Managing Postpartum Complications in the Emergency Department (Pharmacology CME) -
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Publication Date: March 2022 (Volume 24, Number 3)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 03/01/2025.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 1 Pharmacology CME credit, subject to your state and institutional approval.

Authors

Nicole Yuzuk, DO

Ultrasound Director, Core Faculty, St. Joseph’s University Medical Center, Paterson, NJ

Joseph Bove, DO

Emergency Physician, St. Joseph’s University Medical Center, Paterson, NJ

Riddhi Desai, DO

Department of Emergency Medicine, St. Joseph’s University Medical Center, Paterson, NJ

Peer Reviewers

Jennifer Beck-Esmay, MD, FACEP

Associate Professor of Emergency Medicine; Assistant Residency Director, Mount Sinai Morningside-West; Icahn School of Medicine at Mount Sinai, New York, NY

Elizabeth Leenellett, MD, FACEP

Associate Professor and Vice Chair, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH

Abstract

Postpartum patients may present to the emergency department with complaints ranging from minor issues, requiring only patient education and reassurance, to severe, life-threatening complications that require prompt diagnosis and multidisciplinary consultation and management. At times, vague presentations or overlapping conditions can make it difficult for the emergency clinician to recognize an emergent condition and initiate proper treatment. This issue reviews the major common emergencies that present in postpartum patients, by chief complaint, including hemorrhage, infection, pre-eclampsia, eclampsia, headache, and cardiopulmonary conditions, and reviews the most recent evidence and guidelines.

Case Presentations

CASE 1

A woman 3 weeks’ post partum presents with gradually worsening cough and severe shortness of breath…

Early on Sunday morning, a 33-year-old woman presents with gradually worsening cough and shortness of breath that is so severe that if she takes more than 4 steps, she has to sit down to catch her breath.
Her blood pressure in triage is 185/115 mm Hg, she is tachycardic with a heart rate of 120 beats/min, and she is tachypneic and speaking in short phrases. Her temperature is 37°C, and her oxygen saturation is 95%.
She has no past medical history, and states she had an uncomplicated delivery of twin boys 3 weeks ago via cesarean delivery. On physical examination, there is jugular venous distension, crackles bilaterally, and lower extremity edema. Her abdomen is soft and nontender.
You wonder why her blood pressure is so high and whether her high blood pressure is related to her shortness of breath...

CASE 2

A man brings his wife into the ED for altered mental status 2 weeks after having a baby…

The patient is wheeled into the resuscitation room for evaluation. The husband states she has been intermittently confused and at times thinks she is still pregnant, despite caring for the newborn.
On examination, she is afebrile, her blood pressure is 190/110 mm Hg, and heart rate is 98 beats/min. She is moving all extremities, but has global weakness and is oriented only to herself and her husband.
Her husband states that she had an uneventful vaginal delivery 2 weeks prior, after a normal pregnancy. He also reports she had been complaining of a pressure-like headache for the past 2 days, for which she had been taking acetaminophen 650 mg every 8 hours, with temporary improvement.
After obtaining a bedside blood sugar (which is normal), she starts to seize on the stretcher. Your differential is long, and includes stroke and drug overdose, but you also wonder whether this could be eclampsia. With so many possibilities, you consider what the best pharmacologic intervention would be...

CASE 3

A 25-year-old woman with headache, blurry vision, and right arm numbness presents after delivering a baby 3 days ago…

She reports having had an epidural with her recent vaginal delivery, and thought her symptoms may be related to that.
Her blood pressure is 135/90 mm Hg; heart rate, 85 beats/min; temperature, 36.5ºC; and oxygen saturation 99% on room air. She has decreased sensation to pinprick throughout her right upper extremity, but otherwise the neurologic exam is normal.
A “Code Stroke” is activated, and she is sent for a noncontrast head CT; however, you know that a negative CT does not rule out stroke and wonder whether she will need a more extensive evaluation...

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