Postpartum (within 1st month) Emergencies and their Management

Authors: Megha Rajpal, MD and Brendan Milliner, MD (EM Resident Physicians, Icahn School of Medicine at Mount Sinai) // Edited by: Jennifer Robertson, MD, MSEd and Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

 Case 1: Vaginal Bleeding

A 35-year-old female presents to the emergency department (ED) with four days of heavy vaginal bleeding.  She says she has had to change her pad once every hour.  The patient also states that she had an uncomplicated spontaneous vaginal delivery (SVD) of a full-term female one week prior to her ED presentation. She was discharged home with her baby after the delivery.  The patient denies any history of fever or pain.  On examination, she is afebrile and hemodynamically stable.  On pelvic examination, her cervical os is closed, but active bleeding is present.  There is no cervical motion tenderness or signs of trauma.

Vaginal bleeding after a SVD or Caesarean (C)-section can be normal.  However, heavy postpartum bleeding can signify more serious hemorrhage.  Postpartum hemorrhage (PPH) can be divided into two categories:

  1. Early: Early PPH is defined as heavy bleeding that occurs less than 24 hours after delivery. Most often, it is caused by uterine atony.  Other differential diagnoses of early PPH include genital tract laceration (s), retained placental parts, placenta accreta, hematomas, uterine inversion, uterine rupture, and coagulopathy.1
  2. Late: Late PPH occurs after 24 hours but no later than six weeks after delivery. Differential diagnoses of late PPH include endometritis, retained placental parts, or delayed placental site involution.1,2

Pearls:

  • Uterine atony is the most common cause of early PPH.
  • Retained placenta is a common cause of early and late PPH.

Tests to order in the ED may include:

  • Complete blood count (CBC), coagulation studies, type and screen with crossmatch if necessary.
  • Ultrasound (US) looking for retained placental tissue (r/o by demonstrating a normal uterine stripe). US is also useful to distinguish between retained tissue (echogenic) and intrauterine clot (sonolucent).  You can also visualize occult hematomas.
  • Computed tomography (CT) can help visualize a hematoma if US is non-diagnostic.

How can we manage this patient in the ED?

  • Before any orders are placed, assess the patient’s airway, breathing and circulation (ABCs). Two large bore intravenous (IV) lines should be placed, the extent of blood loss should be estimated, and the patient should be immediately.
  • If the uterus feels boggy, start with a manual massage.
  • Use medications to treat uterine atony by increasing uterine muscular tone.1,3
Drug Dose Side effects
Oxytocin (first line) 10U IM, 20-30U in 1L NS at 200cc/hr IV Hypotension, cramping
Ergonovine maleate 0.2mg intramuscular (IM) Cramping
Methylergonovine 0.2mg IM Cramping
15-methyl-prostaglandin 0.25mg IM Nausea, vomiting
  • If bleeding continues after the above therapies, look for vaginal trauma and retained placental products.
  • If uterine inversion is visualized, then the uterine anatomy should be restored manually. If any placenta is attached, then it should be removed.
  • Refractory bleeding from any source may require emergent surgical intervention or arterial embolization by interventional radiology (IR). Patients with uterine rupture require surgical intervention.  Retroperitoneal hematomas also require surgery or embolization.

Pitfalls:

  1. Failure to realize the extent of blood loss. Young women can compensate for acute blood loss Therefore, they may not develop signs of hypovolemia until later.
  2. Failure to give oxytocin for uterine atony because manual uterine massage is working. However, once massage has ceased, bleeding can resume again and can be brisk.
  3. Failure to detect vaginal lacerations. After uterine atony, lacerations are the second most common cause of PPH.

Case 2: Fever

A 30-year-old postpartum female presents to the ED complaining of fever.  She had an uncomplicated SVD of a full-term female week ago.  She was discharged home with her baby one day after the delivery.  She notes she has not been feeling well for two days and on the day of presentation to the ED, she developed a temperature of 100.9 °Fahrenheit (F).

Postpartum, or puerperal, fever can be divided into two general categories:

  1. Early puerperal fever (occurring < 48 hours after delivery): diagnoses may include uterine and/or pelvic infections, urinary tract infections (UTI) or respiratory tract infections.1
  2. Late puerperal fever (occurring > 48 hours but < 6 weeks after delivery): diagnoses may include uterine and pelvic infections, abdominal and episiotomy wound infections, breast infections, or thrombophlebitis

In a patient who has post-partum fever (PPF), a thorough history of present illness (HPI) and obstetric (OB) history should be obtained. Perform a detailed physical examination with emphasis on the genital tract, breasts, wounds, urinary, and respiratory systems.  Look for abdominal and uterine tenderness and evaluate uterine tone. Consider abscess or hematoma if an adnexal mass is palpated.

Lower abdominal pain can be from non-specific inflammation or it could be from retained placental products and persistent contractions.  Vaginal discharge could be normal or a sign of endometritis.  Abdominal tenderness, foul-smelling lochia, tachycardia, decreased bowel sounds are all non-specific.  Make sure to examine any wound sites for signs of cellulitis, necrotizing fasciitis, and dehiscence.  Mastitis can present with fever, fatigue, and upper respiratory infection symptoms so make sure to do a comprehensive physical examination, including the breasts and lungs. Septic thrombophlebitis can present with just fevers or symptoms of PE. 4

What to order in the ED?

  1. CBC, UA, blood cultures.
  2. Chest X-ray (CXR) if respiratory symptoms are present.
  3. An X-ray might demonstrate soft tissue gas if necrotizing fasciitis is present.
  4. Ultrasound can show endometrial gas
  5. CT for endometritis might show intrauterine debris or fluid in some patients.

Treatment:

Treatment of puerperal fever depends on what is suspected based on history, physical examination and primary ED workup:

Site Cause of fever Treatment
Pelvic Endometritis – most common cause Clindamycin and gentamicin or clindamycin and a third-generation cephalosporin.

Unasyn, Timentin, Zosyn, and Primaxin are all effective single, broad-spectrum antibiotics. 5

Wound infection Open and debride
Necrotizing fasciitis Surgical emergency
Pelvic abscess – US or CT to diagnose Incision and Drainage (I&D)
Septic thrombophlebitis – failure to respond to abx for endometritis Anticoagulation and antibiotics for 7-10 days.6
Urinary Pyelonephritis PO: fluoroquinolone

IV: fluoroquinolone, aminoglycoside, extended spectrum cephalosporin

Pulmonary Atelectasis or pneumonia Macrolide, fluoroquinolone
Breast Engorgement vs. mastitis (flu-like symptoms, focal erythema and tenderness) Mastitis: cover for staphylococcus with dicloxacillin or clindamycin

 

Continue breast-feeding.

Other Viral syndrome, sepsis, bacteremia Treat as clinically indicated

 

Pitfalls:

  1. Failure to consider non-gynecological sources of infection such as UTIs and pneumonia.
  2. Failure to recognize necrotizing fasciitis or call an emergent surgery consult.
  3. Failure to aggressively resuscitate and start antibiotics early.
  4. Thinking that breast pain and fever automatically equate to mastitis. Engorgement is a possibility and antibiotics are not necessary for this.

Case 3: Hypertension

A 40-year-old female presents to the ED with a chief complaint of high blood pressure. She had an uncomplicated C-section one week prior to presentation to the ED.   Her blood pressure in the ED is 190/110 and other vital signs are within normal limits.  The patient denies any other symptoms including headache, nausea, vomiting, blurry vision, chest pain, dyspnea, or focal weakness.

 Definitions:

  1. Postpartum hypertension may be defined several ways including: diastolic blood pressures of ≥ 90mmHg on two consecutive occasions at least four hours apart or a single diastolic blood pressure >110mmHg. It may also be defined as a systolic blood pressure >140mmHg or a diastolic blood pressure > 90mmHg without proteinuria with readings taken on at least two occasions, six hours apart. 7
  2. Pre-eclampsia is defined as a systolic blood pressure >140mmHg or diastolic blood pressure > 90 mmHg and proteinuria of ≥ 0.3 grams (gm) in 24-hour urine specimen. Random urine dipstick of 1+ is suggestive but not diagnostic.8 Note: while some providers continue to screen for proteinuria, others have moved away from this practice as end-organ damage can be present without proteinuria.
  3. Eclampsia is defined as a seizure in association with hypertension and proteinuria. Late postpartum eclampsia (LPPE) is defined as eclamptic seizures that occur > 48 hours after delivery but within four weeks postpartum.
  4. HELLP syndrome is defined as a hemolytic anemia with a microspherocytes or schistocytes on blood smear, elevated liver enzymes (LDH > 600 IU/L, AST > 70 IU/L, bilirubin > 1.2 mg/dL), and a low platelet count (< 100,000/mm^3).9

It is essential to remember that postpartum hypertensive disorders (the ones defined above) do not need to be a continuation of antenatal or gestational hypertensive disorders.  Post-partum hypertension can be a new diagnosis after delivery and it is important to recognize and treat high blood pressure early in order to avoid any complications that may arise from it.

Tests to obtain in the ED include:

  1. Repeat vital signs often
  2. A UA to evaluate for proteinuria
  3. CBC and peripheral blood smear to look for hemolysis, anemia, and/or thrombocytopenia
  4. A basic metabolic panel (BMP) to assess electrolytes
  5. Liver function tests
  6. Baseline magnesium level
  7. Prothrombin time (PT), Partial thromboplastin time (PTT), and fibrinogen to evaluate for disseminated intravascular coagulation (DIC)
  8. Order a CXR in any patient with pulmonary signs and symptoms, especially those who may have HELLP Syndrome
  9. Remember that a hepatic hematoma is a complication of HELLP. Therefore, if your patient with HELLP Syndrome has right upper quadrant (RUQ) pain, order a CT. Note that CT is better than US in diagnosing a hepatic hematoma.
  10. If your patient has altered mental status, hypoglycemia and drug toxicity should be ruled out. Consider ordering a head CT to rule-out intracranial pathology.  Never forget about the non-OB causes of altered mental status.
  11. One rare, but lethal, complication of eclampsia is posterior reversible encephalopathy syndrome (PRES). This syndrome presents with headache, confusion, visual changes, and seizures that can be diagnosed with magnetic resonance imaging (MRI) of the brain. White matter changes are diagnostic of PRES. A 1993 study by Raps et al demonstrated that PRES is an indicator of eclampsia, even in the absence of hypertension and proteinuria.10

Managing Post-Partum Hypertension in the ED:

If your patient has post-partum hypertension without any signs of preeclampsia, then treat if you think it is clinically warranted. An asymptomatic post-partum patient with high blood pressure does not necessarily require treatment.  In addition, there is not strong evidence to show that treating hypertension prevents pre-eclampsia.11

  1. If you choose to treat your patient, labetalol or propranolol should be given. These are preferred first line agents as they do not concentrate in breast milk. Nifedipine or verapamil can be given as second line agents if beta-blockers are contraindicated. 11,12
  2. Pre-eclampsia, unlike post-partum hypertension, requires immediate treatment. The goal is to reduce the blood pressure as soon as possible to prevent eclampsia. First line agents to manage blood pressure include labetalol 10-20 mg IV or hydralazine 5mg IV.  Magnesium sulfate (4-6 gm IV over 15 minutes followed by a drip at 2 gm/hr) should also be given as it is neuroprotective and can reduce risk of eclampsia.13
  3. For persistent seizures, give diazepam 0.1-0.3 mg/kg IV push (P), lorazepam 0.02-0.03 mg/kg IVP or Phenytoin 20 mg/kg IV as a 50 mg/min infusion.
  4. Like pre-eclampsia, the goals of treating HELLP are to control blood pressure and prevent seizures. Administer platelets if the platelet count is < 20,000/microliter (µL) or if there are overt signs of bleeding.
  5. If a ruptured hepatic hematoma is suspected on physical examination, focus on resuscitating and obtaining OB/Gynecology (GYN) consult.

Pitfall:

  1. Not recognizing and diagnosing pre-eclampsia. In one retrospective chart review of 24 women with post-partum eclampsia, 22 women had only one warning sign or symptom and 12 women had two.  Only 1/3 of these women sought medical attention for their prodromal complaints and 6/7 of these women were discharged from the ED without treatment.14

Case 4: Headache

The same patient above, instead of the complaint of high blood pressure, complains of a headache.  She reports her headache is severe, constant, and is associated with nausea and vomiting. However, she denies focal weakness, visual complaints and seizure activity.  Pre-eclampsia remains on the differential as headache can be a presenting sign for this diagnosis. However, besides pre-eclampsia, there are other causes of headache that can occur in post-partum patients.   These possible causes include central nervous system (CNS) infection, subarachnoid hemorrhage (SAH), intracranial hemorrhage (ICH), vasculitis, cerebral venous sinus thrombosis, carotid or vertebral artery dissection, ischemic stroke, post-dural puncture headache and other less emergent causes such as tension and migraine headaches.

In a retrospective review of 95 women with severe post-partum headache, 39% were diagnosed with tension headache, 24% with pre-eclampsia/eclampsia, 16% with post-dural puncture headache, 11% with migraine, and 10% with serious conditions such as ICH, mass, cerebral venous sinus thrombosis. 15 While performing the physical examination, be sure to look for meningismus, papilledema, and check reflexes.  While there are multiple etiologies of headache, the more urgent and “cannot miss” causes of headache and some of their concerning symptoms include:

  1. Pre-eclampsia: hypertension plus concerning symptoms as mentioned in the prior section. Remember patient does not need to have a history of pre-eclampsia during pregnancy to be diagnosed with it during postpartum period.
  2. Post-dural headache: constant, dull, throbbing pain exacerbated by an upright position
  3. CNS infection: fever, leukocytosis, altered mental status
  4. SAH: sudden onset headache with or without focal neurologic examination findings
  5. Cerebral venous sinus thrombosis: progressive headache with or without focal neurologic findings. Patients may or may not have signs of intracranial hypertension. Pregnancy and the puerperium are risk factors for central venous sinus thrombosis, likely due to the hypercoagulable state of pregnancy.
  6. The risk of both hemorrhagic and ischemic stroke peaks in the six weeks postpartum

Tests to order in the ED:

  1. If a post-dural headache, migraine, or tension headache is suspected, then no tests are necessary.
  2. Of course if your patient has neurologic signs, altered mental status, fever, and/or meningismus, a CT head should be obtained along with a CBC, BMP and blood cultures. A lumbar puncture (LP) with cerebrospinal (CSF) cultures should be considered if deemed safe to perform.
  3. Consider LP if meningitis is suspected
  4. If cerebral venous sinus thrombosis is suspected, MRI and magnetic resonance venography (MRV) are the gold standard diagnostic imaging modalities

ED Treatments:

  1. The recommended treatment for a post-dural headache is bed rest and analgesics. However, an epidural blood patch is definitive treatment.16
  2. Pre-eclampsia treatment as discussed above.
  3. Cerebral venous sinus thrombosis are typically treated with anti-coagulation, however neurology should be consulted.
  4. Treat SAH, migraines, and tension headaches as you would in any other patient. Note that the ergot alkaloids are contraindicated in patients who are breastfeeding.

Pitfall:

  1. Blaming a post-partum patient’s headache on recent stressors.

Case 5: Cardiomyopathy

A 38-year-old female arrives in the ED complaining of progressively worsening shortness of breath, cough, and orthopnea.  She delivered twins by C-section one week prior to presenting to the ED and she also relays a history of pre-eclampsia during the pregnancy. Her vital signs in the ED are the following: blood pressure (BP) 180/110, heart rate (HR) 125, respiratory rate (RR) 25, temperature 99°F, pulse oximetry 95% on room air (RA).  On examination, she has jugular venous distention (JVD), pulmonary rales, a S3 gallop, and bilateral lower extremity edema.  You are concerned that the patient may have peri-partum cardiomyopathy.

Peripartum cardiomyopathy is defined as the development of cardiac failure in the final month of pregnancy. Peripartum cardiomyopathy may also occur in the first five post-partum months if no other identifiable cause or history of cardiac disease can be identified.17  The majority (97%) of patients present in the first two post-partum months. The diagnosis is more common in older, multi-parous women and in patients with twin gestations.  Patients often have superimposed pre-eclampsia, obesity, or coexisting obstetric infection.18

Patients present with symptoms of left heart failure including dyspnea, orthopnea, and rales.  

Tests to consider ordering in the ED:

  1. An electrocardiogram (ECG), which may demonstrate ST-T wave changes or LV hypertrophy(LVH)
  2. A CXR may show cardiomegaly and pulmonary edema
  3. If obtained, an echocardiogram (Echo) may demonstrate four chamber enlargement and abnormalities of LV contractility.

ED Management:

  1. Treatment for peripartum cardiomyopathy is similar to that for any heart failure: oxygen as needed, diuretics when appropriate acutely, vasodilators, and arrhythmia management.

Pitfall:

  1. Shortness of breath, tachypnea, and tachycardia in a postpartum patient is concerning. A full evaluation should be conducted in the ED. Remember that anxiety is always a diagnosis of exclusion.

Summary: Common postpartum emergencies include hemorrhage, infections, hypertension, preeclampsia/eclampsia, and headache. HELLP and peripartum cardiomyopathy are rare postpartum complications.   A careful history and physical examination, knowledge of differential diagnoses, and early treatments are essential in managing the postpartum patient.

Postpartum hemorrhage requires rapid resuscitation even if signs and symptoms of shock are not initially present.  Preeclampsia and eclampsia do not always occur during pregnancy and CAN de novo in the postpartum period.  Headache is usually a common and benign complaint, but it can be a presenting symptom of preeclampsia, SAH or cerebral venous sinus thrombosis.  

 If the history and physical exam are concerning enough for one of the malignant pathologies mentioned above, admission for observation may be prudent, even with a negative ED workup. Because these patients can be complicated, consultation with OB, anesthesia, neurology, and/or cardiology is also recommended.

 References / Further reading:

  1. Mendelson MH, Lang J. “Postpartum Emergencies”. Wolfson AB (Ed.). Lippincott Williams and Wilkins. Philadelphia, PA; 2005: 522-27.
  2. Babarinsa IA, Hayman RG, Draycott TJ. Secondary post-partum haemorrhage: Challenges in evidence-based causes and management. Eur J Obstet Gynecol Reporod Biol. 2011;159:255–260.
  3. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: Postpartum hemorrhage. Obstet Gynecol. 2006;108:1039–1047.
  4. Jaiyeoba O. Postoperative infections in obstetrics and gynecology. Clin Obstet Gynecol. 2012;55:904–913
  5. Mackeen AD, Packard RE, Ota E, Speer L. Antibiotic regimens for postpartum endometritis. Cochrane Database Syst Rev. 2015.
  6. Garcia J, Aboujaoude R, Apuzzio J, et al. Septic pelvic thrombophlebitis: Diagnosis and management. Infect Dis Obstet Gynecol. 2006;2006:15614.
  7. Brown MA, Hague WM, Higgins J, et al. The detection, investigation and management of hypertension in pregnancy: executive summary. Aust N Z J Obstet Gynaecol.  2000;40(2): 133-138.
  8. ACOG Practice Bulletin: Diagnosis and management of pre-eclampsia and eclampsia. Obstet Gynaecol. 2002;99(1): 159-167.
  9. Stone JH. HELLP Syndrome: Hemolysis, elevated liver enzyme, and low platelets. JAMA.  1998;280:559-562.
  10. Raps EC, Galetta SL, Broderick M, et al. Delayed peripartum vasculopathy: cerebral eclampsia revisited. Ann Neurol.  1993;33:222-225.
  11. Abalos E, Duley L, Steyn DW, et al. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Sys Rev. 2007.
  12. American College of Emergency Physicians Clinical Policies Subcommittee. Clinical policy: critical issues in the evaluation and management of adult patients with asymptomatic hypertension in the emergency department. Ann Emerg Med.  2006;47:237-249.
  13. Sibai BM. Magnesium sulfate prophylaxis in preeclampsia: evidence from randomized trials. Clin Obstet Gynecol. 2005;48:478-488.
  14. Sibai B, Schneider J, Morrison J, et al. The late postpartum eclampsia controversy. Obstet Gynecol. 1980;55:74-78.
  15. Stella CL, Jodicke CD, How HY, et al. Postpartum headache: is your work-up complete? Am J Obstet Gynecol.2007;196:318-322.
  16. Schievink WI. Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA. 2006:295:2286-2296.
  17. Pearson G, Veille JC, Rahimtoola S, et al. Peripartum cardiomyopathy: National Heart, Lung, and Blood Institute and Office of Rare Diseases (National Institutes of Health) workshop recommendations and review. JAMA. 2000;283(9):1183-1188.
  18.  Homans D. Peripartum cardiomyopathy.  N Engl J Med.  1985;312:1432-1437

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