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 and symptoms include foul lochia and chills. The postpartum uterus should be firm, nontender, and below the umbilicus; with endometritis a soft, subinvoluted uterus may lead to excessive vaginal bleeding.

When endometritis is suspected, laboratory or imaging data are rarely needed before initiating treatment. If despite treatment, a patient has persistent fever or unusually severe or localized pain, further studies may be helpful. A WBC with differential, blood cultures (which are positive in 10–20% of patients), and endometrial cultures may be diagnostic and can help direct antimicrobial therapy. Endometrial cultures should be acquired with a double or triple lumen technique to prevent vaginal and cervical contamination. Pelvic ultrasonography can identify retained products of conception, which need to be removed by dilatation and curettage because they are an ongoing nidus of infection. Computed tomography (CT) or magnetic resonance imaging (MRI) are used to diagnose alternative causes of persistent pain and fever including ovarian vein thrombosis, abscess, or hematoma. Please refer to a full discussion of ovarian vein thrombosis in Chapter 223 Common Medical Problems in Pregnancy.

The most common infectious agents when endometritis is suspected in the first 24 to 48 hours postpartum are Gram-positive cocci (predominantly group B streptococci, Staphylococcus epidermidis, and Enterococcus sp) or Gram-negative bacteria (predominantly Gardnerella vaginalis, Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis). After 48 hours, involvement of anaerobic bacteria (predominantly peptostreptococci, Bacteroides sp, and Prevotella sp) is likely, and by seven days, C. trachomatis is often found. The treatment regimen for postpartum endometritis includes broad spectrum parenteral antibiotics. In the first 48 hours after delivery, the recommended regimen is clindamycin (900 mg every eight hours) plus gentamicin (1.75 mg/ kg every eight hours or 5 mg/kg every 24 hours). If there is persistent fever or enterococcus is suspected, ampicillin or vancomycin in penicillin allergy should be added. Alternative regimens include cefotetan, cefoxitin, piperacillin/tazobactam, and ampicillin/sulbactam. There is a trend to use clindamycin and gentamicin for predelivery chorioamnionitis and ampicillin sulbactam for postpartum fever due to endometritis. With anaphylaxis to penicillin or cephalosporins, clindamycin and gentamcin are still preferred. Treatment continues until a patient has been afebrile for 48 hours and uterine tenderness has resolved. Oral therapy after parenteral therapy is not recommended as there is no evidence for improved outcome or decreased risk of recurrence. However, patients with bacteremia confirmed by positive blood cultures should complete a 7–10 day course of antibiotics. Late postpartum endometritis (48 hours to six weeks postpartum) may be treated with oral metronidazole and doxycycline (100 mg IV or orally every 12 hours) for 14 days.

Wound Infection

Postpartum wound infections complicate 2% to 8% of cesarean sections. Risk factors for wound infection include nonelective cesarean section, preoperative fever, prolonged rupture of membranes, diabetes mellitus, and obesity. Patients with postpartum endometritis are also at increased risk for wound infection. Approximately 3% to 5% of patients with endometritis have a concurrent wound infection. On clinical examination, the infected abdominal incision is erythematous, indurated, and tender and may have purulent drainage. Frequently the incision requires opening and drainage. The fascia should be examined to ensure that it is intact and no dehiscence has taken place. Gram stain and culture of wound drainage is rarely needed before broad spectrum antibiotics are initiated. The wound should be irrigated and dressed with clean bandages two to three times daily. Antibiotics are typically required for at least a week or until signs of infection have resolved.

Episiotomy infection occurs after 1% to 2% of vaginal deliveries. The infection may be limited to the skin and superficial fascia along the incision site or may spread beyond this area. Treatment may require debridement and broad spectrum antibiotics. Some experts are recommending antibiotic prophylaxis for repair of third and fourth degree episiotomy extensions following episiotomy extensions.

Serious complications of wound and episiotomy infections include dehiscence and necrotizing fasciitis. These are more common in diabetics and severely obese women. Necrotizing fasciitis is a potentially fatal illness without aggressive medical and surgical management. Clinical signs of necrotizing fasciitis include discolored or pale wound margins without sensation, leukocytosis, metabolic derangement, disseminated intravascular coagulation (DIC) and hypotension. Discoloration that follows a facial plane in the perineum is often the first clinical clue to fasciitis. The most common bacterial pathogens to cause necrotizing fasciitis are group B streptococci, anaerobes, and nonhemolytic streptococci and staphylococci. Treatment requires immediate surgical debridement and broad spectrum antibiotics.

Breast Infection

The majority of postpartum patients experience breast discomfort with swollen, firm, and tender breasts. Simple engorgement causes low grade fevers without any other clinical signs of infection and typically resolves within 48 hours. Breast infections, including mastitis and abscess, are rare in women who do not breastfeed but occur in 2% to 3% of breastfeeding women. The patient may describe chills, flu-like symptoms, and have high fevers (102° to 104°F). Mastitis causes localized erythema and swelling with a cellulitic appearance. A breast abscess is characterized by fluctuance and diffuse erythema, with a localized area of tenderness.

The most frequent pathogen in postpartum breast infection is Staphylococcus aureus, and toxic shock has been reported with mastitis in the postpartum period. Other less common pathogens include β-hemolytic streptococci, H influenzae, H parainfluenzae, Escherichia coli, and Klebsiella pneumoniae.

Clinical evaluation includes culture of expressed breast milk and aspirated fluid if there is a fluctuant mass. Prompt antibiotic treatment is required and should continue for seven days or until resolution of infection. Recommended antibiotic coverage includes Nafcillin 2 g IV every 4 hours or dicloxacillin 500 mg orally every 6 hours or cephalexin 500 mg orally every 6 hours. Alternative regimens include amoxicillin/clavulanate 875 mg orally every 12 hours or azithromycin 500 mg orally initially, then 250 mg orally daily. If methicillin-resistant Staphylococcus aureus (MRSA) is suspected then TMP-SMX-DS orally every 12 hours or vancomycin 1 g IV every 12 hours are recommended.

For mastitis, the patient should be encouraged to avoid milk stasis by continuing to nurse or pump expressed milk. Hot compresses also aid in comfort and expression of milk. Patients should be closely followed as an abscess can develop even after antibiotics have begun. If a patient has a breast abscess, then incision and drainage or needle aspiration may be warranted. Patients with breast abcesses should be advised to discontinue breastfeeding until after drainage is performed, if indicated, and signs of infection are resolved. In communities with a high rate of MRSA, it is found in up to 50% of women with postpartum breast abscesses.

Postpartum Headache

Hormonal fluctuations, sleep deprivation, and anxiety all contribute to the increased frequency of headaches in the postpartum period. The differential diagnosis of headache varies from minor to life-threatening causes and therefore warrants a prompt and thorough clinical evaluation. Alarm symptoms that warrant emergent evaluation with neurolgic imaging include headache of acute onset, abnormal or focal neurologic findings, seizure, and/or decreased level of consciousness. If a postpartum patient has a new Horner’s syndrome, the anterior and posterior circulation should be imaged at the same time to rule out dissection. Table 224-1 summarizes the differential diagnosis of postpartum headache along with common features, and modes of evaluation or treatment.

Migraine