II. Definitions

  1. Postpartum Period
    1. First 12 weeks following delivery ("fourth trimester")

III. Epidemiology

  1. Deaths related to pregnancy occur in the Postpartum Period in 60% of cases
    1. Li (1996) Int J Gynaecol Obstet 54(1): 1-10 [PubMed]

IV. Management: Timing of Follow-up

  1. Visit 1: Early follow-up within first 3 weeks
    1. Recommended by ACOG to be within first 3 weeks (WHO recommends at 3 days and 7-14 days)
  2. Visit 2: Postpartum Visit at 6-8 weeks
    1. Standard postpartum follow-up at 6-8 weeks

V. Management: Early postpartum concerns (initial and first 2 weeks)

  1. Secondary Postpartum Hemorrhage at >24 hours after delivery (2% of women)
    1. Typically due to Retained Placenta or Endometritis
  2. Postpartum Endometritis
    1. See Maternal Fever
    2. Highest risks include Cesarean Section, Chorioamnionitis, prolonged Rupture of Membranes
    3. May present only with fever
    4. Late Endometritis occurs >7 days after delivery
  3. Lactation
    1. See Lactation Technique
    2. See Lactation Problems for the Infant
    3. See Lactation Problems for the Mother
  4. Deep Vein Thrombosis
    1. See Thromboembolic Disease in Pregnancy
    2. Relative Risk of Venous Thromboembolism in first 6 weeks postpartum is 5 fold higher than in pregnancy
      1. Venous Thromboembolism Risk does not return to baseline until 12 weeks postpartum
    3. Additional VTE Risk factors include Cesarean Section, advanced maternal age, Preeclampsia, Endometritis
    4. Consider DVT Prophylaxis with Warfarin for first 6 weeks after delivery in those with prior VTE
  5. Hypertension in Pregnancy (Preeclampsia)
    1. Pregnancy Induced Hypertension may occur up to 6 weeks after delivery (have high index of suspicion)
  6. Acute Neurologic Events
    1. Cerebral Venous Sinus Thrombosis
    2. Cerebrovascular Accident
  7. Postpartum Dyspnea
    1. See Dyspnea Causes and Acute Dyspnea
    2. Acute Pulmonary Embolism
    3. Pneumonia
    4. Pneumothorax
    5. Postpartum Anemia
    6. Amniotic Fluid Embolism
    7. Postpartum Cardiomyopathy
  8. Other concerns
    1. Postpartum Anemia
    2. Contraception (address early, esp. in the prenatal period)

VI. Management: Later postpartum concerns (after first 2 weeks)

  1. Mood Disorders and psychosocial factors
    1. Postpartum Blues
    2. Postpartum Depression
      1. Affects 10% of women in first year postpartum
      2. AAP recommends screening at the 1,2,4 and 6 month visits
    3. Postpartum Psychosocial Issues
    4. Postpartum Fatigue
  2. Postpartum Thyroiditis
    1. Affects 10% of women in first year postpartum, with either Hypothyroidism or Hyperthyroidism (including Graves)
  3. Urinary Incontinence
    1. Moderate to severe Urinary Incontinence affects up to 28% of women in the first year postpartum
    2. Pelvic Floor Exercises started prenatally reduces postpartum Urinary Incontinence
  4. Sexuality
    1. Start Contraception discussion (focusing on most reliable methods) in the prenatal period
    2. See Female Sexual Dysfunction
    3. Libido may be reduced for up to one year postpartum (related to lower Estrogen levels)
  5. Intimate Partner Violence
    1. Routine screening recommended by USPTF
    2. See HITS Screen for Intimate Partner Violence
  6. Gestational Diabetes
    1. Gestational Diabetes confers a 8-20 fold increased lifetime Diabetes Mellitus risk
    2. Consider Impaired Glucose Tolerance screening at 4-12 weeks postpartum and every 1-3 years
  7. Excessive Retained Weight
    1. Retained weight from pregnancy is 5.4 kg (11.8 lbs) over prepregnant weight at 6 months postpartum
    2. Discuss lifestyle changes (Weight Reduction, Exercise in Obesity)
  8. Constipation
    1. Increase non-caffeinated fluid per day
    2. After initial management (e.g. Fleets Enema and Magnesium Citrate), short-term Polyethylene Glycol (Miralax)
    3. Institute fiber supplementation for maintenance once Constipation improves
    4. Manage Hemorrhoids
  9. Other concerns
    1. Lactation Mastitis

VII. Complications

  1. Increased mortality
    1. Women are at the highest risk of death in the first 42 days after delivery (accounts for 45% of maternal deaths)

VIII. References

  1. Lively and Clare (2022) Crit Dec Emerg Med 36(5): 4-10
  2. Paladine (2019) Am Fam Physician 100(8):485-91 [PubMed]

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