Postpartum emergencies
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
- Acute fatty liver of pregnancy
- Amniotic fluid embolus
- Chorioamnionitis
- Eclampsia
- HELLP syndrome
- Mastitis
- Peripartum cardiomyopathy
- Postpartum endometritis (postpartum PID)
- Postpartum headache
- Postpartum hemorrhage
- Preeclampsia
- Resuscitative hysterotomy
- Retained products of conception
- Septic abortion
- Uterine rupture
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