Postpartum complications

Infectious

Postpartum endometritis

• Definition & Etiology:
  • Most common cause of postpartum fever (day 2–3).
  • Polymicrobial: Vaginal flora (anaerobes: Bacteroides, Peptostreptococcus; aerobes: E. coli, GBS).
• Risk Factors:
  • Cesarean delivery (single most important risk factor).
  • PROM (>18 hrs), prolonged labor, operative vaginal delivery, chorioamnionitis.
• Clinical Features:
  • Postpartum fever (≥38.0°C / 100.4°F) on day 2–3.
  • Foul-smelling / purulent lochia.
  • Uterine / fundal tenderness, lower abdominal pain, leukocytosis.
• Diagnosis:
  • Clinical: Fever + uterine tenderness + foul lochia post-delivery.
  • Pelvic US: Indicated only if refractory to Abx to rule out RPOC or pelvic abscess.
  • Endometrial cultures not routinely recommended (contamination risk).
• Management:
  • 1st-line: IV Clindamycin + IV Gentamicin until afebrile x 24–48 hrs (add Ampicillin if non-responsive or Enterococcus suspected). c
  • Refractory (>48–72 hrs Abx):
    • Pelvic US: Check for RPOC (treat w/ D&C) or Abscess (treat w/ drainage).
    • Septic Pelvic Thrombophlebitis (SPT): Suspect if US (-) and fever persists -> add therapeutic heparin.
• Key Differentials:
  • Chorioamnionitis: Intrapartum presentation (fetal tachycardia, fever before delivery).
  • Wound Infection: Incisional erythema/drainage without fundal tenderness.
  • SPT: Persistent fever despite 48–72 hrs of broad-spectrum IV Abx + negative imaging.
• Complications: Sepsis, pelvic abscess, SPT, Asherman syndrome.

Musculoskeletal

Diastasis recti

• Definition & Pathophysiology:
  • Widening and thinning of the linea alba with separation of the rectus abdominis muscles.
  • No true fascial defect is present (distinguishes it from a true hernia).
• Risk Factors (RF):
  • Multiparity / prior pregnancy (mechanical stretch + hormonal laxity).
  • Obesity / central adiposity.
  • Neonates / infants (normal physiologic finding, especially in premature infants).
• Clinical Features:
  • Painless, longitudinal midline abdominal bulge (xiphoid to umbilicus).
  • Accentuates with ↑ intra-abdominal pressure (e.g., head raise / crunch maneuver, Valsalva, coughing).
  • Flattens / disappears when the pt is relaxed and supine.
• Diagnosis:
  • Clinical: Palpation of widened inter-rectus distance (> 2 cm) on physical exam.
  • Imaging (US/CT): Not routinely required; used only if diagnostic ambiguity exists to rule out a true hernia.
• Key Differentials:
  • Umbilical / Ventral Hernia: Has a true fascial ring; carries risk of incarceration and strangulation.
  • Rectus Sheath Hematoma: Acute, painful, unilateral; (+) Fothergill sign (mass remains fixed/palpable with abdominal wall contraction).
• Management & High-Yield Pearls:
  • First-line: Reassurance and observation ± core-strengthening physical therapy.
  • Neonates: Spontaneous resolution with abdominal wall development.
  • Highest-Yield Exam Pearl: NO risk of bowel incarceration or strangulation because the linea alba remains intact (no true fascial defect) $\to$ routine surgical repair is not indicated.
  • Refractory / Elective: Surgical plication / abdominoplasty (reserved strictly for severe cosmetic or functional impairment failing conservative therapy).