Managing Postpartum Complications in the Emergency Department (Pharmacology CME)

Table of Contents

 

About This Issue

Postpartum patients can present with many different complaints, from headache, fever, and breast pain to hemorrhage, hypertension, shortness of breath, chest pain, and seizures. Determining the cause of often varied and overlapping symptoms requires a systematic, symptom-based approach. This issue presents key recommendations for management of postpartum patients and discusses:

How to determine the cause and severity of postpartum bleeding and initiate management options: uterine massage, balloon tamponade, and tranexamic acid.

Investigating fever and potential infection from mastitis or endometritis, with recommendations on safe options for antibiotics for breastfeeding mothers.

The criteria for diagnosing postpartum pre-eclampsia and eclampsia and how to determine severity.

Diagnosing HELLP syndrome and peripartum cardiomyopathy with laboratory testing and imaging studies.

Differentiating a tension or migraine headache from eclampsia or cerebral venous thrombosis.

When anticoagulation is (and is not) an appropriate treatment for cerebral venous thrombosis.

First-line therapies for antihypertensive therapy in postpartum and breastfeeding patients.

Managing seizures with magnesium sulfate.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Hemorrhage
   2. Headache
   3. Fever and Infection
   4. Pre-eclampsia/Eclampsia
   5. HELLP Syndrome
   6. Peripartum Cardiomyopathy
7. Differential Diagnosis
8. Prehospital Care
   1. Postpartum Hemorrhage
   2. Altered Mental Status/Seizures
   3. Dyspnea and Chest Pain
   4. Fever and Hypotension
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Hemorrhage
    2. Headache
    3. Fever and Infection
    4. Cardiopulmonary Complaints
       1. Imaging Studies
       2. Electrocardiogram
       3. Laboratory Studies
       4. Other Studies
11. Treatment
    1. Treatment of Hemorrhage
    2. Treatment of Headache
       1. Treatment of Cerebral Venous Thrombosis
    3. Treatment of Infection
       1. Treatment for Mastitis
       2. Treatment for Endometritis
       3. Treatment for Wound Infection
    4. Treatment for Pre-eclampsia/Eclampsia and HELLP Syndrome
       1. Treatment of Seizure
       2. Treatment of HELLP Syndrome
    5. Treatment of Peripartum Cardiomyopathy
12. Special Populations
13. Controversies and Cutting Edge
    1. Endovascular Therapies for Cerebral Venous Thrombosis
    2. Thromboelastography for Postpartum Hemorrhage
    3. HELLP Syndrome Treatment
    4. Bromocriptine for Peripartum Cardiomyopathy
14. Disposition
15. Summary
16. Time- and Cost-Effective Strategies
17. Risk Management Pitfalls for Managing Postpartum Complications
18. Case Conclusions
19. Clinical Pathways
    1. Clinical Pathway For Management of the Postpartum Patient With a Headache
    2. Clinical Pathway for Management of the Postpartum Patient With Elevated Blood Pressure (Systolic ≥140 mm Hg, Diastolic ≥90 mm Hg)
20. Tables and Figures
21. References

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

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...

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...

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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Clinical Pathway For Management of the Postpartum Patient With a Headache

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

7. * Goldszmidt E, Kern R, Chaput A, et al. The incidence and etiology of postpartum headaches: a prospective cohort study. Can J Anaesth. 2005;52(9):971-977. (Prospective cohort study; 985 patients) DOI: 10.1007/BF03022061

11. * ACOG Committee Opinion no. 361: breastfeeding: maternal and infant aspects. Obstet Gynecol. 2007;109(2, Part 1):479. (Practice bulletin) DOI: 10.1097/00006250-200702000-00064

13. * Gestational hypertension and preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol. 2020;135(6):e237-e260. (Practice guidelines) DOI: 10.1097/AOG.0000000000003891

30. * American College of Obstetricians and Gynecologists’ Presidential Task Force on Pregnancy and Heart Disease and Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 212: pregnancy and heart disease. Obstet Gynecol. 2019;133(5):e320-e356. (Practice bulletin) DOI: 10.1097/AOG.0000000000003243

44. * Xu W, Gao L, Li T, et al. The performance of CT versus MRI in the differential diagnosis of cerebral venous thrombosis. Thromb Haemost. 2018;118(06):1067-1077. (Meta-analysis; 4595 patients) DOI: 10.1055/s-0038-1642636

51. * WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116. (Randomized double-blind placebo-controlled trial; 20,021 patients) DOI: 10.1016/S0140-6736(17)30638-4

53. Swaminathan A. Post-partum hemorrhage. 2018. Accessed February 10, 2022. (Review blog)

59. * Misra UK, Kalita J, Chandra S, et al. Low molecular weight heparin versus unfractionated heparin in cerebral venous sinus thrombosis: a randomized controlled trial. Eur J Neurol. 2012;19(7):1030-1036. (Randomized controlled trial; 66 patients) DOI: 10.1111/j.1468-1331.2012.03690.x

72. Trimethoprim-sulfamethoxazole. Drugs and Lactation Database (LactMed). Accessed February 10, 2022. (Review article)

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Keywords: postpartum, hemorrhage, bleeding, pre-eclampsia, eclampsia, headache, peripartum cardiomyopathy, cerebral venous thrombosis, hypertension, mastitis, endometritis, HELLP