Table 3.
Included studiesa reporting postpartum ED use classified by diagnosis
| Pathology (number of studies) |
Study | Country (year) | Pathology | Findings |
|---|---|---|---|---|
| Cardiovascular (2) | Kamel et al14 | The United States (2016) | Aortic dissection and rupture | Significantly increased risk of aortic dissection and rupture during pregnancy and postpartum period compared with non-peripartum women |
| Wang and Wang15 | China (2018) | PPCM | Four percent of postpartum women presenting to the ED had PPCM; among PPCM patients presenting to the ED, 9% had hypertension and 56% had physiologic dyspnea of pregnancy | |
| Hypertensive disorders of pregnancy (3) | Brousseau et al17 | The United States (2017) | Postpartum hypertension | Women with postpartum hypertension typically present within 1 week after delivery and are likely to be readmitted. Many knew they had hypertension; surveillance may not be sufficient to curb readmission rates |
| Sharara | Qatar (2012) | Eclampsia prevalence in Qatar | Eclampsia occurred in 0.31/1,000 deliveries, and 31.4% of women who developed eclampsia were postpartum. Of the postpartum patients, most had their first seizure within 2–72 hours after delivery | |
| Yancey et al11 | The United States (2011) | Preeclampsia | Patients most commonly presented 3–10 days postpartum, with headache as the most common chief complaint, followed by vision changes, and gastrointestinal upset; 95% had proteinuria, elevated uric acid, or abnormal liver function tests. Almost all had elevated blood pressure in the ED | |
| Infectious disease (9) | Agarwal | India (2019) | Sepsis | The Sepsis in Obstetrics Score had a positive predictive value of 83% for severe sepsis and good correlation with organ failure in peripartum women |
| Albright | The United States (2014) | Sepsis | The Sepsis in Obstetrics Score identified peripartum patients who were at high risk for ICU admissions | |
| Albright | The United States (2017) | Sepsis | The Sepsis in Obstetrics Score is valid to identify risk of sepsis-related ICU admissions, with a negative predictive value of 98.6% | |
| Amir | Australia (2006) | Mastitis (Staphylococcus aureus) | No association was found between maternal nasal colonization of S. aureus and S. aureus mastitis; however, more infants of mothers with S. aureus mastitis were nasal carriers. Nipple damage positively correlated with mastitis risk | |
| Amir | Australia (2006) | Mastitis | Negative emotions associated with the physical symptoms of mastitis may lead some women to stop breastfeeding. | |
| Bosma | The United States (2016) | Breast abscess | (12% of patients were postpartum in this study.) Nearly half of women presenting to the ED who believed they had breast abscesses were diagnosed with the disease; the remainder had mastitis. Appropriate follow-up and/or imaging did not occur in approximately one-fourth of cases | |
| Hu | Australia (2017) | Breast abscess/mastitis | Of women presenting to the ED for infectious breast disease, 16.8% were referred to the ED by general practitioners, 2.5% by midwives, and 80.7% self-presented; 42% were admitted for only 1 day or were discharged and the rest were admitted. In all, 1.7% of women in the study re-presented to the ED at least once | |
| Parriot | The United States (2016) | Postpartum infection | ED visits and readmissions were grouped together. Clinical and hospital volumes did not affect postdischarge infection rates in postpartum women. UTIs and surgical complications were most common; 7% of infections after initial hospital discharge involved sepsis or blood stream infection | |
| Yokoe et al20 | The United States (2001) | Postpartum infection | 94% of infections in the postpartum period were detected after discharge. In the cohort, 64% of ED visits for women with vaginal delivery were infection related, compared with 80% for women with cesarean delivery | |
| Multiple pathologies (2) | Brousseau et al16 | The United States (2018) | Multiple | The median time to ED visit was 7.5 days postpartum. Common chief complaints included: wound complication (17.5%), fever (17.1%), abdominal pain (15.9%), headache/dizziness (12.3%), breast problem (10.7%), and hypertension (10.3%) |
| Cano Alonso | Spain (2009) | Multiple | Use of MDCT in EDs to diagnose acute female pelvic disease was assessed. While ultrasound is the modality of choice for acute pelvic pain in the ED, MDCT can be used when ultrasound is equivocal or gynecologic pathology is not at the top of the differential diagnosis. The study included women not in the postpartum period as well as those in the postpartum period | |
| Neurologic (4) | Basurto Ona | Spain (2015) | PDPH | 13 RCTs were reviewed. Not all patients were postpartum. Compared with placebo, caffeine was effective at treating PDPH. Gabapentin, hydrocortisone, and theophylline lowered pain severity. Evidence for sumatriptan, adrenocorticotropic hormone, pregabalin, and cosyntropin was lacking |
| Behcet et al21 | Tukey (2007) | Stroke | Strokes were most likely to occur in the third trimester and postpartum period, particularly the first week postpartum. Most commonly these strokes were caused by preeclampsia and eclampsia. The mortality rate for all patients with stroke was 34.2%, but the rate was higher when hemorrhage was present | |
| Houtchens | The United States (2018) | MS | MS relapse rates dropped during pregnancy, rose during the first 6 postpartum months, and dropped again at months 6–12 postpartum. Women did not commonly use disease-modifying drugs before or during pregnancy, but use increased during the postpartum period | |
| Karadas et al22 | Turkey (2014) | Cerebral venous sinus thrombosis | Of patients presenting to the ED, headache was the most common symptom, and the most common predisposing condition was the postpartum state | |
| OB/GYN (1) | La Rosa | The United States (2019) | Outcomes after cesarean | Patients were randomized to azithromycin or placebo after cesarean. Women prescribed azithromycin had lower rates of unexpected visits |
| Psychiatric (11) | Barker | Canada (2016) | Psychiatric disease | For 60.4% of women, their first mental health physician contact since delivery was in the ED. Most of the presentations were for mood or anxiety disorders; 13.6% of presenting women were admitted. Women having first psychiatric physician contact in the ED were more likely to have low income, residential instability, material deprivation and to live in rural areas |
| Bryan | The United States (1999) | Postpartum depression | 3.7% of women had postpartum depression during the first postpartum year. 0.5% had preexisting depression that continued through the postpartum period. This incidence was lower than prospective studies had previously found | |
| Glasser | Israel (2018) | Postpartum suicidality | Compared to same-age women, postpartum women were less likely to attempt suicide. Among postpartum deaths, 3.6% were secondary to suicides, 1% to injuries of undetermined intent, 1.5% to accidents, and 4.7% to assaults | |
| Kramlinger | The United States (1984) | Psychiatric disease and thyroid hormone level | One patient in the population was postpartum. Postpartum patients with known psychotic disease may have high thyroxine secondary to the postpartum state and be clinically euthyroid. Thyroxine normalized in this patient within days | |
| Lai et al23 | Taiwan (2004) | Postpartum psychiatric disease with catatonia | Postpartum patients presenting to the ED most often had depression (53.3%), but one-fifth had mania, one-fifth had schizophrenia, and 1 person had psychosis due to medical condition. Of 4 patients with catatonic features, 3 improved with intramuscular lorazepam | |
| Lewkowitz et al79 | The United States (2019) | Postpartum psychiatric illness in stillbirth vs. live birth | Stillbirth after 23 weeks’ gestation increased readmission risk for psychiatric illness by a factor of 2.5. This most commonly presented as depression or anxiety, but increased risk of substance abuse-related ED visits in this population is also noted | |
| Polachek et al24 | Canada (2016) | Psychiatric disease | Of women admitted to psychiatric services in the postpartum period, 4.9% represented to the ED for psychiatric reasons within 1 week. Women with prior psychiatric admissions before the postpartum period used the ED more often and had less physician follow-up | |
| Rochon-Terry | Canada (2016) | Psychiatric hospitalizations in postpartum women with schizophrenia | Among women with schizophrenia, 10% had premature deliveries. Their postpartum risk of visiting the ED for psychiatric reasons, while lower in the postpartum period than it was prior to conception, was higher in the first 9 days of postpartum. Self-harm visits were less likely during the peripartum period | |
| Polachek | Canada (2018) | Postpartum psychiatric admissions | Non-admission ED visits were observed in 11.4% within 1 week postpartum, 15.7% within 1 month, and 33.9% within 1 year. Postpartum women without recent mental illness presented around 4.5 months with affective and adjustment disorders. Those with a history of severe mental illness presented within 9 days for affective and psychotic disorders. Those with non-psychotic mental health history came at 6 months for adjustment and affective disorders. Those with social and substance abuse history came at 7 months and were most likely to be involuntary, pose threats to self, and return to the ED within 1 year | |
| Polachek | Canada (2017) | Psychiatric admissions postpartum and follow-up ED visits; length of postpartum psych stay | Postpartum women previously admitted for psychiatric disease had higher rates of re-presenting to the ED within 7 days, but lower rates of re-presentation 30 days and 1 year after discharge | |
| Xu | Australia (2017) | Postpartum depression | Women who had more ED presentations during pregnancy had more PP ED visits for depression. | |
| Trauma/IPV (2) | Nannini et al38 | The United States (2008) | Patterns of physical injury during ED visits for assault | Of the 0.9% of women visiting the ED for assault postpartum, the most frequent injuries were superficial contusions, open wounds, and other head and neck injuries. Postpartum women were less likely to have trauma to the abdomen or torso, but visits for assault with fracture were twice as common in the postpartum period than during pregnancy. More than 5% of visits were multisystem injuries and could not be classified to one region of the body |
| Nannini et al38 | The United States (2008) | Injury etiology and ED visits in pregnant and postpartum women | 22 deaths occurred in the cohort, and 7 of these were due to injury. 13.6% of women had an injury-related visit, with 55% occurring postpartum, and 91% were ED visits without admission. A vast majority (89%) were unintentional injury: most were motor vehicle accidents, followed by falls and then overexertion. Assault accounted for 5.4% of injuries. Self-inflicted injuries accounted for <1%. 22% of women visiting for injury visited more than once | |
| Venous thromboembolic events (5) | Goodacre et al33 | The United Kingdom (2018) | PE | In pregnant and postpartum women suspected of having PE, D-dimer and clinical decision rules were not cost effective, accurate, or effective at selecting women for diagnostic imaging |
| Goodacre et al32 | The United Kingdom (2019) | PE | In pregnant and postpartum women suspected of having PE, D-dimer and clinical decision rules were not useful in a clinical setting | |
| Kabrhel et al34 | The United States (2010) | PE | 1% of the women included in the study were early postpartum (<4 weeks). Postpartum women often had a positive D-dimer test regardless of whether or not they had a PE | |
| Kamel et al14 | The United States (2014) | Thrombotic events | Until at least 12 weeks postpartum, women were at greater risk of thrombosis, but the risk after 6 weeks, while increased, had a low absolute value | |
| Robison | The United States (2017) | Heparin protocol in PP venous thromboembolism | The protocol implemented increased enoxaparin use from <1% to >30% without differences in ED visits between groups. However, the study was underpowered to assess a difference in ED visits |
Abbreviations: CT, computed tomography; ED, emergency department; ICU, intensive care unit; IM, intramuscular; IPV, intimate partner violence; MDCT, multidetector CT; MS, multiple sclerosis; OB/GYN, obstetrics and gynecology; PDPH, postdural puncture headache; PE, pulmonary embolism; PP, postpartum; PPCM, peripartum cardiomyopathy; PPD, postpartum depression; RCT, randomized controlled trial; UTI, urinary tract infection.
a
Excluding case reports.