The Fourth Trimester: Emergencies in the Postpartum Period

Catherine A. Marco, MD, FACEP, Professor, Department of Emergency Medicine, Penn State Health, Hershey Medical Center, Hershey, PA

Introduction

The United States has one of the highest maternal mortality ratios (MMR) of all industrialized countries (17.4 for every 100,000 births), with significant racial disparities.¹ The MMR for Black women is 2.5 times that of white women and three times that of Hispanic women. American Indians and Alaska Natives also have a higher MMR. Half of maternal deaths occur after the day of birth.² Most of the maternal mortality before or during birth is due to hemorrhage. The most common causes of maternal death within 42 days are infection, severe bleeding, cardiomyopathy, other heart conditions, hypertension, embolism, and mental health conditions.³

Maternal mortality is defined by the World Health Organization as deaths during pregnancy and up to 42 days postpartum that are related to the pregnancy, irrespective of the site and duration of the pregnancy. It excludes accidental or incidental deaths. The Centers for Disease Control and Prevention (CDC) defines four categories of pregnancy outcomes: healthy pregnancy, maternal morbidity, severe maternal morbidity (SMM), and maternal mortality. SMM refers to the serious complications of delivery that result in short- or long-term consequences to a patient’s health.⁴ The CDC has defined 21 procedures and conditions that are indicators of SMM, including blood transfusions, disseminated intravascular coagulation (DIC), acute renal failure (ARF), sepsis, acute respiratory distress syndrome (ARDS), hysterectomy, and eclampsia.

Risk factors for SMM include maternal age (advanced maternal age, > 35 years), comorbidities (e.g., hypertension, diabetes, heart failure), and delivery type (cesarean).⁵ Additionally, predelivery hospitalizations, especially for preeclampsia, are associated with SMM.^6,7 Data since the onset of the COVID-19 pandemic suggest that a diagnosis of COVID-19 also has been associated with adverse outcomes in pregnancy.^8,9

Starting in the 1930s, with improvements in maternal care, safer surgical procedures, the use of antibiotics, and better living conditions, MMRs dropped in the United States and most of the world. However, between 1997 and 2008, the rate in the United States started increasing and now is leveled at 14 deaths per 100,000 live births. It is important to note that half of the U.S. states do not report MMR data. Out-of-hospital (OOH) births, which include both home births and deliveries at birth centers, have been increasing in the United States. In 2017, one in 62 births (1.61%) were OOH.¹⁰ The data are conflicting regarding whether these planned OOH births are safe.¹¹ Intentional or unintentional OOH deliveries and their complications represent some of the more acute presentations to the emergency department (ED).

Some ED visit studies report that up to 25% of women visit the ED within six months of delivery, with 50% of those visits happening within 10 days of hospital discharge. The median time to first ED visit was seven days.^12,13 Obstetric wound complications (18%); fever (17%); abdominal pain (16%); vaginal bleeding (10.7%); breast problems (10%); and headache, dizziness, and hypertension (10%) were the most common chief complaints. Forty-six percent of these patients were primiparous, and 43.7% who visited the ED had delivered via a cesarean. Most of these patients (80%) were discharged after their ED visit. Despite these reassuring numbers, emergency clinicians must be knowledgeable about postpartum emergencies, some of which can rapidly become deadly.

Hypertension and Cardiovascular Disease

Cardiovascular diseases contribute to 26.5% of pregnancy-related deaths, and the postpartum period is a time of particularly increased risk for these diseases.¹⁴ The rate of acquired heart disease manifestations, such as heart failure, myocardial infarction, and arrhythmia, has been rising.

Cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a diagnosis of exclusion in the setting of left ventricular systolic dysfunction (left ventricular ejection fraction, or LVEF, < 45%) occurring in the last month of pregnancy or in the first five months after delivery, with no other identifiable cause. The incidence is in 1:1,000 to 1:4,000 births, and risk factors include older age, Black race (as a proxy for social inequality), multiple gestation, and hypertensive disorders of pregnancy.¹⁵ Most patients are diagnosed after delivery, typically presenting within the first month postpartum.¹⁶ PPCM is the leading cause of late postpartum death (23%).¹⁴

The ED evaluation of postpartum patients with shortness of breath, chest discomfort, palpitations, arrhythmias, signs of fluid retention, or elevated brain natriuretic peptide (BNP) includes an echocardiogram to assess for PPCM. BNP levels increase in pregnancy and early after delivery; however, in the absence of disease, they still fall within normal parameters. Significant increases in BNP are noted in heart failure and hypertensive disorders, generally > 100 pg/mL in the setting of heart failure. Hypertensive disorders frequently are seen in patients with PPCM and are discussed in detail later in this article.

The emergency management of patients with suspected or diagnosed PPCM is similar to treatment of other etiologies of heart failure, with oxygenation, optimization of preload with diuretics, afterload reduction, and inotropic support as needed.¹⁵ Notably, left ventricular dysfunction is associated with thromboembolic risk, and thromboprophylaxis is suggested in patients with LVEF ≤ 30%.¹⁷

In patients with signs of fluid overload, with or without a formal diagnosis of PPCM, hospital admission generally is indicated. Consultation with OB/GYN is needed to guide workup, management, and ED disposition.

Pregnancy-Associated Myocardial Infarction

Acute myocardial infarctions (AMIs) are rare in pregnancy and the puerperium, affecting about 8.1 per 100,000 hospitalized women.¹⁸ The risk of AMI is three- to four-fold higher than in non-pregnant women of childbearing age. Hormonal and cardiovascular system hemodynamic changes, along with a hypercoagulable state, contribute to this increased risk. (See Table 1.) An important risk factor for pregnancy-associated myocardial infarction (PAMI) is maternal age older than 35 years. In one study of patients undergoing coronary revascularization, findings included: coronary atherosclerosis with or without intracoronary thrombus (43%), coronary thrombus without atherosclerotic disease (21%), coronary dissection (16%), and normal coronary arteries (29%).¹⁹

Spontaneous coronary artery dissection (SCAD) is an important cause of AMI in patients without conventional risk factors for atherosclerosis and may cause up to 40% of AMIs occurring in pregnancy and the postpartum period.²⁰ The majority (75%) of SCAD cases occur in the postpartum period, with patients typically presenting within the first month postpartum with chest pain, accompanied by nausea, dyspnea, or diaphoresis. Patients with SCAD often have undiagnosed fibromuscular dysplasia and other arteriopathies.²¹

The diagnosis of AMI in postpartum patients is largely similar to that of the general population. Patients present with new onset of chest pain or shortness of breath, ischemic changes on the electrocardiogram (ECG), elevated cardiac biomarkers, or in cardiac arrest.²¹ The ECG shows ST-segment elevation in 42.2% of patients.¹⁸ High-sensitivity troponin T might be elevated immediately post-partum, and troponin I levels may be increased in patients with gestational hypertension and preeclampsia, so laboratory results should be interpreted within this context.²² A point-of-care ultrasound (POCUS) also may supplement the clinical picture of AMI and demonstrate regional wall motion abnormalities.²¹

The management of PAMI is identical to that of the non-puerperal woman: aspirin (325 mg PO, chewed); heparin or low molecular weight heparin; ticagrelor or clopidogrel; and nitroglycerin as needed for pain, if not contraindicated. If percutaneous coronary intervention (PCI) is not available, thrombolytics can be considered.²¹

Revascularization procedures in patients with SCAD generally are limited to patients who are hemodynamically unstable or those who have obstructed coronary blood flow, since PCI in this population has higher rates of failure and complications, and spontaneous healing of the vessel often is noted. Patients with ST-elevation myocardial infarction (STEMI) on ECG should be evaluated immediately by interventional cardiology.²³ Patients with elevated cardiac biomarkers, regional wall motion abnormalities on echocardiogram, hemodynamic instability, or persistent chest pain should have an emergent cardiology consultation and admission.

The differential diagnosis for postpartum chest pain includes aortic dissection, pulmonary embolism, Takotsubo cardiomyopathy, peripartum cardiomyopathy, myocarditis, and preeclampsia.²¹

Thromboembolism

Pregnancy is associated with several physiologic changes that increase the risk of venous thromboembolism (VTE), which includes both lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE). The physiologic changes include increases in procoagulant factors, venous stasis, and compression of the pelvic vasculature. (See Table 1.) These pregnancy-associated risks persist for 12 weeks postpartum, with the highest risk for VTE in the first week postpartum.²⁴ The prevalence of pregnancy-associated VTE is reported at one to two per 1,000 pregnancies.²⁵

PE accounts for up to 10% of pregnancy-related deaths and occurs more commonly in the postpartum period.²⁶ Patients with PE typically present with shortness of breath, tachycardia, chest pain, and, if a DVT is present, leg swelling and pain.²⁵ Hypotension and cardiac arrest also can be presenting signs.

The diagnosis of PE in the postpartum period is identical to that of non-puerperal patients. Pulmonary angiography computed tomography (CT) scan is the gold standard. Clinical decision rules widely used in emergency medicine exclude patients in the puerperal period, since they all have more than a very low risk of PE. The pregnancy-adapted YEARS algorithm has gained acceptance in emergency medicine. In a multicenter study, it ruled out PE without adverse patient events.²⁷ As D-dimer levels progressively increase in pregnancy, a D-dimer alone is not recommended in the evaluation for VTE in pregnancy or the postpartum period.²⁸ Otherwise, the diagnosis of VTE is similar to that outside of pregnancy.

In the ED, management decision should involve early consultation with OB/GYN. Some hospitals have developed PE response teams (PERTs). These multidisciplinary teams help with the diagnosis, classification, management, and disposition of patients experiencing a PE. Besides anticoagulation for stable patients with no contraindications, interventions range from systemic thrombolysis, catheter-directed thrombolysis, large-bore suction embolectomy, mechanic circulatory support, and surgical embolectomy.²⁹

Stroke

Pregnancy or puerperium-associated stroke (PAS) is a rare event but can result in significant maternal morbidity and mortality. It has a reported incidence of 24 per 100,000 person-years.³⁰ In the CONCEPTION study in France, 42.9% of strokes were ischemic, 41% were hemorrhagic, and 17.4% were cerebral venous thrombosis.³³ More than half of pregnancy-related strokes occur in the postpartum period, and most of these occur within 10 days of discharge after delivery.³¹ Contributors to, and risk factors for, stroke in this population include the hemodynamic changes of pregnancy, a hypercoagulable state, and hypertensive disorders of pregnancy. Increased maternal age probably also is a contributor to an increased incidence of strokes in pregnancy and postpartum.³² Although patients with a hypertensive disorder in pregnancy are at increased risk of stroke, most postpartum strokes occur in patients without a history of hypertension.³⁰

The presentation of stroke in the postpartum period is identical to that of non-puerperal patients. The management of acute stroke also is very similar, and ED protocols should align with those established for non-pregnant and non-puerperal patients. Table 2 summarizes the ED management of stroke.^32,34

Hypertensive Disorders in Pregnancy

Hypertensive disorders complicate about 5% to 10% of pregnancies, with rates increasing in the United States.³⁵ They account for 7% of pregnancy-related deaths.²⁶ The risk factors are not completely understood, but conditions that reduce uteroplacental blood flow and result in vascular insufficiency are associated with the occurrence of hypertension in pregnancy. Hypertensive disorders of pregnancy include:

• Gestational hypertension: systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg after 20 weeks’ gestation;
• Chronic hypertension: blood pressure (BP) ≥ 140/90 mmHg prior to 20 weeks’ gestation;
• Preeclampsia: hypertension (≥ 140 mmHg SBP or ≥ 90 mmHg DBP after 20 weeks’ gestation accompanied by proteinuria (generally, a urine protein:creatinine ratio ≥ 0.3 or urine dipstick with ≥ 2+ protein);
• Preeclampsia with severe features: severely elevated blood pressure with SBP ≥ 160 mmHg or DBP ≥ 110 mmHg after 20 weeks, or mildly elevated blood pressure ( ≥ 140 mmHg SBP or ≥ 90 mmHg DBP) with any features of organ dysfunction described later. Note, there is no requirement for proteinuria in the diagnosis of severe preeclampsia.
• Hemolysis, elevated liver enzymes, low platelet (HELLP) syndrome: a severe form of preeclampsia characterized by hemolysis with lactate dehydrogenase (LDH) typically ≥ 600 IU/L, aspartate transferase (AST) or alanine transaminase (ALT) > 2 x the upper limit of normal, and platelets < 100 x 10⁹/L;
• Eclampsia: characterized by seizures with no other identifiable cause.

Preeclampsia, although a pregnancy-specific disease, can affect any organ system. This is reflected in the diagnostic markers for severe preeclampsia, including any of the following:

• severely elevated blood pressure, SBP ≥ 160 mmHg or DBP ≥ 110 mmHg;
• thrombocytopenia < 100,000/mL;
• renal dysfunction (serum creatinine ≥ 1.1 mg/dL or greater than 2 x the baseline creatinine);
• hepatocellular necrosis (elevated transaminases > 2 x the upper limit of normal);
• neurologic symptoms (unrelieved headache, mental status changes, or vision changes);
• pulmonary edema.

All individuals with a hypertensive disorder during pregnancy are recommended to have a blood pressure evaluation within seven to 10 days following hospital discharge after delivery. Expedited follow-up within 72 hours of discharge is recommended in those with severely elevated blood pressures (defined as > 160/110 mmHg) during the delivery admission.³⁷

In the postpartum period, 8% of patients develop new-onset hypertension. Blood pressure may rise due to fluid shifts occurring between postpartum days 3-6, with an increase in complications related to hypertension and fluid overload, such as pulmonary edema, manifesting during this period.

Laboratory studies in the evaluation of hypertensive patients include serum creatinine, liver transaminases, a complete blood count, and a urinalysis. And ECG and troponins also should be obtained in those with chest pain and shortness of breath. A BNP and a chest X-ray are useful for those with signs of volume overload. First-line agents for acute treatment of severely elevated blood pressures include hydralazine (5 mg to 10 mg intravenous [IV] or intramuscular [IM]), labetalol (20 mg to 40 mg IV), and nifedipine (10 mg to 20 mg orally [PO]), with a general goal of acute treatment to lower blood pressure to < 160/110 mmHg. Diuretics, such as furosemide, given intermittently in IV doses or as a continuous infusion in severe cases of hypertension and volume overload can help mobilize extracellular fluid and reduce the need for further antihypertensive agents. Patients with refractory hypertension may need intensive care unit (ICU) admission with the use of additional IV medications, such as a nicardipine infusion. Seizure prophylaxis with IV magnesium sulfate also is initiated in patients with severe preeclampsia in the immediate postpartum period, which is discussed later in further detail.

For stable patients, and in consultation with OB/GYN, oral maintenance therapy with beta-blockers or calcium channel blockers can be initiated, with general BP goals of < 140-150/90-100 mmHg upon discharge. However, the patient may require hospitalization for several days for medication titration. Persistent postpartum hypertension due to other conditions like thrombotic microangiopathy, reversible cerebral vasoconstriction syndrome, or pheochromocytoma are much less common.

HELLP Syndrome

The constellation of hemolysis (lactate dehydrogenase levels > 600 U/L; microangiopathic hemolytic anemia on peripheral smear), elevated liver enzymes (> 2 x upper limit of normal AST and ALT), and low platelet count (< 100 x 10⁹/L) is termed HELLP syndrome, which is considered a severe form of preeclampsia. Risk factors for developing HELLP syndrome include multiparity, older maternal age, previous history of preeclampsia or HELLP syndrome, and infection with SARS-CoV-2 during pregnancy. It is rare, with a reported prevalence rate of less than 1% of all pregnancies.³⁸ Among patients with preeclampsia, those with HELLP syndrome have higher rates of complications, including stroke, pulmonary edema, acute renal failure, hepatic hematoma, coagulopathy, acute respiratory distress syndrome, and sepsis.³⁹ The management of HELLP syndrome is similar to that of severe preeclampsia, with meticulous supportive management in a monitored bed or in an ICU setting, IV antihypertensives (see earlier), and seizure prophylaxis. This is accompanied by close monitoring of vital signs, pulse oximetry, volume status, and laboratory studies. A POCUS can be a useful screening tool for identifying liver hematomas or rupture at the bedside, and CT may be used as a confirmatory test in stable patients.³⁸ A multidisciplinary group of clinicians might be required to care for these patients, including OB/GYN, critical care, nephrology, hematology, hepatology, and surgery.

The differential diagnosis of other clinical and laboratory abnormalities that may overlap with HELLP syndrome includes: preeclampsia with disseminated intravascular coagulation (DIC) (increased prothrombin time [PT] and partial thromboplastin time [PTT], decreased fibrinogen); acute fatty liver of pregnancy (elevated direct bilirubin and ammonia, low glucose); thrombotic thrombocytopenic purpura (clinical pentad, ADAMTS-13 is elevated, no proteinuria); pregnancy-related hemolytic uremic syndrome; systemic lupus erythematosus (SLE) flare (other features of SLE); antiphospholipid syndrome (liver function tests [LFTs] are normal); and fulminant viral hepatitis.³⁸

In patients with severe preeclampsia or eclampsia, magnesium sulfate is used to prevent and control seizures. This typically is administered as a loading dose of 4 g to 6 g of magnesium sulfate diluted in 100 mL of IV fluid given over 15-20 minutes, followed by maintenance dosing of 2 g/hour IV (with adjustment to 1 g/hour in the setting of renal dysfunction). Magnesium also can be given IM. Magnesium sulfate is highly effective in controlling eclamptic seizures and lowers the incidence of recurrent seizures, compared with alternative anticonvulsant agents. In the minority of patients who continue to seize after receiving magnesium sulfate, an additional magnesium bolus of 2 g to 4 g should be administered. Careful attention to a patient’s respiratory status is important since high doses of magnesium can cause respiratory suppression. For patients who continue to seize after 20 minutes or with more than two seizures, the optimal additional anticonvulsant has not been established. Benzodiazepines (lorazepam 4 mg IV or midazolam 10 mg IM if no IV access), sodium amobarbital (250 mg IV over three minutes), or phenytoin (1,250 mg IV at a rate of 50 mg/minute) all have been proposed. Head imaging should be strongly considered with persistent or recurrent seizures on magnesium sulfate, since it has been demonstrated that most of these patients will have abnormal findings.⁴⁰

In pregnancy and the postpartum period, any patient presenting with seizures with no known history of seizure disorder should be managed as having eclampsia while other causes are excluded, and magnesium sulfate should be started while further workup is performed.

Neurologic Symptoms

Headaches and other visual disturbances in a patient with severe preeclampsia are especially worrisome and often precede eclampsia. Prior to an eclamptic seizure, headaches have been reported in 75% of individuals and visual changes in up to 30%. Headaches associated with preeclampsia most often are described as bilateral throbbing headaches with blurred vision and scotoma. An emergent non-contrast brain CT scan should be obtained in patients with a neurologic deficit following an eclamptic seizure. In patients with eclampsia, magnetic resonance imaging (MRI) often is consistent with features of posterior reversible encephalopathy syndrome (PRES), with hyperintense T2 lesions in the subcortical and cortical regions of the parietal and occipital lobes.

Other Neurologic Conditions

In the postpartum period, up to 40% of patients report acute headaches, especially in the first week postpartum.⁴¹ Although migraine frequency often increases as estrogen levels fall in the postpartum period, migraines should be considered a diagnosis of exclusion. The differential for headaches in the postpartum period includes post-dural puncture headaches, which occur in about 1% of patients following spinal or epidural anesthesia. Symptoms typically occur within the first seven days postpartum, with a typical pattern of worsening on standing and improvement with laying supine for 10-15 minutes. Headaches that are new, worsening, different in character, have associated neurological symptoms, or are positional should be evaluated for secondary causes (e.g., subarachnoid hemorrhage [SAH]). An overview of differential diagnoses for headaches is presented in Table 3. Regardless of breastfeeding status, patients presenting with headaches in the postpartum setting should undergo the same diagnostic workup and treatment indicated for any other patient with that same clinical presentation.

Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is defined as blood loss ≥ 1,000 mL or blood loss accompanied by signs of hypovolemia. Primary PPH occurs within the first 24 hours following delivery, while secondary PPH occurs between 24 hours to 12 weeks after delivery. Post-abortion hemorrhage occurs in 1% to 2% of surgical abortion cases and is the most common contributor to abortion-related maternal mortality. The National Partnership for Maternal Safety recommends that PPH protocols be implemented and followed in every labor and delivery unit in the United States. An example of a PPH checklist can be found at: https://www.acog.org/-/media/project/acog/acogorg/files/forms/districts/smi-ob-hemorrhage-bundle-hemorrhage-checklist.pdf.

Primary Postpartum Hemorrhage

The most common causes of primary postpartum hemorrhage are uterine atony (50% to 80% of cases), genital tract lacerations, retained placental fragments, abnormal placentation, and coagulopathies. These can be remembered as the 4 Ts: tone (uterine atony), tissue (retained placenta), trauma (lacerations), and thrombin (coagulopathies).⁴² In the ED, patients who have given birth outside of the hospital can present with primary PPH.

The initial evaluation should include an inspection of the vagina and cervix for lacerations and hematomas and a bimanual examination with assessment of uterine tone. On examination, uterine atony is characterized by a soft, boggy uterus, often with expression of clots with bimanual massage. Initial steps to treat atony are uterine fundal massage, uterotonics (see Table 4), and IV fluids using a large-bore IV (16 G or 18 G). Placement of a Foley catheter can assist with uterine contraction as well. The blood bank should be notified, and a type and crossmatch sent. Obstetrics also should be notified early, since some patients require operative management. If the placenta has not been completely removed, manual placental removal can be performed. Trailing membranes can be removed using a ring forceps, or manually by wrapping the examiner’s fingers in gauze and sweeping membranes out of the cervix or vaginal canal.⁴³

Changes in vital signs may not occur until significant blood loss has occurred. This is further compounded by rises in blood pressure that may occur in the setting of catecholamine response to hemorrhage. Normal blood pressure values can be seen in patients with preeclampsia despite being in a hypovolemic state. Close monitoring of urine output is beneficial as it reflects end organ perfusion. Laboratory studies should include complete blood count (CBC), type and cross, PT/international normalized ratio (INR), PTT, and fibrinogen.

Prompt administration of crystalloid and blood is needed when excessive blood loss is first recognized. Along with evaluating the source of bleeding, efforts to initiate resuscitation should be made, with placement of two large-bore IVs and notification of obstetric/surgical and anesthesia teams. Fluid resuscitation is given at a volume two to three times the estimated volume of blood loss, since most administered fluid does not remain in the intravascular space. Many institutions have massive transfusion protocols (MTP) that can be activated in the setting of profound hemorrhage.

Secondary Hemorrhage

The incidence of secondary PPH (occurring between 24 hours after delivery and up to 12 weeks postpartum) is around 2%, with the peak incidence one to two weeks postpartum.⁴⁵ The most common etiologies are retained placental fragments, abnormal involution of the placental site, and endometritis. Less common causes include uterine artery pseudoaneurysm, inherited coagulopathic disorders, and choriocarcinoma. Placental site subinvolution can occur with incomplete remodeling of spiral arteries and in the presence of retained placental fragments or infection.

Evaluation of delayed PPH starts with history and examination. A history of heavy periods or unusual bleeding after procedures can point toward unrecognized bleeding disorders like von Willebrand disease. Signs of uterine infection include pelvic pain, uterine tenderness, malodorous vaginal discharge, fever, and tachycardia. Laboratory evaluation includes a CBC, PT/INR, PTT, fibrinogen, and a quantitative human chorionic gonadotropin (hCG). Serum hCG levels can help distinguish between retained products of conception (POC), a new pregnancy, or choriocarcinoma.

A pelvic ultrasound can help determine the etiology of secondary PPH in most cases. However, ultrasound findings of an enlarged uterus with intracavitary fluid, gas, and debris may be normal findings in the postpartum period. With retained products, an echogenic intracavitary mass or endometrial thickening may be seen with vascularity on color Doppler, while no flow is expected to be seen within a blood clot. Retained products can be present without vascular flow as well. With placental site subinvolution, dilated uterine vessels can appear as tubular hypoechoic areas in the inner third of the myometrium, with increased peak systolic velocity on pulse Doppler.

Management of the hemodynamically unstable patient is largely the same as noted earlier for management of acute primary PPH, with crystalloid resuscitation, transfusion of blood products, and correction of any coagulopathies. As with the prior cases, OB/GYN should be consulted early to assist in management and disposition planning. A balloon tamponade device (Bakri balloon or the Rusch balloon) or packing with gauze or hemostatic dressing may be placed to allow for further diagnostic evaluation. The Bakri balloon is a commercially available device that is filled with as much as 800 mL of either water or saline once placed inside the uterus. Other devices have been used for uterine tamponade, including a Foley catheter placed into the uterus and inflated with up to 60 cc of saline.⁴⁶ Uterine vacuum devices, such as the Jada, also are becoming more common. The device is placed in the uterus, connected to low continuous wall suction, and acts to compress the uterus with suction power.⁴⁷ Based on the etiology of bleeding, further treatment can include uterotonics, antibiotics, or additional surgical or interventional radiology management.

Postpartum Infections

Postpartum infections are estimated to affect 5% to 7% of women, although detailed epidemiologic data are difficult to obtain, since surveillance systems are historically limited to acute care settings.⁴⁸ Factors that increase the risk of postpartum infections include lower socioeconomic status, obesity, diabetes, extremes of maternal age, cesarean delivery, operative vaginal delivery, preterm labor, and prolonged rupture of membranes.⁴⁹ The infections that will be discussed in this section include endometritis, surgical site infections, mastitis, and urinary tract infections (UTIs).

Endometritis

Endometritis is an infection or inflammation of the endometrium, typically from microbes that ascend from the cervix and vagina.⁵⁰ Postpartum endometritis is the most common cause of postpartum fever within the first week, and it should be assumed until ruled out.⁵¹ The most significant risk factor is cesarean delivery, as endometritis complicates 2% to 16% of cesarean deliveries. In addition to fever, common presenting signs and symptoms include lower abdominal pain, uterine tenderness, and foul-smelling lochia.⁵² If left untreated, the mortality rate can be as high as 17%.⁵³

Endometritis is a clinical diagnosis, as neither ultrasound nor CT display characteristic uterine findings that reliably differentiate endometritis from the normal postpartum state. However, imaging can be considered to rule out other processes or when the patient is not responding appropriately to treatment.⁵⁴ The diagnostic evaluation in the ED typically consists of a thorough history and physical examination, and at minimum a CBC, lactate, and urine culture. The CBC may show an elevated white blood cell count, but this finding is nonspecific and can be seen in the normal postpartum state. There is no consensus at this time on the utility of routine blood cultures in the patient with clinical endometritis, but blood cultures can be considered in suspected sepsis, noting that the relative risk of positive blood cultures after cesarean delivery compared to vaginal delivery is 3.2.⁵⁵ Unless a sexually transmitted infection (STI) is suspected, vaginal and endometrial cultures do not need to be obtained in the ED, since they often are contaminated and rarely change management.

Postpartum endometritis typically is a polymicrobial infection involving mixed aerobes and anaerobes that have ascended from the lower genital tract. The initial antibiotic regimen in a patient who is known to be Group B streptococci (GBS) negative should consist of clindamycin 900 mg IV every eight hours plus gentamicin 5 mg/kg IV every 24 hours. In patients who are known to be GBS-positive or have unknown GBS status, add ampicillin 2 g IV every six hours or switch to monotherapy with ampicillin-sulbactam 3 g IV every six hours.^53,56 In all cases of presumed endometritis, OB/GYN should be consulted. In some mild cases, they may elect to discharge the patient with close outpatient follow-up, but that decision should not be made without their involvement, as most patients require admission and IV antibiotics.

A diagnosis of septic pelvic thrombophlebitis should be considered in patients who present with three to five days of persistent fever despite antibiotic therapy for presumptive endometritis. This is a rare condition, occurring in one in 3,000 deliveries, which exists on a spectrum that includes ovarian vein thrombophlebitis and deep septic pelvic thrombophlebitis.^57,58 Laboratory studies, including blood cultures, are recommended as part of the ED workup. Although there is no consensus on the optimal imaging modality, CT or MRI should be considered to aid in the diagnosis.⁵⁹ The treatment of septic pelvic thrombophlebitis includes anticoagulation with unfractionated heparin or low molecular weight heparin, in addition to broad-spectrum antibiotics. Antibiotics should target streptococci, enterobacteriaceae, and anaerobes, with regimens such as piperacillin-tazobactam 4.5 g IV three times per day; ceftriaxone 1 g IV daily plus metronidazole 500 mg IV three times per day; or cefepime 2 g IV three times per day plus metronidazole 500 mg IV three times per day. OB/GYN should be involved early and can assist with decisions about imaging, management, and disposition.

Surgical Site Infections

Wound infections complicate 2% to 7% of cesarean deliveries and usually present four to seven days after delivery, although earlier and later presentations do occur.⁶⁰ Risk factors include diabetes, obesity, use of systemic steroids, and pre-operative infections, such as intra-amniotic infection or bacterial vaginosis. As with other wound infections, postpartum surgical site infections often present with pain, erythema, discharge, and induration of the surgical site. Deeper infections may be visible as collections of fluid or gas on ultrasound or CT imaging.⁶¹ Localized, superficial infections, such as cellulitis, can be treated with antibiotics alone. The regimen for purulent cellulitis should cover methicillin-resistant Staphylococcus aureus (MRSA), with antibiotics such as clindamycin 450 mg PO three times per day or 600 mg IV three times per day; trimethoprim-sulfamethoxazole 800 mg/160 mg PO twice per day; doxycycline 100 mg PO or IV twice per day; or vancomycin 20 mg/kg IV twice per day. Local drug sensitivities and antibiograms can aid in appropriate agent selection in cases of suspected MRSA. Antibiotics for nonpurulent cellulitis should cover beta-hemolytic streptococci and methicillin-sensitive Staphylococcus aureus. Options include cefalexin 500 mg PO four times per day; clindamycin 450 mg PO three times per day or 600 mg IV three times per day; dicloxacillin 500 mg four times per day; or vancomycin 20 mg/kg IV twice per day.⁶⁰ The presence of systemic symptoms or any evidence of deeper infections should prompt antibiotic treatment similar to that described earlier for endometritis and also may require surgical intervention.⁶² OB/GYN should be involved early and can assist with decisions about imaging, management, and disposition.

Lactational Mastitis

Lactational mastitis, defined as inflammation of the breast tissue, affects approximately 2% to 20% of people who are breastfeeding.⁶³ Risk factors for developing lactational mastitis include nipple injury, breastfeeding difficulties, hyperlactation, breast pump use, and prior history of mastitis.⁶³ The typical clinical presentation includes unilateral breast pain, warmth, and erythema, and patients often have systemic symptoms, including fevers, chills, and malaise.⁶⁴ Mastitis is a clinical diagnosis, and laboratory testing or imaging are not routinely needed. However, the presence of a fluctuant mass in the setting of mastitis should raise concern for an abscess, and an ultrasound is indicated in these cases.⁶⁵ If mastitis is diagnosed prior to the development of an abscess, outpatient treatment and OB/GYN follow-up can be appropriate. In early cases, if symptoms are focal and mild, it is reasonable to start with conservative treatment. Because milk stasis often is the inciting factor for mastitis, conservative treatment includes physiologic breastfeeding or milk expression, in addition to over-the-counter analgesic medication and warmth or cold application for symptomatic relief.⁶⁶ If symptoms are moderate or severe, or if the patient has persistent symptoms despite 24-48 hours of conservative treatment, antibiotics targeting S. aureus and Streptococcus are indicated. Appropriate antibiotic regimens include 10- to 14-day courses of oral dicloxacillin 500 mg four times per day; cephalexin 500 mg PO four times per day; amoxicillin/clavulanate 875 mg/125 mg PO twice per day; clindamycin 300 mg PO four times per day (in penicillin-allergic patients); or trimethoprim/sulfamethoxazole 800 mg/160 mg PO twice per day (in penicillin-allergic patients).⁶⁴ If the patient has developed a breast abscess, needle aspiration is recommended over incision and drainage because of the risk of scarring and structural damage from the latter.^67,68 Generally, aspiration should be performed by a surgical specialist, but small, uncomplicated, superficial abscesses may be aspirated by an ED physician who is comfortable with the procedure when surgical specialists are not available.

Urinary Tract Infections

When using midstream urine samples, bacteriuria occurs in up to 12% of postpartum women, but a minority of these women have symptoms of a UTI.^69,70 Risk factors for postpartum bacteriuria and UTI include cesarean delivery, bladder catheterization, renal disease, and African American, Native American, or Hispanic ethnicities.⁷¹ In the absence of culture results, the decision to treat should be made based on risk factors, symptoms, and additional urinalysis findings such as pyuria. The first-line treatment options for cystitis include cefpodoxime 200 mg twice per day, amoxicillin-clavulanate 875 mg/125 mg PO twice per day, and fosfomycin 3 g PO once, while broad-spectrum IV beta-lactams, such as ceftriaxone 1 g IV daily or piperacillin-tazobactam 3.375 g IV four times per day, should be given for patients with suspected pyelonephritis.

Mental Health and Substance Use Disorders

Perinatal mental health conditions are exceptionally common, affecting more than one in five people after delivery.⁷² Perinatal mental health conditions include depression, anxiety, bipolar disorder, acute postpartum psychosis, and the symptom of suicidality.⁷² This prevalence inevitably brings many patients to the ED; for instance, a single-center analysis of ED visits determined that postpartum patients with mental health conditions sought emergency care in this period twice as frequently as those without them.⁷³ Furthermore, mental health and substance use disorders (SUDs) represent a significant and preventable contributor to morbidity and mortality for pregnant and postpartum patients. According to data from state-level maternal mortality review committees, mental health disorders were the primary underlying cause of 22.7% of pregnancy-related deaths in 2017-2019, and of 22.5% in 2020.⁷⁴ Additionally, 8.4% of pregnancy-related deaths are attributed to suicide, and 2.9% to homicide.⁷⁴

Multiple pressure points evolve after delivery for patients who have, or who ultimately develop, these disorders. Sleep, already challenged by body changes in the third trimester, becomes even further compromised in response to the neonate’s needs. Physiologic changes of pregnancy that may contribute to feelings of inadequacy and body dysmorphia continue with the challenges of physical recovery after childbirth (including cesarean deliveries).⁷⁵ Social supports may be compromised, and rates of intimate partner violence increase in the postpartum period.⁷⁶ Women who have experienced a miscarriage, stillbirth, or neonatal death also are dealing with grief. Stigma exists around seeking help and the diagnosis of these mental health disorders. Patients also may have misplaced concerns about the efficacy or safety of available treatments, particularly when it comes to exposure to the infant transplacentally or through breastfeeding. The lack of parental leave policies in the United States does not help with overcoming other financial, social, and logistical barriers to mental healthcare postpartum. Financial stressors also increase during pregnancy and the postpartum period. Finally, although recent legislation has helped to expand Medicaid coverage to 12 months postpartum in 47 states, Medicaid beneficiaries are at a two-fold higher risk of postpartum depression and may be at risk to be inadequately treated.⁷⁷ Table 5 summarizes risk factors for the development of mental health illness in pregnancy and the postpartum period.

Importantly, early recognition and treatment have been demonstrated to improve outcomes and increase treatment rates.⁷⁸ Thus, ED physicians must be able to screen, recognize, refer, and provide first-line therapies for these conditions to help reduce maternal mortality.

Postpartum Blues, Postpartum Depression, Anxiety, and Bipolar Disorder

One common experience that may mimic depression and affects up to 85% of patients after delivery is postpartum blues. It is defined as a period of depressive symptoms and mood swings that occurs within the first week after delivery. Postpartum blues usually peak around days 3-5 postpartum and resolve within the first two weeks after delivery. While supportive care, education, and social support/sleep hygiene preservation typically are the extent of treatment needed, close follow-up is advised, since these patients are at additional risk for postpartum depression.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) does not separately recognize postpartum depression, anxiety, or bipolar disorder as their own categories or diagnoses. Instead, the DSM uses standard criteria with a modifier for peripartum onset, defining this within four weeks of delivery. However, the American College of Obstetricians and Gynecologists (ACOG), the CDC, and other organizations have endorsed extending this period to fully encompass the 12 months after childbirth, aligning with other definitions of postpartum morbidities and mortality.

In its clinical practice guideline regarding the screening and diagnosis of perinatal mood disorders, ACOG strongly recommends screening for perinatal depression and anxiety at postpartum visits. Depression associated with pregnancy affects approximately one in seven patients, with 40% of these cases diagnosed in the postpartum period.⁷⁹ It manifests as persistent sadness, low self-esteem, sleep disturbances, loss of appetite, irritability, anxiety, impaired concentration, and difficulties bonding with the baby.⁸⁰ Approximately two-thirds of these patients are affected by comorbid psychiatric conditions, with the vast majority (82.9%) being anxiety disorders.⁷⁹ Screening for anxiety and depression disorders using standard questionnaires is recommended. (See Table 6.)

Bipolar disorders also are exceptionally common, occurring in one in five patients diagnosed with perinatal depression.⁷⁹ Patients with known bipolar disorder also are at high risk of relapse in the postpartum period — approximately 35% overall. However, the risk is significantly higher in those who discontinue pharmacotherapy in pregnancy (66%) as opposed to those who continue therapy (23%).⁸¹ Bipolar disorder is the strongest risk factor (aside from prior history) for postpartum psychosis and infanticide, impressing the importance of continued therapy for these individuals to avoid significant harm.

In the ED, patients with mental health disorder symptoms can be screened using available tools and questionnaires. (See Table 5.) Any patients with symptoms of suicidality or homicidality should be evaluated by a mental health provider in the ED.

Postpartum Psychosis and Risk for Self-Harm in the Postpartum Period

One of the most concerning and presentations of psychiatric illness in the postpartum period is psychosis. This obstetrical and psychiatric emergency is characterized by sudden-onset symptoms, typically within the first two to three weeks after delivery. Common features include agitation, confusion, hallucinations, delusions, paranoia, disorganized thoughts, and a marked lack of insight or lack of touch with reality, which often is very different from baseline function.⁸² These symptoms may wax and wane throughout an episode as well, so clinicians must always maintain a high degree of suspicion in patients with reports of unusual behavior.

Bipolar disorder is a significant risk factor for postpartum psychosis, with some series estimating a prevalence as high as 7% to 17%.^81,83 Prior history of postpartum psychosis and significant sleep deprivation of > 48 hours also are significant risk factors. While most cases of psychosis are associated with bipolar disorder, patients may manifest mental illness for the first time postpartum. Approximately half of patients with postpartum psychosis will experience lifelong psychiatric conditions after the index episode, impressing the importance of connecting these patients to ongoing care with psychiatrists.⁸⁴

Although complicating only one to two per 1,000 births, postpartum psychosis has the potential to be particularly devastating, with elevated risk of self-harm, suicide, and infanticide. Particularly worrisome to a clinician are intrusive thoughts to harm the baby. While these thoughts are fleeting and common in most postpartum patients (up to 70%), most patients find these thoughts upsetting and, thus, have low likelihood of acting on them.⁸⁵ However, those with psychosis are more likely to find these thoughts comforting or appropriate. The astute clinician should not shy away from asking about these thoughts, as they may be a very helpful screening tool for psychosis. Emergent psychiatric evaluation and hospitalization is warranted for any patient with suicidal or homicidal ideation.

As with every psychiatric condition, medical causes must be excluded. The workup includes a CBC and a basic metabolic panel (BMP), vitamin levels (B12, folate, thiamine), thyroid function tests (TFTs), LFTs, urinalysis, possibly adjunctive neuroimaging, urine and blood cultures, and a toxicology screen depending on clinical suspicion and local practice.⁸²

Pharmacotherapy for Postpartum Mood Disorders

ACOG strongly notes that medications should not be withheld or discontinued for mental health conditions based on pregnancy or lactation status alone.⁸⁵ Discontinuation in most circumstances may result in the unintended consequence of precipitating relapse of the psychiatric condition; symptom relapse risk is approximately five-fold higher in those who discontinue medication than in those who continue it.⁸⁶

For patients starting pharmacotherapy, selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are acceptable first-line therapies for both mild-to-moderate depression and anxiety, with sertraline or escitalopram considered most appropriate if the patient has no prior medication history. In its clinical practice guideline on perinatal mental health disorder treatment, ACOG provides several therapy options, guidance for dosing and follow-up, and warning signs for several other medications for postpartum depression.⁸⁵ Follow-up with a psychiatrist or obstetrician-gynecologist should be arranged within one to two weeks of initiating medication to ensure abatement of mood symptoms. Bipolar disorder and postpartum psychosis should be managed by psychiatrists with expertise in mood-stabilizing medications, and in cases of relapse should be guided by the patient’s prior history with pharmacotherapy. Stabilization of patients experiencing postpartum psychosis while awaiting psychiatric consultation also may require the use of sedative antipsychotics such as olanzapine 2.5 mg to 20 mg PO/IM/sublingual (SL) or haloperidol 0.5 mg to 5 mg PO/IM/IV, or short-term benzodiazepines such as lorazepam 0.25 mg to 2 mg PO/IM/IV in patients presenting with significant agitation posing a risk to themselves and/or the healthcare professionals.⁸⁵

Although outside the scope of practice of emergency medicine, brexanolone and zuranolone are new medications approved by the Food and Drug Administration specifically for moderate-to-severe postpartum depression. Zuranolone is an oral medication, while brexanolone is administered intravenously over a 60-hour time period.

Multiple resources exist to help care clinicians recognize and treat mental health conditions in the postpartum period and expand access to patients to expert psychiatry services. Table 7 summarizes useful resources for emergency clinicians, but, in all cases, OB/GYN should be consulted, along with a psychiatric evaluation for those with psychosis, severe depression, mania, or anyone with suicidal or homicidal ideation.

Substance Use Disorders in the Postpartum Period

Substance use disorders (SUDs) also are quite common among pregnant and postpartum patients, with estimates that between 8% and 11% of pregnant patients aged 15-44 used tobacco, alcohol, or illicit drugs in the past month.⁸⁷ ED visits for SUD in pregnancy and the postpartum period have been increasing in the United States (12.4% average annual percent change).⁸⁸ Any evaluation for psychiatric concerns also should include SUD screening using a questionnaire such as the National Institute on Drug Abuse (NIDA) Quick Screen, 4Ps, or CRAFFT.⁸⁹

Opioid use disorder (OUD) has garnered significant attention in the obstetrics and gynecology community, given that opioids are commonly prescribed after childbirth, there was a four-fold rise in neonatal abstinence syndrome between 1999 and 2013, and substance use is a major risk factor for pregnancy-associated death.⁸⁹ The preventive nature of appropriate prescribing after delivery has become increasingly recognized as a tool to prevent the development of OUD.⁷⁵ Medication-assisted therapy (MAT) for maintenance of recovery for patients with OUD is appropriate throughout pregnancy and the postpartum period. Importantly, the use of methadone or buprenorphine does not contraindicate breastfeeding. Given the positive effects on maternal-infant bonding, breastfeeding should be encouraged so long as there are no other contraindications such as human immunodeficiency virus or recent relapse on an illicit substance.⁸⁹ Discontinuation of MAT in the postpartum period may increase the risk of relapse and overdose. Table 8 describes treatment options for SUDs.⁹⁰

Patients with SUDs may be hesitant to either disclose or seek treatment out of concern for legal consequences, including the potential for parent-child separation. Mandatory reporting laws vary by state in these instances. Both the American College of Emergency Physicians (ACEP) and ACOG have been outspoken that avenues should be sought outside of the legal system to address substance abuse among pregnant and postpartum patients and advocate for expansion of educational resources, treatment programs, and medications that can address this special population.⁹¹ Drug screens should only be used in the ED when clinically indicated.

Conclusions

Postpartum complaints are common in the ED. Emergency physicians should be prepared to manage the most common of these postpartum emergencies, which include cardiomyopathy, AMIs, hypertensive diseases, thromboembolism, and stroke. Postpartum hemorrhage, mostly due to uterine atony in the first 24 hours postpartum, requires aggressive resuscitation and prompt mobilization of ED resources. Postpartum infections include endometritis, wound complications, mastitis, and UTIs and also are common ED presentations. Mental health disorders, including its most severe form, postpartum psychosis, are increasing and if not screened and managed appropriately, can have devastating consequences. Finally, SUDs have an increasing prevalence in the United States, and emergency clinicians must be ready to identify and start the management of these patients. Although certain minor conditions can be managed by the emergency physician alone, most of these postpartum emergencies will require consultation with OB/GYN and other services, such as cardiology, neurology, and psychiatry.

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