Postpartum Complications

Postpartum Hemorrhage - Code Red Crisis

• Definition: Blood loss >500mL (vaginal), >1000mL (LSCS); or hemodynamic instability. Severe PPH: >2L.
• Etiology (4 T's 📌): Tone (uterine atony, ~70-80%), Trauma (lacerations, ~20%), Tissue (retained products, ~10%), Thrombin (coagulopathy, ~1%).
• Code Red Protocol:
  • Help: Call multidisciplinary team (obstetrician, anesthetist, blood bank).
  • ABC: Secure IV access (x2 large bore), O2, fluids, blood transfusion.
  • Uterotonics (for Atony):
    • Oxytocin 10-40 IU IV infusion.
    • Methylergometrine 0.2mg IM/IV (Contra: HTN).
    • Carboprost 0.25mg IM (Contra: Asthma).
    • Misoprostol 800-1000µg PR/SL/PO.
    • Tranexamic acid 1g IV (within 3 hrs).
  • Mechanical/Surgical: Uterine massage, Bakri balloon, B-Lynch suture, UAE, Hysterectomy.
  • Other T's: Repair trauma, remove retained tissue, correct coagulopathy.
• Shock Index (HR/SBP): >0.9 suggests significant blood loss.

⭐ Active Management of Third Stage of Labor (AMTSL) - controlled cord traction, uterotonic (Oxytocin 10 IU IM/IV), uterine massage - reduces PPH incidence by ~60%.

Puerperal Sepsis & Infections - Fever Pitch Peril

• Definition: Genital tract infection; from rupture of membranes (ROM)/labor up to 42 days postpartum. Fever ≥38°C (100.4°F) on any 2 of the first 10 days postpartum (excluding the first 24 hours).
• Common Sites: Endometrium (endometritis - most common), C-section wound, perineal tear, UTI.
• Organisms: Polymicrobial. Common: Group A & B Streptococci, E. coli, Staphylococcus aureus, anaerobes (Bacteroides, Peptostreptococcus).
• Risk Factors: Caesarean section (highest risk), prolonged ROM (>18 hrs), prolonged labor, multiple vaginal examinations, retained products of conception (RPOC), manual removal of placenta, anemia, poor hygiene.
• Clinical Features: Fever, chills, tachycardia, malaise, lower abdominal pain, uterine tenderness/subinvolution, foul-smelling or purulent lochia.
  • Wound infection: Local pain, erythema, warmth, swelling, discharge.
• Diagnosis: Primarily clinical. Investigations: CBC (leukocytosis), high vaginal swab (HVS) C&S, blood cultures (if systemic signs), urine C&S. Ultrasound (USG) to rule out RPOC or abscess.
• Management:
  • Prompt broad-spectrum IV antibiotics (e.g., Clindamycin + Gentamicin; Piperacillin-Tazobactam).
  • Supportive care: IV fluids, antipyretics, analgesia. Surgical drainage for abscess/infected hematoma.
• Complications: Septic shock, pelvic abscess, septic pelvic thrombophlebitis (SPT), peritonitis, disseminated intravascular coagulation (DIC).

⭐ Endometritis is the most common cause of puerperal pyrexia, typically presenting with fever and uterine tenderness 2-3 days postpartum (but can occur up to 6 weeks).

Postpartum VTE - Clot Shot Chaos

• Venous Thromboembolism (DVT/PE): Increased risk up to 6-12 weeks postpartum; peak in 1st week. Virchow's triad (stasis, hypercoagulability, endothelial injury) is amplified.
• Key Risk Factors:
  • Cesarean section (especially emergency)
  • Previous VTE
  • Obesity (BMI >30 kg/m²)
  • Age >35 years
  • Prolonged immobility
  • Inherited or acquired thrombophilia
  • Major postpartum hemorrhage (>1L)
• Deep Vein Thrombosis (DVT):
  • Symptoms: Unilateral leg pain, swelling, tenderness, warmth, redness.
  • Diagnosis: Compression ultrasonography (CUS). D-dimer has high negative predictive value if pre-test probability is low.
• Pulmonary Embolism (PE):
  • Symptoms: Sudden onset dyspnea, pleuritic chest pain, tachycardia, tachypnea, cough, hemoptysis.
  • Diagnosis: CT Pulmonary Angiography (CTPA) is gold standard; V/Q scan if CTPA contraindicated.
• Prevention:
  • Early ambulation for all postpartum women.
  • Prophylactic anticoagulation (e.g., LMWH Enoxaparin 40mg SC OD) for high-risk women (e.g., C-section with other risk factors).
• Treatment:
  • Therapeutic anticoagulation: LMWH (e.g., Enoxaparin 1mg/kg SC BID or 1.5mg/kg SC OD) is preferred initially.
  • Bridge to Vitamin K antagonist (Warfarin) for long-term, target INR 2.0-3.0.
  • Duration: Minimum 3-6 months. LMWH and Warfarin are safe during breastfeeding.
• 📌 Mnemonic for DVT signs: SWELLING (Swelling, Warmth, Erythema, Leg pain, Lack of pulse (rare), Inflammation, No symptoms (sometimes), Girth increase).

⭐ Pulmonary embolism is a leading cause of direct maternal mortality in developed countries. The risk of VTE is highest in the first 3 weeks postpartum, particularly after Cesarean section.

Postpartum Psychiatric Disorders - Mind Over Muddle

• Postpartum Blues (PPB):
  • Onset: 2-3 days postpartum, resolves by 2 weeks.
  • Features: Mild depression, tearfulness, irritability.
  • Tx: Reassurance, support.
• Postpartum Depression (PPD):
  • Onset: Within 4 weeks (up to 1 yr).
  • Features: Depressed mood, anhedonia. Edinburgh Postnatal Depression Scale (EPDS) >12.
  • Tx: Psychotherapy, SSRIs.
• Postpartum Psychosis (PPP):
  • Onset: Usually within 2 weeks. Medical emergency.
  • Features: Delusions, hallucinations, risk to self/baby.
  • Tx: Hospitalization, antipsychotics, ECT.

⭐ PPP has a high recurrence rate (~50%) in subsequent pregnancies and is often associated with bipolar disorder.

High‑Yield Points - ⚡ Biggest Takeaways

• PPH: Most common cause is uterine atony. AMTSL is crucial for prevention.
• Puerperal sepsis: Marked by fever >38°C postpartum; Group A Strep is key pathogen.
• Thromboembolism (DVT/PE): Major mortality risk, explained by Virchow's triad.
• Postpartum psychiatric issues: Distinguish common blues, depression (use EPDS), and psychosis (emergency).
• Mastitis: Usually unilateral, S. aureus common; continue breastfeeding advised.
• Sheehan's syndrome: Pituitary necrosis post-severe PPH; presents with lactation failure.
• RPOC: Frequent cause of secondary PPH and infection; ultrasound confirms_diagnosis_