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Postpartum Complications Dr. Ahmed Rashad

PGY2 Family Medicine ResidentUnder supervision ofDr. Fathiya Almeer Consultant Family Medicine

+Objectives

Introduction to postpartum period and its significance

Discuss different issues and complications regarding this period to the mother

We will focus on non-bleeding complications

Management of some of the complications

Take home message

+Introduction

A postpartum period (or postnatal period) is the period beginning immediately after the birth of a child and extending for about six weeks.

It is the time after birth, a time in which the mother's body, including hormone levels and uterus size, returns to a non-pregnant state.

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Upon spontaneous vaginal delivery, the mother spends an average of 1-2 days in hospital, up to 3-4 days in caesarian sections.

Providing support and reassurance during the postpartum period helps to instill a sense of confidence in new mothers and a healthy mother-infant relationship.

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Postpartum Complications

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Early Complications/ Issues Late Complications

Pain Postpartum thyroiditis

Breast Engorgement Postpartum depression

Voiding difficulty and retention Sexual dysfunction

Preeclampsia/ Eclampsia Weight retention and gain

Postpartum pyrexia

Varicose veins

Postpartum blues

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Pain

• Pain and fatigue are the two most common complaints after vaginal or cesarean delivery.[1]

• Afterpains may occur after uncomplicated vaginal delivery due to hypertonic uterine contractions.

• Short acting NSAIDs as ibuprofen are as or more effective than opioids for relief of pain.[2]

• The pain usually spontaneously resolves by the end of the first postpartum week.

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Breast Engorgement

• The breast becomes firm, enlarged, tender, and may be warm to the touch.

• Early engorgement is secondary to edema, tissue swelling, and accumulated milk, while late engorgement is due solely to accumulated milk.

• Cool compresses or ice packs and mild analgesics, may provide effective pain management.

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Voiding difficulty and urinary retention

• It is a relatively common complication in the early puerperium

• ; absence of spontaneous micturition within six hours of vaginal delivery or within six hours of removal of an indwelling catheter.[3]

• appears to be due to injury to the pudendal nerve during the birth process. [4]

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Preeclampsia/ Eclampsia

• Delayed postpartum onset or exacerbation of disease

• Signs and symptoms can be atypical; for example, the patient may have thunderclap headaches alternating with mild headaches or intermittent hypertension.

• Risk factors are similar to those for preeclampsia during pregnancy

+Case 1

You are taking obstetric calls for your group this weekend. The nurse calls you to evaluate one of your patients. She is a 28-year-old G1P1 who have just delivered last night. On postpartum day 1, your patient complains of sore breasts from breast-feeding, and her abdomen is sore “from all the rubbing.” Following delivery and on morning rounds her temperature was 38.5° C.

What is the most likely cause and the most appropriate course of action?

+Postpartum fever

+Definition

Postpartum fever is defined as a temperature of 38.7 degrees C (101.6 degrees F) or greater for the first 24 hours or greater than 38.0 degrees C (100.4 degrees F) on any two of the first 10 days postpartum.

If fever is present, a physical examination should be performed to identify the source of infection and direct optimal therapy.

+Differential Diagnosis

Urinary tract infection

Mastitis or breast abscess

Atelectasis

Wound infection (episiotomy or other surgical site infection)

Endometritis or deep surgical infection

Septic pelvic thrombophlebitis

Drug reaction

Complications related to anesthesia

+Postpartum Endometritis

Postpartum endometritis is a common cause of postpartum febrile morbidity.

The infection begins in the decidua, and then may extend into the myometrial and parametrial tissues.

The infection is polymicrobial.

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Cesarean delivery is the most important risk factor for development of postpartum endometritis.

The diagnosis of postpartum endometritis is based upon clinical criteria of fever and uterine tenderness occurring in a postpartum woman.

Other signs and symptoms which support the diagnosis include foul lochia, chills, and lower abdominal pain.

+Treatment

Broad spectrum antibiotics with coverage of beta-lactamase producing anaerobes.

Example clindamycin(900 mg every eight hours) plus gentamicin (1.5 mg/kg every eight hours or 5 mg/kg every 24 hours in patients with normal renal function) (Grade 2B). Ampicillin-sulbactam (1.5 g every six hours) is a reasonable alternative in areas with significant clindamycin resistance in B.

+Lactational mastitis

Lactational mastitis is a localized, painful inflammation of the breast that occurs in breastfeeding women.

Mastitis typically presents as a hard, red, tender, swollen area of one breast often associated with systemic complaints including fever, myalgia, chills, malaise, and flu-like symptoms.

Ultrasound is the most effective method of differentiating mastitis from a breast abscess.

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Most lactation associated breast infections are caused by staphylococcus aureus

Lactational mastitis should be managed initially with systematic emptying of the breast, anti-inflammatory agents and symptomatic treatment to reduce pain and swelling.

If there is difficulty with breastfeeding, hand expression or breast pumps can be effective for maintaining the milk supply until the mother can resume nursing.

+Septic thrombolphlebitis

occurs in the setting of pelvic vein endothelial damage, venous stasis and hypercoagulability

There are two types of SPT: ovarian vein thrombophlebitis (OVT) and deep septic pelvic thrombophlebitis (DSPT).

Patients with OVT usually present with fever and abdominal pain within one week after delivery or surgery, and thrombosis of the right ovarian vein is visualized radiographically in about 20 percent of cases

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Patients with DSPT usually present within a few days after delivery or surgery with unlocalized fever that persists despite antibiotics, in the absence of radiographic evidence of thrombosis. “a diagnosis of exclusion”

+Risk Factors

• Cesarean section (1:800 deliveries)

• Pregnancy (1 in 500 to 3000 deliveries)

• Pelvic infection (eg, postpartum endometritis, pelvic inflammatory disease)

• Induced abortion

• Pelvic surgery (eg, hysterectomy)

• Underlying malignancy

• Hormonal stimulation

+Management

Broad Spectrum Antibiotics

• Antibiotics should be continued for at least 48 hours following resolution of leukocytosis and clinical improvement.

Systemic anticoagulation

• If septic emboli or extensive pelvic thromboses are documented radiographically, anticoagulate with low molecular weight heparin or warfarin for at least six weeks

+Case 2 A 26 year old white female presented to your office with

complaints of heart palpitations. She states that the palpitations have been constant over the past two weeks but seem worse at nighttime. When asked to describe them, she states that they are regular and it feels as if her heart is going to jump out of her chest. She denies chest pain, shortness of breath or lightheadedness. She has felt a bit warm of late but denies any frank diaphoresis. It is of note that she recently delivered a normal baby boy during an uncomplicated delivery 5 weeks before this visit. She complains of feeling tired but unable to get a good night sleep. She denies any nausea, vomiting or abdominal pain.

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Her blood work at the time of the clinic visit included a

• CBC (WBC 14.2, Hct, 38.6, MCV normal, platelet count normal, differential 56% neutrophiles, 7% bands, 34% lymphocytes and 3% monocytes)

• Electrolytes (NA 142, K 3.6, Cl 101), glucose 86, BUN 26, creatinine 1.

• TFTs thyroxine 16.2 (NL 4-13), T3 resin uptake 34% (NL 25 - 35%) and a TSH of <0.05 (NL 0.3 - 5.0).

What is your diagnosis and management ?

+Postpartum thyroiditis

Postpartum thyroiditis is a destructive thyroiditis induced by an autoimmune mechanism within one year after parturition. [5]

It usually presents in one of three ways:

1. Transient hyperthyroidism alone

2. Transient hypothyroidism alone

3. Transient hyperthyroidism followed by hypothyroidism and then recovery

+Prevalence

The reported prevalence of postpartum thyroiditis varies globally and ranges from 1 to 17 percent. [6]

Higher rates, up to 25 percent, have been reported in women with type 1 diabetes mellitus, and among women with a prior history of postpartum thyroiditis

+Pathogenesis

It is considered a variant form of chronic autoimmune thyroiditis (Hashimoto's thyroiditis).

Women destined to develop postpartum thyroiditis usually have high serum antithyroid peroxidase antibody concentrations early in pregnancy, which decline later and then rise again after delivery. [7]

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+Clinical Presentation

The symptoms and signs of hyperthyroidism, when present, are typically mild and consist mainly of fatigue, weight loss, palpitations, heat intolerance, anxiety, irritability, tachycardia, and tremor.

Similarly, hypothyroidism is also usually mild, leading to lack of energy, cold intolerance, constipation, sluggishness, and dry skin. [8]

+Laboratory

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Serum antithyroid peroxidase antibody concentrations are high in 60 to 85 percent of women with postpartum thyroiditis. [9]

It is highest during the hypothyroid phase.

+Diagnosis

+Screening

There is insufficient evidence to support a recommendation for screening all pregnant women for postpartum thyroiditis.

However, women at highest risk for developing postpartum thyroiditis should have a serum TSH measurement at three and six months postpartum.

+Management

The American Thyroid Association [10],has outlined the following:

1. The majority of women with postpartum thyroiditis need no treatment during either the hyperthyroid or the hypothyroid phases of their illness.

2. TFTs should be monitored every four to eight weeks to confirm resolution of biochemical abnormalities or to detect the development of more severe hypothyroidism, indicating possible permanent hypothyroidism.

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3. Women who have bothersome symptoms of hyperthyroidism can be treated with 40 to 120 mg propranolol or 25 to 50 mg atenolol daily until their serum T3 and serum free T4 concentrations are normal.

4. Women with symptomatic hypothyroidism should be treated with levothyroxine (T4) irrespective of the degree of TSH elevation.

+Case 3

A 26-year-old primigravida delivers a healthy male infant at 40 weeks of gestation who she breastfeeds on demand. She was doing fairly well until day 4 postpartum. At that time, she developed insomnia, fatigue, and feelings of sadness and depression. The patient has a history of bipolar disorder, but she has not had an episode of either hypomania or depression for the past 5 years. Despite your concern regarding her history of bipolar disorder, she begins to improve on the day 8 postpartum and returns to her normal mental state at 2 weeks postpartum. When you see her in the office in 6 weeks she is well.

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What is the most likely diagnosis in this patient?

What is the best initial choice of treatment for this

patient?

+Postpartum blues and depression Pregnant women and their

friends, families, and clinicians expect the postpartum period to be a happy time, characterized by the joyful homecoming of the newborn. Unfortunately, this is not the case in many mothers.

+Postpartum blues

Postpartum blues refer to a transient condition characterized by mood swings from elation to sadness, irritability, anxiety, decreased concentration, insomnia, tearfulness, and crying spells. [11]

Forty to 80 percent of postpartum women develop these mood changes, generally within two to three days of delivery. [12]

Symptoms typically peak on the fifth postpartum day and resolve within two weeks

+Etiology

Although there are no conclusive data regarding the etiology of postpartum blues, multiple factors are probably involved.

Although all women experience hormonal fluctuations postpartum, some women may be more sensitive to these changes than others.

+Women at high risk

Major risk factors for postpartum blues include [13]:

• History of depression

• Depressive symptoms during pregnancy

• Family history of depression

• Premenstrual or oral contraceptive associated mood changes

• Stress around child care

• Psychosocial impairment in the areas of work, relationships, and leisure activities.

+Postpartum depression

The term postpartum depression is commonly used to describe depression that begins within the first month after delivery, using the same criteria as for non-pregnancy related depression.

It often goes unrecognized because many of the usual discomforts of the puerperium (eg, fatigue, difficulty sleeping, low libido) are similar to symptoms of depression.

+Prevalence

Postpartum depression (PPD) affects many women worldwide.

Although the prevalence of depression is similar for postpartum and non-pregnant women.

The onset of new episodes of depression is higher in the first five weeks postpartum than in non-pregnant controls.

+Risk factors

Marital conflict

Stressful life events in the previous 12 months

Lack of perceived social support from family and friends for the pregnancy

Lack of emotional and financial support from the partner

Living without a partner

Unplanned pregnancy

Having contemplated terminating the current pregnancy

Previous miscarriage

Family psychiatric history

+Screening

The Edinburgh Postnatal Depression Scale (EPDS) is a 10 item self-report questionnaire designed specifically for the detection of depression in the postpartum period. [14]

Women who report depressive symptoms without suicidal ideation or major functional impairment (or score between 5 and 9 on the EPDS) are reevaluated within one month to determine the state of depression

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+Management

A biopsychosocial approach to treatment is often utilized to maximize clinical response.

Pharmacotherapy has been proven to be an effective treatment of depression.

The major issue in selecting a medication for treatment of PPD is whether or not the woman is breastfeeding. If she is not, then drug choices are based upon the same selection criteria used for nonpuerperal depression.

+Antidepressants in lactating mothers All psychotropic medications are transferred into breast

milk, and thus are passed on to the nursing infant.

Exposure of most infants to antidepressants via human milk is clinically insignificant, with some exceptions.

The benefits of breastfeeding generally outweigh the relatively small risk of the psychotropic medication

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In women who choose to breastfeed while using antidepressants, we suggest sertraline or paroxetine in women whose psychiatric disorder is effectively managed by these medications

However, if the woman was taking a different SSRI successfully during pregnancy, we do not suggest switching SSRIs during lactation

+Other complications

Sexual dysfunction

• 47 to 57 % of women interviewed at three months postpartum noted a decreased interest. [15]

• Lower libido has been attributed to fatigue, pain, and concern over injury.

• Dyspareunia is common, occurring in about 50 percent of women at two months postpartum.

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Postpartum weight retention

• Weight retained after pregnancy is defined as the difference between postpartum and pre-pregnancy weight.

• Approximately one-half of gestational weight gain is lost in the first six weeks after delivery, with a slower rate of loss through the first six months postpartum. [16]

+References

[1]Declercq E, Cunningham DK, Johnson C, Sakala C. Mothers' reports of postpartum pain associated with vaginal and cesarean deliveries: results of a national survey. Birth 2008; 35:16.

[2]Deussen AR, Ashwood P, Martis R. Analgesia for relief of pain due to uterine cramping/involution after birth. Cochrane Database Syst Rev 2011; :CD004908.

[3]Saultz JW, Toffler WL, Shackles JY. Postpartum urinary retention. J Am Board Fam Pract 1991; 4:341.

[4]Saultz JW, Toffler WL, Shackles JY. Postpartum urinary retention. J Am Board Fam Pract 1991; 4:341.

[5] Marqusee E, Hill JA, Mandel SJ. Thyroiditis after pregnancy loss. J Clin Endocrinol Metab 1997; 82:2455.

[6]Nicholson WK, Robinson KA, Smallridge RC, et al. Prevalence of postpartum thyroid dysfunction: a quantitative review. Thyroid 2006; 16:573.

[7]Stagnaro-Green A, Roman SH, Cobin RH, et al. A prospective study of lymphocyte-initiated immunosuppression in normal pregnancy: evidence of a T-cell etiology for postpartum thyroid dysfunction. J Clin Endocrinol Metab 1992; 74:645.

+[8]Stagnaro-Green A. Approach to the patient with postpartum thyroiditis. J Clin Endocrinol Metab 2012; 97:334.

[9]Nikolai TF, Turney SL, Roberts RC. Postpartum lymphocytic thyroiditis. Prevalence, clinical course, and long-term follow-up. Arch Intern Med 1987; 147:221.

[10]Stagnaro-Green A, Abalovich M, Alexander E, et al. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid 2011; 21:1081.

[11]O'Hara MW, Schlechte JA, Lewis DA, Wright EJ. Prospective study of postpartum blues. Biologic and psychosocial factors. Arch Gen Psychiatry 1991; 48:801.

[12]Steiner M. Postpartum psychiatric disorders. Can J Psychiatry 1990; 35:89.

[13]Bloch M, Rotenberg N, Koren D, Klein E. Risk factors associated with the development of postpartum mood disorders. J Affect Disord 2005; 88:9.

[14]Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150:782.

[15]Leeman LM, Rogers RG. Sex after childbirth: postpartum sexual function. Obstet Gynecol 2012; 119:647.

[16]Gunderson EP, Abrams B, Selvin S. Does the pattern of postpartum weight change differ according to pregravid body size? Int J Obes Relat Metab Disord 2001; 25:853.

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