non bleeding complications post partum by HMC FM resident

1. Postpartum
Complications
Dr. Ahmed Ewida
PGY2 Family Medicine Resident

2. 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

3. Introduction
 A postpartum 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.

4.  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.

5. Postpartum Complications

6. Early Complications/ Issues Late Complications
Pain Postpartum thyroiditis
Breast Engorgement Postpartum depression
Voiding difficulty and retention Postpartum psychosis
Preeclampsia/ Eclampsia Sexual dysfunction
Postpartum fever and infection Weight retention and gain
Varicose veins
Postpartum blues

7.  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.

8.  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.

9.  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]

10.  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

11. Case 1
 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?

12. Postpartum fever

13. 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.

14. 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

15. 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.

16.  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.

17. Treatment
 Broad spectrum antibiotics with coverage of
beta-lactamase producing anaerobes.
 Example clindamycin(900 mg Q8) plus
gentamicin (1.5 mg/kg Q8 or 5 mg/kg QD in
patients with normal renal function) (
Grade 2B). Ampicillin-sulbactam (1.5 g Q6) is
a reasonable alternative in areas with
significant clindamycin resistance in B.

18. 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.

19.  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.

20. 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

21.  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”

22. 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

23. 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

24. 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 night. 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.

25.  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 ?

26. Postpartum thyroiditis
 Postpartum thyroiditis is a destructive
thyroiditis induced by an autoimmune
mechanism within one year afte. [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

27. Prevalence
 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

28. Pathogenesis
 It is considered a variant form of chronic
autoimmune thyroiditis (Hashimoto's
thyroiditis).
 usually have high serum anti-thyroid
peroxidase antibody concentrations early
in pregnancy, which decline later and
then rise again after delivery. [7]

29. Clinical Presentation
 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]

30.  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.

31. Diagnosis

32. Screening
 There is insufficient evidence to support a
recommendation for screening
 However, women at highest risk for
developing postpartum thyroiditis should
have a serum TSH measurement at three
and six months postpartum.

33. 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.

34. 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.

35. 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.

36.  What is the most likely diagnosis in this
patient?
 What is the best initial choice of treatment
for this
patient?

37. 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.

38. 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.
 Forty to 80 percent of postpartum women
develop these mood changes, generally within
two to three days of delivery.
 Symptoms typically peak on the fifth postpartum
day and resolve within two weeks

39. 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.

40. 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.

41. Postpartum depression
 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.

42. 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.

43. Risk factors
 Marital conflict
 Stressful life events in the previous 12 months
 Lack of social support from family and
 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

44. 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

46. 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.

47. 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

48.  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

49. Postpartum psychosis
 Postpartum psychosis most commonly
presents within two weeks of childbirth.
 Women with postpartum psychosis are
more likely to commit suicide or
infanticide than the general population.

50. DEFINITIONS
disturbance in an individual's perception of
reality. Psychosis can be manifested
through one or more of the following:
Delusions: fixed, false beliefs
Hallucinations: false perceptions (eg,
visual, auditory, or olfactory)
Thought disorganization

51. Prevalence
 Postpartum psychosis is relatively rare
(prevalence 0.1 to 0.2 percent)

52. Risk factors
 History of postpartum psychosis
 History of bipolar disorder
 Family history of postpartum psychosis
 First pregnancy
 Recent discontinuation of lithium or other
mood stabilizers

53. Examination
 The onset and course of psychotic symptoms (eg,
episodic versus chronic)
 The nature of the affective symptoms (eg,
depressed, manic, or mixed state, or not present)
 The impact of these symptoms on the patient's
behavior and functioning
 The patient's history and family history of prior
affective or psychotic episodes
 Safety of the child and others under the patient’s
care
 The presence of a comorbid substance-use
disorder

54. DIAGNOSIS
 DSM-5 does not classify postpartum
psychosis as a distinct diagnostic entity

55. TREATMENT
General principles of treatment include:
Early identification of psychotic symptoms
Emergent evaluation
Hospitalization for safety and acute
management
Pharmacotherapy
Coordination of care among clinicians
Involvement of family and other support systems
for the patient and the newborn
Psycho-education for the patient and family
members

56. Acute management
 A woman experiencing psychosis will not
be able to care for herself or her baby;
she should be hospitalized until stable.
 The mother should not be left alone with
the infant.
 Hospitals may make supervised day-time
visits with the infant.

57. Management:
After ensuring safety:
Antipsychotic medication
Electroconvulsive therapy
Psychosocial interventions

58. Breastfeeding
 The benefits of breastfeeding need to be
weighed against risks to the infant for
each psychotropic medication.
 All psychotropic medications are
transferred into breast milk, and thus are
passed on to the nursing infant.
 the effects of some of these medications
are believed to be clinically insignificant.

59. 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.

60.  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]
Postpartum weight
retention

61. Risk factors for weight retention
include:
 Excessive weight gain during pregnancy — women who
gain more than the IOM guideline are twice as likely to
retain ≥9 kgs postpartum
 Black race — black women retain more weight than
white women, despite comparable prepregnancy BMI
or weight gain during pregnancy.
 Obesity — an increasing BMI correlates with an
increased tendency to postpartum weight retention.
 Quitting cigarette smoking — women who quit smoking
during pregnancy and do not resume postpartum are
at high risk of retaining weight