Chapter 224. Postpartum Consultation for Common Complaints

1. What are the common causes of postpartum fever?

2. What antibiotics are recommended for common postpartum infections?

3. What is the differential diagnosis for a postpartum headache?

4. When does a postpartum headache require radiologic imaging?

5. What are the common postpartum neuropathies?

6. What is the differential diagnosis for a postpartum seizure?

7. What is the postpartum course and management for autoimmune diseases including myasthenia gravis, multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosus?

8. What is the postpartum management for thyroid disorders and diabetes mellitus?

9. What is the postpartum management for preeclampsia and chronic hypertension?

10. What is the long-term cardiovascular risk for patients with a history of preeclampsia?

The postpartum period, lasting six months, is a unique time during which there is a physiological return to the prepregnancy state. Night sweats, mood disturbance, urinary frequency, perineal and vaginal discomfort, and breast engorgement are all common complaints from postpartum women. Clinicians treating postpartum patients in the hospital setting must be able to differentiate these normal changes from disease states at a time of increased risk for flares of chronic medical conditions and the onset of new conditions.

Postpartum Fever

Low grade fever frequently occurs in the first 24 hours after delivery. Postpartum fever is defined as a temperature of ≥ 38.0 degrees Celsius (100.4 degrees Fahrenheit) on any two of the first ten days postpartum exclusive of the first 24 hours. Infection is the leading cause of postpartum fever in the United States; the overall postpartum infection rate is around 6%, with the incidence of planned cesarean deliveries up to 10%, and higher in unplanned deliveries. Endometritis is the most common infection in the postpartum period, followed by urinary tract infection, lower genital tract infection, wound infection, pulmonary infection, thrombophlebitis, cholecystitis, and mastitis. A recent database analysis looking at readmissions within six weeks of delivery found that the cause of readmission is primarily infectious in origin, and that hypertension and uterine and wound infections were the most common causes for readmission. A surprising finding suggested that a recent pregnancy increases the risk for pneumonia, appendicitis, and cholecystitis. As expected, readmission rates were significantly higher after cesarean section than after vaginal delivery. Pregnant patients have decreased buffering capacity, increased cardiac output, and decreased systemic vascular resistance so patients with sepsis related to postpartum infection may decompensate quickly. Prompt action with close follow-up is recommended.

Postpartum Endometritis

Postpartum endometritis is typically a polymicrobial infection of lower genital tract flora infecting the upper genital tract. The prevalence of endometritis has been greatly reduced with the standard use of antibiotic prophylaxis with cesarean deliveries. The risk of endometritis is increased by various factors:

• Prolonged labor
• Prolonged rupture of membranes
• Multiple vaginal examinations
• Operative vaginal delivery
• Bacterial vaginosis
• Chorioamnionitis
• Cesarean section (especially nonelective)
• Antepartum isolation of group B streptococci, Chlamydia, or mycoplasma

The criteria for diagnosis of endometritis include fever and uterine tenderness. Other signs ...