Postpartum ComplicationsPostpartum Complications

Nori Y. Buising MDNori Y. Buising MD

LTC, MCLTC, MC

ObjectivesObjectives

Recognize common and potentially life-Recognize common and potentially life-threatening postpartum complicationsthreatening postpartum complications– Postpartum hemorrhagePostpartum hemorrhage– Postpartum endometritisPostpartum endometritis– Peripartum cardiomyopathyPeripartum cardiomyopathy– Postpartum thyroiditisPostpartum thyroiditis– Postpartum depressionPostpartum depression

Direct the initial management of the ill Direct the initial management of the ill postpartum patientpostpartum patientKnow the appropriate threshold for consultation Know the appropriate threshold for consultation with specialistwith specialist

Postpartum HemorrhagePostpartum Hemorrhage

Obstetrical emergency that can follow vaginal or Obstetrical emergency that can follow vaginal or cesarean deliverycesarean delivery

Incidence – 3% of birthsIncidence – 3% of births

33rdrd most common cause of maternal death in US most common cause of maternal death in US

DefinitionDefinition– Excessive bleeding that makes the patient Excessive bleeding that makes the patient

symptomatic (lightheaded, syncope) and/or results in symptomatic (lightheaded, syncope) and/or results in signs of hypovolemia (hypotension, tachycardia, signs of hypovolemia (hypotension, tachycardia, oliguria)oliguria)

Board ReviewBoard Review

Which of the following is the most common Which of the following is the most common cause of postpartum hemorrhage?cause of postpartum hemorrhage?– A. primigravida birthA. primigravida birth– B. retained placentaB. retained placenta– C. uterine atonyC. uterine atony– D. uterine ruptureD. uterine rupture– E. lacerations of the cervixE. lacerations of the cervix

Causes of Postpartum HemorrhageCauses of Postpartum Hemorrhage

Four TsFour Ts CauseCause Approximate Approximate incidence (%)incidence (%)

ToneTone Atonic uterusAtonic uterus 7070

TraumaTraumaLacerations, Lacerations, hematomas, hematomas, inversion, ruptureinversion, rupture

2020

TissueTissue Retained tissue, Retained tissue, invasive placentainvasive placenta 1010

ThrombinThrombin CoagulopathiesCoagulopathies 11

Postpartum HemorrhagePostpartum Hemorrhage

Risk FactorsRisk Factors– Prolonged 3Prolonged 3rdrd stage of labor stage of labor– Fibroids, placenta previaFibroids, placenta previa– Previous PPHPrevious PPH– Overdistended uterusOverdistended uterus– EpisiotomyEpisiotomy– Use of magnesium sulfate, preeclampsiaUse of magnesium sulfate, preeclampsia– Induction or augmentation of laborInduction or augmentation of labor

PPH - ManagementPPH - Management

Swift execution of a sequence of interventions Swift execution of a sequence of interventions with prompt assessment of responsewith prompt assessment of responseInitial stepsInitial steps– Fundal massageFundal massage– ABCs, O2, IV access with 16g cathetersABCs, O2, IV access with 16g catheters

Infuse crystalloid; transfuse blood products as neededInfuse crystalloid; transfuse blood products as needed– Examine genital tract, inspect placenta, observe Examine genital tract, inspect placenta, observe

clottingclotting– Give uterotonic drugsGive uterotonic drugs

Oxytocin 20 IU per L of NSOxytocin 20 IU per L of NSCarboprost (Hemabate) 250mcg IM q15-90min up to 2mg Carboprost (Hemabate) 250mcg IM q15-90min up to 2mg Methylergonovine (Methergine) 0.2mg IM q2-4hMethylergonovine (Methergine) 0.2mg IM q2-4hMisoprostol 800 or 1000mg PRMisoprostol 800 or 1000mg PR

Uterotonic Agents for PPHUterotonic Agents for PPH

OxytocinOxytocin

(Pitocin)(Pitocin)

10 units/ml10 units/ml

Dilute 20-Dilute 20-40 units in 40 units in 1 L NS1 L NS

10 IU IM10 IU IM

IVIV

IMIM

ContinuousContinuous

Infusion, Infusion, 250 ml/hr250 ml/hr

Nausea, vomitingNausea, vomiting

Water intox with Water intox with prolonged IV useprolonged IV use

Hypersensitivity to Hypersensitivity to the drugthe drug

Room Room temptemp

CarboprostCarboprost

(Hemabate)(Hemabate)

15-methyl PG 15-methyl PG F2aF2a

0.25 mg/ml0.25 mg/ml

0.25 mg0.25 mg IMIM

IMMIMM

Q 15-90 min Q 15-90 min not to not to exceedexceed

8 doses8 doses

Nausea, vomitingNausea, vomiting

DiarrheaDiarrhea

Fever/ChillsFever/Chills

HAHA

HypertensionHypertension

BronchoconstrictionBronchoconstriction

Hypersensitivity to Hypersensitivity to the drugthe drug

Use with caution Use with caution in patients with in patients with HTN or asthmaHTN or asthma

RefrigRefrig

Methylergon-Methylergon-ovineovine

(Methergine)(Methergine)

0.2 mg/ml0.2 mg/ml

0.2 mg0.2 mg IMIM Q 10 min x Q 10 min x 22

Q 2 – 4 hrsQ 2 – 4 hrs

Nausea, vomitingNausea, vomiting

Hypertension, esp Hypertension, esp in pts with PIH or in pts with PIH or chronic HTNchronic HTN

HypotensionHypotension

HypertensionHypertension

PreeclampsiaPreeclampsia

Hypersensitivity to Hypersensitivity to the drugthe drug

RefrigRefrig

Protect Protect from lightfrom light

MisoprostolMisoprostol

(Cytotec)(Cytotec)

100 and 200 100 and 200 mcg tabsmcg tabs

600-1000 600-1000 mcgmcg

PRPR Single doseSingle dose Nausea, vomitingNausea, vomiting

ShiveringShivering

FeverFever

DiarrheaDiarrhea

Hypersensitivity to Hypersensitivity to the drugthe drug

Room Room temptemp

Drug Dose Route Freq Side Effects Contraind. StoreDrug Dose Route Freq Side Effects Contraind. Store

ManagementManagement

Secondary stepsSecondary steps– Will likely require regional or general anesthesiaWill likely require regional or general anesthesia– Evaluate vagina and cervix for lacerationsEvaluate vagina and cervix for lacerations– Manually explore uterusManually explore uterus

Treatment optionsTreatment options– Repair lacerations with running locked #0 absorbable sutureRepair lacerations with running locked #0 absorbable suture– TamponadeTamponade– Arterial embolizationArterial embolization– LaparotomyLaparotomy

uterine vessel ligationuterine vessel ligationB-Lynch sutureB-Lynch suture

– HysterectomyHysterectomy

PPH – Preventive MeasuresPPH – Preventive Measures

correcting anemia prior to deliverycorrecting anemia prior to delivery

episiotomies only if necessaryepisiotomies only if necessary

active management of third stageactive management of third stageNNT to prevent 1 case of PPH = 12NNT to prevent 1 case of PPH = 12

assess patient after completion of assess patient after completion of paperwork to detect slow steady bleedspaperwork to detect slow steady bleeds

Postpartum EndometritisPostpartum Endometritis

Infection of the decidua (pregnancy Infection of the decidua (pregnancy endometrium)endometrium)IncidenceIncidence– <3% after vaginal delivery<3% after vaginal delivery– 10-50% after cesarean delivery10-50% after cesarean delivery

5-15% after scheduled elective cesareans5-15% after scheduled elective cesareans

Risk FactorsRisk Factors– Prolonged labor, prolonged ROM, multiple vaginal Prolonged labor, prolonged ROM, multiple vaginal

exams, internal monitors, maternal DM, meconium, exams, internal monitors, maternal DM, meconium, manual removal of placenta, low socioeconomic manual removal of placenta, low socioeconomic statusstatus

PP EndometritisPP Endometritis

Polymicrobial, ascending infectionPolymicrobial, ascending infection– Mixture of aerobes and anaerobes from genital tractMixture of aerobes and anaerobes from genital tract– BV and colonization with GBS increase likelihood of BV and colonization with GBS increase likelihood of

infectioninfection

Clinical manifestations (occur within 5 days pp)Clinical manifestations (occur within 5 days pp)– Fever – most common signFever – most common sign– Uterine tendernessUterine tenderness– Foul lochiaFoul lochia– LeukocytosisLeukocytosis– Bacteremia – in 10-20%, usually a single organismBacteremia – in 10-20%, usually a single organism

PP EndometritisPP Endometritis

WorkupWorkup– CBCCBC– Blood culturesBlood cultures– Urine cultureUrine culture– DNA probe for GC/chlamydiaDNA probe for GC/chlamydia– Imaging studies if no response to adequate Imaging studies if no response to adequate

abx in 48-72habx in 48-72hCT scan abd/pelvisCT scan abd/pelvis

US abd/pelvisUS abd/pelvis

PP EndometritisPP Endometritis

TreatmentTreatment– Broad spectrum IV abx Broad spectrum IV abx

Clindamycin 900mg IV q8h and Clindamycin 900mg IV q8h and Gentamicin 1.5mg/kg IV q8hGentamicin 1.5mg/kg IV q8h

– Treat until afebrile for 24-48h and clinically improved; Treat until afebrile for 24-48h and clinically improved; oral therapy not necessaryoral therapy not necessary

– Add ampicillin 2g IV q4h to regimen when not Add ampicillin 2g IV q4h to regimen when not improving to cover resistant enterococciimproving to cover resistant enterococci

PreventionPrevention– Abx prophylaxis for women undergoing C-sectionAbx prophylaxis for women undergoing C-section

Cefazolin 1-2g IV as single doseCefazolin 1-2g IV as single dose

Peripartum CardiomyopathyPeripartum Cardiomyopathy

Rare cause of heart failure in late pregnancy or Rare cause of heart failure in late pregnancy or early puerperiumearly puerperium

DefinitionDefinition– Development of heart failure in last month of Development of heart failure in last month of

pregnancy or within 5 mos of deliverypregnancy or within 5 mos of delivery– No identifiable cause for the failureNo identifiable cause for the failure– No history of heart disease prior to the last month of No history of heart disease prior to the last month of

pregnancypregnancy– Left ventricular systolic dysfunctionLeft ventricular systolic dysfunction

LVEF <45%LVEF <45%

Peripartum CardiomyopathyPeripartum Cardiomyopathy

Incidence – 1:3000 to 1:4000Incidence – 1:3000 to 1:4000

Unknown etiologyUnknown etiology– Potential contributors:Potential contributors:

HormonesHormones

Inflammatory cytokines (TNF-alpha and IL-6)Inflammatory cytokines (TNF-alpha and IL-6)

MyocarditisMyocarditis

Abnormal immune responseAbnormal immune response

Genetic and/or environmental factorsGenetic and/or environmental factors

PPCM – Risk FactorsPPCM – Risk Factors

Age > 30Age > 30MultiparityMultiparityMultiple fetusesMultiple fetusesWomen of African descentWomen of African descentHistory of PIHHistory of PIHMaternal cocaine abuseMaternal cocaine abuseOral tocolytics with beta adrenergic Oral tocolytics with beta adrenergic agonists > 4 weeksagonists > 4 weeks

PPCM - DiagnosisPPCM - Diagnosis

ECGECG

CXRCXR

EchocardiogramEchocardiogram

Viral and bacterial culturesViral and bacterial cultures

Cardiology referralCardiology referral– Cardiac catheterizationCardiac catheterization– Endomyocardial biopsyEndomyocardial biopsy

PPCM - TreatmentPPCM - Treatment

Similar to treating other types of HFSimilar to treating other types of HFDigoxinDigoxinDiureticsDiureticsVasodilator – hydralazineVasodilator – hydralazineBeta blockers – beta-1 selectiveBeta blockers – beta-1 selectiveClass III antiarrhythmicsClass III antiarrhythmicsAnticoagulationAnticoagulation– heparin if pre-delivery (due to short half-life & heparin if pre-delivery (due to short half-life &

reversibility), but may use Coumadin during 3reversibility), but may use Coumadin during 3 rdrd trimester & postpartum, w/ INR goal of 2.0 to 2.5trimester & postpartum, w/ INR goal of 2.0 to 2.5

PPCM - TreatmentPPCM - Treatment

IVIG showed increase in LVEF in small IVIG showed increase in LVEF in small studystudy

Heart transplantationHeart transplantation– If conventional therapy not successfulIf conventional therapy not successful– Should avoid future pregnancyShould avoid future pregnancy

Postpartum ThyroiditisPostpartum Thyroiditis

A variant form of Hashimoto’s thyroiditis A variant form of Hashimoto’s thyroiditis occurring within 1 year after parturitionoccurring within 1 year after parturitionIncidence – 3-16% of postpartum womenIncidence – 3-16% of postpartum women– Up to 25% in women with Type 1 DMUp to 25% in women with Type 1 DM

Most have high serum levels of anti-Most have high serum levels of anti-peroxidase Abperoxidase AbThyroid inflammation damages follicles Thyroid inflammation damages follicles proteolysis of thyroglobulin proteolysis of thyroglobulin release of release of T3 + T4 T3 + T4 TSH suppression TSH suppression

Postpartum ThyroiditisPostpartum Thyroiditis

Clinical manifestationsClinical manifestations– 20-30%20-30%

Hyperthyroidism 2-4 mos pp, lasting 2-8 wks, Hyperthyroidism 2-4 mos pp, lasting 2-8 wks, followed by hypothyroidism, lasting 2-8 wks, then followed by hypothyroidism, lasting 2-8 wks, then recoveryrecovery

– 20-40%20-40%Hyperthyroidism onlyHyperthyroidism only

– 40-50%40-50%Hypothyroidism only, beginning 2-6 mos ppHypothyroidism only, beginning 2-6 mos pp

Postpartum ThyroiditisPostpartum Thyroiditis

Symptoms and signs, when present, are Symptoms and signs, when present, are mildmild– Hyperthyroidism Hyperthyroidism

Anxiety, weakness, irritability, palpitations, Anxiety, weakness, irritability, palpitations, tachycardia, tremortachycardia, tremor

– HypothyroidismHypothyroidismLack of energy, sluggishness, dry skinLack of energy, sluggishness, dry skin

DiagnosisDiagnosis– Small, diffuse, nontender goiter or normal Small, diffuse, nontender goiter or normal

examexam

PP ThyroiditisPP Thyroiditis

Diagnosis contd.Diagnosis contd.– No ophthalmopathyNo ophthalmopathy– High or high normal T3 + T4, low TSH, low High or high normal T3 + T4, low TSH, low

radioiodine uptake (hyper phase)radioiodine uptake (hyper phase)– Low or low normal T4, high TSH (hypo phase)Low or low normal T4, high TSH (hypo phase)

65-85% have high antithyroid Abs65-85% have high antithyroid Abs

PP ThyroiditisPP Thyroiditis

TreatmentTreatment– Most need no treatment unless have Most need no treatment unless have

bothersome sxbothersome sxHyper: atenolol or propanololHyper: atenolol or propanolol

– Avoid in nursing womenAvoid in nursing women

Hypo: levothyroxine 50-100 mcg qd for 8-12 wks, Hypo: levothyroxine 50-100 mcg qd for 8-12 wks, discontinue, re-eval in 4-6 wksdiscontinue, re-eval in 4-6 wks

Educate patient on sx, increased risk of developing Educate patient on sx, increased risk of developing hypothyroidism or goiter, likely recurrence with hypothyroidism or goiter, likely recurrence with subsequent pregnanciessubsequent pregnancies

Board ReviewBoard Review

Which of the following statements about Which of the following statements about postpartum depression is true?postpartum depression is true?– A. Postpartum depression usually occurs 9 to 12 A. Postpartum depression usually occurs 9 to 12

months after delivery.months after delivery.– B. Social support has little impact on the development B. Social support has little impact on the development

of postpartum depression.of postpartum depression.– C. Those with obstetric complications are at increased C. Those with obstetric complications are at increased

risk.risk.– D. Those affected are at increased risk for postpartum D. Those affected are at increased risk for postpartum

depression with subsequent pregnanciesdepression with subsequent pregnancies– E. Patients who have postpartum depression have no E. Patients who have postpartum depression have no

higher risk of developing depression in later years higher risk of developing depression in later years when compared to the general population.when compared to the general population.

Postpartum DepressionPostpartum Depression

Most common complicationMost common complication– Occurs in 13% (1 in 8) of women after pregnancyOccurs in 13% (1 in 8) of women after pregnancy– Recurs in 1 in 4 with prior depressionRecurs in 1 in 4 with prior depression– Begins within 4 weeks after deliveryBegins within 4 weeks after delivery

Multifactorial etiologyMultifactorial etiology– Rapid decline in hormones, genetic susceptibility, life Rapid decline in hormones, genetic susceptibility, life

stressorsstressors

Risk FactorsRisk Factors– Prior h/o depression, family h/o mood disorders, Prior h/o depression, family h/o mood disorders,

stressful life eventsstressful life events

Postpartum DepressionPostpartum Depression

Pattern of sx are similar to other episodes of Pattern of sx are similar to other episodes of depressiondepression– Depressed mood, anxiety, loss of appetite, sleep Depressed mood, anxiety, loss of appetite, sleep

disturbance, fatigue, guilt, decreased concentrationdisturbance, fatigue, guilt, decreased concentration– Must be present most of the day nearly every day for Must be present most of the day nearly every day for

2 wks2 wksNot a separate dx from depression in DSM-IV; “postpartum Not a separate dx from depression in DSM-IV; “postpartum onset specifier” is used for mood d/o within 4 wks pp onset specifier” is used for mood d/o within 4 wks pp

ScreeningScreening– Edinburgh Postnatal Depression ScaleEdinburgh Postnatal Depression Scale– + screen with score >/= 10+ screen with score >/= 10– r/o anemia and thyroid diseaser/o anemia and thyroid disease

PP DepressionPP Depression

Differential DiagnosisDifferential Diagnosis– Baby Blues – common, transient mood disturbanceBaby Blues – common, transient mood disturbance

Sadness, weeping, irritability, anxiety, and confusionSadness, weeping, irritability, anxiety, and confusion

Occurs in 40 - 80% of postpartum womenOccurs in 40 - 80% of postpartum women

Sx peak 4Sx peak 4thth – 5 – 5thth day pp and resolve by 10 – 14 days day pp and resolve by 10 – 14 days

– Postpartum psychosisPostpartum psychosisPsychiatric emergency due to risk of infanticide or suicidePsychiatric emergency due to risk of infanticide or suicide

Bizarre behavior, disorganization of thought, hallucinations, Bizarre behavior, disorganization of thought, hallucinations, delusionsdelusions

usually occurs in first 2 weeks ppusually occurs in first 2 weeks pp

PP DepressionPP Depression

TreatmentTreatment– SSRIs are first-line drugsSSRIs are first-line drugs

Initiate at half the usual starting doseInitiate at half the usual starting doseTreat for at least 6 – 12 months after full remission to prevent Treat for at least 6 – 12 months after full remission to prevent relapserelapseSertraline or paroxetine for breast-feeding mothersSertraline or paroxetine for breast-feeding mothers

– May also respond to psychotherapyMay also respond to psychotherapy– Hormonal therapy??Hormonal therapy??

Patient resourcesPatient resources– National Women’s Health Info Center (National Women’s Health Info Center (

www.4woman.govwww.4woman.gov))– www.depressionafterdelivery.comwww.depressionafterdelivery.com