Postpartum Complications

Mastitis

Mastitis is a painful inflammation of the breast tissue that can occur in breastfeeding women.

Mastitis is caused by bacteria on the mother’s skin or from the baby’s mouth entering cracks in the nipple.

The most common organism responsible is Staphylococcus aureus.

It affects between 2-10% of breastfeeding mothers.

Risk factors associated with the development of mastitis include:

• Mastitis with a previous child

• Prolonged unilateral breast engorgement

• Poor milk drainage

• Nipple cracking or excoriation

Symptoms

The clinical presentation of mastitis includes:

• Fever

• Localized breast tenderness

• Unilateral breast erythema (though bilateral mastitis may occur)

Systemic complaints associated with mastitis can include:

• Myalgia

• Chills

• Malaise

• Flu-like symptoms

Mastitis should be differentiated from breast engorgement, which is common with breastfeeding. Breast engorgement presents with diffusely tender, erythematous breasts bilaterally, often before nursing or during milk let-down. Engorgement is not accompanied by fever or leukocytosis. If you see a fever, think mastitis.

Nipple pain out of proportion to physical findings (e.g. burning or shooting pain), especially in the setting of a recent candidal infection of the mother or infant should raise the suspicion of Candida mastitis.

Diagnosis

The diagnosis of mastitis is made clinically. Laboratory tests are not necessary. If performed, a CBC will demonstrate leukocytosis.

Treatment

Management of mastitis consists of the following objectives:

• Provide symptomatic relief

• Improve breast feeding techniques

• Treat with the appropriate antibiotics

Patients should continue to breastfeed or pump often, as breastfeeding or pumping prevents the bacteria from building up in the ducts. The bacteria present in the milk will not harm the infant.

Dicloxacillin or cephalexin is often given. If there is no response to oral antibiotics the patient may be admitted for IV antibiotics.

If there is no response to IV antibiotics, a breast abscess or candida mastitis may be present.

Postpartum Depression

The DSM-5 definition of the postpartum period is the first four weeks following delivery.

Psychosis

Postpartum psychosis is rare and includes the onset of delusions, hallucinations, and bizarre behavior in the first weeks postpartum.

Women are more likely to experience psychosis after childbirth than at any other point in their lives.

These patients require hospitalization and treatment with antipsychotics.

Blues

Postpartum blues (aka “baby blues”) is a transient condition marked by mild depressive symptoms including dysphoria, insomnia, and poor concentration, lasting less than 2 weeks after delivery.

It may affect 40-80% of women in the first days to weeks following delivery.

A mother with symptoms of postpartum blues is still able to take care of the baby and herself.

Postpartum blues is likely the result of a rapid drop in estrogen and progesterone, as well as interrupted sleep and the stress of caring for a newborn.

These women are at increased risk for developing postpartum depression.

Treatment is good social support and screening for depression, as in all postpartum women.

Depression

Postpartum depression is a unipolar depression that affects the mothers ability to care for the infant or herself.

Many women have changes in sleep pattern, appetite and energy in the first month after delivery. However, when these symptoms persist beyond a few weeks or interfere with the mother’s ability to care for herself or the infant, postpartum depression should be suspected.

Symptoms associated with postpartum depression include:

• Anxiety and panic attacks

• Irritability and anger

• Feeling unable to take care of the baby

• Feeling shame, guilt, or failure

Risk factors include a history of depression or other mental illness.

Postpartum depression can be treated with antidepressants (generally an SSRI is tried) and therapy. Suicidal or homicidal ideation warrants social worker involvement and alerting the patient’s family or spouse.

Complications of postpartum depression include:

• Impaired bonding and child development

• Marital dysfunction

• Suicide and infanticide

Fever

Postpartum fever is defined as any temperature over 100.4 on any two of the first 10 days postpartum. Note the first day is excluded because low grade fever is common during this period.

Endometritis (infection of the endometrium) is the most common cause of postpartum fever.

Common sources of fever in a postpartum woman fall into two categories: post-partum causes and post-operative causes.

Post-partum causes include:

• Endometritis (most common)

• Mastitis

Post-operative causes include:

• UTI, especially if the woman was catheterized or had many vaginal exams. A urinalysis and urine culture should be performed

• Infection of cesarean section wounds, episiotomy or laceration sites

• Pelvic vein thrombosis (septic thrombophlebitis) may occur, especially in a patient who is bedridden with stasis of pelvic veins. The blood often pools in the pelvis as this is the lowest part of the patient while laying in a hospital bed

Endometritis

Endometritis refers to inflammation of the uterine endometrium, most commonly due to bacterial infection.

A cesarean section is the most important risk factor for postpartum endometritis.

Other risk factors include:

• Bacterial vaginosis

• Manual removal of the placenta

• Prolonged labor

• Large amount of meconium in amniotic fluid

• Multiple cervical examinations

The key clinical findings associated with postpartum endometritis include:

• A fever typically 2-10 days after delivery

• Uterine tenderness

• Tachycardia

• Midline lower abdominal pain

• Foul-smelling lochia (postpartum uterine discharge)

Postpartum endometritis is typically treated with IV clindamycin plus gentamicin. Ultrasound is performed to rule out retained products of conception which, if present, must be removed by dilation and curettage.

Postpartum Hemorrhage

Postpartum hemorrhage is defined as:

• Cumulative blood loss ≥1000 mL, or

• Bleeding associated with signs/symptoms of hypovolemia within 24 hours of the birth process

Uterine atony is the most common cause, but hemorrhage can also be caused by lacerations and retained products of conception (such as retained placenta).

Perineal laceration classification:

• First degree: perineal mucosa only, may be managed conservatively

• Second degree: perineal body

• Third degree: rectal sphincter involvement

• Fourth degree: rectal mucosa involvement

Uterine atony is a lack of uterine muscle contraction following delivery. It is most often the result of:

• Over-distention of the uterus from a macrosomic baby

• Multiple gestations

• Polyhydramnios

• Uterine fibroids

Retained placental tissue causes the most substantial volume of postpartum bleeding.

Situations that increase the risk of postpartum hemorrhage include:

• Multiple gestation

• Prolonged labor

• Chorioamnionitis

Other more rare sources of hemorrhage include disseminated intravascular coagulation or uterine inversion. DIC is most common with placental abruption, severe preeclampsia or an IUFD retained for several weeks.

Symptoms

Patients with postpartum hemorrhage will have excessive postpartum bleeding from the genital tract. Additional findings associated with postpartum hemorrhage may include:

• A boggy uterus when palpated if there is uterine atony

• Lacerations visible during vaginal exam if present

• Detection of missing placental parts if present

If the uterine fundus is not palpable and fleshy tissue is visualized in the vagina this suggests uterine inversion.

Diagnosis

Ultrasound can be useful in diagnosing postpartum hemorrhage if the cause is due to retained products of conception.

Treatment

Uterine massage and oxytocin should be used to contract the uterine muscle and clamp bleeding vessels to decrease hemorrhage.

Surgical options should be considered based on the indication:

• Surgical repair of lacerations if present

• Dilation and curettage to remove retained placenta

• Interventional radiology may perform a uterine artery embolization

• Hysterectomy in severe or refractory cases

If oxytocin is not sufficient to control bleeding other uterotonic drugs should be considered. The three most common are misoprostol, methylergonovine, and carboprost.

Misoprostol is inserted rectally (in a higher dose than is used for cervical ripening). It is a prostaglandin E1 analogue.

Methylergonovine is an ergot derivative, and therefore a vasoconstrictor. It is contraindicated in patients with hypertension.

Carboprost is a prostaglandin F2 alpha analog. It is contraindicated in patients with asthma.

Complications

Postpartum hemorrhage is the most common cause of maternal death. Other complications include:

• Severe hemorrhage, which may result in hypovolemia and shock

• Postpartum pituitary necrosis (Sheehan’s postpartum necrosis)