Postpartum emergencies

Background

• Postpartum period is defined as up to 6 weeks after delivery (some complications up to 12 weeks)
• Postpartum patients may present to the ED rather than to OB for emergent complications
• Key EM concern: postpartum hemorrhage is the most common cause of maternal death worldwide

Emergencies

3rd Trimester/Postpartum Emergencies

• Acute fatty liver of pregnancy
• Amniotic fluid embolus
• Chorioamnionitis
• Eclampsia
• HELLP syndrome
• Mastitis
• Peripartum cardiomyopathy
• Postpartum endometritis (postpartum PID)
• Postpartum headache
• Postpartum hemorrhage
• Preeclampsia
• Resuscitative hysterotomy
• Retained products of conception
• Septic abortion
• Uterine rupture

Postpartum hemorrhage

• Defined as >500 mL blood loss (vaginal delivery) or >1000 mL (cesarean)
• Most common cause: uterine atony (70-80%) — risk factors include prolonged labor, overdistension, chorioamnionitis
• Other causes (4 T's): Tone (atony), Trauma (lacerations, uterine rupture), Tissue (retained products), Thrombin (coagulopathy)
• Management: uterine massage, uterotonics (oxytocin, methylergonovine, misoprostol, carboprost), transfusion, OB consultation, may need surgical intervention

Postpartum endometritis

• Polymicrobial uterine infection, typically 2-10 days after delivery
• Higher risk after cesarean section
• Fever, uterine tenderness, purulent lochia
• Treatment: IV broad-spectrum antibiotics (clindamycin + gentamicin is classic regimen)

Postpartum preeclampsia / Eclampsia

• Can occur up to 6 weeks postpartum, even without antepartum diagnosis
• Headache, visual changes, RUQ pain, hypertension, proteinuria
• Treat with IV magnesium sulfate for seizure prophylaxis/treatment and antihypertensives

Peripartum Cardiomyopathy

• Heart failure occurring in last month of pregnancy to 5 months postpartum
• Presents with dyspnea, edema, orthopnea
• Echocardiography for diagnosis; manage as heart failure

DVT / Pulmonary Embolism

• Postpartum period is highest risk for VTE
• Low threshold for workup — D-dimer less useful in postpartum period
• CTA for suspected PE; compression US for DVT

Postpartum Depression / Psychosis

• Depression: common (10-15%), screen with Edinburgh Postnatal Depression Scale
• Psychosis: rare but dangerous — onset typically 2-4 weeks postpartum; hallucinations, delusions, risk of harm to self/infant → psychiatric emergency, admit

Other

• Mastitis / breast abscess
• Wound infection / dehiscence (cesarean)
• Ovarian vein thrombophlebitis (septic pelvic thrombophlebitis)
• Urinary retention

Disposition

• Low threshold for OB consultation
• Admit: hemorrhage, endometritis, preeclampsia/eclampsia, cardiomyopathy, PE, psychosis
• Discharge: mild mastitis, minor wound issues — with close OB follow-up and return precautions

See Also

• Emergent delivery
• Postpartum hemorrhage
• Preeclampsia
• Vaginal bleeding