Postpartum Complications: Sepsis, hematoma, Mastitis, UTI, DVT, Psychological

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Postpartum Complications

The puerperium spans 6 weeks after delivery. Several complications can arise during this period; early recognition and prompt management are the cornerstones of care.

1. Puerperal Sepsis

Definition: Infection of the genital tract within 3 weeks after delivery.

Clinical features:

Pyrexia (fever) and tachycardia
Foul-smelling lochia
Pain and tenderness in the lower abdomen
The most common organism is Streptococcus pyogenes (Group A beta-hemolytic streptococcus), which can cause endometritis and bacteremia. Staphylococci and anaerobes are also implicated.

Pathophysiology: Streptococci enter the uterus after delivery, infecting the wound (endometritis), and can progress to septicemia.

Prevention: Strict asepsis before, during, and after delivery - especially important in domiciliary (home) midwifery services.

Management:

Blood cultures + wound swabs
Broad-spectrum IV antibiotics (e.g., IV amoxicillin-clavulanate ± metronidazole; clindamycin + gentamicin)
Sepsis bundle: IV fluids, monitoring lactate, organ support as needed
Source control (e.g., evacuation of retained products if endometritis)

Park's Textbook of Preventive and Social Medicine

Jawetz Melnick & Adelberg's Medical Microbiology 28E

2. Postpartum Hematoma

Definition: A collection of blood in the connective tissue spaces of the genital tract following delivery, usually within 24 hours.

Sites:

Vulval hematoma - most common; below the pelvic floor
Paravaginal hematoma - above the pelvic floor, extends into the broad ligament
Broad ligament hematoma - serious; can be life-threatening

Causes:

Injury to blood vessels during delivery without a corresponding laceration of the overlying mucosa
Episiotomy or perineal tear with poor hemostasis
Instrumental delivery (forceps)
Bleeding diatheses

Clinical features:

Severe vulval pain and pressure sensation
Visible or palpable tense, fluctuant swelling
Bluish discoloration of the perineum/vulva
Tachycardia and hypotension if large

Management:

Small hematoma (< 4 cm, stable): Conservative - ice packs, analgesia, observation
Large/expanding hematoma: Surgical incision, evacuation of clot, suture of bleeding points, vaginal packing
Blood transfusion if significant blood loss
Antibiotics to prevent secondary infection

3. Mastitis

Definition: Inflammation of the breast parenchyma, most common in the second postpartum week, due to milk stasis and retrograde bacterial infection.

Epidemiology: Affects ~1/3 of breastfeeding women in the US; progresses to breast abscess in up to 10% of cases. - Red Book 2021

Causative organisms:

Staphylococcus aureus (40% of cases) - most common
Escherichia coli
Streptococcus species
Community-acquired MRSA must be considered

Clinical features:

Severe pain, tenderness, swelling, redness of the breast (usually unilateral, one segment)
Fever, chills, myalgias
Flu-like systemic symptoms

Differentials: Breast engorgement, plugged duct, inflammatory breast carcinoma (rare but important)

Ultrasound findings:

Mastitis: hypoechoic fluid surrounding subcutaneous fat lobules, no discrete fluid collection
Abscess: discrete hypoechoic fluid collection with absent vascular signals

Fig: Mastitis - hypoechoic fluid around fat lobules without discrete collection (Tintinalli's Emergency Medicine)

Fig: Breast abscess - discrete hypoechoic fluid collection (Tintinalli's Emergency Medicine)

Management:

Do NOT stop breastfeeding (or pumping) - continued emptying is therapeutic
Frequent analgesia (NSAIDs/paracetamol)
Antibiotics: antistaphylococcal penicillins (dicloxacillin/flucloxacillin) or 1st-generation cephalosporins
Note: Sulfamethoxazole-trimethoprim is contraindicated in lactating mothers with infants < 2 months old
If no improvement in 48 hours: assess for abscess with ultrasound
Breast abscess: ultrasound-guided aspiration/drainage preferred; surgical drainage reserved as last resort (risk of milk fistula); IV vancomycin for septic inpatients

Tintinalli's Emergency Medicine

4. Urinary Tract Infection (UTI)

Context: One of the most common postpartum infections. Predisposing factors are unique to the puerperium.

Risk factors:

Bladder overdistension and incomplete emptying postpartum
Urinary catheterization during labor
Perineal trauma and local contamination
Epidural analgesia (reduces awareness of bladder fullness)
Residual urine from uterine pressure

Causative organisms: E. coli (most common), Klebsiella, Enterococcus, Proteus

Clinical features:

Dysuria, frequency, urgency
Suprapubic tenderness
If ascending to kidneys (pyelonephritis): high fever, rigors, flank/loin pain, vomiting

Management:

Urine culture and sensitivity (midstream clean-catch)
Encourage high fluid intake
Uncomplicated cystitis: 3-7 day course of antibiotics - nitrofurantoin (avoid if breastfeeding), trimethoprim, cefalexin (note: TMP-SMX avoided in first 6 weeks if breastfeeding)
Pyelonephritis: IV cephalosporins or aminoglycosides, then oral step-down
Remove/change urinary catheter early

Park's Textbook of Preventive and Social Medicine

5. Deep Vein Thrombosis (DVT) / Thrombophlebitis

Why postpartum women are high risk (Virchow's triad is fully activated):

Factor	Postpartum Change
Stasis	Immobility, bed rest, prolonged labor
Hypercoagulability	Elevated clotting factors, decreased protein S, increased fibrinogen
Endothelial injury	Pelvic/perineal trauma, C-section

Peak risk period: First 6 weeks postpartum; risk is highest in the first 2 weeks. Risk is 5-10x higher than in non-pregnant women.

Clinical features (superficial/DVT):

Leg becomes tender, pale, and swollen ("white leg" or phlegmasia alba dolens if severe)
Calf tenderness, warmth, erythema
Positive Homans' sign (limited diagnostic value)
Frequently associated with varicose veins

Diagnosis:

Wells score clinical probability assessment
D-dimer (high sensitivity, low specificity postpartum)
Compression duplex ultrasonography - first-line imaging
CT pulmonary angiography if pulmonary embolism suspected

Management:

Low Molecular Weight Heparin (LMWH) - treatment of choice; safe with breastfeeding
Warfarin acceptable postpartum (safe in breastfeeding); target INR 2-3
DOACs (rivaroxaban, apixaban) generally avoided while breastfeeding
Graduated compression stockings
Early mobilization - key prevention strategy
Risk-stratify all postpartum women for VTE prophylaxis

Prevention:

Early ambulation after delivery
Hydration
LMWH thromboprophylaxis in high-risk women (C-section, obesity, prior VTE, thrombophilia)

Park's Textbook of Preventive and Social Medicine

6. Psychological Complications

Psychological disturbances form a spectrum, from mild and transient to severe and life-threatening.

A. Postpartum Blues ("Baby Blues")

Affects up to 65% of mothers
Onset: days 3-5 after delivery
Features: tearfulness, mood lability, anxiety, irritability
Self-limiting; resolves within 2 weeks
Management: reassurance, support, rest

B. Postpartum Depression (PPD)

Affects 3-6% of women (some estimates up to 10-15% for major depression)
DSM-5 specifier: "with peripartum onset" - onset during pregnancy or within 4 weeks of delivery (clinically, often recognized up to 12 months)
Features: persistent low mood, anhedonia, sleep disturbance, guilt, poor bonding with infant, thoughts of self-harm
10% of mothers with blues progress to full major depression

Risk factors: Past history of depression or PPD, bipolar disorder, family history, inadequate social support, stressful life events

Management:

Psychotherapy (CBT, interpersonal therapy) - first-line for mild-moderate
SSRIs (sertraline, paroxetine) - safe in breastfeeding; first-line pharmacotherapy
Brexanolone (IV neuroactive steroid) - FDA-approved specifically for PPD
Screen with Edinburgh Postnatal Depression Scale (EPDS)

C. Postpartum Psychosis (Puerperal Psychosis)

Rare but psychiatric emergency - ~1-2 per 1000 deliveries
Onset: 48-72 hours after delivery (can be delayed)
Often follows a delivery complicated by hemorrhage or infection, but frequently occurs without any obstetric complication

Features (from Adams & Victor's Neurology):

Alternating between noisy hyperactivity and mutism/inactivity
Disorientation, thought disorder
Baby may be rejected as not belonging to the mother
Can present as:
- ~40% predominantly affective
- ~20% schizophreniform
- Remainder: self-limited confusional psychoses (Boyd's series)
Infanticide and suicidal ideation are the most dangerous aspects

Differential diagnosis of postpartum psychosis (must exclude):

Eclampsia
Sheehan's syndrome (pituitary infarction)
Cerebral venous sinus thrombosis
Ergot-induced psychosis
Hypoxic-ischemic brain injury

Management:

Urgent psychiatric admission (mother-baby unit if available)
Mood stabilizers (lithium - caution with breastfeeding), antipsychotics
ECT in severe refractory cases
Risk: most closely related to past history of postpartum psychosis, bipolar disorder, or family history of bipolar disorder

Adams & Victor's Principles of Neurology, 12th Ed

Rosen's Emergency Medicine

Summary Table

Complication	Timing	Key Feature	First-line Management
Puerperal Sepsis	Within 3 weeks	Foul lochia, fever, uterine tenderness	IV broad-spectrum antibiotics
Hematoma	First 24 hours	Tense painful vulval/perineal swelling	Incision & evacuation if large
Mastitis	Week 2 postpartum	Unilateral red, tender breast with fever	Antistaphylococcal antibiotics + continue feeding
UTI/Pyelonephritis	Any time	Dysuria/loin pain; predisposed by catheterization	Antibiotics per culture
DVT/Thrombophlebitis	First 6 weeks (highest: weeks 1-2)	Swollen, tender, pale leg	LMWH anticoagulation
Postpartum Blues	Days 3-5	Tearfulness, transient	Reassurance and support
Postpartum Depression	Within 4 weeks - months	Persistent low mood, poor bonding	SSRI + psychotherapy
Postpartum Psychosis	48-72 hours	Confusion, rejection of infant, infanticidal risk	Emergency psychiatric admission

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