This chapter should be cited as follows: This chapter was last updated:
Lyon, D, Glob. libr. women's med.,
(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10143
April 2008

Puerperium

Postpartum Care

Deborah S. Lyon, MD
Associate Professor, Department of Obstetrics and Gynecology, University of South Florida Health Science Center, Jacksonville, Florida, USA

INTRODUCTION

After a woman has safely negotiated the physiologic hardships of pregnancy and three stages of labor, the attention of virtually everyone (family, friends, and caregivers) often turns to the infant. The enormous physical and emotional changes required to return from the status of term pregnancy to the nonpregnant state are underappreciated and often underevaluated.

The postpartum period has been termed the "fourth stage of labor",1 and has three distinct but continuous phases. The initial or acute period involves the first 6–12 hours postpartum. This is a time of rapid change with a potential for immediate crises such as postpartum hemorrhage, uterine inversion, amniotic fluid embolism, and eclampsia. Although the first several hours postdelivery are usually spent on the labor and delivery floor with intense nursing supervision, space demands often necessitate a somewhat premature transfer to the less intensive care of the postpartum ward. Here, where observation is decreased and maternal fatigue is at its peak, lies the potential for disaster.

The second phase is the subacute postpartum period, which lasts 2–6 weeks. During this phase, the body is undergoing major changes in terms of hemodynamics, genitourinary recovery, metabolism, and emotional status. Nonetheless, the changes are less rapid than in the acute postpartum phase and the patient is generally capable of self-identifying problems. These may run the gamut from ordinary concerns about perineal discomfort to peripartum cardiomyopathy or severe postpartum depression.

The third phase is the delayed postpartum period, which can last up to 6 months. Changes during this phase are extremely gradual, and pathology is rare. This is the time of restoration of muscle tone and connective tissue to the prepregnant state. Although change is subtle during this phase, it behooves caregivers to remember that a woman’s body is nonetheless not fully restored to prepregnant physiology until about 6 months postdelivery.

PHYSIOLOGIC CHANGES OF THE POSTPARTUM PERIOD

Genitourinary Changes

The most obvious postpartum change is involution of the uterus from a 1-kg structure with a 5- to 10-L volume to a 60-g structure holding 3 to 5 mL. This involution begins during the third stage of labor, accelerates after expulsion of the placenta, and continues over the next 5–6 weeks. Typically, the uterus is at the umbilicus after delivery of the placenta, and it decreases in height by about a centimeter a day until it again becomes a pelvic organ at about 12 days postpartum. Slower involution continues over the next several weeks until prepregnant size is attained. Restoration of the normal endometrial lining occurs by the 16th day postpartum.2 A lochial pattern of bleeding may persist much longer, however, with the median in a Philippine study of breastfeeding women being 27 days.3 The cervix closes to about 1 cm over the 1st week postpartum, but may take several months to attain prepregnant firmness and length. The postpartum cervix often has a transverse or “smiling” appearance, as opposed to the nulliparous pinpoint appearance. This persists indefinitely.

SONOGRAPHY

Because the normal pattern of uterine involution varies significantly, it is sometimes difficult to identify an abnormal pattern of subinvolution. Although a patient’s complaints of persistent heavy bleeding should always be taken seriously, some patients do not verbalize these concerns or have a sense of what constitutes heavy bleeding. For this reason, postpartum daily rounds should always include some attempt to quantify bleeding. The fundus should be palpated each time the patient is evaluated, and any increase in fundal height should be further evaluated. Several groups have characterized the sonographic appearance of the postpartum uterus during various stages of involution.4, 5 These references may assist in distinguishing pathology from normal variation.

RESUMPTION OF MENSES

Resumption of menses after delivery is highly variable. For most non-breastfeeding mothers, the first postpartum menses occurs at approximately 55 to 60 days (range 20 to 120) postdelivery.6 Breastfeeding may delay return of menses by several months, especially if the child is getting no other supplemental source of nutrition. Although the first several cycles may be anovulatory, ovulation has been demonstrated in 52% of women whose menses resumed less than 60 days following delivery. It is therefore of primary importance that women be provided adequate birth control very early in the postpartum period.

PELVIC FLOOR SUPPORT

Some changes to the genitourinary system are much longer in resolving, and some may never fully revert to the prepregnant state. A burgeoning volume of literature on pelvic floor support implicates childbirth as the initiation of a whole host of conditions including stress urinary incontinence, incontinence of flatus or feces, uterine prolapse, cystocele, and rectocele.7, 8 Many variables affect the duration and severity of these conditions, including the patient’s intrinsic collagen support, the size of the infant, the route of delivery, and the degree of perineal trauma occurring either naturally (lacerations) or iatrogenically (episiotomy). Even when full recovery of pelvic floor integrity appears to be the case, menopause may elicit a return of many of these problems as the collagen support of estrogen is withdrawn. Although surgical intervention should not be considered until 6 months postpartum (the length of time for complete restoration of connective tissue support), an aggressive program of pelvic floor exercises may be prescribed at any time during the antenatal or postpartum course and has been shown to be of benefit in some series.9

Cardiovascular Changes

Cardiovascular changes in the puerperium are dramatic. Blood volume increases by about 50% at the time of delivery. There is an average 500-mL blood loss at vaginal delivery, and a gradual replacement of this with an “autotransfusion” of 500–750 mL as the uterus contracts. This massive volume shift, as well as hormonal vascular effects and compression–decompression of the great vessels, all result in measurable and significant changes in every cardiac function parameter—mean arterial pressure, cardiac output, stroke volume, and systemic vascular resistance are all affected.10 This makes delivery and the few days following it extremely risky for patients with pre-existing cardiac conditions that limit adaptability to the rapid changes taking place. Most of the hemodynamic recovery occurs in the first 2 weeks postpartum, with more gradual shifts continuing over the next 4 or 5 months.11

Renal Changes

Renal anatomic changes of pregnancy (particularly dilated ureters) persist for at least 5 days postpartum,12 and in some patients may persist much longer.13 Renal function (plasma flow and glomerular filtration rate) are at prepregnant levels by 6 weeks postpartum.14

Metabolic/Hormonal Changes

Metabolic and hormonal changes postpartum are poorly understood and probably of much greater importance than the paucity of literature would suggest. The plummeting of estrogen and progesterone levels may play a role in the mood changes associated with the postpartum period,15, 16 and there is an interesting association of testosterone level with mood as well.17 Changes in blood volume, vascular bed area, all of the cardiac parameters mentioned previously, as well as activity level, sleep pattern, and emotional stressors are all profound during the first 2–6 weeks postpartum, and the ability of the body to metabolically compensate is astounding but imperfect. It is not surprising that many women with seemingly completely normal findings nonetheless complain of periods of profound exhaustion or mood lability during this period.  Weight changes are also uneven, with average weight loss being most dramatic in the first 2–3 weeks.18

Breast Changes

Changes in the breast begin well before delivery but become most dramatic postpartum. Several hormones interact to allow smooth production and excretion of milk, including the withdrawal of estrogen and progesterone, along with prolactin, glucocorticoid, insulin, and thyroid hormone activity. For approximately 3 days postpartum, the breast secretes colostrum, distinct from milk in having higher amounts of immunoglobulins and white blood cells and lower amounts of fat and lactose. Over 2 weeks, the milk assumes its typical nutritional properties.19

Breast milk excretion requires oxytocin release, which usually occurs through a reflex initiated by suckling. Oxytocin causes contraction of the myoepithelial cells surrounding the alveoli and leads to milk ejection. Whereas the mechanics of breastfeeding seem quite straightforward, many women have substantial difficulty in establishing a comfortable breastfeeding capability. The practicalities are such that a lactation consultant is an essential resource of any postpartum service.

Bone Density

Bone density decreases somewhat during normal pregnancy, probably due to calcium mobilization from maternal skeleton to fetal. The effect of breastfeeding on the restoration of bone mineral density is controversial, with some studies showing a continued loss of bone during breastfeeding and others showing stabilization at delivery levels. The exact time course of maternal bone remineralization is unclear, but it would appear that there is no long-term loss of bone mineral density associated with pregnancy.20

Hematologic Changes of the Puerperium

Primary changes of the puerperium include the acute loss and gradual recovery of red blood cells and iron, and a sharp leukocytosis in the 1st postpartum day. Although this leukocytosis may change the parameters whereby a postpartum infection is diagnosed, a white blood cell count can nonetheless be useful in the assessment of febrile morbidity. Hartmann and coworkers21 demonstrated that a rise in white blood cell count of 25–99% from postpartum was associated with a likelihood ratio of serious postpartum infection of 1.7, and a rise of at least 100% with a likelihood ratio of 5.8. The physiologic leukocytosis is probably due to demargination and resolves within a few days of delivery.

MANAGEMENT OF THE NORMAL PUERPERIUM

Hospital Discharge

Clear goals for postpartum hospitalization have not always been well articulated. Because the cost of inpatient care has skyrocketed over the past 30 years, and because third-party payers maintain a very high interest in “necessary days” of hospitalization (those that show a patient not yet having achieved but getting intervention to move her toward a defined goal), the approved length of postpartum stay has decreased to less than 24 hours in many places. This created enough anxiety among patients that it actually became an issue before the US Congress, which passed the Newborns’ and Mothers’ Health Protection Act of 1996.22 This requires insurance carriers to cover at least 48 hours of inpatient care after a vaginal delivery, and 72 hours after a cesarean delivery. It remains unclear what really constitutes an appropriate length of stay and what goals are realistic and appropriate for the immediate postpartum period. Whereas 48 hours is certainly long enough to identify most of the immediately life-threatening issues related to acute physiologic changes of delivery, it is clearly not long enough to identify more subtle concerns such as postpartum depression. There is also considerable anxiety in the nursing and pediatric communities about the short time allowed in which to educate mothers about the care and health of their newborns. The very short postpartum stay has been blamed for this country’s failure to achieve Healthy Person 2000 goals for breastfeeding, because new mothers often go home before milk production is well-established and without the easy availability of educational and emotional support required to continue this process. In the absence of a national consensus regarding goals of hospitalization, each obstetric facility should develop its own flow sheet of anticipated milestones in terms of patient health, comfort, and education, and caregivers should be attuned to any failure to achieve a milestone as a possible harbinger of postpartum complications.

Follow-Up

By the same token, the worth of the postpartum examination has been questioned. The failure of obstetricians to communicate clear goals for this visit is evidenced by the 50% no-show rate many practitioners report as the norm for postpartum visits. Timing of the visit has also varied, from 2 to 6 weeks postpartum, and with some recommending multiple visits during that interval.23 The “right” answer depends on defining what the visit is to accomplish. Screening for readiness to resume employment responsibilities should probably occur fairly late in the postpartum period, at around 6 weeks, whereas screening for postpartum depression is best accomplished within 2 weeks at the latest. The days of screening for return to sexual activity are long gone because most couples disregard medical advice on this subject in any case. Some of the rituals of the postpartum visit, such as the Pap smear, have also fallen to the managed-care dictum of no “unnecessary” intervention. It is true that there is no established medical benefit to a Pap smear if it has been less than 1 year since the patient’s last cytologic evaluation; however, given the poor compliance of most women with routine screening recommendations, it would seem a small investment to do the examination while the patient is already getting a speculum examination rather than telling her to return in 3–5 months for her annual checkup. In short, because there are few national standards here as well, each practice should decide what milestones should be assessed and at what point in the patient’s postpartum course. It may be that a 1-week phone call with mood assessment, followed by a 3- to 6-week postpartum visit with evaluation of uterus, breast, perineum, and thyroid status would work well for one setting, whereas two visits at 2 and 6 weeks might answer patient needs better for another population. In any case, there should be a well-established agenda, understood by the patient and caregivers, to give significance to the postpartum visit.

Perineal Care

Perineal care used to be one of the central facets of the hospitalized postpartum course. With the decrease in use of routine episiotomy, inspection of the perineum is no longer a well-ingrained ritual in the habits of obstetric caregivers. Nonetheless, if a significant laceration or episiotomy has been sustained, the perineum should be inspected at least once prior to discharging the patient to home. Although perineal complications are uncommon, they are invariably highly consequential when they do occur. Sitz baths can provide substantial comfort as well as cleansing, and a simple squirt bottle with tap water can be used for perineal cleansing after bladder or bowel evacuation. If lacerations have occurred in the anterior compartment (upper labia or clitoris), voiding function should be monitored carefully. Occasionally, catheterization is required because of swelling and/or discomfort. This can normally be discontinued after 24 hours. Stool softeners are often prescribed if there has been a third- or fourth-degree laceration, in hopes of preventing undue pressure on the repair site.

Breast Care

LACTATION

Breast care is one of the patient’s primary interests postpartum. For the non-breastfeeding patient, engorgement is an extremely uncomfortable condition and can account for substantial morbidity. For the breastfeeding woman, issues such as nipple care and maintenance of good milk flow are of concern. Health care professionals are unfortunately often poorly trained to address these concerns, with little practical experience to supplement training.

MEDICATION USE IN LACTATION

One of the most commonly asked questions in the postpartum period regards medication use and breastfeeding. Each medication should be reviewed in a current publication prior to approval of its use because intuition does not always suffice with regard to concentration in milk and effects on the infant. One of the most common “medications” used by patients who are breastfeeding is ethanol. This is because there is a substantial mythology that alcohol stimulates breast milk production and is nutritious for the infant. In fact, alcohol slightly decreases milk production, and crosses easily into breast milk, where it has the same effects on the infant as on an adult. There is no established or theoretical benefit to its use, and this should be explicitly discussed with the patient, as she may not bring it up herself.24 Depot medroxyprogesterone acetate, on the other hand, does appear to increase milk production and carries no known deleterious effect on the infant, making it an excellent choice for contraception in the breastfeeding patient.25

CARE OF THE BREASTFEEDING BREASTS

Breasts should be emptied whenever they become uncomfortably full, to avoid engorgement and mastitis. If the infant is not interested in feeding, milk can be expressed and frozen for later use. Use of a breast cream to help protect the nipples against cracking has been helpful. Any signs of skin breakdown should be treated promptly, and a high index of suspicion should be maintained for the possibility of yeast infection, especially if the infant has any sign of thrush.

CARE OF THE NON-BREASTFEEDING BREASTS

Women who are not breastfeeding should be instructed to wear a tightly fitting bra continuously except while in the shower (including while sleeping). Stimulation should be avoided, even to the extent of not allowing a direct stream of water from the shower to hit the breasts. Often this is sufficient to prevent engorgement, but in the event the breasts do fill despite these measures, ice packs and nonsteroidal anti-inflammatories have been very effective at providing relief. Medication should be used only if conservative measures fail. Early pharmaceutical attempts at lactation suppression included high doses of estrogens or androgens, but large doses of estrogen have been associated with a 4-fold to 10-fold increase in the risk of thromboembolic disease,26 and elevated testosterone levels have been associated with depression and anger.17 Bromocriptine has been widely used and is highly effective at suppressing lactation, but it has also been associated with postural hypotension, paradoxical hypertension, and there are case reports of stroke27 and myocardial infarction.28 Although these grave side-effects are extremely uncommon, the fact that most women who choose not to breastfeed will never become engorged is reason enough not to prescribe lactation suppression as a routine postpartum order.

Rh Factor

If the parturient is Rh-negative, the infant’s Rh status should be evaluated via cord blood. If the infant is Rh-positive and there was no evidence of an unusual fetal–maternal transfusion, the standard dose of 300 μg of Rh-immune globulin may be administered. This will provide passive immunity for up to 30 mL of fetal blood in the maternal circulation. If the infant is Rh-positive and concerns exist regarding a greater red cell exchange (abruption, previa, abdominal trauma, severe neonatal anemia, bloody or wine-colored amniotic fluid at rupture of membranes), then a quantitative method such as the Kleihauer–Bettke test should be used to determine an approximate volume of fetal blood in the maternal circulation, and the dose of Rh-immune globulin should be calculated based on this estimate.

Contraception

Whereas patients are often not considering contraception in the immediate postpartum period, providers should be. As indicated previously, couples often resume intercourse prior to a 6-week postpartum check, and ovulation may occur quite soon after delivery in the nonlactating woman. Ideally, options for birth control should have been discussed prior to labor, but no woman should be discharged from the postpartum ward without documentation of contraception planning. Postpartum sterilization should be a selection made prior to labor, and most state Medicaid plans require a consent form be signed at least 30 days in advance to ensure that women do not make an essentially irreversible decision based on the immediate crisis of labor. Other excellent postpartum contraceptive choices include intrauterine devices (copper or levonorgestrel), depot medroxyprogesterone, and in some cases, combination or progestin-only oral contraceptives. Intrauterine devices should not be placed until 6 weeks postpartum to allow for optimal uterine involution, so some parturients choose a single injection of depot medroxyprogesterone at time of hospital discharge to allow near-perfect coverage. One of the primary advantages of depot medroxyprogesterone is its extended action. A single injection will provide reliable contraception for up to 3 months, allowing some flexibility in postpartum follow-up. This is particularly useful when patient compliance is suspect and there is a special need to space pregnancies (such as in adolescents or profoundly anemic women). As noted previously, depot medroxyprogesterone may also actually increase milk production in lactating women.25 Progestin-only oral contraceptives have been highly studied and found to be safe in breastfeeding women, but are associated with elevated levels of maternal milk triglycerides compared with nonhormonal methods.29 They also have a somewhat higher failure rate than other methods. This is compensated for in the exclusively breastfeeding patient by the ovulation suppression associated with lactation. As soon as supplementation occurs, however, the ovulation-suppressing benefits of breastfeeding sharply diminish, and risk of unexpected pregnancy increases. Use of combination estrogen-progesterone contraceptives remains controversial. If administered immediately postpartum, they may diminish or entirely prevent milk production. In addition, there is a distinct increase in thromboembolic risk associated with immediate postpartum estrogen use. If use is deferred 2 weeks, however, they may suppress the quantity of milk only very slightly, and there is no evidence of any deleterious effect on infants of breastfeeding mothers who use combination contraceptives.30 The risk of thromboembolism also decreases as vascular responsiveness returns, activity is increased, and uterine involution allows improved blood return from the pelvis and lower extremities. Thus, if combination contraceptives are used, it is recommended that low-dose formulations be prescribed and that they not be initiated prior to 2 weeks postpartum. Although there are no data with regard to combination contraceptive patches or vaginal rings, they should theoretically have the same limitations and outcomes as oral preparations because they function in much the same way.

Exercise

Exercise during the postpartum period should be in proportion to the patient’s previous fitness and current energy level. Whereas most healthy women are capable of beginning a formal exercise program within days of delivery, the physical stressors of late pregnancy, labor and delivery, and caring for a newborn all take their toll in both exercise intensity and endurance. In general, it can be assumed that the level of exercise a patient was undertaking prior to pregnancy should be achievable by about 4–6 weeks postpartum if resumed in gradual increments. Complications such as postpartum hemorrhage, hypertensive disease, or postpartum depression may all delay the normal return of good physical condition, and the notion of “No pain, No gain” should be discouraged in favor of a more gradual physical conditioning program.31 Concerns about exercise diminishing milk production or infant acceptance of breast milk appear unfounded.32

PATHOLOGY DISTINCTIVE TO THE POSTPARTUM PERIOD

 Postpartum Hemorrhage

Defining the risk of postpartum hemorrhage is next to impossible, because of variations in definition and inaccuracies inherent in clinical estimates.  It is nonetheless the most common life-threatening condition in pregnancy, and still causes more direct maternal mortality than any other condition, particularly in the developing world.  Most obstetricians have a well-defined management algorithm for this condition that includes vigorous uterine massage, manual extraction of clots and placental fragments, and various pharmaceutical regimens such as pitocin, 15-methyl prostaglandin F2alpha, and methergine.  Recently the gastrology agent misoprostol has shown amazing utility in the setting of postpartum hemorrhage despite labeling suggesting it is absolutely contraindicated in pregnancy.  Because misoprostol is inexpensive, easily stored, and has very few side effects or monitoring requirements, it is rapidly becoming an agent of choice in the developed world, and has a clear and invaluable role in the developing world where other alternatives are not available.33

Mastitis

Mastitis is arguably the most easily recognized complication of the postpartum period next to hemorrhage. It occurs in 5% of breastfeeding women34 and is associated with fevers that can be quite high, erythema of a portion of a breast, induration, exquisite tenderness, and systemic findings such as chills and malaise. Ninety-five percent of these infections are from single-organism Gram-positive sources, and 50% are due to Staphylococcus aureus. The organism is commonly transferred from the infant’s mouth during breastfeeding. Treatment includes thorough and frequent expression of milk (there is no risk to the infant of continuing to breastfeed, if the patient’s pain threshold will allow it; otherwise she should be instructed to manually express her breasts at frequent intervals) to prevent stasis, analgesics such as aspirin or acetominophen, local comfort measures such as a well-supporting bra and local heat, and a semisynthetic penicillin (erythromycin or cephalosporins are acceptable alternatives). Failure of the process to respond promptly suggests an abscess, and consideration must be given to incision and drainage.

Epidural Back Pain

Back pain is a common complaint of pregnancy, but new-onset postpartum back pain has often been associated with use of epidural analgesia. It appears to be more common with a dense motor block, presumably because this allows for nonphysiologic labor positions to be maintained for prolonged periods. It is also more common when epinephrine is used in the anesthetic, or when chloroprocaine is used rather than bupivacaine. Attention must be paid to this complaint because it is occasionally related to an epidural hematoma or abscess. Careful imaging studies are required to identify these complications. In general, new-onset postpartum backache related to epidural anesthesia is not severe, although it may persist for many months.35

Postpartum Renal Failure

Several extremely serious and sometimes lethal conditions may occur in the puerperium. Hypertensive crises such as eclampsia are certainly in this group, but are common in pregnancy as well as postpartum, and are thus dealt with extensively in other chapters.

Postpartum renal failure is an idiopathic condition that is uncommon but devastating. It is similar to hemolytic uremic syndrome, and is manifested by renal failure, microangiopathic hemolytic anemia, thrombocytopenia, and hypertension. It can occur anywhere from 72 hours to 10 weeks following delivery. It can be extremely difficult to distinguish idiopathic postpartum renal failure from severe preeclampsia, acute tubular necrosis from hemorrhage, and sepsis. Once other diagnoses are excluded, the treatment for postpartum renal failure is supportive, with dialysis as the primary intervention. It is usually reversible.36

Sheehan’s Syndrome

Postpartum pituitary necrosis, commonly known as Sheehan’s syndrome, may occur following profound hemorrhage or eclampsia. The mechanism of injury is thought to be hypoxic because the anterior pituitary is the area of the brain most sensitive to hypoperfusion. The posterior pituitary is generally spared. Clinical signs include absence of lactation, amenorrhea, loss of axillary and pubic hair, genital and breast atrophy, “superinvolution” of the uterus, infertility, hypothyroidism (fatigue, cold intolerance, edema), and adrenocortical insufficiency (fatigue, anorexia, weight loss, decreased skin pigmentation, abnormal stress response).37 Many of these symptoms overlap common postpartum findings, so the diagnosis may be elusive, especially if necrosis is incomplete and areas of the anterior pituitary are spared. Any prolonged amenorrhea in the face of inability to lactate should lead the clinician to consider this diagnosis in the differential. Pituitary function is not generally retrieved, so replacement of anterior pituitary hormones must be lifelong.

Peripartum Cardiomyopathy and Cerebrovascular Disease

Peripartum cardiomyopathy may appear in the last month of pregnancy, but it more commonly occurs within the first 5 months postpartum.38 Incidence is between 1 in 2400 and 1 in 15,000 deliveries. Risk factors include increased age, black race, multiple gestation, and preeclampsia. Although presenting symptoms are typical of heart failure (dyspnea, fatigue, and edema), these may be subtle and are easily missed unless the myopathy is florid. Failure may lead to findings of rales, an audible third heart sound, peripheral edema, and jugular venous distention. Cardiomegaly will be evident on chest x-ray, but is likely to be underdiagnosed because films may be portable and of suboptimal quality and because there is a mild degree of cardiomegaly associated with pregnancy. An electrocardiogram may be completely normal or may include changes consistent with left ventricular hypertrophy, bundle branch block, or arrhythmias. The echocardiogram is the test of choice, and it will show left heart dilatation, hypodynamic wall motion, and possibly, ventricular thrombi. To be classified as peripartum cardiomyopathy, the condition must be idiopathic and limited to the timeframe noted previously. Treatment is similar to that for any heart failure and is aimed at controlling afterload through sodium restriction and diuretics and controlling rhythm with digitalization. If thrombi are present, anticoagulation is also required. About half of these patients will have complete resolution with appropriate therapy, usually within 6 months. Future pregnancies are not contraindicated in these patients, but recurrence is not unusual. 

Cerebrovascular disease among pregnant and postpartum women is more common than previously assumed,39 possibly because of more women becoming pregnant in their 40s, and possibly also due to better diagnostic techniques.  Risk factors include most that are common to cerebrovascular disease in non-pregnant individuals, such as migraine, thrombophilia, known pre-existing heart disease, sickle cell disease, and hypertension.  Other associated conditions have included systemic lupus erythematosus, postpartum hemorrhage, preeclampsia, transfusion, and postpartum infection.  Presence of any of these risk factors should heighten clinical suspicion for cerebrovascular compromise in this usually very  healthy population.

Postpartum Angiopathy

Call–Fleming syndrome is a rare cerebral vasoconstriction syndrome occurring in the postpartum period.  It can be easily confused with eclampsia because of a very similar clinical presentation, but occurs in the absence of concomitant hypertension or proteinuria.  Treatment is symptomatic and prognosis is excellent if iatrogenic harm is avoided.40

Postpartum Depression

Postpartum depression has been the subject of many monographs, book chapters, research studies, and media blitzes. Although not qualitatively different from any other major depressive episode, it is described with a separate specifier in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders.41 Few other life stressors besides delivery so frequently lead to mood disorders, and often the patient’s role as an infant’s caregiver may limit diagnostic and intervention measures. In fact, a recent attempt to validate two psychological/physiologic health status questionnaires in the postpartum population ended with the conclusion that community normative values could not be assumed as normative in this group.42  Most women experience some period of transient depressed mood within the 1st week of delivery, referred to as postpartum blues. This may represent a combination of physical exhaustion, an overwhelming sense of the responsibilities of parenthood, and massive hormonal and metabolic shifts. For most parturients, this period is brief (days to a week) and unnerving but manageable. Some patients, however, continue down the slope to feelings of despair, gross inadequacy, isolation, and depersonalization. In some cases, this can become a psychotic condition, leading to suicide or homicide.43  Even at considerably less than these extremes, postpartum depression can be quite debilitating. Early identification is paramount in providing effective intervention. Patients at particularly high risk for postpartum depression include those with a past history of depression, with complicated or extremely high-risk pregnancies, with poor social supports, and with particularly unrealistic initial expectations of motherhood. Patients often do not volunteer their depressed emotion, and even direct inquiry may be unrevealing if the patient is highly socially responsive. A standardized screening tool such as the Edinburgh Postpartum Depression Scale44 or the Beck Depression Inventory45 can easily be incorporated into a 1- or 2-week phone call or 2- or 3-week follow-up visit protocol to allow thorough screening for this common and potentially devastating condition.46

SYSTEMIC PATHOLOGY OF SPECIAL INTEREST IN THE POSTPARTUM PERIOD

Several conditions, although far from unique to the postpartum period, pose special risk or concern during this time. These include thyroiditis, connective tissue disease, thromboembolic disease, and domestic violence. Postpartum depression should by all rights also go in this category because the primary predisposing factor is a past history of depression. Nonetheless, because of its unique features in the postpartum period, it is addressed in the next section.

Thyroiditis

Postpartum thyroiditis carries features strongly suggesting that it is an autoimmune disease.47 Its incidence varies by region, ranging from 1.1% in Thailand to 8.8% in the United States to 16.7% of puerperal patients in the United Kingdom. The only known risk factor is a prior history of type I diabetes, which in the United States increased the incidence of thyroiditis to 25% of parturients. One third of these patients will develop permanent hypothyroidism. Clinical features include painless enlargement of the thyroid gland and depression, but these findings are easily missed or misattributed. There is no recommendation for screening, so the only hope for prompt diagnosis remains a high index of suspicion. Thyroid function tests should be drawn in any patient exhibiting features of either hyper- or hypothyroidism because either manifestation may be evident. Management should be in consultation with an endocrinologist, and patients with a hypothyroid phase of the disease should probably be treated indefinitely, as even biochemical euthyroidism does not appear to indicate complete resolution of the disease.

Connective Tissue Disease

Many connective tissue diseases show significant regression during pregnancy, followed by postpartum flares. Of particular interest, however, is the new onset of disease in the postpartum period. Several series have suggested that, in women who eventually develop diseases such as rheumatoid arthritis, there is an uneven distribution of disease onset, with 12% to 20% developing initial signs and symptoms during the 1st year postpartum or postabortion.48 The immunology of the postpartum period is poorly understood, but the unexpectedly high new onset of connective tissue diseases as well as thyroiditis suggests a susceptibility to autoimmune phenomena not present at other times in a woman’s life.

Thromboembolic Disease

Thromboembolic disease is overrepresented in parturients because of a particular propensity for Virchow’s triad of risk factors—stasis due to poor return from the lower extremities (partly a compression phenomenon from the uterus against the inferior vena cava, and partly a progesterone effect of smooth muscle relaxation leading to decreased vascular tone), hypercoagulability due to high endogenous estrogen levels, and trauma associated with prolonged labor or cesarean delivery. Special risk factors include hypertensive disorders, multiple-order gestation, smoking, and operative delivery, but these risk factors do not account for the majority of the pregnancy-related risk, at least of pulmonary embolism and stroke.49 Thus, no parturient may truly be considered at low risk for thromboembolic phenomena until the resolution of her hormonal and anatomic risks—in other words, until she has successfully traversed the postpartum period.

Domestic Violence

Domestic violence cannot be considered a disease by the strictest interpretation of the term, and yet it is occurring in epidemic proportions and with substantial consequent morbidity in this country.50 Women aged 16–24 years are at highest risk, and frequency of physical violence in this population appears highest at 3 months postpartum (higher than preconceptually or during any part of the pregnancy).51 As with many of the other conditions discussed in this section, the best screening tool remains a thorough history and a high index of suspicion.

SUMMARY

The postpartum period is one of rapid and then gradual resolution of most of the changes of pregnancy back to the prepregnant condition. Whereas these changes are physiologic, much like pregnancy itself, there remains a great deal of biologic hazard in traversing this territory. Caregivers and community have focused heavily on the delivery and the baby and have tended to neglect the puerperium as an area worthy of attention. Consequently, many complications go unnoticed altogether or are identified late. A wise practitioner will maintain a consistent personal algorithm for routine care of the parturient and an aggressive differential diagnosis of complaints lodged during this time. Effective screening practices along with a high index of suspicion will go a long way in providing a smooth return of the parturient to whatever degree of normalcy a new mother will achieve.

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