123 Postpartum Emergencies
Key Points• The most common infection after childbirth is a genital tract infection.
• Because lochia will contaminate a clean-catch specimen in the first 4 to 8 weeks postpartum, urine should be obtained by catheterization in the immediate postpartum period to rule out a urinary tract infection.
• In the immediate postpartum period, an acute abdomen may not be manifested as abdominal rigidity on examination because of laxity of the abdominal wall tissue at this time.
• Leukocytosis cannot be used to help differentiate an infection in the first 2 weeks postpartum because of the physiologic leukocytosis that occurs during pregnancy and delivery.
• Fever is the most important criterion for the diagnosis of postpartum metritis.
Epidemiology
Despite the fact that the first postpartum visit is generally scheduled at 6 weeks, most life-threatening complications arise within the first 3 weeks following delivery and are thus likely to be seen in the emergency department (ED). These complications are primarily related to infection, hemorrhage, pregnancy-induced hypertension, and embolic events.1,2 Infection is one of the top five causes of mortality, with approximately 13% of pregnancy-related deaths between 1991 and 1999 being due to infection.2 In the general population, the incidence of pregnancy-induced venous thromboembolism (VTE) is approximately 0.49 to 1.72 per 1000 deliveries.3 The risk for VTE is five times higher in a pregnant than in a nonpregnant patient. When compared with pregnancy, the risk for VTE is even higher postpartum: a postpartum woman’s risk for VTE is 20- to 80-fold higher in the first 6 weeks, and in the first postpartum week the risk is 100-fold higher.3,4 The majority of deaths from VTE occur during the first 2 weeks of the puerperium, but a significant number of nonfatal events occur 2 to 6 weeks after delivery.4 Approximately 75% of cases of pregnancy-associated VTE are deep vein thrombosis (DVT) and approximately 25% are pulmonary embolism (PE).3
Pathophysiology: the Puerperium
Originally, the puerperium was defined as the period of confinement during and just after birth; it is now generally accepted to mean the 6 weeks after delivery. The puerperium has also been referred to as “the fourth trimester.” This period is marked by multiple physiologic changes (Table 123.1) as the woman returns to the prepregnant state, including healing physically from any trauma during delivery, and adjusts to the many physiologic and psychologic demands involved in caring for a newborn. Just as in pregnancy, when there are so many physiologic changes, the potential exists for the normal healing process to go awry and emergencies to occur.
Table 123.1 Physiologic Changes in the Puerperium
| IMMEDIATELY FOLLOWING DELIVERY | BY POSTPARTUM TIME* |
|---|---|
| Uterus palpable at the umbilicus | By the 2nd wk, the uterus has shrunk back into the pelvis; complete involution takes 6-8 wk |
| Uterine blood flow via the uterine artery = 500-600 mL/min | By the 2nd wk, uterine blood flow = 30-45 mL/min |
| Cardiac output and blood volume increased by 30% to 50% | By the 2nd week, values are normalized to baseline |
| Breasts produce colostrum | By day 5, mature breast milk produced |
| Thyroid size and function increase | In 3 mo, the size of thyroid decreases; by the 4th wk, biochemical changes resolve (T3,T4, TSH are normalized) |
| Bladder has enlarged capacity and insensitivity to increased intravesicular pressure; renal pelvis and ureters dilated | 2-3 mo to return to normal |
| GFR increased | 8 wk to return to prepregnant GFR |
| Rectus abdominis muscles lengthened | 3-4 wk minimum to shorten; may be altered by exercise and overall baseline tone of the mother |
| Leukocytosis | 2 wk to return to baseline |
| Fibrinogen level elevated | Increases on days 2-4; returns to normal levels by the end of the first week |
| Stretch marks | 6-12 mo; depigmentation occurs but never fully resolves |
| Thicker and fuller hair | 3-4 mo; delayed alopecia |
| Lower mean velocity of blood flow in the common femoral vein after cesarean section | 6 wk to return to baseline |
GFR, Glomerular filtration rate; T3, triiodothyronine; T4, thyroxine; TSH, thyroid-stimulating hormone;
Presenting Signs and Symptoms
The most common complaints in the postpartum period are fatigue (56%), breast problems (20%), backache (20%), depression (17%), hemorrhoids (15%), and headache (15%).5
Differential Diagnosis and Medical Decision Making
Infections
Puerperal fever is defined as a temperature of 38° C (100.4° F) or higher that occurs on any 2 of the first 10 days postpartum, exclusive of the first 24 hours; the temperature should be taken orally by a standard technique at least four times daily.6 The usual cause is a genital tract infection, which can lead to significant morbidity and mortality.
Mild hypoventilation after delivery as a result of pain or limited ambulation, or both, predisposes some women to pneumonia. Additionally, minor elevations in temperature are occasionally caused by thrombosis of the superficial or deep veins of the lower extremities (Box 123.1).1,6
Genitourinary
Metritis and Pelvic Infections
The single most significant risk factor for the development of metritis is the route of delivery. Women who deliver by cesarean section have a 6% to 18% incidence of metritis versus 0.9% to 3.9% with vaginal deliveries.7,8 Other recognized risk factors for the development of metritis are chorioamnionitis, anal sphincter laceration, prolonged rupture of membranes, and weight on admission of more than 200 lb. Rates of metritis are lower now than in the past 2 decades because of the routine use of prophylactic antibiotics for cesarean deliveries.6,7
Leukocytosis is often present but the white blood count is frequently elevated during the first 2 weeks postpartum. Chills may indicate bacteremia, which occurs in 10% to 20% of women with pelvic infection. Blood for culture is best obtained during the peak temperature elevations and chills that are associated with bacteremia.9 Complications of pelvic infections can be quite severe. If a patient with metritis does not respond to antibiotics after 48 to 72 hours, suspicion for complications should be high.
Perineal Pain
Although some discomfort is to be expected after delivery because of disruption and distention of the soft tissues of the birth canal, painful perineal tissue is a significant issue for many women. In fact, perineal pain was noted by 42% of recently delivered women to be a significant problem in the first 2 weeks following delivery, and as might be expected, the percentage was higher in patients with assisted vaginal deliveries (84%). By 8 weeks postpartum the percentage was down to 22% and by 12 weeks down to approximately 7%.5
