Diferencia entre revisiones de «Postpartum emergencies»

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

References

Authors:

@@ Línea 1: / Línea 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==
+{{Postpartum emergencies DDX}}
-== Diagnosis ==
+===[[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
-== Work-Up ==
+===[[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)
-== DDx ==
+===[[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
-== Treatment ==
+===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
-== Disposition ==
+===[[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
-*15% of all cases of eclampsia
+===Postpartum Depression / Psychosis===
-*40% have no history of HTN or proteinuria
+*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
-*Symptoms
+===Other===
-*headache,
+*Mastitis / breast abscess
-*confusion,
+*Wound infection / dehiscence (cesarean)
-*visual disturbances
+*Ovarian vein thrombophlebitis (septic pelvic thrombophlebitis)
-*nausea, vomiting
+*Urinary retention
-*epigastric
-pain.
+==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
-Exam altered mental status focal neurologic deficits reduced visual acuity hyperreflexia right upper quadrant or diffuse abdominal tenderness, peripheral edema
+==See Also==
+*[[Emergent delivery]]
+*[[Postpartum hemorrhage]]
+*[[Preeclampsia]]
+*[[Vaginal bleeding]]
-*
+==References==
+<references/>
-Blood Pressure UA (proteinuria - absence does not rule out!
+[[Category:OBGYN]]
-Treatment
-control of blood pressure and prevention of progression to eclampsia
-<br/>Brain damage due to intracranial hemorrhage or ischemia may result in permanent neurologic damage and is the most common cause of death in women with eclampsia
-<br/>just as for the antepartum patient—the postpartum patient will benefit from careful, ongoing monitoring of blood pressure and lowering of blood pressures to 130 to 150 mm Hg systolic and 80 to 100 mm Hg diastolic.
-<br/>Intravenous labetalol in an initial dose of 20 mg followed at 10-minute intervals by doses of 20 to 80 mg, to a total cumulative dose of 300 mg, is usually effective. Instead of intermittent therapy, an IV infusion of 1 to 2 mg/min may be used after the first dose. Hydralazine may also be used in a dose of 5 mg by slow IV push over 1 to 2 minutes; a repeat bolus of 5 to 10 mg can be given every 20 minutes to a total dose of 30 mg
-<br/>One goal of therapy in the patient with postpartum preeclampsia is to prevent progression to eclampsia. Magnesium sulfate has been shown to be effective in this regard, reducing the risk of eclampsia by 50% compared with placebo.
-Magnesium sulfate is given at a loading dose of 4 to 6 g IV over 15 minutes followed by 2 to 3 g IV per hour. Patients should be observed to detect any loss of reflexes and respiratory depression, both of which are signs of hypermagnesemia. If seizures recur at therapeutic doses of magnesium, other anticonvulsant drugs can be administered. At that point, consideration should also be given to other possible causes of seizures, such as intracranial hemorrhage or metabolic abnormalities.
-HELLP Syndrome
-*Presents in postpartum period in 30%
-*usually within 48 hr of delivery
-*80% had no evidence of preeclampsia before delivery
-% to 90% of patients have right upper quadrant or epigastric pain, 86% to 100% have proteinuria, and 82% to 88% have hypertension
-Patients may be seriously ill at presentation (or shortly thereafter) as a result of disseminated intravascular coagulation, acute renal failure, pulmonary edema, subcapsular liver hematoma, or retinal detachment
-w/u
-CBC w/ diff Chemistry Magnesium level UA Coags Fibrinogen (DIC)
-MRI to evaluate PRES CT to evaluate for hepatic hematoma
-When diagnosis of the HELLP syndrome is confirmed by pathognomonic laboratory abnormalities, efforts should be directed, as in eclampsia, toward controlling blood pressure and preventing seizures
-Platelet transfusion may be indicated when counts are less than 20,000 cells/μL or if there is evidence of bleeding. Although dexamethasone was previously thought to enhance recovery, this drug has not been shown to be effective in large randomized trials
-<br/>Evidence of abdominal distention or increasing abdominal girth is suggestive of a ruptured hepatic hematoma. Treatment should be aimed at maintaining adequate intravascular volume hemodynamically stable, percutaneous embolization of the hepatic artery can be done82; if not, operative management should be considered
-Peripartum Cardiomyopathy
-*Presentation similar to typical CHF
-*ECG
-DDX
-*Respiratory tract infection
-*PE
-*MI
-*Postpartum fluid overload
-== Background ==
-== Diagnosis ==
-== Work-Up ==
-== DDx ==
-== Treatment ==
-== Disposition ==
-== See Also ==
-== Source ==
-<br/>[[Category:OBGYN]] <br/><br/>