Postpartum Emergencies

David C. Jones

POSTPARTUM EMERGENCIES

Most pregnancies conclude successfully, and when postpartum complications arise, they usually arise prior to discharge from the hospital.

SEIZURES

Eclampsia is the most common etiology for postpartum or peripartum seizures. While most eclamptic seizures occur prior to or during labor, 20% occur postpar­tum. Most of those occur within the first 48 hours, but they may be seen as late as a week after birth and have even been reported 23 days after delivery. If there is no history of a prior seizure disorder, the diagnosis of eclampsia should be assumed until proven otherwise. The first priority in these cases is to stop the seizure, and the drug of choice for this is magnesium sulfate. There are several protocols for admin­istration, but a reasonable choice with eclampsia is to load with 6 mg intravenously over 20 minutes and then begin an infusion of 2 mg per hour, aiming for a therapeu­tic level of 5 to 8 mg/dL. This infusion is continued for 24 to 48 hours, although this will most likely be managed by the admitting obstetrician. If the magnesium fails to control the seizure, secondary medications that may be used include thiopental 100 mg administered slowly intravenously or diazepam 2 to 10 mg intravenously.

Since eclampsia is usually accompanied by the standard signs of preec­lampsia, the presence of hypertension and proteinuria as well as the symptoms of a severe headache, blurred vision, and scotoma would help support that diag­nosis. The physical examination may also reveal right upper quadrant pain (due to swelling of the liver within the capsule), hyperreflexia, edema (particularly of the hands and face), and clonus. Laboratory studies may show an elevated uric acid, and possibly elevated liver functions, and elevated serum creatinine or thrombocytopenia. While eclampsia is the most likely diagnosis, once the sei­zure is controlled, other possible etiologies should be considered. A CT scan is indicated in the evaluation as the differential diagnosis includes cerebral venous thrombosis, hemorrhagic stroke, CNS tumors, and the syndrome of inappropri­ate antidiuretic hormone secretion. If associated symptoms such as hyperten­sion are found, they should be controlled with relatively rapidly acting agents such as beta-blockers (e.g., labetalol) or calcium channel blockers (e.g., nife­dipine). These patients are usually admitted to the labor and delivery suite or to a monitored floor where the magnesium infusion is continued for at least 24 hours and monitoring for further seizures is maintained.

Primary Medical Problems of the Postpartum Patient seen at the Emergency Department

Infection

Genital tr act

Endometritis

Parametritis

Pelvic cellulitis (including infected vaginal lacerations and repaired episiotomies)

Necrotizing fasciitis, toxic shock syndrome

Septic pelvic thrombophlebitis

Mastitis

Urinarytr act

Cystitis

Pyelonephritis

Postpartum hemorrhage

Early

Late

Thrombosis and thrombophlebitis

Superficial thrombophlebitis

Deep venous thrombosis

Pulmonary embolism

Ovarian torsion

Postpartum seizures

Eclampsia

Other

Postpartum psychological reactions

Initial maternal indifference

Postpartum "blues"

Postpartum depression

Postpartum psychosis

POSTPARTUM HEMORRHAGE

Blood loss exceeding 500 mL at a vaginal delivery is generally considered a postpartum hemorrhage (PPH); however, studies have shown that the average blood loss at a delivery is about 600 mL.

Immediate PPH is usually due to uterine atony, but other etiologies must be considered including lacerations, retained placenta, uterine rupture (if the patient has a history of prior c-section), and coagulation abnormalities. When a patient is seen emergently after a delivery outside the hospital, heavy bleeding can potentially lead to a state of shock, and fluid resuscitation must be pursued in parallel to the workup of the bleeding. Obstetric hemorrhage requiring a transfusion generally requires many units of blood, so getting units of packed cells typed and crossmatched should be done at the first thought a transfusion may be necessary. Late hemorrhage is more likely caused by retained placenta or membranes, infection, subinvolution of the placental site, coital trauma, or breakdown of genital tract laceration repairs.

Workup and Treatment

When a patient presents with bleeding, initial assessment must include vital signs, complete blood count, and obviously physical examination. The initial vital signs may suggest the need for fluid resuscitation, and placing one or two large-bore IVs is appropriate. The initial focus of the physical examination is the uterus.

If there is no evidence of retained products of conception or uterine bleeding persists despite their removal, other nonsurgical approaches are available. Intra­uterine balloon tamponade is an effective treatment for PPH, particularly those related to bleeding from the lower uterine segment such as a relative low placen­tal implantation (4). This balloon is useful both in terms of treating atony and also as a means of deciding who will probably need surgical management (4). In cen­ters that have interventional radiology services available, embolization of the uterine arteries or hypogastric arteries will frequently control bleeding and avoid surgery. The interuterine balloon may also be placed to decrease hemorrhage while the IR team is being assembled. If these nonsurgical methods fail and it is clear that the etiology of the bleeding is uterine rather than from another site, a laparotomy will be required. Surgical ligation of the uterine or hypogastric arter­ies may decrease the pulse pressure and control the bleeding adequately.

Because chorioamnionitis and endometritis may increase the likelihood of uterine atony, signs such as an elevated white blood cell count, c-reactive protein, uterine fundal tenderness, and fever should be evaluated. If there is suspicion of infection, appropriate treatment includes admission to the hospital for inpatient intravenous antibiotics.

In an immediate PPH, evaluation for other etiologies would include a careful examination of the vagina and the cervix for lacerations. Bleeding lac­erations should be repaired with an intermediate-duration absorbable suture. In a delayed PPH when the bleeding is from a prior repair, antibiotic coverage is appropriate. If the repair does not appear infected, a few stitches can be placed to address the bleeding. If the repair is broken down and appears badly infected, a full repair is best postponed until the infection is well-controlled with antibiotics.

Finally, in some patients, there may be coagulopathies, either because of inherent bleeding disorders or because of disseminated intravascular coagula­tion secondary to their ongoing PPH. Coagulation parameters should be mea­sured, and blood product components replaced as necessary. A number of obstetrical disorders, including familial thrombophilias with a bad obstetric history, a history of thromboembolism, and antiphospholipid antibody s yndrome, are now treated with anticoagulation, at both prophylactic and therapeutic doses. A careful history of past medical conditions and medications once again plays an important role here.

THROMBOEMBOLISM

The risk of thromboembolism is increased during pregnancy. In fact, a number of factors come together to make pregnancy and the postpartum period perhaps the highest-risk period in a woman’s life. Stasis, vessel wall injury, and altered clotting factors promoting clotting, the classic triad leading to intravascular thrombosis that was proposed by Virchow, are all present. All of the clotting factors except XI and XIII are increased in pregnancy, and there is mixed evidence that activity of the fibrinolytic system may be decreased during pregnancy. Venous stasis occurs in maternal leg veins primarily through two mechanisms. First, the gravid uterus compresses the inferior vena cava and iliac veins. This leads to both venous stasis and the lower extremity edema commonly experienced by pregnant women in the third trimester. Venous dilation also plays a role, most likely due to progesterone, allowing for more pooling in the leg veins. After delivery, decreased mobility, par­ticularly after a c-section, may play an additional role in promoting stasis. Blood vessel damage may occur directly from delivery. These factors all come together after delivery and put the woman at high risk for thrombosis. Thromboembolism in pregnancy is often the first clue that a patient has a familial or acquired throm­bophilia, and a workup to identify these is appropriate (Table 15.2).

Superficial Thrombophlebitis

Superficial thrombophlebitis is the most common thrombosis identified during pregnancy occurring in 11 per 1,000 deliveries (6). Patients present with pain, redness, and warmth over the affected area. The affected vein may be swollen, but this may be hard to identify. Occasionally, the clot itself is palpable as a “cord.” Superficial thrombosis poses no direct risk to the patient beyond discomfort. It is usually treated with heat, elevation, analgesics (especially aspirin), and occasion­ally, anticoagulation. If there is evidence of cellulitis, prescription of an antibiotic with coverage for skin flora (e.g., Staphylococcus and Streptococcus') such as dicloxacillin is appropriate. Superficial thrombophlebitis, particularly of the saphenous vein, can progress to deep venous thrombosis, so if there is any ques­tion of the extent of the clot, appropriate studies to rule out deep vein thrombosis must be obtained.

Deep Venous Thrombosis

Unlike the more benign superficial thrombophlebitis, DVT poses a direct risk to the patient because it may lead to a pulmonary embolism (PE). Conse­quently, it is of utmost importance to accurately identify and expeditiously treat this condition. The main complaint women present with is pain and leg swelling. This is usually unilateral leg swelling, which helps distinguish it from the normal lower extremity swelling of pregnancy. If a clot reaches the inferior vena cava, bilateral swelling may occur, which can lead to the false

Thrombophilia Panel

Activated partial thromboplastin time Anticardiolipin antibodies

Lupus anticoagulant

Protein S

Protein C

Antithrombin III

Leiden factor V mutation screen

Prothrombin G20210A mutation screen

Hyperhomocysteinemia (fasting homocysteine level)

Activated protein C resistance attribution of the swelling to normal postpartum swelling. The challenge in making this diagnosis is that there are no signs or symptoms (including pain and swelling) that are sensitive or specific. Homan’s sign, the classic sign for DVT of pain in the calf with dorsiflexion of the foot, is not sensitive nor spe­cific. The clinician’s main tool is a high index of suspicion. When history and physical examination findings allow for DVT to be in the differential diagno­sis, it must be ruled out as best as possible. The standard means for assessing this is a venous Doppler flow study. This is a noninvasive study that looks for alterations in flow that suggest an obstruction and has a sensitivity of up to 90% with a specificity of 98% (6). An alternative noninvasive procedure, imped­ance plethysmography, examines changes in resistance in tissue. This evalua­tion tool has largely been replaced by Doppler due to its lower sensitivity and specificity (77% and 93%, respectively), but it still may be useful in some cen­ters because it is a relatively automated study and does not require the skilled examiner needed for a Doppler study (7). Traditionally the gold standard, venography has been replaced by the noninvasive tests. One of the reasons for this shift is not only that venography is invasive, but also that one of its com­plications is venous thrombosis. Because of this, it is reasonable to check other lab studies prior to moving forward with venography. d-Dimer and fibrinopep- tide A are both highly sensitive (but not specific) for venous thrombosis. Normal d-dimer and fibrinopeptide A levels all but rule out thrombosis. In cases where noninvasive tests are inconclusive and the index of suspicion remains high with abnormal d-dimer or fibrinopeptide A levels, venography is still a useful option. [¹²⁵I] fibrinogen is given intravenously and is taken up into the clot. Isotope scanning is useful for clots that are at, or distal to, the midthigh.

Pulmonary embolization arises mostly from DVT above the knee. While DVTs below the knee were once treated less aggressively, the realization that 20% will propagate above the knee has led to the treatment being uniform despite precise location. Up to 25% of untreated DVTs will embolize to the lung, leading to death in up to 15% of patients. By contrast, when patients are appro­priately anticoagulated, the tenth day after childbirth or abortion” in the International Classi­fications of Diseases (ICD-10). Similarly, the Joint Commission on Maternal Wel­fare in the United States defines a puerperal fever as used for reporting puerperal morbidity as an “oral temperature of 38.0 °C (100.4 °F) or more on any 2 of the first 10 days postpartum” (15). The most frequent etiology of postpartum fever is infection of the genital tract. The rate of postpartum infection is estimated at 1% to 8% (16). Most risk factors for postpartum infection are related to events taking place during labor and delivery. These include chorioamnionitis, use of an inter- uterine fetal monitor (e.g., scalp electrodes, intrauterine pressure catheter), multiple cervical examinations, duration of labor, duration of rupture of the membranes, obesity, diabetes, manual removal of the placenta, vaginal lacera­tions (particularly fourth-degree lacerations), and postpartum anemia. Endo­metritis is frequently seen after c-section but may occur after vaginal delivery as well. While it normally presents prior to discharge from the hospital, it may pres­ent later. A number of terms are synonymous for this infection including 1endometritis, endomyometritis, metritis, and endoparametritis. The diagnosis is usually straightforward and is based on the finding of fever, abdominal pain, and uterine tenderness without another obvious source. Other diagnoses that should be considered include infections of other sites such as a pelvic abscess, wound infection (e.g., vaginal laceration after vaginal delivery or abdominal wound after a c-section), appendicitis, septic pelvic thrombophlebitis, pyelone­phritis, mastitis, and pneumonia. If a woman presents only with low-grade fevers, breast engorgement may be the etiology. Instrumental delivery may be associated with an increased risk of infection, and c-section, particularly after labor, is perhaps the strongest risk factor for infection.

The initial workup includes a thorough review of the history of the labor and delivery, including length of labor and length of rupture of the membranes, mode of delivery, and type of anesthesia (pudendal blocks may predispose to infected pelvic hematomas). The past medical history should assess risk factors such as conditions predisposing to infection such as diabetes, HIV infection, or sickle cell disease. Vital signs are taken to document fever and heart rate, as tachycardia may be present. Physical examination, particularly of the abdomen, pelvis, and costovertebral angle, often narrows the differential diagnosis. While uterine tenderness is always present with endometritis, it may be hard to differ­entiate post-cesarean operative pain from endometritis. After c-section, inspec­tion of the skin incision is important. Erythema or induration suggests a wound infection. A fluctuant or draining incisional wound may represent an infected hematoma or abscess. After a vaginal delivery, inspection of the perineum is important to look for an infection or breakdown of a vaginal laceration repair. While a bimanual pelvic examination may be uncomfortable, particularly after a vaginal delivery, it may be necessary unless the source of the fever is obvious. In that instance, it should be gently performed to palpate for a pelvic abscess or hematoma. Hematomas and abscesses are more common with operative vaginal deliveries and when a pudendal block has been given for anesthesia. A rectovagi­nal examination may also be required to palpate for a hematoma or abscess, especially if there was a fourth-degree laceration. While a speculum examina­tion is of limited use in this evaluation, if the patient had a third-degree lacera­tion, it should be carefully examined to make sure that there was not actually a fourth-degree laceration that was missed and consequently not repaired. Pelvic and rectovaginal examinations must be performed very gently both to minimize discomfort for the woman and to minimize the risk that any repairs will be dis­rupted by the examination. Costovertebral angle tenderness is suggestive of pyelonephritis, and costovertebral angle ecchymosis is a sign of a dissecting pel­vis hematoma. Occasionally, other parts of the examination produce useful clues. One of the infrequent complications seen after pudendal or paracervical block is a subgluteal or a retropsoas abscess. These abscesses commonly produce significant pain for the patient during ambulation, and she limps, favoring the affected side. On physical examination, extension and abduction of the hip is painful. When this abscess is suspected, CT scan may reveal gas formation. Immediate assessment for possible surgical intervention with drainage and deb­ridement should be arranged when this is suspected.

While physical examination usually makes these diagnoses, ancillary tests that may be supportive include complete blood count, urinalysis, urine culture, and occasionally, a cervical swab for GC/Chlamydia. If there is a con­cern regarding possible sepsis, blood cultures may be helpful. Otherwise, wound and endometrial cultures are not useful. Ultrasound and CT scan may be help­ful in identifying an abscess, particularly in obese patients where it may be dif­ficult to examine adequately to palpate an abscess. Ultrasound may also help identify retained placenta associated with endometritis; however, there is commonly a small amount of debris retained after a vaginal delivery, and this should not be misconstrued as retained placenta (17).

Treatment of Endometritis and Pelvis Abscess

As is the case with pelvic inflammatory disease, these infections tend to be polymi­crobial. They are generally ascending infections caused by aerobes and anaerobes from the lower genital tract. The list of specific organisms cited as causative agents includes group A and group B streptococci, enterococci, Staphylococcus aureus, Gardnerella vaginalis, Escherichia coli, Enterobacter, Proteus mirabilis, Bacteroides bivius, and other Bacteroides species, peptococci and peptostreptococci, Ureaplasma urealyticum, and Mycoplasma hominis. Of note, while Chlamydia trachomatis is not usually thought of as a possible agent, it has been associated with late-onset postpar­tum endometritis, which should therefore not be overlooked in the emergency department (18). Appropriate antibiotic regimens need to cover both Gram-positive and Gram-negative aerobes and also anaerobes. Frequently used combinations include ampicillin, gentamicin, and clindamycin; ampicillin, gentamicin, and met­ronidazole; ampicillin plus sulbactam; ticarcillin plus clavulanic acid, etc. Fever curves usually trend downward within 48 hours, and once a patient is afebrile for 48 hours they may usually be discharged without further antibiotics. Although cure rates with initial therapy exceed 95%, failures may be due to abscesses or septic pelvic thrombophlebitis, and imaging should be obtained to assess these possibilities. A reevaluation for nongenital etiologies is also appropriate if there is any question regarding the location of the infection. If an abscess is identified, drainage will be necessary; however, it may often be performed by interventional radiology without requiring surgical drainage. When a patient has persistent fevers with resolution of her pain, there are two likely diagnoses. One is septic pelvic thrombophlebitis. This may occasionally be diagnosed by ultrasound (e.g., ovarian vein thrombosis). If a diag­nosis of septic pelvic thrombophlebitis is made, prolonged therapy with antibiotics is usually adequate, as studies have failed to support the long held assumption that heparin accelerated recovery. An alternative explanation for prolonged febrile morbidity without tenderness is drug fever, and in that case, stopping the antibiotics will bring about resolution of the fever.

Treatment of Abdominal and Vaginal Wound Infections

Wound infections are more commonly seen with c-sections than with vaginal lac­erations. The most common presentation is of erythema and/or induration around the incision. The patient can have a fever, but this is not universal. Sometimes the incision will have opened with drainage of pus. Abdominal wound infections are generally caused by skin flora, and coverage should be considered accordingly (e.g., dicloxacillin, cephalexin). If a wound is fluctuant, it should be opened and drained. If there is necrotic tissue, debridement is necessary. When patients are admitted for wound infections, intravenous antibiotics are frequently given that offer coverage for skin flora (e.g., nafcillin). While wet-dry dressings may provide an appropriate initial treatment, they are appropriately but slowly being replaced by other “moisture-retentive” or “semi-occlusive” dressings involving hydrogels, hydrocolloids, calcium alginates, etc. These advanced dressings promote more rapid wound-healing at an overall lower total cost (19-22). Large open wounds may also benefit from negative pressure wound therapy.

When there is a vaginal laceration infection, a repair may appear to be failing or tearing out. The antibiotic coverage for infections of vaginal lacera­tions is often broader due to the range of possible bacteria (e.g., vibramicin and metronidazole, amoxicillin plus clavulanic acid, or sulfamethoxazole plus trimethoprim). If the examination finds a fluctuant mass, induration, substan­tial edema or cellulitis, a more aggressive course with inpatient therapy and broad-spectrum antibiotics may be necessary. While most patients show rapid improvement, spreading edema or erythema may indicate necrotizing fasciitis, and surgical exploration and debridement may be required. Rapidly progressing sepsis secondary to toxic shock syndrome or invasive group A streptococcal dis­ease must be recognized rapidly (23,24). This condition is uncommon, but the risk of mortality is significant, so a high index of suspicion must be maintained. The CDC recommends high-dose parenteral penicillin and clindamycin for toxic shock syndrome or necrotizing fasciitis (25).

Because the timing to repair the dehiscence of a repaired laceration or epi­siotomy varies based on the condition of the tissue, patients should be referred to an obstetrician/gynecologist for consultation if they do not have one.

MASTITIS

Mastitis is a frequent cause for women to seek medical care during the late post­partum. The incidence of mastitis is reported to be about 2.5%; however, the actual incidence is likely higher due to underreporting (26). Most infections are unilateral, but occasionally, it may affect both breasts. As with postpartum wound infections, the primary etiologic agents are maternal skin flora though infant nasal-oral flora may be the causative agent. The site of the infection is usually obvious upon breast observation. Erythema and tenderness with occa­sional induration are the hallmarks of this infection. Occasionally, an abscess can develop, and a fluctuant mass may be palpated. In the absence of an abscess, agents active against skin flora (e.g., dicloxacillin, cephelexin) are used. The mother should continue to breastfeed. Improvement is usually seen in the first 48 hours, although antibiotics are continued for 2 weeks. If an abscess is sus­pected, an obstetric or surgical consultation should be obtained for incision and drainage. The same antibiotics mentioned above are appropriate after an inci­sion and drainage of an abscess. It is quite uncommon for mastitis to require admission for intravenous antibiotics.

PYELONEPHRITIS

The incidence of pyelonephritis is higher during pregnancy due to the physiologic dilation of the urinary tract. This occurs secondary to the combination of pressure on the distal ureters from the gravid uterus and adjacent vasculature as well as a decrease in ureteral tone due to progestational effects. These factors result in uri­nary stasis with mild hydronephrosis and hydroureter (the “physiologic hydro­nephrosis of pregnancy”). Frequent vaginal examinations and possible bladder catheterizations may lead to an increased incidence of bacteriuria postpartum, with an increased risk of pyelonephritis. Women present with fever and costover­tebral angle tenderness over the infected kidney. They will frequently report the other routine symptoms of a urinary tract infection including frequency, urgency, and dysuria. The most common etiology is E. coli; however, other organisms such as Klebsiella, Enterobacter, Protues, Pseudomonas, Enterococcus, and ^-streptococcus are also seen. Because of the wide number of etiologic agents and the increased incidence of antibiotic resistance, it is important that a urine culture and sensitiv­ity be obtained. In order to avoid contamination from the vaginal lochia, a catheter specimen is most appropriate. While pyelonephritis is usually treated as an outpa­tient in the nonpregnant state, pregnancy-associated pyelonephritis carries a significantly higher risk of urosepsis. Consequently, inpatient therapy with intrave­nous antibiotics is usually pursued. The initial choice for antibiotics is usually cefazolin or gentamicin, or both if the patient appears very ill and sepsis is sus­pected. Patients usually respond quickly with resolution of fever and costoverte­bral angle tenderness in 48 hours. Once the culture and sensitivity are available, the therapy may be altered as appropriate.

PSYCHOLOGICAL ISSUES

The postpartum period is one that finds women at an increased risk for psychologic disorders. These may range from relatively mild disorders, such as the “baby blues” to more severe difficulties such as depression and psychosis. While these difficulties are often attributed to the “hormonal changes” women are undergoing at this time, the reasons are many and likely include such factors as a recognition of the incredible responsibility of raising an infant and the shift in focus of family members’ and friends’ attention from the pregnant mother­to-be to the newborn infant. Other risk factors include a family history of depres­sion, being a single mother, or having marital/relationship difficulty and other socioeconomic stresses. It is critical to distinguish between the more severe and lesser conditions. As many as 40% of primiparous women have reported experi­encing indifference to their infants when they first held them after birth (27). Several intrapartum factors were identified to be associated with this indiffer­ence including amniotomy, painful labor, and the dose of pethidine. This early maternal indifference resolved over the first few days after delivery. Even more common were the mild depression characterized as the “baby blues” or “postpar­tum blues.” Over half of the women reported spells of tearfulness, insomnia, anxiety, depressed mood, headaches, confusion, fatigue, or other emotional dis­tresses that lasted up to 2 weeks. For these milder conditions, reassurance and support from the medical team, family members, and friends are usually all that is necessary. When a mother has a past history of treatment for depression, anx­iety, or similar conditions, treatment with selective serotonin reuptake inhibi­tors may be helpful. In many instances, women with a past history of postpartum psychological difficulty are started prophylactically on these medications. Refer­ral to, or consultation with, a mental health care provider is always appropriate. When a woman presents with symptoms of major depression, consultation is mandatory, as this is a more severe disorder that hangs on much longer and is not likely to resolve quickly through enhanced family support. The symptoms to watch for are those seen in depression diagnosed outside of pregnancy: insomnia or hypersomnia, change in appetite or weight, feelings of worthlessness, inabil­ity to concentrate or make decisions, difficulty working, and thoughts of death or suicide. Women in this state may go beyond mere indifference and actually reject their infant. While some reports give an incidence of a major depressive disorder in up to 10% to 15% of postpartum women, this figure seems high in clinical experience (28). Because the symptoms are so oppressive and make life at home and work so difficult, these women almost always require medication and may be affected for up to 2 to 3 months.

The most serious condition, postpartum psychosis, is seen after only 0.2% of deliveries. Reported risk factors include nulliparity, not having an involved partner at the time of delivery, and delivery by cesarean section. A past history of bipolar disorder also carries an increased risk for psychosis, and a prior episode of postpartum psychosis carries a 15% risk of recurrence. Most episodes are affective (manic or depressive psychosis), while a minority are schizophrenia­like conditions. Psychiatric consultation is mandatory, and these patients are usually hospitalized. While the course of these conditions is usually measured in weeks, a controlled follow-up study found evidence that difficulties in the mother-child relationship may persist for as long as 4.5 years postpartum (29).

SUMMARY

When a postpartum patient presents to the emergency department, it is vital that she is examined carefully and her concerns taken seriously without simply attributing symptoms to the “normal postpartum state.” Some conditions are

rapidly life-threatening, such as seizures, PPH, and PE, and treatments must be instituted rapidly. Other conditions, particularly infections may vary from inconvenience to potentially life-threatening, and an expeditious workup and initiation of appropriate therapy is critical. Some conditions such as pyelone­phritis are managed differently during a pregnancy, and this must be taken into account. Postpartum psychological complaints should never be brushed aside and minimized. A careful evaluation to separate less serious psychological con­ditions that may be treated with reassurance and support, from more serious ones that need psychiatric consultation, is crucial to ensure that new mothers and their infants stay safe at a time when many women have mood fluctuations.

Finally, often the patient’s midwife or obstetrician has information relating to the pregnancy or delivery that is very helpful, and they should be contacted. Consultation from that individual or the on-call obstetrician for the emergency department may be very useful to effi ciently establish a diagnosis, institute treatment, and facilitate either discharge to home or admission to the hospital as is appropriate.

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