Normal and Abnormal Puerperium
INTRODUCTION 　

Puerperium is defined as the time from the delivery of the placenta through the first few weeks after the delivery. This period usually is considered to be 6 weeks in duration. By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery have resolved and the body has reverted to the nonpregnant state.

An overview of the relevant anatomy and physiology in the postpartum period is as follows:

Uterus

The pregnant term uterus (not including baby, placenta, fluids, etc) weighs approximately 1000 grams. The uterus recedes to a nonpregnant state, with a weight of 50-100 grams, during the 6 weeks after delivery.

Immediately after delivery, the uterus can be palpated at or near the umbilicus. Most of the reduction in size and weight occurs in the first 2 weeks, at which time the uterus has decreased enough in size to be located in the true pelvis.

The endometrial lining rapidly regenerates, so that by the seventh day the endometrial glands already are evident. By day 16, the endometrium is restored throughout the uterus, except at the placental site.

The placental site goes through a series of changes in the postpartum period. Immediately after delivery, the contractions of the arterial smooth muscle and compression of the vessels by contraction of the myometrium result in hemostasis. The size of the placental bed decreases by half, and the changes in the placental bed result in the quantity and quality of the lochia that is experienced.

Initially postpartum, a large amount of red blood comes from the uterus as the contraction phase rapidly occurs. The volume rapidly decreases. The duration of this discharge (lochia), known as lochia rubra, is variable. The red discharge changes to a brownish-red color, with a more watery consistency, which is known as lochia serosa. Over a period of weeks, the discharge continues to decrease in amount and color and changes to a yellow discharge, which is known as lochia alba. The amount of time the lochia can last varies, averaging about 5 weeks, with a waxing and waning amount of flow and color.

Each woman will have her own pattern, with the various phases of the lochia lasting for different lengths of time. Fifteen percent of women have lochia at 6 weeks?postpartum. Often, women experience an increase in the amount of bleeding at 7-14 days secondary to the sloughing of the eschar on the placental site.

Cervix

The cervix also begins to rapidly change back to a nonpregnant state, but it never returns to the nulliparous state. By the end of the first week, the external os is closed to the extent that a finger could not be easily introduced.

Vagina

The vagina, which was distended to accommodate the baby, diminishes in size to a nonpregnant state, but it does not completely return to its prepregnant size. There is resolution of the increased vascularity and edema by 3 weeks, and the rugae of the vagina begin to reappear in the woman who is not breastfeeding. At this time, the vaginal epithelium appears atrophic on smear. This is restored by weeks 6-10; however, it is further delayed in the breastfeeding mother because of the persistently decreased estrogen levels.

Perineum

The perineum has been stretched and traumatized, and sometimes torn or cut, during the process of labor and delivery. The swollen and engorged vulva rapidly resolves, and swelling and engorgement are completely gone within 1-2 weeks. Most of the muscle tone is regained by 6 weeks, with more improvement over the following few months. The muscle tone may or may not return to normal, depending on the extent of injury that was experienced.

Abdominal wall

The abdominal wall remains soft and poorly toned for many weeks. The return to a prepregnant state depends greatly on exercise.

Ovaries

The resumption of normal function by the ovaries is highly variable. It is greatly influenced by the mother𠏋 decision whether to breastfeed the infant. The woman who decides to breastfeed has a longer period of amenorrhea and anovulation than does the mother who chooses to bottle-feed the infant. The non-breastfeeding mother may ovulate as early as 27 days after the delivery. Most women have had a menstrual period by 12 weeks, with a mean time to first menses being 7-9 weeks. In the breastfeeding woman, this resumption of menses is highly variable and depends on a number of factors, including how much and how often the baby is fed and whether the baby𠏋 food is supplemented with formula. The delay in the return to normal ovarian function in the lactating mother is caused by the suppression of ovulation due to the elevation in prolactin. One half to three fourths of women who breastfeed return to periods within 36 weeks of delivery.

Breasts

The changes to the breasts that prepare the body for breastfeeding occur throughout the pregnancy. By 16 weeks?gestation, lactation can occur. Lactogenesis is triggered initially by the delivery of the placenta, which results in falling levels of estrogen and progesterone, with the continued presence of prolactin. If the mother is not breastfeeding, the prolactin levels decrease and return to normal within 2-3 weeks.

The colostrum is the liquid that is initially released by the breasts during the first 2-4 days after delivery. It is high in protein and is very protective for the newborn. The colostrum, which the baby receives in the first few days postpartum, already is present in the breasts, and suckling by the newborn triggers its release. The process, which started out as an endocrine process, switches to an autocrine process; the removal of milk from the breast stimulates more milk production. Over these first 7 days, the milk matures and has all of the necessary nutrients that the baby needs in this neonatal period. The milk continues to change throughout the period of breastfeeding to meet the changing demands of the baby.

ROUTINE POSTPARTUM CARE 　

The immediate postpartum period occurs most often in the hospital setting, where the majority of women remain in the hospital approximately 2 days after a vaginal delivery and 3-5 days after a cesarean section. During this time, women are recovering from their delivery, as well as beginning to care for the newborn. This period is used both to make sure the mother is stable and to educate her in the care of her baby, especially the first-time mother. While still in the hospital, the mother is monitored for blood loss, signs of infection, abnormal blood pressure, contraction of the uterus, and the ability to void.

It is customary to check the blood type of the baby and to administer the RhoGAM vaccine to the Rh-negative mother if her baby𠏋 blood type is Rh positive. Usually, the mother has at least her hematocrit level checked on the first postpartum day. Women are encouraged to ambulate and to eat a regular diet.

Vaginal delivery

After a vaginal delivery, most women experience swelling of their perineum and pain. This is intensified if the woman has had an episiotomy or a laceration. Routine care of this area includes ice applied to the perineum to reduce the swelling and help with pain relief. Conventional treatment is to use ice for the first 24 hours after delivery and then switch to warm sitz baths. However, there is little evidence to support this method over other methods of treatment of the postpartum perineum. Pain medications are very helpful both systemically as nonsteroidal anti-inflammatories (NSAIDs) or narcotics, as well as local anesthetic spray to the perineum.

Another postpartum issue that is likely to affect the women who have vaginal deliveries is hemorrhoids. Symptomatic relief is the best treatment during this immediate postpartum period, because often the hemorrhoids will resolve as the perineum recovers. This can be achieved by the use of corticosteroid creams, witch hazel compresses, and local anesthetics.

Tampon use can be resumed when the patient is comfortable inserting the tampon and it is comfortable to wear. This will take longer for the woman who has had an episiotomy or a laceration than for one who has not. The vagina and perineum should be fully healed, which takes about 3 weeks. It also is important to change the tampons frequently to prevent infection.

Cesarean section

The woman who has had a cesarean section does not usually have the pain and discomfort from her perineum, but rather from her abdominal incision. This, too, can be treated with ice to the incision, as well as with the use of systemic pain medication. Often, women who have had a cesarean section are slower to begin ambulating, eating, and voiding. However, they should be encouraged to resume these and other normal activities quickly.

Sexual intercourse

Sexual intercourse may resume when there is no bright red bleeding, the vagina and vulva are healed, and the woman is physically comfortable, as well as emotionally ready. The physical readiness usually takes about 3 weeks. Birth control is important to protect against pregnancy, as the first ovulation is very unpredictable.

Patient education

Substantial education takes place during the hospital stay, especially for the mother who has just had her first child. The mother, and often the father, is taught routine care of the baby, feeding, diapering, and bathing, as well as what can be expected from the baby in terms of sleep, urination, bowel movements, and eating.

The mother who is breastfeeding should receive education, support, and guidance with the breastfeeding. Breastfeeding is neither easy nor automatic. It requires much effort on the part of the mother and her support team. Breastfeeding should be initiated as soon after delivery as possible; in a normal, uncomplicated vaginal delivery this can be done almost immediately after the birth. The mother should be encouraged to feed the baby every 2-3 hours (at least while she is awake during the day) to stimulate mild production. Feedings do not need to be long, but they should be frequent. The milk production should be well established by 36-96 hours.

In women who choose not to breastfeed, the care of the breasts is quite different. Care should be taken not to stimulate the breasts in any way to try to prevent milk production. Ice packs applied to the breasts and the use of a tight bra or a binder also can help to prevent breast engorgement. Acetaminophen or NSAIDs can help with the symptoms of breast engorgement (eg, tenderness, swelling, fever) if it does occur. At one time, bromocriptine was administered to suppress milk production. However, its use has diminished because it requires 2 weeks of administration, does not always work, and can produce adverse reactions.

Discharge instructions

It is important to give the mother discharge instructions. The most important information is who and where to call if she has problems or questions. She also needs details about resuming her normal activity. Instructions vary, depending on whether the mother has had a vaginal delivery or a cesarean section.

The woman who has had a vaginal delivery may resume all physical activity as long as she is comfortable and without pain or discomfort with the activity. This includes using stairs, riding in a car, driving a car, or doing muscle-toning exercises. The caveat to resuming normal activity is not to overdo activity on one day to the point that the mother is completely exhausted the next day. Pregnancy, labor, and delivery, as well as care for the newborn, are strenuous and stressful, and the mother needs sufficient rest to recover. The woman who has had a cesarean section needs to be more careful about resuming some of her activities. It is important for her to prevent overuse of her abdomen until her incision is well healed to prevent an early dehiscence or a hernia later on.

Women conventionally return for their postpartum visit at about 6 weeks after delivery. There is no sound reason for this; the time probably has become the standard so those women who are returning to work can be medically cleared to return. There is nothing that should be or needs to be done at a postpartum visit that cannot be done earlier or later than 6 weeks. Often, an earlier visit can aid a new mother in resolving problems she may be having or provide a time to answer questions that she might have.

It is very important to counsel the mother about birth control options before she leaves the hospital. She may not be ready to decide about a method, but she needs to know what her options are. Her decision will be based on a number of factors, including her motivation in using a particular method, how many children she has, and whether she is breastfeeding. There are many available options.

　
HEMORRHAGE 　

Postpartum hemorrhage is defined as excessive blood loss during or after the third stage of labor. The average blood loss is 500 mL at vaginal delivery and 1000 mL at cesarean section. Since diagnosis is based on subjective observation, it is difficult to define clinically.

Objectively, postpartum hemorrhage is defined as a 10% change in hematocrit between admission and postpartum or the need for transfusion after delivery secondary to blood loss.

Early postpartum hemorrhage is described as that occurring within the first 24 hours after delivery. Late postpartum hemorrhage most frequently occurs 1-2 weeks after delivery but may occur up to 6 weeks?postpartum.

Etiology

Early postpartum hemorrhage may result from uterine atony, retained products of conception, uterine rupture, uterine inversion, placenta accreta, lower genital tract lacerations, coagulopathy, and hematoma. Causes of late postpartum hemorrhage include retained products of conception, infection, subinvolution of placental site, and coagulopathy.

Uterine atony and lower genital tract lacerations are the most common causes of postpartum hemorrhage. Factors predisposing to uterine atony include overdistension of the uterus secondary to multiple gestations, polyhydramnios, macrosomia, rapid or prolonged labor, grand multiparity, oxytocin administration, intra-amniotic infection, and use of uterine relaxing agents, such as terbutaline, magnesium sulfate, halogenated anesthetics, or nitroglycerin. In uterine atony, lack of closure of the spiral arteries and venous sinuses coupled with the increased blood flow to the pregnant uterus causes excessive bleeding.

Lower genital tract lacerations, including cervical and vaginal lacerations, such as sulcal tears, are the result of obstetrical trauma and are more common with operative vaginal deliveries, such as forceps or vacuum extraction. Other predisposing factors include macrosomia, precipitous delivery, and episiotomy.

Incidence

Vaginal delivery is associated with a 3.9% incidence of postpartum hemorrhage. Cesarean section is associated with a 6.4% incidence of postpartum hemorrhage. Delayed postpartum hemorrhage occurs in 1-2% of patients.

Morbidity and mortality

In the US, postpartum hemorrhage is responsible for 5% of maternal deaths. Other causes of morbidity include the need for blood transfusions or surgical intervention that may lead to future infertility.

History

The antepartum or early intrapartum identification of risk factors for postpartum hemorrhage allows for advanced preparation and possible avoidance of severe sequelae.

It is important to interview every patient on admission to the labor floor and request information about parity, multiple gestation, polyhydramnios, previous episode of postpartum hemorrhage, history of bleeding disorders, and desire for future fertility.

It is important to note the use of prolonged oxytocin administration, as well as the use of magnesium sulfate during the patient𠏋 labor course.

Physical

Physical examination is performed simultaneously with resuscitative measures. The exam should include a vigorous bimanual exam, which may reveal a retained placenta or hematoma of the perineum or pelvis, and which also allows for uterine massage.

The exam should include a close inspection of the lower genital tract, looking for lacerations. The placenta should be examined closely to determine if there are any fragments missing.

Workup

Because the onset of postpartum hemorrhage is acute, intervention is immediate, and resolution generally is within minutes, there is little role for laboratory studies or imaging in the management of the immediate course of this process. However, it is important to check a patient𠏋 CBC and prothrombin time/partial thromboplastin time (PT/PTT) to rule out resulting anemia or a coagulopathy, which may require further treatment. ABO and D blood type determination should be obtained on admission of each patient to the labor ward. Adequate IV access should be acquired on admission.

Treatment

Initial therapy includes oxygen delivery, bimanual massage, removal of any blood clots from the uterus, emptying of the bladder, and the routine administration of dilute oxytocin infusion (10-40 U in 1000 cc lactated Ringer [LR] solution or normal saline [NS]). If retained products of conception are noted, manual removal or uterine curettage should be performed.

If oxytocin is ineffective, carboprost in a dose of 0.25 mg intramuscular (IM) can be administered every 15 minutes, up to 3 doses. Studies indicate 75-88% success rate when carboprost is used alone and a 95% success rate when used in combination with other oxytocic agents.

Methylergonovine also can be given in a dose of 0.2 mg IM. Because this agent causes intense vasoconstriction and may cause transient hypertension, it is contraindicated in patients with hypertensive disease. Blood pressure should be checked prior to its administration.

When postpartum hemorrhage is not responsive to pharmacological therapy and no vaginal or cervical lacerations have been identified, other, more invasive treatment methods, should be considered, as follows:

　

When all other therapies fail, emergency hysterectomy often is a necessary and lifesaving procedure.

INFECTIONS 　

Endometritis

Endometritis is an ascending polymicrobial infection. The causative agents usually are normal vaginal flora or enteric bacteria.

Etiology

Endometritis is the primary cause of postpartum infection. The most common organisms are divided into 4 groups, aerobic gram-negative bacilli, anaerobic gram-negative bacilli, aerobic streptococci, and anaerobic gram-positive cocci. Specifically, Escherichia coli, Klebsiella pneumoniae, and Proteus species are the most frequently identified organisms.

Endometritis occurring on postpartum day 1 or 2 most frequently is caused by group A Streptococcus. If the infection develops on day 3 or 4, the causative organism frequently is enteric bacteria, most commonly E coli, or anaerobic bacteria. Endometritis that develops more than 7 days after delivery most frequently is caused by Chlamydia trachomatis. Endometritis following cesarean section most frequently is caused by anaerobic gram-negative bacilli, specifically Bacteroides species.

Known risk factors for endometritis include cesarean section, young age, low socioeconomic status, prolonged labor, prolonged rupture of membranes, multiple vaginal exams, placement of an intrauterine catheter, preexisting infection or colonization of the lower genital tract, twin delivery, and manual removal of the placenta.

Incidence

Endometritis complicates 1-3% of all vaginal deliveries and 5-15% of scheduled cesarean section. The incidence of endometritis in patients who undergo cesarean section after an extended period labor is 30-35% and falls to 15-20% if the patient receives prophylactic antibiotics.

Morbidity and mortality

Following 48-72 hours of IV antibiotic therapy, 90% of women recover. Less than 2% of patients develop life-threatening complications such as septic shock, pelvic abscess, or septic pelvic thrombophlebitis.

History

A patient may report any of the following symptoms: fever, chills, lower abdominal pain, foul smelling lochia, increased vaginal bleeding, anorexia, and malaise.

Physical

A focused physical exam is important and should include vital signs, an exam of the respiratory system, breasts, abdomen, perineum, and the lower extremities. A patient with endometritis typically has a fever of 38蚓, tachycardia, and fundal tenderness. Some patients may develop mucopurulent vaginal discharge while others have scant and odorless discharge.

Differential diagnosis

　

Workup

　

Treatment

Treatment of endometritis is with intravenous (IV) antibiotics. Parenteral antibiotics usually are stopped once the patient is afebrile for 24 hours. In general, an extended course of oral antibiotics has not been found to be beneficial. However, there are 2 exceptions. In patients who respond quickly to IV antibiotics and desire early discharge, a short course of oral antibiotics may be substituted for continued IV therapy. The other exception includes patients with staphylococcal bacteremia requiring an extended period of treatment.

There is no consensus regarding the antibiotic regimen for treatment of endometritis. Gentamicin in combination with clindamycin has become the standard by which all other regimens are judged. Gentamicin and clindamycin have a cure rate of approximately 90%. This combination is not effective against Enterococcus faecalis, which may be the cause in as many as 25% of these infections. The addition of ampicillin, or vancomycin if there is a penicillin allergy, is considered when the patient does not respond to the initial therapy of gentamicin and clindamycin to cover this organism.

Alternatively, broad-spectrum second- and third-generation cephalosporins, extended spectrum penicillins, and combination beta-lactamase inhibitors with penicillins have been used in an attempt to avoid polypharmacy and its associated toxicities. In general, these alternative therapies have a cure rate of 80-90%. The most accepted among this category of drugs are cefoxitin or moxalactam.

The high rate of endometritis following cesarean section raises the question of whether there is a role for antibiotic prophylaxis at cesarean section and, if so, what antibiotic to use. In emergency cesarean sections, use of prophylactic cefazolin has been shown to reduce the rate of postpartum endometritis and wound infection. Other studies have demonstrated that ampicillin/sulbactam, cefazolin, and cefotetan all are acceptable choices for single-dose antibiotic prophylaxis.

Controversy still exists in the literature with regard to the need for prophylactic antibiotics during elective cesareans. The Cochran Database demonstrated a reduction in endometritis by two thirds in women who received prophylactic antibiotics undergoing elective or nonelective cesarean section. Other studies have shown that prophylactic antibiotic therapy at elective cesarean section was not associated with decreased incidence of endometritis.

　

Urinary Tract Infections

A urinary tract infection (UTI) is defined as a bacterial inflammation of the bladder or urethra. Greater than 105 colony-forming units from a clean catch urine specimen or greater than 10,000 colony-forming units on a catheterized specimen is considered diagnostic of a urinary tract infection.

Etiology

Risk factors for postpartum UTI include cesarean delivery, forceps delivery, vacuum delivery, tocolysis, induction of labor, maternal renal disease, preeclampsia, eclampsia, epidural anesthesia, bladder catheterization, length of hospital stay, and previous UTI during pregnancy.

The most common pathogen is E coli. In pregnancy, group B Streptococcus is a major pathogen. Other causative organisms include Staphylococcus saprophyticus, Enterococcus faecalis, Proteus, and K pneumoniae.

Incidence

Postpartum bacteruria occurs in 3-34% of patients, resulting in a symptomatic infection in approximately 2% of these patients.

History

A patient may report frequency, urgency, dysuria, hematuria, suprapubic or lower abdominal pain, or no symptoms at all.

Physical

On exam, vital signs are stable and the patient is afebrile. Suprapubic tenderness may be elicited on abdominal exam.

Differential diagnosis

　

Workup

Appropriate lab tests include urinalysis, urine culture from either a clean catch or catheterized specimen, and a CBC.

Treatment

Treatment is started empirically in uncomplicated infection since the usual organisms have predictable susceptibility profiles. When sensitivities are available, they should be used to guide antimicrobial selection. Treatment is with either a 3- or 7-day course antibiotic regimen. Commonly used antibiotics include trimethoprim/sulfamethoxazole, ciprofloxacin, and norfloxacin. Amoxicillin still is used often but has lower cure rates secondary to increasing resistance of E coli. The quinolones are very effective but considerably more expensive than amoxicillin and trimethoprim/sulfamethoxazole and should not be used if breastfeeding.

　

Mastitis

Mastitis is defined as inflammation of the mammary gland.

Etiology

Both milk stasis and cracked nipples, which contribute to the influx of skin flora, are the underlying factors associated with the development of mastitis. The most common causative organism, isolated in approximately one half of all cases, is Staphylococcus aureus. Other common pathogens include Staphylococcus epidermidis, Staphylococcus saprophyticus, Streptococcus viridans, and E coli.

Incidence

In the US, the incidence of postpartum mastitis is 2.5-3%.

Morbidity and mortality

Neglected, resistant, or recurrent infections can lead to the development of an abscess, requiring parenteral antibiotics and surgical drainage. Abscess development complicates 5-11% of the cases of postpartum mastitis and should be suspected when antibiotic therapy fails.

The diagnosis of mastitis is determined solely on the clinical picture.

History

Fever, chills, myalgias, warmth, swelling, and breast tenderness characterize this disease.

Physical

Examination should focus on vital signs, review of systems, and a complete examination to look for other sources of infection. Typical findings include an area of the breast that is warm, red, and tender.

Differential diagnosis

　

Workup

No lab tests are required. Expressed milk can be sent for analysis, but the accuracy and reliability of these results are controversial and aid little in the diagnosis and treatment of mastitis.

Treatment

Milk stasis sets the stage for the development of mastitis, which can be treated with moist heat, massage, fluids, rest, proper positioning of the infant during nursing, nursing or manual expression of milk, and analgesics.

When mastitis develops, penicillinase-resistant penicillins and cephalosporins, such as dicloxacillin or cephalexin, are the drugs of choice. Erythromycin, clindamycin, and vancomycin may be used for patients who are resistant to penicillin. Resolution usually occurs 48 hours after the onset of antimicrobial therapy.

　

Wound Infection

Wound infections in the postpartum period include infections of the perineum developing at the site of an episiotomy or laceration, as well as infection of the abdominal incision after a cesarean section. Wound infections are diagnosed on the basis of erythema, induration, warmth, tenderness, and purulent drainage from the incision site, with or without fever. This definition can be applied both to the perineum and to abdominal incisions.

Etiology

Perineal infections: Infections of the perineum are rare. In general, they become apparent on the third or fourth postpartum day. Known risk factors include infected lochia, fecal contamination of the wound, and poor hygiene. These infections generally are polymicrobial, arising from the vaginal flora.

Abdominal wound infections: Abdominal wound infections are most frequently the result of contamination with vaginal flora. However, S Aureus, either from the skin or from an exogenous source, is isolated in 25% of these infections. Genital mycoplasma is commonly isolated from infected wounds that are resistant to treatment with penicillins. Known risk factors include diabetes, hypertension, obesity, treatment with corticosteroids, immunosuppression, anemia, development of a hematoma, chorioamnionitis, prolonged labor, prolonged rupture of membranes, prolonged operating time, abdominal twin delivery, and excessive blood loss.

Incidence

The incidence of perineal infections is .35-10%. The incidence of incisional abdominal wound infections is 3-15% and can be decreased to approximately 2% with the use of prophylactic antibiotics.

Morbidity and mortality

The most common consequence of wound infection is increased length of hospital stay. About 7% of abdominal wound infections are further complicated by wound dehiscence. More serious sequelae, such as necrotizing fasciitis, are rare but have a high mortality rate.

Differential diagnosis

　

History

Patients with perineal infections may complain of an inordinate amount of pain, foul-smelling discharge, or vulvar edema.

Abdominal wound infections develop around postoperative day 4 and often are preceded by endometritis. These patients present with persistent fever despite antibiotic treatment.

Physical

Perineal infections: An infected perineum often looks erythematous, edematous, and may have purulent discharge. An inspection is performed to identify a hematoma, perineal abscess, or stitch abscess.

Abdominal wound infections: Infected incisions may be erythematous, warm, tender, and indurated. There may or may not be obvious purulent drainage. A fluid collection may be appreciated near the wound, which when entered may release serosanguinous or purulent fluid

Workup

Often, the diagnosis of wound infection is made based on the clinical findings. Serial CBCs with differential may be helpful, especially if a patient does not respond to therapy as anticipated.

Treatment

Perineal infections: Treatment of perineal infections includes symptomatic relief with nonsteroidal anti-inflammatory drugs (NSAIDs), local anesthetic spray, and sitz baths. If an abscess is identified, it must be drained, and broad-spectrum antibiotics may be initiated.

Abdominal wound infections: These are treated with drainage and inspection of the fascia to ensure that it is intact. If the patient is febrile antibiotics may be used.

Most patients respond quickly to the antibiotic once the wound is drained. Antibiotics generally are continued until the patient has been afebrile for 24-48 hours. Patients do not require long-term antibiotics unless a cellulitis has developed. Recent studies have shown that closed suction drainage or suturing of the subcutaneous fat decreases the incidence of wound infection when the subcutaneous tissue is greater than 2 cm in depth.

SEPTIC PELVIC THROMBOPHLEBITIS 　

Septic pelvic thrombophlebitis is defined as venous inflammation with thrombus formation in association with fevers unresponsive to antibiotic therapy.

Etiology

Bacterial infection of the endometrium seeds organisms into the venous circulation, which damages the vascular endothelium and in turn results in thrombus formation. The thrombus acts as a suitable medium for proliferation of anaerobic bacteria. Ovarian veins often are involved since they drain the upper half of the uterus. When the ovarian veins are involved, the infection most often is unilateral, involving the right more frequently than the left. Occasionally, the thrombus has been noted to extend to the vena cava or the left renal vein. Ovarian vein involvement usually manifests itself within a few days postpartum. Disease with later onset more commonly involves the iliofemoral vein.

Risk factors include low socioeconomic status, cesarean section, prolonged rupture of membranes, and excessive blood loss.

Incidence

Septic pelvic thrombophlebitis occurs in 1 out of every 2000-3000 pregnancies. It is 10 times more common after cesarean section (1 per 800) than after vaginal delivery (1 per 9000). It affects less than 1% of patients with endometritis.

Morbidity and mortality

Septic thrombophlebitis may result in the migration of small septic thrombi into the pulmonary circulation, resulting in effusions, infections, and abscesses. Only rarely is a thrombus large enough to cause death.

History

Septic pelvic thrombophlebitis usually accompanies endometritis. Patients report initial improvement after IV antibiotic is initiated for treatment of the endometritis. The patient does not appear ill. Patients with ovarian vein thrombosis may describe lower abdominal pain, with or without radiation to the flank, groin, or upper abdomen. Other symptoms include nausea, vomiting, and bloating. Frequently, patients with enigmatic fever are asymptomatic except for chills.

Physical

Vital signs demonstrate fever greater than 38蚓 and resting tachycardia. If pulmonary involvement is significant, the patient may be tachypneic and have stridor. On abdominal exam, 50-70% of patients with ovarian vein thrombosis have a tender, palpable, rope-like mass extending cephalad beyond the uterine cornu.

Differential diagnosis

　

Workup

　

Treatment

The standard therapy after diagnosis of septic pelvic thrombophlebitis includes anticoagulation with IV heparin to an activated PTT that is twice normal and continued antibiotic therapy. A therapeutic activated PTT (a)PTT usually is reached within 24 hours, and heparin is continued for 7-10 days. In general, long-term anticoagulation is not required. Antibiotic therapy most commonly is with gentamicin and clindamycin. Other choices include a second- or third-generation cephalosporin, imipenem, cilastin, or ampicillin and sulbactam. All of these antibiotics have a cure rate of greater than 90%. Initially, it was thought that patients defervesce within 24-28 hours. More recent studies show that it takes 5-6 days for the fevers to resolve.

In a recent prospective randomized study, women who were treated with heparin in addition to antibiotics responded no faster than did patients treated with antibiotics alone. These findings do not support the empiric practice of heparin therapy for septic pelvic thrombophlebitis and raise the question of whether a new standard protocol should be developed.

ENDOCRINE DISORDERS 　

Postpartum thyroid dysfunction can occur any time in the first postpartum year. Clinical or laboratory dysfunction occurs in 5-10% of postpartum women. It may be caused by primary disorders of the thyroid, such as postpartum thyroiditis and Graves disease, or secondary disorders of the hypothalamic-pituitary axis, such as Sheehan syndrome and lymphocytic hypophysitis.

　

Postpartum Thyroiditis

Postpartum thyroiditis (PPT) is a transient destructive lymphocytic thyroiditis occurring within the first year after delivery.

Etiology

PPT develops 1-8 months postpartum. It is an autoimmune disorder in which microsomal antibodies of the thyroid play a central role. Postpartum thyroiditis has 2 phases: thyrotoxicosis and hypothyroidism.

　

Risk factors for development of PPT include positive anti-thyroid antibody test, history of PPT, and a family or personal history of other thyroid or autoimmune disorders.

Incidence

Approximately 4% of women develop transient thyrotoxicosis in the postpartum period. Of these, 66-90% return to a euthyroid state; 33% progress to hypothyroid. Approximately 2-8% of women develop hypothyroidism in the postpartum period. One third of these patients experience transient thyrotoxicosis, while 10-30% will go one to develop permanent thyroid dysfunction.

Morbidity and mortality

Patients with high antithyroid antibodies during pregnancy, multiparity, and history of spontaneous abortions are at high risk for permanent hypothyroidism. Having developed PPT, these women are at significant risk for recurrent disease after subsequent pregnancies.

History

Patients with thyrotoxicosis may report fatigue, palpitations, heat intolerance, tremulousness, and nervousness and emotion liability. Patients with the hypothyroid phase often complain of fatigue, dry skin, coarse hair, cold intolerance, depression, and memory and concentration impairment. Since many of these symptoms are mild and nonspecific and often are associated with the normal postpartum state, PPT may go undiagnosed.

Physical

On exam, a patient may have tachycardia, mild exophthalmos, and a painless goiter.

Workup

The first laboratory test to be performed should be the thyroid-stimulating hormone (TSH) test. It is decreased during the thyrotoxicosis stage and increased during the hypothyroid phase. If the TSH level is abnormal, thyroid stimulating antibodies, free thyroxine index (FTI), and radioactive iodine uptake (RIU) should be checked to distinguish this disorder from Graves disease. In PPT, RIU is low, thyroid-stimulating antibodies are undetectable, and FTI is high.

There is no thorough, cost-effective screening for PPT; therefore, screening should be limited to high-risk patients such as those with previous PPT or other autoimmune disorders.

Treatment

There is no treatment to prevent PPT.

Thyrotoxicosis phase: No treatment is required for the thyrotoxicosis phase unless the patient's symptoms are severe. In this case, a beta-blocker is useful. For example, propranolol can be started at 20 mg every 8 hours and doubled if the patient remains symptomatic. Propylthiouracil (PTU) has no role in the treatment of PPT since the disorder is caused by the release of hormone from the damaged thyroid and not secondary to increased synthesis and secretion.

Hypothyroid phase: Since the hypothyroid phase of PPT often is transient, no treatment is required unless necessitated by the patient's symptoms. Treatment is with thyroxine (T4) replacement. It most often is given for 12-18 months, then gradually withdrawn. The starting dose is 0.05-0.075 mg and may be increased by 0.025 mg every 4-8 weeks, until a therapeutic level is achieved.

　

Postpartum Graves Disease

Postpartum Graves disease is not as common as PPT, but accounts for 15% of postpartum thyrotoxicosis. Similar to classic Graves disease, postpartum Graves disease is an autoimmune disorder characterized by diffuse hyperplasia of the thyroid gland caused by the production of antibodies to the thyroid TSH receptor, resulting in increased thyroid hormone production and release. There are no clinical features that distinguish postpartum Graves disease from Graves disease in other settings; therefore, diagnosis and management of this disorder is beyond the scope of this chapter. (See also eMedicine Graves Disease)

Lymphocytic Hypophysitis

Lymphocytic hypophysitis is a rare autoimmune disorder causing pituitary enlargement and hypopituitarism leading to a decrease in TSH and hypothyroidism. Symptoms include headache, visual field deficits, difficulty lactating, and amenorrhea. Diagnosis requires histopathologic examination. Most cases do not require transphenoidal hypophysectomy, so diagnosis is based on history, physical, diagnostic imaging, and the temporal relationship to pregnancy. Identification of the disorder becomes clearer as the pituitary reverts back to its normal size and recovers some of its normal function. During the acute phase of this disease, hormone replacement often is necessary.

Sheehan Syndrome

Sheehan syndrome is the result of ischemia, congestion, and infarction of the pituitary gland, resulting in panhypopituitarism caused by severe blood loss at the time of delivery. Patients have trouble lactating, and develop amenorrhea, as well as symptoms of cortisol and thyroid hormone deficiency. Treatment is with hormone replacement in order to maintain normal metabolism and response to stress.

PSYCHIATRIC DISORDERS 　

Three psychiatric disorders may arise in the postpartum period. They are postpartum blues, postpartum depression, and postpartum psychosis.

　

Etiology

The specific etiology of these disorders is unknown. The current view is based on a multifactorial model. Psychologically, it is thought that these disorders result from the stress of the peripartum period and the responsibility of child rearing. Others ascribe the symptoms to the sudden decrease in the endorphins of labor and the sudden fall in estrogen and progesterone levels that occur after delivery. Low free serum tryptophan levels have been observed, which is consistent with finding in major depression in other settings. Postpartum thyroid dysfunction has also been correlated with postpartum psychiatric disorders.

Risk factors include undesired pregnancy, feeling unloved by mate, age less than 20 years, unmarried status, medically indigent, low self-esteem, dissatisfaction with extent of education, economic problems with housing or income, poor relationship with husband or boyfriend, being part of a family with 6 or more siblings, limited parental support (either as a child or as an adult), and past or present evidence of emotional problems. Women with a history of postpartum depression and postpartum psychosis have a 50% chance of recurrence. Women with a previous history of depression unrelated to childbirth have a 30% chance of developing postpartum depression.

Incidence

Morbidity and mortality

Psychiatric disorders can have deleterious effects on the social, cognitive, and emotional development of the newborn. These ailments also can lead to marital difficulties.

History

Treatment

　
BIBLIOGRAPHY