post-partum / puerperial complications

Introduction

most patients have an uneventful post partum course, but unfortunately many develop complications and issues which can create substantial impacts and in some cases can be life threatening.

urinary tract infections (UTIs) / cystitis
endometritis
biliary colic commonly presents in the puerperium
constipation
haemorrhoids and other anal conditions
diarrhea due to:
- overflow incontinence from fecal impaction or paravaginal haematoma
- antibiotic-related diarrhoea
- other causes
urinary retention due to
- cauda equina syndrome from epidural haematoma or abscess following spinal anesthetic, or a disc prolapse
- paravaginal haematoma
- urethral trauma
- medications
- constipation
other causes of abdominal pain not specific to puerperium

eclampsia may 1st present in the 1st week post partum as a seizure
deep venous thrombosis (DVT) or pulmonary embolism (PE) - more likely after LUSCS
rarely, air embolism
- rarely, fatal air embolism may occur following manual repositioning of uterine inversion in 3rd stage of labour as well as during the 2nd stage of labour (especially with forceps delivery), and rarely, following drainage of a LUSCS wound abscess.
- fatal air embolism is a rare cause of death in the puerperium and presumably occurs when there is delay in the usual thrombotic occlusion of the placental bed vasculature which becomes exposed to air within the uterus
  - it is mainly associated with coitus or oral sex, and a significant number also were associated with amphetamine use as well as coitus
  - a 1936 case report of a patient on day 8 when she was in knee chest exercise posture for 5 minutes and noted to have a moderate subinvoluted uterus with small amount of RPOC, and another case report of similar position causing death in 1938 on day 7 and again associated with some RPOC

RPOC and endometritis
episiotomy wound or perinear tear repair complications
- massive haematomas can be life threatening
traumatic delivery issues:
- fractured coccyx
- vaginal bleeding from vaginal tears, cervical tears
- psoas muscle haematoma
- vulval haematoma
- supravaginal haematoma
  - this may be life threatening as they are usually arterial bleeds similar to ruptured ectopics and cause shock
  - located above the levator ani muscle and are due to damage to the uterine artery branches in the broad ligament and can dissect retroperitoneally or develop within the broad ligament
  - difficult to diagnose and thus often present as shock
- paravaginal haematoma
  - this may be life threatening as they are usually arterial bleeds similar to ruptured ectopics and cause shock
  - caused by damage to the descending branch of the uterine artery
  - some 1 in 1000 to 1 in 4000 deliveries, most occur within 1st few days of delivery, but some present 2-4 wks post partum ¹⁾
  - mass often occludes the vaginal canal and extends into the ischiorectal fossa
  - difficult to diagnose early as often non-specific symptoms with pelvic or rectal pain
  - later may develop urinary retention due to mass effect, bruising buttocks/perineum, obvious paravaginal mass on bimanual PV exam and then shock
  - see https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1576/toag.9.3.195.27341

presence of buttock bruising or urinary retention should prompt a search for a paravaginal haematoma

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