Postpartum emergencies: Difference between revisions

Latest revision as of 00:35, 21 March 2026

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

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

References

Authors:

@@ Line 1: / Line 1: @@
-==Late Postpartum Eclampsia==
+==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
-=== Background ===
+==Emergencies==
-*15% of all cases of eclampsia
+{{Postpartum emergencies DDX}}
-*40% have no history of HTN or proteinuria
-=== Diagnosis ===
+===[[Postpartum hemorrhage]]===
-Hypertension
+*Defined as >500 mL blood loss (vaginal delivery) or >1000 mL (cesarean)
-*Sys >140 or dia > 90 AND
+*Most common cause: '''uterine atony''' (70-80%) — risk factors include prolonged labor, overdistension, chorioamnionitis
-* Proteinuria > 0.3g in 24-hr
+*Other causes (4 T's): Tone (atony), Trauma (lacerations, uterine rupture), Tissue (retained products), Thrombin (coagulopathy)
-**Urine dipstick of 1+ is suggestive
+*Management: uterine massage, uterotonics ([[oxytocin]], [[methylergonovine]], [[misoprostol]], [[carboprost]]), transfusion, OB consultation, may need surgical intervention
-***Lack of proteinuria is not rule-out!
-*History
+===[[Postpartum endometritis]]===
-**Headache
+*Polymicrobial uterine infection, typically 2-10 days after delivery
-**Confusion
+*Higher risk after cesarean section
-**Visual disturbances
+*Fever, uterine tenderness, purulent lochia
-**Nausea/vomiting
+*Treatment: IV broad-spectrum antibiotics (clindamycin + gentamicin is classic regimen)
-**Epigastric pain
-*Physical
+===[[Postpartum preeclampsia]] / Eclampsia===
-**AMS
+*Can occur up to 6 weeks postpartum, even without antepartum diagnosis
-**Focal neurologic deficits
+*Headache, visual changes, RUQ pain, hypertension, proteinuria
-**Visual symptoms
+*Treat with IV [[magnesium sulfate]] for seizure prophylaxis/treatment and antihypertensives
-**Hyperreflexia
-**RUQ or diffuse abdominal tenderness
-**Peripheral edema
-=== Work-Up ===
+===Peripartum Cardiomyopathy===
-*UA
+*Heart failure occurring in last month of pregnancy to 5 months postpartum
+*Presents with dyspnea, edema, orthopnea
+*Echocardiography for diagnosis; manage as heart failure
-=== Treatment ===
+===[[DVT]] / [[Pulmonary Embolism]]===
-*Control blood pressure
+*Postpartum period is highest risk for VTE
-**Lower to Sys 130-150, dia 80-100
+*Low threshold for workup — D-dimer less useful in postpartum period
-*Labetalol
+*CTA for suspected PE; compression US for DVT
-**Option 1: Initial 20mg; then doses of 20-80mg q10min to total of 300mg
-**Option 2: Initial 20mg; then IV infusion of 1-2mg/min
-*Hydralazine
-** 5mg IV over 1-2min; repeat bolus of 5-10mg q20min PRN to total of 30mg
-*Prevent eclampsia
-** Magnesium: Load 4-6g IV over 15min followed by 2-3g per hr
-***Observe for loss of reflexes, respiratory depression
-**If seizures recur:
-***Consider other anticonvulsant drugs
-***Consider alternative diagnosis
-== HELLP Syndrome ==
+===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
-=== Background ===
+===Other===
-*Presents in postpartum period in 30%
+*Mastitis / breast abscess
-**Usually within 48 hr of delivery
+*Wound infection / dehiscence (cesarean)
-*80% had no evidence of preeclampsia before delivery
+*Ovarian vein thrombophlebitis (septic pelvic thrombophlebitis)
+*Urinary retention
-=== Diagnosis ===
+==Disposition==
-*Signs/Symptoms
+*Low threshold for OB consultation
-**RUQ or epigastric pain - 40-90%
+*Admit: hemorrhage, endometritis, preeclampsia/eclampsia, cardiomyopathy, PE, psychosis
-**Proteinuria - 86-100%
+*Discharge: mild mastitis, minor wound issues — with close OB follow-up and return precautions
-**Hypertension - 82-88%
-*Labs
-**CBC w/ diff
-***Microangiopathic hemolytic anemia
-***Plt count <100
-**LFT
-***AST > 70, bilirubin > 1.2
-**LDH > 600
-=== Work-Up ===
+==See Also==
-*CBC w/ diff
+*[[Emergent delivery]]
-*Chemistry
+*[[Postpartum hemorrhage]]
-*LFT
+*[[Preeclampsia]]
-*LDH
+*[[Vaginal bleeding]]
-*PT/PTT/INR
-*FDP, fibrinogen, D-Dimer
-*CT to evaluate for hepatic hematoma (if needed)
-=== Treatment ===
+==References==
-*Same as for eclampsia
+<references/>
-=== Complications ===
+[[Category:OBGYN]]
-* DIC
-* Acute renal failure
-* Subcapsular liver hematoma
-**Abdominal distention
-**Mainttain adequate intravascular volume
-***If unstable consider embolization vs surgery
-== Peripartum Cardiomyopathy ==
-=== Background ===
-*Presentation similar to typical CHF
-=== Diagnosis ===
-*Development of heart failure in ast month of pregnancy or w/in 5 months of delivery
-*Absence of an identifiable cause for the heart failure
-*Absence of recognizable heart disease prior to the last month of
-pregnancy
-*Left ventricular systolic dysfunction
-=== DDX ===
-*Respiratory tract infection
-*PE
-*MI
-*Postpartum fluid overload
-=== Treatment ===
-*Treat like usual heart failure
-== Source ==
-EBM, Volume 12, Number 8, Aug 2010. Postpartum Emergencies
-<br/>[[Category:OB/GYN]] <br/><br/>