HELLP!!! Pregnancy Complications in the Postpartum Period
- Jan 28th, 2015
- Dina Al-Joburi
Author: Dina Al-Joburi, DO (EM Resident Physician, Drexel University College of Medicine) // Editors: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Justin Bright, MD
You are working a shift in the ED and have to pick between two charts, that of a 23 y/o G7P6 who is 20 weeks pregnant presenting with vaginal bleeding or a 23 y/o female presenting with a headache… you think to yourself, “well that’s easy, any chart wins over a pregnant patient.” Two hours later, you’re thinking to yourself, “wow, was I wrong!” after that headache turned out to be an eclamptic nightmare requiring your patient to be showered with Magnesium in order to stop her seizure.
Postpartum complications include a large spectrum that extends far beyond Sheehan’s syndrome, which was the one complication embedded in us during medical school. These complications can affect any organ system and present in any way, so it is important to keep them on your differential when presented with common ED complaints, such as headache, shortness of breath, or fever.
Preeclampsia and eclampsia result from widespread vascular endothelial malfunction and vasospasm and is typically seen after 20 weeks of pregnancy. Preeclampsia manifests as hypertension plus proteinuria or evidence of end-organ damage, and eclampsia presents as new-onset convulsions or coma. Although preeclampsia and eclampsia are most common in the third trimester of pregnancy, they can both carry over into the postpartum period or even initially present in the postpartum period. Failure to recognize postpartum preeclampsia/eclampsia can have many consequences, such as, stroke, renal failure, pulmonary edema, or thromboembolic events.
In order to accurately diagnose this serious postpartum complication, it is important to understand how they can present. Preeclampsia can be seen up to 4-6 weeks post-delivery and patients can present with headache, vision changes, vomiting, and decreased urination. Eclampsia — more specifically late postpartum eclampsia (LPE) — is when convulsions occur between 48 hours and 4 weeks post-delivery. It is important to note that the occurrence of LPE can present without the typical preeclamptic prodrome, such as, proteinuria or hypertension. Failure to realize this atypical presentation of eclampsia results in unnecessary tests and increased time to magnesium sulfate administration (8). LPE has also been associated with Posterior Reversible Encephalopathy Syndrome, a clinicoradiological syndrome presenting as altered mental status, headache, visual change, in addition to, radiologic findings of cerebral white matter edema (3).
Also on the spectrum of pre-eclampsia/eclampsia is hemolysis, elevated liver enzymes, and low platelet count — or what is more commonly called HELLP syndrome. It too can present in the postpartum period, typically 48 hours to 7 days after delivery, and can be seen in women who had uncomplicated, normotensive pregnancies. These patients may be asymptomatic with abnormal labs or present with right upper quadrant pain (secondary to periportal or subcapsular hemorrhage) and other nonspecific symptoms, like nausea and malaise (2).
Peripartum Cardiomyopathy (PPCM)
Peripartum cardiomyopathy is a pregnancy-induced dilated cardiomyopathy that presents with similar symptoms as those seen in heart failure, such as, dyspnea, edema, orthopnea, and paroxysmal nocturnal dyspnea. The exact etiology of PPCM is unknown. If left unidentified the patient is at risk for thromboembolic events or arrhythmias.
The diagnostic criteria for PPCM includes: 1) occurring during the last month of pregnancy or first five months after delivery, 2) Absence of an identifiable cause for cardiac failure, 3) absence of heart disease prior to last five months of pregnancy, and 4) Echo shows LV systolic dysfunction, EF of <45% (4). Risks include multiple fetuses, multiparity, age >30, obesity, hypertension, maternal cocaine abuse, and long-term tocolytic therapy (6).
Pregnancy is the perfect example of Virchow’s triad in action and these physiologic effects are seen well after delivery. First, the mother is hypercoagulable secondary to an increase in procoagulants (Factor II, Factor VII, Factor X and Fibrin) and a decrease in anticoagulants. Next, venous stasis can result from IVC obstruction by the uterus, or post-surgical bed-rest as seen in patients who have undergone a c-section. Lastly, the trauma of delivery causes vascular endothelial damage.
Thromboembolic disease can manifest in the more common clinical presentations such as pulmonary emboli or lower extremity DVT, but thrombi can also present in more subtle ways, such as, ovarian vein thrombosis and cerebral venous sinus thrombosis. Ovarian vein thrombosis most commonly affects the right ovarian vein. The right ovarian vein is more susceptible to compression because of the angle it enters the IVC and the dextrorotation of the uterus can compress the vein against the pelvic rim (7). It can present as fever, malaise, right ureteral obstruction and hydronephrosis, and right-sided abdominal pain. Missing this diagnosis can result in pulmonary embolism or sepsis. Cerebral venous sinus thrombosis presents with a wide-variety of symptoms that depend on what part of the brain the thrombus affects. It most frequently presents as a headache, but can also present as a seizure or stroke-like symptoms. The frequency of peripartum and postpartum cerebral venous sinus thrombosis is about 12 cases per 100,000 deliveries (5).
Postpartum fever is defined as a temperature greater than 38.0°C on any two of the first ten days following delivery excluding the first 24 hours (1). The differential includes endometritis, endomyometritis, wound cellulitis, mastitis, and septic thrombophlebitis. Endometritis and endomyometritis are infections that result from the ascension of genital/GI tract bacteria into the uterus. Patients typically present with abdominal pain, uterine tenderness, and vaginal discharge. Risk factors include prolonged rupture of membranes, retained placenta requiring manual removal, and internal fetal monitoring. Mastitis results from the introduction of bacteria from infant’s mouth to mother’s breast. Typically patients present with unilateral breast edema, erythema, warmth, and tenderness.
Postpartum complications are not limited to the examples highlighted above, but they underscore the importance of obtaining an obstetric history and keeping pregnancy complications in your differential well after the fetus has been delivered.
References // Further Reading
1) Adair FL. The American Committee of Maternal Welfare, Inc: The Chairman’s Address. Am J Obstet Gynecol. 1935;30:868
2) Esan K, Moneim T, Page IJ. Postpartum HELLP syndrome after a normotensive pregnancy. Br J Gen Pract. 1997;47:441–442.
3) Hinchey J, Chaves C, Appignani B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996;334:494–500)
4) Lampert MB, Lang RM. Peripartum cardiomyopathy. Am Heart J 1995 Oct;130:860-70.
5) Lanska, D. J., and R. J. Kryscio. “Risk Factors for Peripartum and Postpartum Stroke and Intracranial Venous Thrombosis.” Stroke 31.6 (2000): 1274-282. Web.
6) Shaikh N. An obstetric emergency called peripartum cardiomyopathy! J Emerg Trauma Shock 2010;3:39-42.
7) Slam, Kristine, MD, Sara Duckett, MD, Arul S. Thirumoorthi, BS, and Paul Clark, MD. “Ovarian Vein Thrombosis in Two Postpartum Women.” Hospital Physician (2008): 31-35.
8) Stella CL, Sibai BM. Preeclampsia: diagnosis and
management of the atypical presentation. J Matern Fetal Neonatal Med 2006;19:381-6.