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
Take home message
3. +
Introduction
A postpartum period (or postnatal 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.
7. +
Early Complications/ Issues Late Complications
Pain Postpartum thyroiditis
Breast Engorgement Postpartum depression
Voiding difficulty and retention Sexual dysfunction
Preeclampsia/ Eclampsia Weight retention and gain
Postpartum pyrexia
Varicose veins
Postpartum blues
8. +
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.
9. +
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.
10. +
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]
11. +
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
12. +
Case 1
You are taking obstetric calls for your group this
weekend. The nurse calls you to evaluate one of your
patients. She is a 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?
14. +
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.
15. +
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
16. +
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.
17. +
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.
18. +
Treatment
Broad spectrum antibiotics with coverage of beta-
lactamase producing anaerobes.
Example clindamycin(900 mg every eight hours) plus
gentamicin (1.5 mg/kg every eight hours or 5 mg/kg
every 24 hours in patients with normal renal function) (
Grade 2B). Ampicillin-sulbactam (1.5 g every six hours) is a
reasonable alternative in areas with significant
clindamycin resistance in B.
19. +
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.
20. +
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.
21. +
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
22. +
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”
24. +
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
25. +
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 nighttime. 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.
26. +
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 ?
27. +
Postpartum thyroiditis
Postpartum thyroiditis is a destructive thyroiditis induced
by an autoimmune mechanism within one year after
parturition. [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
28. +
Prevalence
The reported prevalence of postpartum thyroiditis 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
29. +
Pathogenesis
It is considered a variant form of chronic autoimmune
thyroiditis (Hashimoto's thyroiditis).
Women destined to develop postpartum thyroiditis
usually have high serum antithyroid peroxidase antibody
concentrations early in pregnancy, which decline later
and then rise again after delivery. [7]
31. +
Clinical Presentation
The symptoms and signs of hyperthyroidism, when
present, are 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]
33. +
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.
35. +
Screening
There is insufficient evidence to support a
recommendation for screening all pregnant women for
postpartum thyroiditis.
However, women at highest risk for developing
postpartum thyroiditis should have a serum TSH
measurement at three and six months postpartum.
36. +
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.
37. +
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.
38. +
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.
39. +
What is the most likely diagnosis in this patient?
What is the best initial choice of treatment for this
patient?
40. +
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.
41. +
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. [11]
Forty to 80 percent of postpartum women develop these
mood changes, generally within two to three days of
delivery. [12]
Symptoms typically peak on the fifth postpartum day
and resolve within two weeks
42. +
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.
43. +
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.
44. +
Postpartum depression
The term postpartum depression is commonly used to
describe 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.
45. +
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.
46. +
Risk factors
Marital conflict
Stressful life events in the previous 12 months
Lack of perceived social support from family and friends for the
pregnancy
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
47. +
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
49. +
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.
50. +
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
51. +
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
52. +
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.
53. +
Postpartum weight retention
• 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]
54. +
References
[1]Declercq
E, Cunningham DK, Johnson C, Sakala C. Mothers' reports of postpartum pain associated with vaginal and c
[2]Deussen
AR, Ashwood P, Martis R. Analgesia for relief of pain due to uterine cramping/involution after birth. Cochran
[3]Saultz
JW, Toffler WL, Shackles JY. Postpartum urinary retention. J Am Board Fam Pract 1991; 4:341.
[4]Saultz
JW, Toffler WL, Shackles JY. Postpartum urinary retention. J Am Board Fam Pract 1991; 4:341.
[5]
Marqusee E, Hill JA, Mandel SJ. Thyroiditis after pregnancy loss. J Clin Endocrinol Metab 1997; 82:2455.
[6]Nicholson WK, Robinson KA, Smallridge RC, et al. Prevalence of postpartum thyroid dysfunction: a quantit
.
[
7]Stagnaro-Green A, Roman SH, Cobin RH, et al. A prospective study of lymphocyte-initiated immunosuppre
55. +
[8]Stagnaro
-Green A. Approach to the patient with postpartum thyroiditis. J Clin Endocrinol Metab 2012; 97:334
.
[9]Nikolai
TF, Turney SL, Roberts RC. Postpartum lymphocytic thyroiditis. Prevalence, clinical course, and long-t
[10]Stagnaro-Green A, Abalovich M, Alexander E, et al. Guidelines of the American
Thyroid Association for the diagnosis and management of thyroid disease during
pregnancy and postpartum. Thyroid 2011; 21:1081.
[11]O'Hara MW, Schlechte JA, Lewis DA, Wright EJ. Prospective study of postpartum
blues. Biologic and psychosocial factors. Arch Gen Psychiatry 1991; 48:801.
[12]Steiner M. Postpartum psychiatric disorders. Can J Psychiatry 1990; 35:89.
[13]Bloch M, Rotenberg N, Koren D, Klein E. Risk factors associated with the
development of postpartum mood disorders. J Affect Disord 2005; 88:9.
[14]Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development
of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry 1987; 150:782.
[15]Leeman LM, Rogers RG. Sex after childbirth: postpartum sexual function. Obstet
Gynecol 2012; 119:647.
[16]Gunderson EP, Abrams B, Selvin S. Does the pattern of postpartum weight
change differ according to pregravid body size? Int J Obes Relat Metab Disord 2001;
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