Postpartum emergencies: Difference between revisions

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(Expanded with concise EM-focused content: hemorrhage 4Ts, endometritis, postpartum preeclampsia, cardiomyopathy, VTE, psychosis)
 
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<h2>Late Postpartum Pre/E<a href="http://www.example.com">link title</a>clampsia</h2>
==Background==
<h3> Background </h3>
*Postpartum period is defined as up to 6 weeks after delivery (some complications up to 12 weeks)
<ul><li>15% of all cases of eclampsia
*Postpartum patients may present to the ED rather than to OB for emergent complications
</li><li>40% have no history of HTN or proteinuria
*Key EM concern: '''postpartum hemorrhage''' is the most common cause of maternal death worldwide
</li></ul>
 
<h3> Diagnosis </h3>
==Emergencies==
<p>Hypertension
{{Postpartum emergencies DDX}}
</p>
 
<ul><li>Sys &gt;140 or dia &gt; 90 AND
===[[Postpartum hemorrhage]]===
</li><li> Proteinuria &gt; 0.3g in 24-hr
*Defined as >500 mL blood loss (vaginal delivery) or >1000 mL (cesarean)
<ul><li>Urine dipstick of 1+ is suggestive
*Most common cause: '''uterine atony''' (70-80%) — risk factors include prolonged labor, overdistension, chorioamnionitis
<ul><li>Lack of proteinuria is not rule-out!
*Other causes (4 T's): Tone (atony), Trauma (lacerations, uterine rupture), Tissue (retained products), Thrombin (coagulopathy)
</li></ul>
*Management: uterine massage, uterotonics ([[oxytocin]], [[methylergonovine]], [[misoprostol]], [[carboprost]]), transfusion, OB consultation, may need surgical intervention
</li></ul>
 
</li></ul>
===[[Postpartum endometritis]]===
<ul><li>History
*Polymicrobial uterine infection, typically 2-10 days after delivery
<ul><li>Headache
*Higher risk after cesarean section
</li><li>Confusion
*Fever, uterine tenderness, purulent lochia
</li><li>Visual disturbances
*Treatment: IV broad-spectrum antibiotics (clindamycin + gentamicin is classic regimen)
</li><li>Nausea/vomiting
 
</li><li>Epigastric pain
===[[Postpartum preeclampsia]] / Eclampsia===
</li></ul>
*Can occur up to 6 weeks postpartum, even without antepartum diagnosis
</li></ul>
*Headache, visual changes, RUQ pain, hypertension, proteinuria
<ul><li>Physical
*Treat with IV [[magnesium sulfate]] for seizure prophylaxis/treatment and antihypertensives
<ul><li>AMS
 
</li><li>Focal neurologic deficits
===Peripartum Cardiomyopathy===
</li><li>Visual symptoms
*Heart failure occurring in last month of pregnancy to 5 months postpartum
</li><li>Hyperreflexia
*Presents with dyspnea, edema, orthopnea
</li><li>RUQ or diffuse abdominal tenderness
*Echocardiography for diagnosis; manage as heart failure
</li><li>Peripheral edema
 
</li></ul>
===[[DVT]] / [[Pulmonary Embolism]]===
</li></ul>
*Postpartum period is highest risk for VTE
<h3> Work-Up </h3>
*Low threshold for workup — D-dimer less useful in postpartum period
<ul><li>UA
*CTA for suspected PE; compression US for DVT
</li></ul>
 
<h3> Treatment </h3>
===Postpartum Depression / Psychosis===
<ul><li>Control blood pressure
*Depression: common (10-15%), screen with Edinburgh Postnatal Depression Scale
<ul><li>Lower to Sys 130-150, dia 80-100
*Psychosis: rare but dangerous — onset typically 2-4 weeks postpartum; hallucinations, delusions, risk of harm to self/infant → psychiatric emergency, admit
</li></ul>
 
</li><li>Labetalol
===Other===
<ul><li>Option 1: Initial 20mg; then doses of 20-80mg q10min to total of 300mg
*Mastitis / breast abscess
</li><li>Option 2: Initial 20mg; then IV infusion of 1-2mg/min
*Wound infection / dehiscence (cesarean)
</li></ul>
*Ovarian vein thrombophlebitis (septic pelvic thrombophlebitis)
</li><li>Hydralazine
*Urinary retention
<ul><li> 5mg IV over 1-2min; repeat bolus of 5-10mg q20min PRN to total of 30mg
 
</li></ul>
==Disposition==
</li><li>Prevent eclampsia
*Low threshold for OB consultation
<ul><li> Magnesium: Load 4-6g IV over 15min followed by 2-3g per hr
*Admit: hemorrhage, endometritis, preeclampsia/eclampsia, cardiomyopathy, PE, psychosis
<ul><li>Observe for loss of reflexes, respiratory depression
*Discharge: mild mastitis, minor wound issues — with close OB follow-up and return precautions
</li></ul>
 
</li><li>If seizures recur:
==See Also==
<ul><li>Consider other anticonvulsant drugs
*[[Emergent delivery]]
</li><li>Consider alternative diagnosis
*[[Postpartum hemorrhage]]
</li></ul>
*[[Preeclampsia]]
</li></ul>
*[[Vaginal bleeding]]
</li></ul>
 
<h2> HELLP Syndrome </h2>
==References==
<h3> Background </h3>
<references/>
<ul><li>Presents in postpartum period in 30%
 
<ul><li>Usually within 48 hr of delivery
[[Category:OBGYN]]
</li></ul>
</li><li>80% had no evidence of preeclampsia before delivery
</li></ul>
<h3> Diagnosis </h3>
<ul><li>Signs/Symptoms
<ul><li>RUQ or epigastric pain - 40-90%
</li><li>Proteinuria - 86-100%
</li><li>Hypertension - 82-88%
</li></ul>
</li><li>Labs
<ul><li>CBC w/ diff
<ul><li>Microangiopathic hemolytic anemia
</li><li>Plt count &lt;100
</li></ul>
</li><li>LFT
<ul><li>AST &gt; 70, bilirubin &gt; 1.2
</li></ul>
</li><li>LDH &gt; 600
</li></ul>
</li></ul>
<h3> Work-Up </h3>
<ul><li>CBC w/ diff
</li><li>Chemistry
</li><li>LFT
</li><li>LDH
</li><li>PT/PTT/INR
</li><li>FDP, fibrinogen, D-Dimer
</li><li>CT to evaluate for hepatic hematoma (if needed)
</li></ul>
<h3> Treatment </h3>
<ul><li>Same as for eclampsia
</li></ul>
<h3> Complications </h3>
<ul><li> DIC
</li><li> Acute renal failure
</li><li> Subcapsular liver hematoma
<ul><li>Abdominal distention
</li><li>Mainttain adequate intravascular volume
<ul><li>If unstable consider embolization vs surgery
</li></ul>
</li></ul>
</li></ul>
<h2> Peripartum Cardiomyopathy </h2>
<h3> Background </h3>
<ul><li>Presentation similar to typical CHF
</li></ul>
<h3> Diagnosis </h3>
<ul><li>Development of heart failure in ast month of pregnancy or w/in 5 months of delivery
</li><li>Absence of an identifiable cause for the heart failure
</li><li>Absence of recognizable heart disease prior to the last month of
</li></ul>
<p>pregnancy
</p>
<ul><li>Left ventricular systolic dysfunction
</li></ul>
<h3> DDX </h3>
<ul><li>Respiratory tract infection
</li><li>PE
</li><li>MI
</li><li>Postpartum fluid overload
</li></ul>
<h3> Treatment </h3>
<ul><li>Treat like usual heart failure
</li></ul>
<h2> Source </h2>
<p>EBM, Volume 12, Number 8, Aug 2010. Postpartum Emergencies
</p><p><br /> <br /><br />
</p><span _fcknotitle="true" class="fck_mw_category" sort="OB/GYN">OB/GYN</span> <br/>

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

See Also

References

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