OB/GYN
Postpartum Complications
OB/GYN

Postpartum Complications

Endometritis, PPH, sepsis, peripartum CM, depression.

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◆Postpartum hemorrhage (PPH)

  • •Definition: >500 mL after vaginal, >1000 mL after C/S, OR symptomatic blood loss
  • •Early (<24h) vs late (>24h, up to 6 weeks)
  • •4 T's: Tone (atony, MOST common) + Trauma + Tissue (retained placenta) + Thrombin (coagulopathy)
  • •Step ladder: massage + oxytocin → tranexamic acid → methylergonovine (avoid HTN) → carboprost (avoid asthma) → misoprostol
  • •Mechanical: bimanual compression, Bakri balloon
  • •Surgical: B-Lynch suture, uterine artery ligation/embolization, hysterectomy

◆Endometritis

  • •Most common cause of postpartum fever days 2–10
  • •Biggest RF: cesarean delivery (×5–10 risk vs vaginal)
  • •Triad: fever + uterine tenderness + foul lochia
  • •Empiric: IV clindamycin + gentamicin (no cultures needed first)
  • •Polymicrobial — E. coli most common single
  • •Continue until afebrile 24–48 hours

◆Postpartum fever differential

  • •Endometritis: uterine tenderness, foul lochia
  • •Surgical site infection: incision erythema/discharge
  • •Mastitis: breast pain/erythema (dicloxacillin; continue breastfeeding)
  • •Pyelonephritis: flank pain, CVA tenderness
  • •Septic pelvic thrombophlebitis: persistent fever despite abx
  • •Atelectasis: post-anesthesia, low-grade
  • •DVT/PE: chest pain, dyspnea, swelling

◆Mastitis vs breast abscess

  • •Mastitis: unilateral erythema + induration + fever; S. aureus (also continuing to nurse helps)
  • •Treat: dicloxacillin or cephalexin × 10–14 days; continue breastfeeding
  • •Abscess: fluctuant mass — needs I&D + abx
  • •Inflammatory breast cancer: rapidly progressive, peau d'orange (DDx)

◆Peripartum cardiomyopathy

  • •Last month of pregnancy or within 5 months postpartum
  • •Dilated cardiomyopathy, EF <45%
  • •Treat like HFrEF: diuretics + β-blocker + ACEi/ARB (POSTPARTUM only)
  • •During pregnancy: avoid ACEi/ARB, use hydralazine + nitrate
  • •Anticoagulate if EF <30% (LV thrombus risk)
  • •Recurrence risk in subsequent pregnancy is high if EF doesn't recover

◆Sheehan syndrome

  • •Postpartum hemorrhage → pituitary infarction (pituitary doubles in pregnancy)
  • •First sign: failure to lactate (prolactin)
  • •Then: amenorrhea, hypothyroid symptoms, adrenal insufficiency
  • •Replace: hydrocortisone FIRST, then levothyroxine, then estrogen

◆Postpartum mood disorders

  • •Postpartum blues: 2–3 days to <2 weeks; mild; reassurance
  • •Postpartum depression: 4 weeks to 12 months; SSRI + CBT
  • •Postpartum psychosis: days–weeks; delusions, hallucinations, infanticide risk → EMERGENCY hospitalization
  • •#1 RF for postpartum depression: prior history of depression

◆Postpartum DVT/PE

  • •Highest VTE risk in 6-week postpartum period (vs nonpregnant)
  • •LMWH for treatment
  • •Prophylaxis after C/S in high-risk

◆Normal postpartum lochia

  • •Lochia rubra: days 1–4 (red/dark)
  • •Lochia serosa: days 4–10 (pink/brown)
  • •Lochia alba: days 11–6 weeks (white/yellow)

High-yield pearls

  • ◆Postpartum fever + uterine tenderness = endometritis (clinda + gent)
  • ◆PPH first step: massage + oxytocin
  • ◆Mastitis: keep nursing + dicloxacillin
  • ◆Peripartum CM: ACEi after delivery only
  • ◆Sheehan: failure to lactate is first sign; replace cortisol BEFORE thyroid
  • ◆Postpartum psychosis = psychiatric emergency
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