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(Expanded with concise EM-focused content: hemorrhage 4Ts, endometritis, postpartum preeclampsia, cardiomyopathy, VTE, psychosis)
 
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== Late Postpartum Pre/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==
{{Postpartum emergencies DDX}}


*15% of all cases of eclampsia
===[[Postpartum hemorrhage]]===
*40% have no history of HTN or proteinuria
*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


=== Diagnosis ===
===[[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)


Hypertension
===[[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


*Sys >140 or dia > 90 AND
===Peripartum Cardiomyopathy===
*Proteinuria > 0.3g in 24-hr
*Heart failure occurring in last month of pregnancy to 5 months postpartum
**Urine dipstick of 1+ is suggestive
*Presents with dyspnea, edema, orthopnea
***Lack of proteinuria is not rule-out!
*Echocardiography for diagnosis; manage as heart failure


*History
===[[DVT]] / [[Pulmonary Embolism]]===
**Headache
*Postpartum period is highest risk for VTE
**Confusion
*Low threshold for workup — D-dimer less useful in postpartum period
**Visual disturbances
*CTA for suspected PE; compression US for DVT
**Nausea/vomiting
**Epigastric pain


*Physical
===Postpartum Depression / Psychosis===
**AMS
*Depression: common (10-15%), screen with Edinburgh Postnatal Depression Scale
**Focal neurologic deficits
*Psychosis: rare but dangerous — onset typically 2-4 weeks postpartum; hallucinations, delusions, risk of harm to self/infant → psychiatric emergency, admit
**Visual symptoms
**Hyperreflexia
**RUQ or diffuse abdominal tenderness
**Peripheral edema


=== Work-Up ===
===Other===
*Mastitis / breast abscess
*Wound infection / dehiscence (cesarean)
*Ovarian vein thrombophlebitis (septic pelvic thrombophlebitis)
*Urinary retention


*UA
==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


=== Treatment ===
==See Also==
*[[Emergent delivery]]
*[[Postpartum hemorrhage]]
*[[Preeclampsia]]
*[[Vaginal bleeding]]


*Control blood pressure
==References==
**Lower to Sys 130-150, dia 80-100
<references/>
*Labetalol
**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 ==
[[Category:OBGYN]]
 
=== Background ===
 
*Presents in postpartum period in 30%
**Usually within 48 hr of delivery
*80% had no evidence of preeclampsia before delivery
 
=== Diagnosis ===
 
*Signs/Symptoms
**RUQ or epigastric pain - 40-90%
**Proteinuria - 86-100%
**Hypertension - 82-88%
*Labs
**CBC w/ diff
***Microangiopathic hemolytic anemia
***Plt count <100
**LFT
***AST > 70, bilirubin > 1.2
**LDH > 600
 
=== Work-Up ===
 
*CBC w/ diff
*Chemistry
*LFT
*LDH
*PT/PTT/INR
*FDP, fibrinogen, D-Dimer
*CT to evaluate for hepatic hematoma (if needed)
 
=== Treatment ===
 
*Same as for eclampsia
 
=== Complications ===
 
*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/><br/>
 
[[Category:OB/GYN]]

Revisión actual - 00:35 21 mar 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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