Normal and Abnormal Puerperium
Author: Guillermo M Guzman, MD, Staff Physician, Department of Obstetrics and Gynecology, Holy Rosary Medical Center, Ontario, OR
Coauthor(s): John P O'Grady, MD, MA, Professor of Obstetrics and Gynecology, Tufts University School of Medicine; Medical Director, Family Life Center and Mercy Perinatal Service, Mercy Medical Center; Attending Physician, Department of Obstetrics and Gynecology, Baystate Medical Center and St Elizabeth's Medical Center
Puerperium is defined as the time from the delivery of the placenta through the first few weeks after the delivery. This period is usually 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 follows.
The pregnant term uterus (not including baby, placenta, fluids, etc) weighs approximately 1000 g. In the 6 weeks following delivery, the uterus recedes to a weight of 50-100 g.
Immediately postpartum, the uterine fundus is palpable at or near the level of the maternal umbilicus. Thereafter, most of the reduction in size and weight occurs in the first 2 weeks, at which time the uterus has shrunk enough to return to the true pelvis. Over the next several
weeks, the uterus slowly returns to its nonpregnant state, although the overall uterine size remains larger than prior to gestation.
The endometrial lining rapidly regenerates, so that by the seventh day endometrial glands are already evident. By the 16th day, the endometrium is restored throughout the uterus, except at the placental site.
The placental site undergoes 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 ("physiologic ligatures") 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.
Immediately after delivery, a large amount of red blood flows from the uterus until the contraction phase occurs. Thereafter, the volume of vaginal discharge (lochia) rapidly decreases. The duration of this discharge, known as lochia rubra, is variable. The red discharge progressively changes to brownish red, with a more watery consistency (lochia serosa). Over a period of weeks, the discharge continues to decrease in amount and color and eventually changes to yellow (lochia alba).1 The period of time the lochia can last varies, although it averages approximately 5 weeks.2
The amount of flow and color of the lochia can vary considerably. Fifteen percent of women have continue to have lochia 6 weeks or more 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. This is the classic time for delayed postpartum hemorrhages to occur.
The cervix also begins to rapidly revert to a nonpregnant state, but it never returns to the nulliparous state. By the end of the first week, the external os closes such that a finger cannot be easily introduced.
The vagina also regresses but it does not completely return to its prepregnant size. Resolution of the increased vascularity and edema occurs by 3 weeks, and the rugae of the vagina begin to reappear in women who are 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 breastfeeding mothers because of persistently decreased estrogen levels.
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 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 to muscle, nerve, and connecting tissues.
The abdominal wall remains soft and poorly toned for many weeks. The return to a prepregnant state depends greatly on maternal exercise.
The resumption of normal function by the ovaries is highly variable and is greatly influenced by breastfeeding the infant. The woman who breastfeeds her infant has a longer period of amenorrhea and anovulation than the mother who chooses to bottle-feed. The mother who does not breastfeed may ovulate as early as 27 days after delivery. Most women have a menstrual period by 12 weeks; the mean time to first menses is 7-9 weeks.
In the breastfeeding woman, the 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's 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. Half to three fourths of women who breastfeed return to periods within 36 weeks of delivery.
The changes to the breasts that prepare the body for breastfeeding occur throughout pregnancy. If delivery ensues, lactation can be established as early as 16 weeks' gestation. Lactogenesis is initially triggered 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. High in protein content, this liquid is protective for the newborn. The colostrum, which the baby receives in the first few days postpartum, is already present in the breasts, and suckling by the newborn triggers its release. The process, which begins as an endocrine process, switches to an autocrine process; the removal of milk from the breast stimulates more milk production. Over the first 7 days, the milk matures and contains all necessary nutrients in the 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 most often occurs in the hospital setting, where the majority of women remain for approximately 2 days after a vaginal delivery and 3-5 days after a cesarean delivery. During this time, women are recovering from their delivery and are beginning to care for the newborn. This period is used 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 ability to void.
Routine practices include a check of the baby's blood type and administration of the RhoGAM vaccine to the Rh-negative mother if her baby has an Rh-positive blood type. At minimum, the mother's hematocrit level is checked on the first postpartum day. Women are encouraged to ambulate and to eat a regular diet.
After a vaginal delivery, most women experience swelling of the perineum and consequent 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 to 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, little evidence supports this method over other methods of postpartum perineum treatment. Pain medications are helpful both systemically as nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotics and as local anesthetic spray to the perineum.
Hemorrhoids are another postpartum issue likely to affect women who have vaginal deliveries. Symptomatic relief is the best treatment during this immediate postpartum period because hemorrhoids often 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 can wear it without discomfort. This takes longer for the woman who has had an episiotomy or a laceration than for one who has not. The vagina and perineum should first be fully healed, which takes about 3 weeks. Tampons must be changed frequently to prevent infection.
The woman who has had a cesarean delivery usually does not experience pain and discomfort from her perineum but rather from her abdominal incision. This, too, can be treated with ice to the incision and with the use of systemic pain medication. Women who have had a cesarean delivery are often slower to begin ambulating, eating, and voiding; however, encourage them to quickly resume these and other normal activities.
Sexual intercourse may resume when bright red bleeding ceases, the vagina and vulva are healed, and the woman is physically comfortable and emotionally ready. Physical readiness usually takes about 3 weeks. Birth control is important to protect against pregnancy because the first ovulation is very unpredictable.
Substantial education takes place during the hospital stay, especially for the first-time mother. The mother (and often the father) is taught routine care of the baby, including feeding, diapering, and bathing, as well as what can be expected from the baby in terms of sleep, urination, bowel movements, and eating.
Provide education, support, and guidance to the breastfeeding mother. 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 breastfeeding is possible almost immediately after birth. Encourage the mother to feed the baby every 2-3 hours (at least while she is awake during the day) to stimulate milk production. Long feedings are unnecessary, but they should be frequent. 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 in order to prevent milk production. Ice packs applied to the breasts and the use of a tight brassiere or a binder can also help to prevent breast engorgement. Acetaminophen or NSAIDs can alleviate the symptoms of breast engorgement (eg, tenderness, swelling, fever) if it occurs. Bromocriptine was formerly 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.
The mother must be given 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 or a cesarean delivery.
The woman who has had a vaginal delivery may resume all physical activity, including using stairs, riding or driving in a car, and performing muscle-toning exercises, as long as she experiences no pain or discomfort. The key to resuming normal activity is not to overdo it on one day to the point that the mother is completely exhausted the next day. Pregnancy, labor, delivery, and care of the newborn are strenuous and stressful, and the mother needs sufficient rest to recover. The woman who has had a cesarean delivery must be more careful about resuming some of her activities. She must avoid overuse of her abdomen until her incision is well healed in order to prevent an early dehiscence or a hernia later on.
Women typically return for their postpartum visit at approximately 6 weeks after delivery. No sound reason for this exists; the time has probably become the standard so that women who are returning to work can be medically cleared to return. Anything that must be done at a 6-weeks' postpartum visit can be done earlier or later than 6 weeks. An earlier visit can often aid a new mother in resolving problems she may be having or in providing a time to answer her questions.
The mother must be counseled about birth control options before she leaves the hospital. She may not be ready to decide about a method, but she needs to know the options. 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. Many options are available, as follows:
- Natural methods can be used in highly motivated couples, to include the use of monitoring the basal body temperature and the quality and quantity of the cervical mucus to determine what phase of the menstrual cycle the woman is in and if it is safe to have intercourse.
- Barrier methods of contraception, such as condoms, are widely available, as are vaginal spermicides. Condoms are available over-the-counter, while diaphragms and cervical caps must be fitted.
- Hormonal methods of contraception are numerous. Combined estrogen-progestin agents are taken daily by mouth or monthly by injection. Progestin-only agents are available for daily intake or by long-acting injections that are effective for 12 weeks.
- Intrauterine devices can be placed a few weeks after delivery.
- Permanent methods of birth control (ie, tubal ligation, vasectomy) are best for the couple who has more than one child and who are sure that they do not want more.
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 delivery. Since diagnosis is based on subjective observation, it is difficult to define clinically.
Objectively, postpartum hemorrhage is defined as a 10% change in hematocrit level between admission and the postpartum period or the need for transfusion after delivery secondary to blood loss.3
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.
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.
Active management of the third stage of labor with administration of uterotonics before the placenta is delivered (oxytocin still being the agent of choice), early clamping and cutting of the umbilical cord, and traction on the umbilical cord have proven to reduce blood loss and decrease the rate of postpartum hemorrhage.
Lower genital tract lacerations, including cervical and vaginal lacerations (eg, sulcal tears), are the result of obstetrical trauma and are more common with operative vaginal deliveries, such as with forceps or vacuum extraction. Other predisposing factors include macrosomia, precipitous delivery, and episiotomy.
Vaginal delivery is associated with a 3.9% incidence of postpartum hemorrhage.3 Cesarean delivery is associated with a 6.4% incidence of postpartum hemorrhage. Delayed postpartum hemorrhage occurs in 1-2% of patients.
Morbidity and mortality
In the United States, 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.
The antepartum or early intrapartum identification of risk factors for postpartum hemorrhage allows for advanced preparation and possible avoidance of severe sequelae.
Every patient must be interviewed upon admission to the labor floor. Request information about parity, multiple gestation, polyhydramnios, previous episodes of postpartum hemorrhage, history of bleeding disorders, and desire for future fertility.
Note the use of prolonged oxytocin administration, as well as the use of magnesium sulfate during the patient's labor course.
Physical examination is performed simultaneously with resuscitative measures. Perform a vigorous bimanual examination, which may reveal a retained placenta or a hematoma of the perineum or pelvis, and which also allows for uterine massage.
Closely inspect the lower genital tract in order to identify lacerations. Closely examine the placenta to determine if any fragments are missing.
The onset of postpartum hemorrhage is acute, intervention is immediate, and resolution is generally within minutes; consequently, laboratory studies or imaging in the management of the immediate course of this process has little role. However, it is important to check a patient's CBC count and prothrombin time/activated partial thromboplastin time (PT/aPTT) to exclude resulting anemia or coagulopathy, which may require further treatment. Upon admission of each patient to the labor ward, obtain ABO and D blood type determinations, and acquire adequate intravenous access.
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 mL of lactated Ringer solution [LRS] or isotonic sodium chloride solution). If retained products of conception are noted, perform manual removal or uterine curettage.
If oxytocin is ineffective, carboprost in an intramuscularly administered dose of 0.25 mg can be administered every 15 minutes, not to exceed 3 doses. Studies indicate a 75-88% success rate when carboprost is used alone and a 95% success rate when it is used in combination with other oxytocic agents.
Methylergonovine can also be intramuscularly administered in a dose of 0.2 mg. Because this agent causes intense vasoconstriction and may cause transient hypertension, it is contraindicated in patients with hypertensive disease. Check blood pressure prior to administration.
Misoprostol has been used clinically for the treatment of postpartum hemorrhage.4 ,5 However, further research is needed to determine the effectiveness, optimal dosage, and route of administration.4 ,5 A 2010 Monte Carlo simulation indicated that both sublingual and prophylactic oral misoprostol lowered mortality but raised costs (estimated incremental costs per disability-adjusted life year were $6 and $170, respectively).6 Also, a 2010 prospective, randomized, double-blind trial of rectal misoprostol vs intravenous oxytocin to prevent blood loss after cesarean delivery revealed that blood loss was significantly lower in the misoprostol group.7
When postpartum hemorrhage is not responsive to pharmacological therapy and no vaginal or cervical lacerations have been identified, consider the following more invasive treatment methods:
- Uterine packing is now considered safe and effective therapy for the treatment of postpartum hemorrhage.8 Use prophylactic antibiotics and concomitant oxytocin with this technique. The timing of removal of the packing is controversial, but most physicians favor 24-36 hours. This treatment is successful in half of patients. If unsuccessful, it still provides time in which the patient can be stabilized before other surgical techniques are employed.
- A Foley catheter with a large bulb (24F) can be used as an alternative to uterine packing.9 This technique can be highly effective, is inexpensive, requires no special training, and may prevent the need for surgery.9
- Uterine artery embolization, which is performed under local anesthesia, is a minimally invasive technique.10 The success rate is greater than 90%.11 This procedure is believed to preserve fertility.11 ,10 Complications are rare (6-7%) and include fever, infection, and nontarget embolization. In patients at high risk for postpartum hemorrhage, such as those with placenta previa, placenta accreta, coagulopathy, or cervical pregnancy, the catheter can be placed prophylactically.11
- The B-Lynch suture technique:12 A suture is passed through the anterior uterine wall in the lower uterine segment approximately 3 cm medial to the lateral edge of the uterus. The suture is wrapped over the fundus 3–4 cm medial to the cornual and inserted into the posterior uterine wall again in the lower uterine segment approximately 3 cm medial to the lateral edge of the uterus and brought out 3 cm medial to the other edge of the uterus. The suture is wrapped over the fundus and directed into and out of the anterior uterine wall parallel to the previous anterior sutures. The uterus is compressed in an accordionlike fashion and the suture is tied across the lower uterine segment. The B-Lynch suture technique and other compression suture techniques are operative approaches to postpartum hemorrhage that have proven to preserve fertility.13 As practitioners become proficient in this technique, it may be considered before uterine artery or hypogastric artery ligation and hysterectomy.
When conservative therapy fails, the next step is surgery with either bilateral uterine artery ligation or hypogastric artery ligation. Uterine artery ligation is thought to be successful in 80-95% of patients. If this therapy fails, hypogastric artery ligation is an option. However, this approach is technically difficult and is only successful in 42-50% of patients.14 Instead, stepwise devascularization of the uterus is now thought to be the next best approach, with possible ligation of the utero-ovarian and infundibulopelvic vessels.15
When all other therapies fail, emergency hysterectomy is often a necessary and lifesaving procedure.
Endometritis is an ascending polymicrobial infection. The causative agents are usually normal vaginal flora or enteric bacteria.
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 streptococci. If the infection develops on day 3 or 4, the causative organism is frequently enteric bacteria, most commonly E coli, or anaerobic bacteria. Endometritis that develops more than 7 days after delivery is most frequently caused by Chlamydia trachomatis. Endometritis following cesarean delivery is most frequently caused by anaerobic gram-negative bacilli, specifically Bacteroides species.
Known risk factors for endometritis include cesarean delivery, young age, low socioeconomic status, prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, placement of an intrauterine catheter, preexisting infection or colonization of the lower genital tract, twin delivery, and manual removal of the placenta. It has also been shown that manual removal of the placenta at cesarean delivery increases the incidence of endometritis.
Endometritis complicates 1-3% of all vaginal deliveries and 5-15% of scheduled cesarean deliveries. The incidence of endometritis in patients who undergo cesarean delivery after an extended period of labor is 30-35% and falls to 15-20% if the patient receives prophylactic antibiotics.
Morbidity and mortality
Following 48-72 hours of intravenous antibiotic therapy, 90% of women recover. Fewer than 2% of patients develop life-threatening complications such as septic shock, pelvic abscess, or septic pelvic thrombophlebitis.16
A patient may report any of the following symptoms: fever, chills, lower abdominal pain, malodorous lochia, increased vaginal bleeding, anorexia, and malaise.
A focused physical examination is important and should include vital signs, an examination of the respiratory system, breasts, abdomen, perineum, and lower extremities. A patient with endometritis typically has a fever of 38°C, tachycardia, and fundal tenderness. Some patients may develop mucopurulent vaginal discharge, whereas others have scant and odorless discharge.
- Urinary tract infection
- Acute pyelonephritis
- Lower genital tract infection
- Wound infection
- Laboratory tests: The appropriate tests for a febrile postpartum patient may include a CBC count with differential, urinalysis, urine culture, and blood cultures.
- Imaging: If a respiratory process is high on the differential, obtain a chest radiograph.
Treatment of endometritis is with intravenous antibiotics. Parenteral antibiotics are usually stopped once the patient is afebrile for 24-48 hours, tolerating a regular diet, and ambulating without difficulty.17 In general, an extended course of oral antibiotics has not been found to be beneficial,18 although 2 exceptions have been noted. In patients who respond quickly to intravenous antibiotics and who desire early discharge, a short course of oral antibiotics may be substituted for continued intravenous therapy. The other exception includes patients with staphylococcal bacteremia requiring an extended period of treatment.
No consensus exists regarding the antibiotic regimen for treatment of endometritis, although gentamicin in combination with clindamycin has become the standard by which all other regimens are judged.19 Gentamicin and clindamycin have a cure rate of approximately 90%.20 A once daily dose of gentamicin and clindamycin antibiotics has a similar success rate to the standard every 8 hour dose schedule. This combination is not effective against Enterococcus faecalis, which may be the cause in up to 25% of these infections. The addition of ampicillin (or vancomycin for patients with a penicillin allergy), is considered when the patient does not respond to the initial therapy of gentamicin and clindamycin to cover this organism.20
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 delivery raises the question of whether there is a role for antibiotic prophylaxis at cesarean delivery and, if so, what antibiotic to use. Olsen et al note that awareness of risk factors for infection can guide the decision to use prophylactic antibiotics.21 In emergency cesarean deliveries, 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 are all acceptable choices for single-dose antibiotic prophylaxis.22
Controversy still exists with regard to the need for prophylactic antibiotics during elective deliveries. The Cochrane Database demonstrated a two-thirds reduction in endometritis in women undergoing elective or nonelective cesarean delivery who receive prophylactic antibiotics;23 this was supported by a secondary analysis of an observational study in 2009.24 Other studies have shown that prophylactic antibiotic therapy at elective cesarean delivery was not associated with decreased incidence of endometritis.25 ,26
The timing of prophylaxis is also an issue; 2 recent studies showed lower rates of infection when antimicrobial prophylaxis occurred before skin incision vs after cord clamping.27 ,28 However, another trial that studied the same timing issue found that the timing of prophylaxis did not affect maternal infectious morbidity.29
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 UTI.
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.30
The most common pathogen is E coli. 31 In pregnancy, group B streptococci are a major pathogen. Other causative organisms include Staphylococcus saprophyticus, E faecalis, Proteus, and K pneumoniae.
Postpartum bacteruria occurs in 3-34% of patients, resulting in a symptomatic infection in approximately 2% of these patients.
A patient may report frequency, urgency, dysuria, hematuria, suprapubic or lower abdominal pain, or no symptoms at all.
On examination, vital signs are stable and the patient is afebrile. Suprapubic tenderness may be elicited on abdominal examination.
- Acute cystitis
- Acute pyelonephritis
Appropriate laboratory tests include urinalysis, urine culture from either a clean-catch or catheterized specimen, and CBC count.
Treatment is started empirically in uncomplicated infection because the usual organisms have predictable susceptibility profiles. When sensitivities are available, use them to guide antimicrobial selection. Treatment is with a 3- or 7-day antibiotic regimen.30 Commonly used antibiotics include trimethoprim/sulfamethoxazole, ciprofloxacin, and norfloxacin. Amoxicillin is often still used, but it has lower cure rates secondary to increasing resistance of E coli. The quinolones are very effective but are considerably more expensive than amoxicillin and trimethoprim/sulfamethoxazole and should not be used in breastfeeding mothers.
Mastitis is defined as inflammation of the mammary gland.
Milk stasis and cracked nipples, which contribute to the influx of skin flora, are the underlying factors associated with the development of mastitis. Mastitis is also associated with primiparity, incomplete emptying of the breast, and improper nursing technique. The most common causative organism, isolated in approximately half of all cases, is Staphylococcus aureus .32 Other common pathogens include Staphylococcus epidermidis, S saprophyticus, Streptococcus viridans, and E coli.
In the United States, the incidence of postpartum mastitis is 2.5-3%.33 ,32 Mastitis typically develops during the first 3 months postpartum, with the highest incidence in the first few weeks after delivery.
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. Mastitis and breast abscess also increase the risk of viral transmission from mother to infant.
The diagnosis of mastitis is solely based on the clinical picture.
Fever, chills, myalgias, erythema, warmth, swelling, and breast tenderness characterize this disease.
Focus examination 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. When the exam reveals a tender, hard, possibly fluctuant mass with overlying erythema, a breast abscess should be considered.
- Breast abscess
No laboratory 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.
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 infections that are resistant to penicillin. Resolution usually occurs 48 hours after the onset of antimicrobial therapy.
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 birth. 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.
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 are generally 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.34 Genital Mycoplasma species are commonly isolated from infected wounds that are resistant to treatment with penicillins.35 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.
The incidence of perineal infections is 0.35-10%. 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 patients with such conditions have a high mortality rate.
- Perineal infection
- Perineal cellulitis
- Necrotizing fasciitis
- Abdominal wound infection
- Wound dehiscence
Patients with perineal infections may complain of an inordinate amount of pain, malodorous discharge, or vulvar edema.
Abdominal wound infections develop around postoperative day 4 and are often preceded by endometritis. These patients present with persistent fever despite antibiotic treatment.
Perineal infections: An infected perineum often looks erythematous and edematous and may be accompanied by purulent discharge. Perform an inspection to identify hematoma, perineal abscess, or stitch abscess.
Abdominal wound infections: Infected incisions may be erythematous, warm, tender, and indurated. Purulent drainage may or may not be obvious. A fluid collection may be appreciated near the wound, which, when entered, may release serosanguineous or purulent fluid.
The diagnosis of wound infection is often made based on the clinical findings. Serial CBC counts with differentials may be helpful, especially if a patient does not respond to therapy as anticipated.
Perineal infections: Treatment of perineal infections includes symptomatic relief with NSAIDs, local anesthetic spray, and sitz baths. Identified abscesses must be drained, and broad-spectrum antibiotics may be initiated.
Abdominal wound infections: These infections are treated with drainage and inspection of the fascia to ensure that it is intact. Antibiotics may be used if the patient is afebrile.
Most patients respond quickly to the antibiotic once the wound is drained. Antibiotics are generally continued until the patient has been afebrile for 24-48 hours. Patients do not require long-term antibiotics unless cellulitis has developed. 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.36 ,37
Septic Pelvic Thrombophlebitis
Septic pelvic thrombophlebitis is defined as venous inflammation with thrombus formation in association with fevers unresponsive to antibiotic therapy.
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 are often involved because they drain the upper half of the uterus. When the ovarian veins are involved, the infection is most often unilateral, involving the right more frequently than the left. Occasionally, the thrombus has been noted to extend to the vena cava or to the left renal vein. Ovarian vein involvement usually manifests within a few days postpartum. Disease with later onset more commonly involves the iliofemoral vein.
Risk factors include low socioeconomic status, cesarean birth, prolonged rupture of membranes, and excessive blood loss.
Septic pelvic thrombophlebitis occurs in 1 of every 2000-3000 pregnancies and is 10 times more common after cesarean birth (1 per 800) than after vaginal delivery (1 per 9000).38 The condition 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.
Septic pelvic thrombophlebitis usually accompanies endometritis. Patients report initial improvement after an intravenous 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.
Vital signs demonstrate fever greater than 38°C and resting tachycardia. If pulmonary involvement is significant, the patient may be tachypneic and stridulous. On abdominal examination, 50-70% of patients with ovarian vein thrombosis have a tender, palpable, ropelike mass extending cephalad beyond the uterine cornu.
- Ovarian vein syndrome
- Broad ligament hematoma
- Adnexal torsion
- Pelvic abscess
- Enigmatic fever
- Drug fever
- Viral syndrome
- Collagen vascular disease
- Pelvic abscess
- Important laboratory studies included urinalysis, urine culture, and CBC count with differential.
- Imaging: CT scan and MRI are the studies of choice for the diagnosis of septic pelvic thrombophlebitis.38 ,39 MRI has 92% sensitivity and 100% specificity, and CT imaging has a 100% sensitivity and specificity for identifying ovarian vein thrombosis. These imaging modalities are capable of identifying both ovarian vein and iliofemoral involvement.
The standard therapy after diagnosis of septic pelvic thrombophlebitis includes anticoagulation with intravenous heparin to an aPTT that is twice normal and continued antibiotic therapy. A therapeutic aPTT is usually reached within 24 hours, and heparin is continued for 7-10 days. In general, long-term anticoagulation is not required. Antibiotic therapy is most commonly 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.40 More recent studies show that it takes 5-6 days for the fevers to resolve.40 ,41
In a 1999 prospective randomized study, women who were treated with heparin in addition to antibiotics responded no faster than patients treated with antibiotics alone.38 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.38
Postpartum thyroid dysfunction can occur any time in the first postpartum year. Clinical or laboratory dysfunction occurs in 5-10% of postpartum women and may be caused by primary disorders of the thyroid, such as postpartum thyroiditis (PPT) and Graves disease, or by secondary disorders of the hypothalamic-pituitary axis, such as Sheehan syndrome and lymphocytic hypophysitis.42
PPT is a transient destructive lymphocytic thyroiditis occurring within the first year after delivery.
PPT develops 1-8 months postpartum and is an autoimmune disorder in which microsomal antibodies of the thyroid play a central role. PPT has 2 phases: thyrotoxicosis and hypothyroidism.
- Thyrotoxicosis occurs 1-4 months postpartum and is always self-limited. The condition is caused by the increase release of stored hormone as a result of disruption of the thyroid gland.
- Hypothyroidism arises between the fourth and eighth month postpartum.
Risk factors for development of PPT include a positive antithyroid antibody test finding, history of PPT, and family or personal history of other thyroid or autoimmune disorders.
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. A third of these patients experience transient thyrotoxicosis, whereas 10-30% go on to develop permanent thyroid dysfunction.
Morbidity and mortality
Patients with high antithyroid antibody levels 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.43
Patients with thyrotoxicosis may report fatigue, palpitations, heat intolerance, tremulousness, nervousness, and emotional lability. Patients in the hypothyroid phase often complain of fatigue, dry skin, coarse hair, cold intolerance, depression, and memory and concentration impairment. Because many of these symptoms are mild and nonspecific and are often associated with the normal postpartum state, PPT may go undiagnosed.
On examination, a patient may have tachycardia, mild exophthalmos, and a painless goiter.
The first laboratory test to be performed should be the thyroid-stimulating hormone (TSH) test.44 TSH is decreased during the thyrotoxicosis stage and increased during the hypothyroid phase. If the TSH level is abnormal, check thyroid stimulating antibodies, free thyroxine index (FTI), and radioactive iodine uptake (RIU) in order to distinguish this disorder from Graves disease. In PPT, RIU is low, thyroid-stimulating antibodies are undetectable, and FTI is high.
A thorough, cost-effective screening test for PPT does not exist; therefore, limit screening to high-risk patients such as those with previous PPT or other autoimmune disorders.45
No treatment is available to prevent PPT.45
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 can be doubled if the patient remains symptomatic. Propylthiouracil (PTU) has no role in the treatment of PPT because the disorder is caused by the release of hormone from the damaged thyroid and is not secondary to increased synthesis and secretion.
Hypothyroid phase: Since the hypothyroid phase of PPT is often transient, no treatment is required unless necessitated by the patient's symptoms. Treatment is with thyroxine (T4) replacement. T4 is most often given for 12-18 months, then gradually withdrawn. The starting dose is 0.05-0.075 mg, which 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 it 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. No clinical features distinguish postpartum Graves disease from Graves disease in other settings; therefore, diagnosis and management of this disorder is beyond the scope of this article (see Graves Disease ).
Lymphocytic hypophysitis is a rare autoimmune disorder causing pituitary enlargement and hypopituitarism, leading to a decrease in TSH and to hypothyroidism. Symptoms include headache, visual field deficits, difficulty lactating, and amenorrhea. Diagnosis requires histopathologic examination. Most patients do not require transsphenoidal 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 to its normal size and recovers some of its normal function. During the acute phase of this disease, hormone replacement is often necessary.
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.
Three psychiatric disorders may arise in the postpartum period: postpartum blues, postpartum depression (PPD), and postpartum psychosis.
- Postpartum blues is a transient disorder the lasts hours to weeks and is characterized by bouts of crying and sadness.
- PPD is a more prolonged affective disorder that lasts for weeks to months. PPD is not well defined in terms of diagnostic criteria, but the signs and symptoms do not differ from depression in other settings.
- Postpartum psychosis occurs in the first postpartum year and refers to a group of severe and varied disorders that elicit psychotic symptoms.
The specific etiology of these disorders is unknown. The current view is based on a multifactorial model. Psychologically, these disorders are thought to result from the stress of the peripartum period and the responsibilities of child rearing. Other authorities 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 findings 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 younger than 20 years, unmarried status, medical indigence, 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 PPD 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 PPD.
- Approximately 50-70% of women who have given birth develop symptoms of postpartum blues.
- PPD occurs in 10-15% of new mothers.46
- The incidence of postpartum or puerperal psychosis is 0.14-0.26%.
Morbidity and mortality
Psychiatric disorders can have deleterious effects on the social, cognitive, and emotional development of the newborn.47 These ailments can also lead to marital difficulties.
- Postpartum blues is a mild, transient, self-limited disorder that usually develops when the patient returns home. It commonly arises during the first 2 weeks after delivery and is characterized by bouts of sadness, crying, anxiety, irritation, restlessness, mood lability, headache, confusion, forgetfulness, and insomnia.
- PPD: Patients suffering from PPD report insomnia, lethargy, loss of libido, diminished appetite, pessimism, incapacity for familial love, feelings of inadequacy, ambivalence or negative feelings toward the infant, and an inability to cope. Consult a psychiatrist when PPD is associated with comorbid drug abuse, lack of interest in the infant, excessive concern for the infant's health, suicidal or homicidal ideations, hallucinations, psychotic behavior, overall impairment of function, or failure to respond to therapeutic trial.
- Postpartum psychosis: The signs and symptoms of postpartum psychosis typically do not differ from those of acute psychosis in other settings. Patients with postpartum psychosis usually present with schizophrenia or manic depression, which signals the emergence of preexisting mental illness induced by the physical and emotional stresses of pregnancy and delivery.
- Postpartum blues, which has little effect on a patient's ability to function, often resolves by postpartum day 10; therefore, no pharmacotherapy is indicated. Providing support and education has been shown to have a positive effect.
- PPD generally lasts for 3-6 months, with 25% of patients still affected at 1 year. PPD greatly affects the patient's ability to complete activities associated with daily living.
- Supportive care and reassurance from healthcare professionals and the patient's family is the first-line therapy for patients with PPD.48 Research on pharmacological treatment for PPD is limited because postpartum women are often excluded from large clinical trials.47 Empirically, the standard treatment modalities for major depression have been applied to PPD.
- First-line agents include selective serotonin reuptake inhibitors (SSRIs) or secondary amines. Studies on these drugs show that they can be used by nursing mothers without adverse effects on the infant. Consider electroconvulsive therapy for patients with PPD because it is one of the most effective treatments available for major depression. Treatment is recommended for 9-12 months beyond remission of symptoms, with tapering over the last 1-2 months.
- Postpartum psychosis: Treatment of postpartum psychosis should be supervised by a psychiatrist and should involve hospitalization. Specific therapy is controversial and should be targeted to the patient's specific symptoms. Patients with postpartum psychosis are thought to have a better prognosis than those with nonpuerperal psychosis. Postpartum psychosis generally lasts only 2-3 months.
- Secondary to the overlap between the normal sequelae of childbirth and the symptoms of PPD, the former is often underdiagnosed.46 Screening for PPD increases the identification of women suffering from this disorder.46 The Edinburgh Postnatal Depression Scale has proven to be an effective tool for this type of screening.49 ,50 ,51 It requires little extra time and is acceptable to both patients and physicians.51 ,52
normal puerperium, abnormal puerperium, maternal death, postpartum care, postpartum hemorrhage, endometritis, urinary tract infection, uterine atony, mastitis, wound infection, septic pelvic thrombophlebitis, postpartum thyroiditis, postpartum depression, postpartum psychosis
Fri, 23 Jul 2010 @00:10