented

Continued bleeding: if a patient continues to bleed despite use of all interventions described above, packing the uterus may be necessary; Antony et al (2017) evaluated intraluminal pressures of various improvised intrauterine tamponade devices used to control PPH; a condom catheter with sutures at the bottom ruptured at 3 L and the latex and silicone Foley catheters ruptured at 50 mL; the Blakemore tube used for gastrointestinal hemorrhage can be adapted for intrauterine tamponade; the Bakri balloon or the uterine balloon tamponade (BT) catheter can be used to control PPH (ruptured at 3-4 L); they are inserted into the uterus and inflated to apply pressure and stop bleeding; the recommended inflation volume is 500 mL; if more volume is required, consider alternative methods, eg, uterine packing with gauze; gauze packing should be done using a rope-like material, eg, Kerlix, to facilitate easy removal and reduce the risk for retained foreign bodies or sepsis

Sepsis: the most common cause of postpartum fever is endometritis; incidence peaks 2 days after delivery; caused by ascending infection with polymicrobial organisms; patients typically present with fever, tenderness, abdominal pain, and foul-smelling vaginal discharge; treatment includes clindamycin and gentamicin; in severe cases, it can progress to more serious complications, eg, peritonitis, intraabdominal abscess, necrotizing fasciitis

Mastitis: often presents with high fever; usually caused by a blocked milk duct; can be treated with warm compresses and antibiotics (ABs); if methicillin-resistant Staphylococcus aureus infection is a concern, treat with trimethoprim-sulfamethoxazole (eg, Bactrim, Cotrim, Septra); can progress to sepsis in immunocompromised individuals or those with delayed access to care; prompt treatment with broad-spectrum ABs, IV fluids, and hospital admission is important; complications include abscess formation and recurrent mastitis; bedside ultrasonography is used to confirm abscess

Pseudomembranous colitis: postpartum women who receive ABs during childbirth are at risk of developing Clostridioides difficile infection (CDI), leading to pseudomembranous colitis; symptoms include low-grade fever, abdominal pain, malaise, and watery diarrhea; treated by discontinuing the offending AB and starting appropriate ABs; mild CDI can be managed at home; severe CDI (ie, leukocytosis [>15,000/mm³], elevated creatinine level [>1.5 mg/dL], or worsening kidney function) requires hospitalization and treatment with ABs; fulminant CDI (most severe form) is characterized by hypotension, altered mental status, and complications like toxic megacolon; 2021 Infectious Diseases Society of America guidelines recommend fidaxomicin as preferred treatment for nonsevere and severe CDI; oral or rectal vancomycin is an alternative option, especially for fulminant cases; for toxic megacolon, surgical consultation is advised

Preeclampsia: a pregnancy-specific condition caused by poor blood flow to the placenta, leading to the release of inflammatory oxidative stressors that cause systemic vasoconstriction and endothelial damage; symptoms include headaches, vision changes, difficulty breathing, nausea, edema, and pain under the shoulder; can develop ≤6 wk postpartum; often misdiagnosed, with a persistent headache being a common presenting symptom in 70% of cases; diagnosis requires a blood pressure reading ≥140/90 mm Hg confirmed with a second reading 4 hr later; other symptoms include proteinuria, thrombocytopenia, acute kidney injury, transaminitis, pulmonary edema, headache, and visual symptoms; treatment starts with 4 g IV magnesium over 30 min, followed by 2 g/hr; if infused quickly, hypotension may occur (usually fluid-responsive); the first sign of magnesium overdose is decreased reflexes, followed by altered mental status; standard supportive care and management of maternal hypertension is recommended

Pulmonary embolism (PE): classic symptoms include acute shortness of breath, chest pain, cough, and sweating; while traditional risk assessment tools (eg, Wells score, Geneva score, Pulmonary Embolism Rule-out Criteria score) may not be reliable in this population, the YEARS algorithm is helpful; postpartum women, especially ≤6 wk, are considered at increased risk for PE; YEARS criteria — clinical signs of deep vein thrombosis (DVT), hemoptysis; D-dimer cutoff is 1000 mg/L; in patients having clinical signs of DVT, the D-dimer cutoff is 500 mg/dL; computed tomography pulmonary angiography (CTPA) is often preferred over ventilation-perfusion (V/Q) scans for diagnosing PE; while CTPA exposes the mother to more radiation, it delivers less radiation to the fetus than a V/Q scan

Treatment: for stable women who are not breastfeeding, any anticoagulant medication can be used; for women who are breastfeeding or wish to breastfeed, low-molecular-weight heparin (LMWH) is generally preferred; the use of rivaroxaban or apixaban during lactation is less ideal; according to the American College of Obstetrics and Gynecology, warfarin can be considered in high-risk situations or when patient compliance with LMWH is an issue; however, LMWH remains the preferred anticoagulant because of its safety profile and ease of administration; for women who are unstable, lysis is recommended; embolectomy or extracorporeal membrane oxygenation may be considered; 30% of patients treated with lysis are at high risk of vaginal or intraabdominal hemorrhage; if bleeding occurs, prompt management with massive transfusion protocols is essential

Postpartum cardiomyopathy: echocardiography is recommended if chest pain and shortness of breath are reported during the postpartum period; postpartum cardiomyopathy can develop ≤5 mo after delivery; treatment is similar to that for other types of heart failure

Depression: postpartum depression (PPD) can manifest ≤1 yr after childbirth; symptoms include fatigue, anxiety, overwhelming guilt, and difficulty bonding with the baby; a high index of suspicion is necessary, even if symptoms occur beyond the traditional 4-wk window; men may also suffer from PPD; the Edinburgh Postnatal Depression Scale is the only validated diagnostic tool; it consists of questions rated on a scale of 1 to 4; a score ≥11 is diagnostic for depression; scores between 5 and 9 mandate 1-mo follow-up; a comprehensive screening may not always be feasible in a busy emergency department; the clinician can ask a few targeted questions; postpartum hypothyroidism — may contribute to depressive symptoms and should be considered in women with persistent fatigue, hair loss, and decreased milk production; maintain a low threshold for testing thyroid function and arrange follow-up

Readings

Antony KM, Racusin DA, Belfort MA, et al. Under Pressure: Intraluminal Filling Pressures of Postpartum Hemorrhage Tamponade Balloons. AJP Rep. 2017;7(2):e86–e92. doi:10.1055/s-0037-1602657; Batra P, Fridman M, Leng M, et al. Emergency Department Care in the Postpartum Period: California Births, 2009-2011. Obstet Gynecol. 2017;130(5):1073-1081. doi:10.1097/AOG.0000000000002269; Betts KS, Kisely S, Alati R. Predicting common maternal postpartum complications: leveraging health administrative data and machine learning. BJOG. 2019;126(6):702-709. doi:10.1111/1471-0528.15607; Hundal P, Valani R, Quan C, et al. Causes of early postpartum complications that result in visits to the emergency department. PLoS One. 2021;16(11):e0260101. Published 2021 Nov 29. doi:10.1371/journal.pone.0260101; Johnson S, Lavergne V, Skinner AM, et al. Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults. Clin Infect Dis. 2021;73(5):e1029-e1044. doi:10.1093/cid/ciab549; Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323-e333. doi:10.1016/S2214-109X(14)70227-X.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Malik was recorded at Managing Medical Emergencies 2024, held on May 15, 2024, in Hanover, NH, and presented by Dartmouth Health. For information on upcoming CME activities from this presenter, please visit dh.cloud-cme.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

EM420102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.