Diseases and Complications of the Puerperium

Abstract

Background

In terms of maternal morbidity and mortality, the puerperium is just as significant as pregnancy and childbirth. Nearly half of all maternal deaths occur in the time after delivery.

Methods

This review is based on pertinent articles in English and German from the years 2000–2020 that were retrieved by a selective search in MEDLINE and EMBASE, as well as on the available guidelines in English and German and on German-language textbooks of obstetrics.

Results

The most common and severe complications are, in the post-placental phase, bleeding and disturbances of uterine involution; in the first seven days after delivery, infection (e.g., endomyometritis, which occurs after 1.6% [0.9; 2.5] of all births) and hypertension-related conditions. Thromboembolism, incontinence and disorders of the pelvic floor, mental disease, and endocrine disturbances can arise at any time during the puerperium. In an Australian study, the incidence of embolism was 0.45 per 1000 births, with 61.3% arising exclusively after delivery.

Conclusion

Basic familiarity with the most common and severe diseases in the puerperium is important for non-gynecologists as well, among other things because highly acute, life-threatening complications can arise that demand urgent intervention.

The period following delivery of the placenta and the 6 weeks thereafter are referred to as the postpartum period or puerperium (1). This period is subdivided into:

• The immediate postnatal period (the first 3 h postpartum, during which the risk of hemorrhage is high)

• The early postnatal period (the first 7 days postpartum, during which the risk of infections and maternal hypertensive disorders of pregnancy is high)

• The late postnatal period (6–8 weeks) (1).

Definition.

The period following delivery of the placenta and the 6 weeks thereafter are referred to as the postpartum period or puerperium. It it subdivided into the immediate postnatal period, the early postnatal period, and the late postnatal period.

Mortality.

In terms of global maternal mortality, almost 50% of deaths occur in the puerperium and thereafter. The Global Burden of Disease Study reported maternal mortality in Germany for 2013 to be 6.5 (95% confidence interval: [5.0; 7.9]) per 100,000 births.

In terms of maternal morbidity and mortality, the puerperium is as important as the pregnancy and birth. Although a number of pregnancy-related diseases do not appear until the puerperium (for example, delayed uterine atony), they may occur equally as frequently (for example, HELLP syndrome) or even more frequently (for example, embolisms) during this period. With regard to global maternal mortality, approximately one quarter of deaths occur in the antenatal and one quarter in the perinatal period, while almost half occur in the puerperium and thereafter (2, 3). The Global Burden of Disease Study reported maternal mortality in Germany for 2013 to be 6.5 (95% confidence interval: [5.0; 7.9]) per 100 000 births (2). One can assume underrecording since recording is primarily done by the maternity units and after transfer to another department/hospital (for example, for intensive care), recording is oftentimes not continued; additionally, in the case of sickness and death following a prolonged period after the birth (for example, due to pulmonary embolism), it is likely that many deaths are no longer correctly recorded as maternal deaths. Although postnatal care is usually provided by midwives and gynecologists, women also turn to physicians in other disciplines. It is important for the latter to be familiar with the most common and serious clinical pictures in the puerperium in order to be able to assess when and how urgently a patient should present to a gynecologist or colleagues in other specialties. Potentially life-threatening diseases (table 1) primarily include: severe hemorrhage immediately postpartum; hypertensive complications as well as infections (in particular endomyometritis) in the early postnatal period; and thrombosis/embolism, as well as complications due to pre-existing diseases, such as cardiac diseases, throughout the puerperium. Potentially non-life-threatening conditions include other infections (urinary tract infection, mastitis, and wound infections), breastfeeding disorders, incontinence, pelvic floor dysfunction, and postpartum thyroiditis.

Table 1. Potentially life-threatening diseases: symptoms and incidences.

Disease	Symptoms	Incidence
Delayed uterine atony(> 24 h postpartum)	Signs of poor uterine involution (uterine subinvolution): Increased uterine height (abdominal palpation), soft-doughy uterus, pain at the uterine border, possible subfebrile temperature, frontal headache, intermittent, persistent, possibly increasing bleeding Also additional severe bleeding, possibly symptoms of shock	Atonic bleeding (postpartum overall): 2.5%; 95% CI: [2.32; 2.62] (36) Delayed uterine atony (> 24 h postpartum): 0.2–2.5% (industrialized countries) (e93– e96)
Endomyometritis(chorioamnionitis and sepsis)	Fever, tachycardia, lower abdominal pain, relatively soft uterus that is painful on palpation, foul-smelling lochia, general feeling of being unwell, increased leukocytes (e29)	Chorionamnionitis 3.9% (8) Endomyometritis 1.6–1.9% (8, e97) Sepsis 0.05% (8)
Group A streptococcal sepsis	Acute disease course, usually within the first 48 h postpartum: high fever (in 73%), diffuse abdominal pain, putrid vaginal discharge, uterine tenderness, fever, chills, increased leukocytes, thrombocytopenia, hypotension (15)	6/100,000 Births (14)
Pre-eclampsia (modified from [4])	Blood pressure > 140/90 mm Hg Headache, photopsia/impaired vision, upper abdominal pain, nausea/vomiting, general malaise, weight gain Impairment to: kidneys, liver, CNS, hematological or respiratory system, IUGR or placental insufficiency	Hypertensive disorders (overall) 5–10% (e98) Pre-eclampsia ca. 4.6% Eclampsia ca. 1.4% (e97) Of which: Eclampsia 11–44% HELLP 7–30% (e100, e101) are postpartum (in relation to eclampsia/HELLP overall)
Eclampsia	Additional tonic-clonic seizures
HELLP syndrome	Upper abdominal pain, nausea, vomiting, hemolysis, elevated liver enzymes, thrombocytopenia
Thrombosis/embolism	As in outside of pregnancy/puerperium Cave: misclassification as physiological symptoms of the puerperium	Thrombosis 0.05–0.3% (23, 24) Embolism 0.08/1000 births (postpartum) (27) and 0.14/1000 (28) to 0.45/1000 (pre- and postpartum) (31) Pulmonary embolism 60.5 (28) to 61.3% postpartum (31)
Sheehan’s syndrome	Hypopituitarism: (reduced lactation, amenorrhea, genital and axillary hair loss, asthenia and weakness, premature skin aging, dry skin, and hypopigmentation)	See Table 2

IUGR, intrauterine growth restriction; CNS, central nervous system; 95% CI, 95% confidence interval

Learning objectives

After reading this article, the reader should:

• Be able to name common and typical disorders of the puerperium and the most important characteristics of their clinical course

• Even as a non-gynecologist, be able to assess when and how rapidly a gynecologist or colleague in another discipline should be consulted

• Know the basics of treatment of these disorders.

Methods

A selective literature search was performed chapter-wise covering the last 20 years in Medline and Embase, taking into consideration German- and English-language articles. The individual chapters were divided between the authors. In addition, the online information platform “Uptodate,” as well as German- and English-language guidelines issued by the following medical societies were included: German Society of Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG/Association of the Scientific Medical Societies in Germany [AWMF] guidelines), American College of Obstetricians and Gynecologists (ACOG), National Institute of Health and Care Excellence (NICE) Guidelines, and the Society of Obstetricians and Gynecologists of Canada (SOGC). For more details on the search, please see the eMethods Section.

Potentially life-threatening diseases.

These primarily include severe hemorrhage in the immediate postnatal period, hypertensive complications and infections in the early postnatal period, and thrombosis/embolism throughout the puerperium, as well as complications due to preexisting diseases, such as cardiac disease.

Hypertensive disorders of pregnancy

The care of patients with hypertensive complications of pregnancy is also important in the puerperium and thereafter, since these indicate a generally increased cardiovascular risk. Risk factors for hypertensive disorders of pregnancy are presented in Box 1. Hypertensive disorders of pregnancy include gestational or pregnancy-induced hypertension (new-onset hypertension 140/90 mm Hg after 20 weeks of gestation), pre-eclampsia (plus proteinuria ≥ 300 mg/day and/or protein/creatinine ratio ≥ 30 mg/mmoL and/or organ manifestation), eclampsia (plus tonic-clonic seizures), and HELLP syndrome (hemolysis, elevated liver enzymes, low platelets = hemolysis, elevated transaminases, and thrombocytopenia < 100 G/L) (4). The view that pre-eclampsia or gestational hypertension are resolved after delivery is deemed to be outdated (e1– e6). The risk for exacerbation or initial manifestation of these diseases persists for up to 7 days postpartum (4, e1– e3, e7). Blood pressure and proteinuria generally normalize within the first week postpartum (e1– e3). In the case of pregnancy-induced hypertension, the current guideline recommends monitoring blood pressure for at least 2 days after delivery. Following pre-eclampsia, blood pressure should be measured: at least 4 × a day until discharge (at least once daily between days 3 and 5 postpartum). In the case of abnormal measurements on day 3–5, measurements should be taken at least every other day during the 2 weeks following discharge, and blood pressure and renal function should always be checked at 12 weeks (5). A clear recommendation in this regard should be made upon discharge from the maternity hospital. Persistent hypertension following delivery (150/100 mmHg and higher) should be treated with drugs according to current recommendations (6, e8).

BOX 1. Risk factors for hypertensive disorders*¹ and thrombosis/embolisms in the puerperium.

For hypertensive disorders of pregnancy

• Antiphospholipid syndrome

  • RR: 9.72; 95% CI: [4.34; 21.75] (37)

• Status following pre-eclampsia

  • RR: 5.0 [1.7; 17.2] (e102) to RR 7.2 [2.74; 18.74] (e103)

  • RR: 7.19 [5.85; 8.83] (37)

• Elevated BMI ≥ 35 kg/m² :

  • RR: 1.59 to 3.5 [1.68; 7.46] (e103– 105)

• Pre-existing diabetes mellitus type 1 and 2

  • RR: 3.56 [2.54; 4.99] (37)

• Positive family history

  • RR: 2.9 [1.70; 4.93] (37)

• Pre-existing kidney disease (e106– e107)

• Primiparity

  • RR: 2.38 [2.28; 2.49] (e105) to RR: 3.8 [1.7; 8.3] (e102, 37)

• Maternal age

  • ≥ 35 Years RR: 1.67 [1.58; 1.77] (e105)

  • Primiparous women ≥ 40 years RR: 1.96 [1.34; 2.87] (37)

  • Multiparous women ≥ 40 years RR 1.68 [1.23; 2.29] (37, e108)

• Chronic hypertension

  • RR: 1.99 [1.78;2.22] (e103) to 5.2 [1.5; 17.2];

  • Diastolic RR ≥ 110 mm HG before the 20th GW (37) and

  • RR 3.2 [1.0; 7.8]; in diastolic RR ≥ 100 mm Hg before the 20th GSW) (37)

• Autoimmune diseases

  • RR: 6.9 [1.1; 42.3] (37, e102)

• Increased resistance/uterine artery notching:

  • High-risk patients, positive LR 21.0 [5.5; 80.5] (38)

  • Low-risk patients, LR 7.5 [5.4; 10.2] (38)

• Multiple pregnancy

  • RR: 2.1 [1.90; 2.32] (e103) to RR 2.93 [2.04; 4.21] (37)

• In-vitro fertilization (IVF)

  • IVF after oocyte donation: RR: 6.60 [4.55; 9.57] compared to spontaneously pregnant women (e109)

  • Versus autologous IVF: AOR: 2.45 [1.53; 3.93] (e110) to 2.64 [2.29; 3.04] (e111); meta-analysis: calculated OR: 2.57 [1.91; 3.47] (e109)

  • Autologous IVF vs. spontaneous pregnancy: RR: 1.71 [1.11; 2.62] (e110) to pooled RR: 1.8 [1.6; 2.1] (e113)

• Gestational diabetes

  • RR: 1.93 [1.66; 2.25] (e105)

• Other:

  • Hydatidiform mole, trisomy, hydrops fetalis, inter alia (4)

*¹ Modified from (4)

Risk factors for thrombosis and embolism

• Cesarean section (overall) RR: 3.86 [2.97; 5.01] (31)

  • Primary cesarean section OR 2.2 [1.5; 3.2] (e70) to RR: 3.70 [2.73; 5.01] (31)

  • Secondary cesarean section RR: 4.09 [2.96; 5.63] (31)

• Maternal age

  • ≥ 35 RR: 1.4 [0.7; 2.6] (31)

  • ≥ 40 RR: 2.24 [1.36; 3.68] (31)

• Multiple pregnancy

  • RR: 3.35 [1.87; 5.99] (31)

• Hypertensive disorder of pregnancy

  • RR: 3.07 [2.25; 4.18] (31)

• Parity

  • ≥ 3 RR: 1.65 [1.13; 2.42] (31)

• Lupus erythematosus

  • RR: 19.7 [8.07; 47.9] (31)

• Status following stillbirth RR 2.26 [0.84; 6.07] (31)

  • Stillbirth in the current pregnancy RR: 6.97 [3.70; 13.2] (31)

• Preterm birth

  • RR: 3.95 [2.84; 5.50] (31)

• SGA < 10th percentile

  • RR: 1.43 [0.98; 2.07] (31)

• LGA > 90th percentile

  • RR 1.48 [1.02; 2.13] (31)

• Peripartum bleeding (≥ 1000 mL)

  • RR: 2.96 [2.15; 4.08] (31)

  • Transfusion (erythrocytes) RR: 6.56 [3.82; 11.3] (31)

  • Transfusion other than erythrocytes (e.g., fresh frozen plasma, thrombocytes, coagulation factors) RR: 23.8 [11.8; 48.11] (31)

• Immobilization

  • During hospital stay: RR 17.5 [7.69; 40.0]

  • Following discharge: RR: 6 [3.74; 10.5] (e63)

• Thrombophilia, primarily antiphospholipid syndrome

  • Incidence of 30% for thrombosis during pregnancy (23) and factor V Leiden (23)

• Status following thrombosis in a previous pregnancy

  • (Recurrence rate: 5–15.5% (23, 29) 15.5% [7.7; 28.7] (30); RR: 3.5 [1.6; 7.8] (e114)

• Obesity (BMI ≥ 30)

  • RR 1.4 [0.7; 2.6] (24)

• Pre-existing maternal heart disease

  • RR: 5.4 [2.6; 11.3] (24)

AOR, adjusted odds ratio; BMI, body mass index; 95% CI, 95% confidence interval; LR, likelihood ratio; LGA, large for gestational age; OR, odds ratio; RR, relative risk; SGA, small for gestational age; GW, gestational week

Potentially non-life-threatening conditions.

Potentially non-life-threatening conditions include other infections (urinary tract infection, mastitis, and wound infections), breastfeeding disorders, incontinence, pelvic floor dysfunction, and postpartum thyroiditis.

From the 4th postpartum day, or when the clinical situation has normalized (blood pressure regularly below 140/90) (5), antihypertensive medication can be phased out. In general, blood pressure reduction can proceed more rapidly following delivery, since uteroplacental perfusion pressure no longer needs to be taken into consideration. During breastfeeding, the available medications include alpha-methyldopa, labetalol, nifedipine, enalapril, captopril, atenolol, and metoprolol (e3, e9). For women in the puerperium with severe pre-eclampsia or following eclamptic seizure, the administration of intravenous magnesium should be continued for up to 48 h postpartum (4, e10). Even in the case of more intensive monitoring of women in the puerperium, as well as in the case of preterm birth or antihypertensive treatment, breastfeeding and the promotion of mother–infant bonding should nevertheless be made possible. If symptoms such as hemolysis, low platelet count, renal failure, or neurological symptoms (seizures, visual changes, paresis) persist, it is essential from a differential diagnostic perspective to consider thrombotic microangiopathies (e.g., aHUS), especially if symptoms worsen (4).

Uterine subinvolution and delayed uterine atony

Hypertensive disorders of pregnancy include:

• Gestational or pregnancy-induced hypertension

• Pre-eclampsia

• Eclampsia

• HELLP syndrome

Uterine subinvolution refers to the failure of the uterus to sufficiently return to its normal state. Physiological involution to the original size of the uterus (approximately 50 g) takes between 5 and 6 weeks. Uterine involution is usually assessed by means of transabdominal palpation of the uterine fundus. This measurement is limited in its objectivity (e11) and lacks a measurable correlation between the rate of involution and the risk of further complications, most notably severe atonic postpartum hemorrhage (e11– e13); it also lacks accurate data on incidence. Risk factors for (physiologically) delayed involution are considered to include cesarean section, multiple pregnancy, fetal macrosomia or polyhydramnios, and uterine fibroids, although quantifiable data on the individual risk factors are not available (e14).

Uterine subinvolution.

Uterine subinvolution refers to the failure of the uterus to sufficiently return to its normal state. Physiological involution to the original size of the uterus of approximately 50 g takes between 5 and 6 weeks.

Lochiostasis (lochia = [physiological] hemorrhage/discharge from the area of the uterine wound/site of placental attachment) is usually the result of a mechanical displacement of the cervix, for example, due to a clot or residual fetal membrane (e15). The retained lochia (lochiometra) cause insufficient uterine involution and create the risk of developing postpartum endomyometritis. From a clinical perspective, uterine subinvolution is striking on abdominal palpation due to the greater uterine height (uterus is soft and doughy, pain at the uterine border is possible in the further course) (table 1). In the case of lochiometra, lochial flow is decreased, and subfebrile temperatures and frontal headache are often present (e16). Sonographically, the uterus appears lax, possibly with a narrow, hypoechoic border, but may also be unremarkable. In addition to adequate mobilization, regular breastfeeding (e17), and abdominal massages, prone positioning of patients is recommended (promoting drainage of lochia through anteversion of the uterus in the prone position) (e15, e16). Oxytocin infusions are used to promote uterine contraction. Methylergometrine, on the other hand, is no longer recommended due to its negative effect on lactation (e18).

Delayed uterine atony.

This occurs within 24 h to 12 weeks postpartum and is potentially life-threatening, especially since women in the puerperium have often already left hospital. Common causes include placental and ovarian remnants, placental polyps, and endomyometritis.

Delayed uterine atony occurs within 24 h and 12 weeks postpartum and is potentially life-threatening, especially since women in the puerperium have often already left hospital (e19). Common causes include placental and ovarian remnants, placental polyps, and endomyometritis (e20). Intermittent or increasing vaginal bleeding is characteristic (7, e21, e22). Specific risk factors for delayed uterine atony are shown in Table 2. There are currently no screening recommendations for early detection (7). On ultrasound, clots and/or perfused or calcified, hypoechoic parietal areas can be visualized. To avoid uterine perforation, therapeutic curettage is performed with blunt instruments under ultrasound guidance. Prophylactic antibiotic administration in the absence of signs of infection is controversial. Depending on the severity of atony, uterotonic drugs (intravenous injection) or prostaglandins can be administered as an adjunct. The material obtained from uterine abrasion should undergo histopathological analysis to exclude trophoblastic neoplasia. From a differential diagnostic perspective, the first menstrual bleeding needs to be considered, especially in non-breastfeeding mothers (e23).

Table 2. Non-infectious diseases in the puerperium (excluding hypertensive disorders and thrombosis/embolism): incidences and risk factors.

Disease and symptoms	Incidence (relative to overall birth numbers)	Risk factors aOR/OR [95% confidence interval], references
Uterine subinvolution Atonic postpartum hemorrhage Delayed uterine atony (> 24 h postpartum) Symptoms see Text and Table 1	Uterine subinvolution: common (Atony see Table 1 “Potentially life-threatening diseases”)	General risk factors for atonic postpartum hemorrhage: Status post severe atonic postpartum hemorrhage aOR 8.97 [5.25; 15.33] (36) Placenta previa or premature placental separation aOR 7.0 [6.6; 7.3] (36) Uterine rupture aOR, 11.6 [9.7; 13.8] (39) Cervical tear aOR 94.0 [87.3; 101.2] (39) Anticoagulant medication aOR 4.79 [2.72; 8.41] (36) Anemia on admission to the maternity unit aOR 4.27 [2.79; 6.54] (36) Severe pre-eclampsia or HELLP aOR 3.03 [1.74; 5.27] (36)to 3.1 [2.9; 3.3] (39) Chorionamnionitis aOR 2.9 [2.5; 3.4] (39) Uterine fibroids aOR 2.0 [1.8; 2.2] (39) to 2.71 [1.69; 4.35] (36) Multiple birth aOR 2.11 [1.39; 3.22] (35) to 2.8 [2.6; 3.0] (39) Assisted reproduction aOR 1.88 [1.33; 2.65] (36) Secondary cesarean section aOR 1.95; [1.53; 2.47] (35); Cesarean section in general aOR 1.4 [1.3; 1.5] (39) Operative vaginal delivery aOR 1.5 [1.17; 1.93] (36); aOR 1.5 [1.4; 1.6] (39) Induction of labor aOR 1.69 [1.39; 2.05] (36) Augmentation of labor aOR 1.59 [1.32; 1.91) (36) Specific risk factors for delayed uterine atony: Delayed uterine atony (previous pregnancy) OR 6.0 [2.1; 16.8] (e21) Status post early uterine atony (current pregnancy) OR 4.7 [1.9; 11.6] (e21) Vaginal bleeding before 24 weeks gestational age OR 3.0 [1.6; 5.9] (e21) Prolonged econd stage of labour OR 3.1 [1.2; 7.5] (e21) Arrested labor during econd stage of labour OR 2.1 [1.0; 4.2] (e21)
Urinary incontinence	Prevalence for all women > 20 years: 20% (Norway, population-based) (19) After cesarean section 15.9% Following vaginal birth 21.0% (at any time) (19) 3 Months postpartum in general: 24% (17) to 29% (18) 20 years after vaginal birth 40.3% and after cesarean section 28.8% (20)	Vaginal birth aOR 2.3 [2.0; 2.6] compared to nulliparous women and 1.7 [1.3; 2.1] compared to cesarean section (19) Cesarean section: aOR 0.28 [0.19; 0.41] (18) to OR 0.54 [0.43; 0.68] (17) compared to vaginal birth, and aOR 1.5 [1.2; 1.9] compared to nulliparous women (19) Maternal age ≥ 35 OR 2.02 [1.35; 3.02] (18)
Urinary retention > 6 hours postpartum	0.45–0.7% (e58– e60)
Urinary retention (increased residual urine >= 100 ml)	Data vary widely: 1.5–47% (e62, e63)	Protracted expulsion period (>10 h), operative vaginal delivery, episiotomy OR 1.7 [1.02; 2.71] (22), high birth weight OR 1.03 [1.01; 1.06] (22), EPA OR 2.08 [1.36; 3.19] (22)
Postpartum thyroiditis	1–16.7% (e69– e82)	Anti-TPO Ab detection RR 5.7 [5.3; 6.1] (e86) In persistent anti-TPO Ab in the 3rd trimester, incidence > 80 % (34, 35, e88), compared to 2% in anti-TPO Ab-negative women (e89) Type 1 diabetes mellitus: incidence 10.5 % (e84) to 25 % (e85) (19.6% [19.5; 19.7] (e83) and 25 % [12.7; 41.2] (e86) compared to 8.8% in non-diabetics (e86)
Sheehan’s syndrome	Rare in industrialized countries (e.g., 5/100,000 in Iceland (e115) Likely to be more common in the case of poor healthcare (e.g., 3% of all women > 20 years in an Indian study (e116)	(Insufficiently treated) hemorrhagic shock (e92)

aOR, adjusted odds ratio; anti-TPO Ab, anti-thyroid peroxidase autoantibodies; HELLP, hemolysis, elevated liver enzymes, low levels of platelets; OR, odds ratio; EPA, epidural anesthesia; RR, relative risk; GW, gestational week

Fever, infection, and sepsis

Fever and infection are common complications in the puerperium and range from mild rises in temperature (for example, in the context of lactation), wound infections, urinary tract infections, and mastitis to a severe, sometimes septic course due to endomyometritis. As a general rule, the patient with fever should present promptly to a gynecologist, since the abovementioned infections, as well as serious infections of other causes, always need to be ruled out and treatment initiated immediately if necessary.

Postpartum endomyometritis

Puerperal endometritis is an infection of the decidua that can develop following vaginal birth or cesarean section (e24). In severe cases, the infection may spread to the myometrium, peritoneum, and beyond, and may also lead to a septic course. A recent meta-analysis reported the incidence of chorioamnionitis (infection of the fetal membranes) to be 3.9%, endometritis to be 1.6%, wound infection to be 1.2%, and sepsis to be 0.05% of all births (vaginal, operative vaginal, and cesarean section) (8). These are mostly polymicrobial infections involving various aerobic and individual anaerobic bacteria (e25, e26). Cesarean section, in particular secondary cesarean section, is the most important risk factor. A large cohort study published in 2009 reported a five-fold increased risk of postoperative infection in the case of cesarean section compared to vaginal delivery (e24). See Box 2 for further risk factors.

BOX 2. Further risk factors for endomyometritis.

• Chorioamnionitis (OR: 5.37) (9).

• Prolonged second stage of delivery > 2h: RR: 3.7; [1.4; 8.5] (e27)

• Labor > 12 h: OR: 4.86) (9)

• Premature rupture of membranes 5.81; [5.12; 6.59] (e28) and > 18 h: 6.9; [2.5; 18.9] (e27))

• Multiple vaginal examinations (> eight compared to ≤ two examinations: OR for chorioamnionitis 5.02) (9)

• Operative vaginal births (OR: 1.86) (9)

• Preterm birth < 32nd GW (OR: 3.05; [1.32; 7.06] (e29) to 3.8; [1.07; 13.7] (e30) obesity (BMI ≥ 40 OR: 4.63; [1.25; 17.14]) (e29)

• Meconium-stained amniotic fluid (OR: 1.4–2.28 for chorioamnionitis) (9, e31)

• Gestational diabetes mellitus

• Manual removal of the placenta

• Pre-existing bacterial vaginosis (OR 3.26 to 5.8) (e32, e33)

• B-streptococcal colonization (OR: for chorioamnionitis 1.88 (9) to 7.2; [2.4; 21.2]) (e34, e35)

BMI, body mass index; OR, odds ratio; RR, relative risk; GW, gestational week

Fever, infection, and sepsis:

Fever and infection are common complications in the puerperium and range from mild rises in temperature (for example, in the context of lactation), wound infections, urinary tract infections, and mastitis to a severe, sometimes septic course due to endomyometritis.

Specific risk factors for uterine atony include:

• Delayed uterine atony in a previous pregnancy

• Status following early uterine atony

• Vaginal bleeding before the 24th GW

• Prolonged second stage of labour or arrested labor during the expulsion period

Postpartum thyroiditis.

Postpartum thyroiditis occurs significantly more frequently in women positive for anti-TPO Ab and with type 1 diabetes mellitus.

Group A streptococcal sepsis.

This is one of the most severe, albeit nowadays rare, infections in the puerperium. The disease follows a highly acute course. In 50% of cases, symptoms develop within the first 48 h after birth.

Typical symptoms include fever, tachycardia, lower abdominal pain, a soft uterus that is painful on palpation, foul-smelling lochia, a general feeling of being unwell, and a (progressive) increase in leukocytes. In the case of fever during the puerperium, one must always assume endomyometritis until another cause of infection is confirmed, and liberal intravenous antibiotic therapy should be initiated. A systematic review published in 2015, as well as several older randomized controlled trials demonstrate good efficacy for clindamycin and gentamicin compared to other regimens (10, e26, e36 - e42), or alternatively, for example, piperacillin with tazobactam (e43 - e46) (Box 3). The most important prophylactic measure is antibiotic administration prior to or during cesarean section (RR 0.38 for endometritis) (10). In some cases, antibiotic administration after cutting the umbilical cord is recommended due to concerns regarding infant side effects. However, a recent Cochrane analysis and meta-analysis demonstrate that administration prior to skin incision offers better protection against postoperative infections without posing any risk to the infant (11, 12) (drop in postoperative infection rate with pre-skin incision administration from 6.2 to 2.5%) (e47). In the case of cesarean section, manual placental separation increases the risk of endometritis compared to spontaneous placental separation (e48– e51). A recent randomized trial (ANODE trial) showed a significant reduction in postpartum infections (RR 0.58; 95% CI: [0.49; 0.69]; p < 0.0001) after operative vaginal deliveries with antibiotic prophylaxis (amoxicillin and clavulanic acid) (13).

BOX 3. Treatment of infections in the puerperium.

Endometritis

• Clindamycin 900 mg i.v. every 8 h together with gentamicin 1,5 mg/kg i.v. evey 8 h (10), alternatively, e.g., piperacillin plus tazobactam (e43)

• Up to 48 h free of fever

Endometritis with group A streptococci

• Penicillin and clindamycin (penicillin G, 4 MU i.v. every 4 h und clindamycin 900 mg i.v. every 8 h), plus vancomycin if necessary (e117)

• Early surgical intervention and debridement of the focus of infection, possibly hysterectomy

Urinary tract infection

• Preferred antibiotics/without restrictions: pivmecillinam, penicillins, cephalosporins, macrolides, nitrofurantoin; with restrictions/second choice: fosfomycin, trimethoprim; attention should be paid to contraindications (www.embryotox.de (www.embryotox.de [e118])

Mastitis

• Oral flucloxacillin 4 × 250–500 mg/day or cephalospor 3 × 250–500 mg/day or a macrolide in the case of penicillin allergy (clarithromycin 4 × 500 mg/day) or clindamycin 3 × 600 mg/day for at least 10–14 days (e119)

• In the case of an abscess, possible surgical debridement

• Fungal mastitis: initially, oral fluconazole 2 × 100–200 mg/day for 1–2 weeks, reduced thereafter to 100–150 mg/day (e120)

Group A streptococcal sepsis represents one of the most severe, albeit nowadays rare, infections in the puerperium (incidence in the US for 1997: 6 per 100,000 births, population-based observational study, maternal mortality 3.5%) (14). The disease follows a highly acute course. In 50% of cases, symptoms develop within the first 48 h after birth (high fever in 73%) (15). Other typical symptoms include: diffuse abdominal pain, purulent vaginal discharge, uterine tenderness, gastrointestinal symptoms, fever, chills, increased leukocytes, thrombocytopenia, and hypotension (15), although its diagnostic differentiation from postpartum infections with other pathogens is often challenging. An acute postoperative course or infection in the pharyngeal region in the postpartum woman or members of her family should attract attention. Emergent intervention involving antibiotic therapy (usually with penicillin and clindamycin) and early surgical debridement of the focus of infection are essential, since the mortality rate in the event of associated secondary toxic shock is still 30–50% (e52) (Box 3).

Breast disorders

Common breast diseases associated with breastfeeding include: nipple soreness, breast engorgement, and mastitis. Symptoms of sore nipples can include fissures, skin abrasions, rhagades, scabbing, or signs of inflammation such as redness, edema, and heat. Signs of infection include a purulent or yellowish coating on the nipples (16). Breast disorders in the puerperium should prompt rapid presentation to a gynecologist or midwife. Details on treatment can be found in the eMethods Section “Breast disorders.”

Bladder and pelvic floor disorders

Breast disorders.

Common breast disorders associated with breastfeeding include: nipple soreness, milk stasis, and mastitis. Symptoms of sore nipples can include fissures, skin abrasions, rhagades, scabbing, or signs of inflammation such as redness, edema, and heat.

During the puerperium, acute disorders such as urinary tract infections and urinary retention can occur. Unexplained fever should always prompt consideration of a urinary tract infection, and appropriate diagnostic and treatment steps should be taken (e53).

At the same time, birth and the puerperium are closely associated with incontinence and pelvic floor disorders, which stay with women for life (often causing a high burden of disease). Therefore, attention should already be paid to these disorders in the puerperium in order to enable prompt access to support and treatment. The focus here is on physiotherapy. For conditions ranging from uterine descent to uterine prolapse, the use of vaginal pessaries is increasingly recommended as early on as in the puerperium; having said that, no studies are available to date that adequately demonstrate the effect of vaginal pessaries. Women with uterine prolapse report experiencing significant symptoms and express a desire for more comprehensive information (as early as prepartum) (e54).

Rates of postpartum urinary incontinence range from 15.9% to 29% 3 months following delivery (17– 19). Virtually all studies demonstrate an increased risk among women that have had vaginal delivery compared to nulliparous women and women that have had cesarean section (17, 18, 20) (table 2). A population-based Norwegian study (EPINCONT) reported an age-adjusted risk of urinary incontinence following vaginal delivery of 2.3 [2.0; 2.6], but of 1.5 [1.2; 1.9] following cesarean section (19). While this study demonstrated a significant association between mode of delivery and urinary incontinence only up to the more advanced age of 50 years, a recent Swedish cohort study in women between 40 and 64 years of age showed no age dependence for significantly increased incontinence rates after vaginal delivery (20, e55). For prepartum counseling, there is a validated algorithm that takes into consideration relevant risk factors such as urinary incontinence before pregnancy, age, BMI and mother’s height, estimated fetal weight, and family history: the UR-CHOICE risk calculator (e56). A 2017 Cochrane analysis showed a marked reduction in risk for postpartum urinary incontinence when pelvic floor muscle training is performed antepartum (RR: 0.71; [0.54; 0.95]) (21), but no clear effect for pelvic floor training started postpartum (RR 0.55; [0.29; 1.07]) (RR 0.55; [0.29; 1.07]) (21).

Incontinence and pelvic floor disorders.

Birth and the puerperium are closely associated with incontinence and pelvic floor disorders. These conditions often accompany women lifelong. Attention should already be paid to these disorders in the puerperium in order to enable prompt access to support and treatment.

As yet, no studies investigating a protective effect on the prevention of permanent pelvic floor damage and uterine prolapse have been conducted on the benefit of a vaginal pessary in the puerperium. In addition to urinary incontinence, fecal (or anal) incontinence represents a particularly serious and distressing disorder. A 2017 Cochrane analysis reported the postpartum incidence here to be as high as 10% (21). Affected women report a significant lack of information regarding anal injuries and fecal incontinence (e57).

Postpartum urinary retention is rarer (incidence, 0.45–0.7% [e58–e60], scant data, potentially high number of unreported cases) and defined as the inability to micturate within 6 h of delivery or catheter removal. Increased residual urine is defined as a bladder filling of 100–150mL or more after spontaneous micturition (e61). Postpartum urinary retention, in particular, often goes unnoticed since it is mostly asymptomatic (22) (variable incidence data: 1.5 [e62] to 47% [e63]). In the intrapartum period, damage due to mechanical pressure to the inferior hypogastric plexus may occur, accompanied by soft tissue edema with obstruction of the bladder neck (e64). Peripartum risk factors are shown in Table 2. The patient’s first spontaneous micturition should occur before transfer from the delivery room, or at the latest 2–3 h after delivery. In the case of urinary retention, a single-use catheter is used to empty the bladder and a speculum insertion is immediately performed to rule out injury/hematoma. Re-evaluation should be carried out after 4 h: if spontaneous micturition is still not possible, a 24-h indwelling catheter and urine sediment analysis (to exclude a urinary tract infection) are recommended. An attempt at treatment with an indirect parasympathomimetic drug can also be made (for example, ubretide 5 mg/day).

Thrombosis and thromboembolism

Thrombosis and thromboembolism.

The incidence of thromboembolic complications (during pregnancy and the puerperium) is reported to be 0.54–1.27/1000 births (23– 28). It must be assumed that thromboembolism is one of the most frequent causes of maternal death.

The incidence of thromboembolic complications (during pregnancy and the puerperium) is reported to be 0.54–1.27/1000 births (23– 28). During this period, women are in a hypercoagulable state, probably to protect against high blood loss during childbirth. Despite incomplete mortality statistics in Germany, it must be assumed that thromboembolism is one of the most frequent causes of maternal death. In the case of thrombosis in a previous pregnancy, a risk recurrence without thromboprophylaxis of 5–15.5% has been reported (23, 29, 30). Other risk factors include maternal age, severe peripartum hemorrhage, multiple pregnancy, hypertensive disorders of pregnancy, parity ≥ 3, lupus, stillbirth, prematurity, obesity, pre-existing thrombophilia, and immobilization (24, 31, e65) (box 1). Cesarean section represents one of the most important risk factors: an odds ratio of 2.2 is reported (e66) for planned (and also performed) cesarean section (in patients with a breech presentation) versus planned vaginal delivery (irrespective of the ultimate mode of delivery), and an odds ratio of 3.7 [2.73; 5.01] (31) for primary (that is to say, performed before the onset of labor) cesarean section versus successful vaginal delivery, with the risk following secondary (i.e., after the onset of labor) cesarean section being even higher (RR: 4.09; [2.96; 5.63]) (31) (box 1). In accordance with the current S3 guideline on cesarean section, there is a general recommendation for thromboprophylaxis following this intervention. Low-molecular-weight heparins are the treatment of choice for the prevention and treatment of thromboembolic complications. Thromboprophylaxis initiated antepartum should be continued for approximately 6 weeks after delivery due to the ongoing risk following delivery, given that many thromboembolic complications occur following discharge from the maternity unit. While several studies showed thrombosis to be more common during pregnancy, the incidence of pulmonary embolism in the puerperium tends to be higher compared to prepartum (27, 28, 31). The risk seems to return to its pre-pregnancy level after approximately 4 weeks postpartum (31). A Scottish retrospective study including 72,000 births reported a prepartum incidence of thrombosis of 0.5/1000 versus 0.21/1000 births postpartum, and 0.07/1000 prepartum versus 0.08/1000 births postpartum for pulmonary embolism (27). In an Australian study including more than 500,000 births (2001–2007) and with at an incidence of pulmonary embolism of 0.45 per 1000 births, 61.3% of pulmonary embolisms occurred exclusively in the postpartum period, 2.7% occurred postpartum but were preceded by prepartum thrombosis, and 4.5% occurred both prepartum and postpartum (31). Similar results were found in a US study including 268,525 births (incidence of embolism, 0.14/1000 births) for the observation period 1978–1996 in which 60.5% of embolisms occurred postpartum (28).

The clinical diagnosis of deep vein thrombosis and pulmonary embolism is challenging after birth due to the fact that symptoms cannot always be differentiated from (physiological) postpartum symptoms. The diagnostic work-up and treatment of venous thrombotic events do not differ significantly from treatment outside of pregnancy and childbirth (e67, e68).

Mental disorders in the puerperium

Mental disorders in the puerperium.

Mental disorders such as depressive disorders, anxiety disorders, and post-traumatic stress disorders represent yet another group of important diseases in the puerperium that are underestimated in terms of incidence.

Mental disorders such as depressive disorders, anxiety disorders, and post-traumatic stress disorders represent yet another group of important diseases in the puerperium that are underestimated in terms of incidence. For more details on these disorders, the reader is referred to the eSupplement “ Mental disorders in the puerperium.”

Endocrine disorders

Endocrine disorders in the puerperium often go undetected or are misinterpreted as postpartum depression. The most common disorders include postpartum thyroiditis (PPT), which develops in 1–16.7% (e69– e82) of women following delivery, with onset 4–24 weeks postpartum, as well as post-miscarriage (32). Characteristic features include symptoms of transient hyperthyroidism, such as tremor, nervousness, tachycardia, and hyperdrosis, potentially progressing in later stages to lack of drive and extreme fatigue as symptoms of hypothyroidism (33). PPT is more common in patients with type I diabetes mellitus (incidence, 10.5–25%) (e83– e86). It is also strongly associated with the presence of anti-thyroid peroxidase (anti-TPO) antibodies (34, 35, e83, e87 - e89, Table 2). Between 12% and 30% of patients go on to develop persistent hypothyroidism (34, e90). Basal TSH levels and, where appropriate, autoantibodies should be regularly monitored: initially every 4–8 weeks (34), and annually once a euthyroid metabolic state has been reached (32) in order to detect persisting dysfunction. From a treatment perspective, oral levothyroxine can be administered for hypothyroidism, while beta-blockers can be used short-term for tachycardia symptoms (in the setting of hyperthyroidism) (33, 34). From a differential diagnostic perspective, it is important to rule out exacerbated autoimmune thyroiditis (AIT). The risk of recurrence of PPT is reported to be 42.4% – 69.2% (e70, e91).

Endocrine disorders.

These often go undetected or are misinterpreted as postpartum depression. The most common disorder is postpartum thyroiditis (PPT), which develops in 1–16.7% of women following delivery, with onset 4–24 weeks postpartum, as well as post-miscarriage.

Rarer endocrine disorders in the puerperium include Sheehan’s syndrome, which is caused by ischemic pituitary necrosis, usually following severe peripartum hemorrhage and shock. In developing countries, it is one of the most frequent causes of hypopituitarism (e92). The diagnosis is often missed and not made until decades later. Characteristic symptoms are caused by insufficient production of pituitary hormones (lactation disorders, amenorrhea, genital and axillary hair loss, weakness, premature skin aging, dry skin, and hypopigmentation). The onset of lactation or menstruation does not rule out its diagnosis. In addition to the hormone deficiencies, frequent normocytic normochromic anemia, and low platelet count that can be detected in laboratory tests, magnetic resonance imaging reveals a completely or partially empty sella turcica as a result of pituitary gland atrophy. Due to the risk of developing severe, life-threatening disease, early diagnosis and prompt replacement of deficient hormones are essential, particularly in hypothyroidism and hypocortisolism (e92).

Supplementary Material

eMethods Section

Search terms

In particular regarding definitions and rare clinical pictures for which there is only scant primary literature, German-language standard textbooks were consulted. The search terms used included, for example: general: “postpartum complications,” “postpartum morbidity and mortality”; hypertensive disorders: “hypertensive Disorders of Pregnancy AND postpartum,” “HELLP,” “preeclampsia” AND “postpartum”; Subinvolutio uterine/Spätatonie: “delayed uterine involution,” “(secondary) postpartum hemorrhage”; endometritis: “postpartum infection”, “postpartum endometritis”, “postpartum sepsis”, “antibiotic prophylaxis AND cesarean section”, “antibiotic therapy AND endometritis”, “group A-streptococcal endometritis”; milk stasis/mastitis: “mastitis puerperalis”, “breast feeding complications”, “breast disorders AND pregnancy OR lactation”; urinary retention/infection: “urinary retention AND postpartum”, “postpartum urinary tract infection”, “postpartum urinary incontinence”; thrombosis/embolism: “thrombosis, pulmonary embolism AND postpartum”; mental disorders: “postpartum mental disease”, “mental disease AND pregnancy”, “postpartum depression”, “postpartum anxiety disorder”, “postpartum PTDS”, “postpartum psychosis”, “postpartum eating disorders”; endocrine disorders: “postpartum endocrine disorders,” “postpartum thyreoditis,” “Sheehan syndrome”.

Breast disorders in the puerperium

Common breast disorders associated with breastfeeding include: nipple soreness, milk stasis, and mastitis. Symptoms of sore nipples can include fissures, skin abrasions, rhagades, scabbing, or signs of inflammation such as redness, edema, and heat. Signs of infection include a purulent or yellowish coating on the nipples (16). Treatment options, in addition to optimizing and changing the breastfeeding position, include topical application of breast milk and highly purified lanolin (e121). The increased initial swelling of the mammary glands seen within the first 10–14 days postpartum need to be differentiated from milk stasis and mastitis. Regular breast emptying (8–12 times/24 h) during this phase promotes venous and lymphatic drainage and milk production (e53). Causes of milk stasis (= insufficient emptying of the breast [e122]) include mechanical obstruction (poor breastfeeding technique, short periods of breastfeeding, or constriction by clothing), lack of let-down reflex (stress or sleep deprivation: catecholamines inhibit oxytocin release centrally and peripherally) or, less frequently, excessive milk production (e123). In contrast to mastitis, milk stasis is not associated with impaired general condition and temperature > 38.4 °C (e124). The local symptoms (redness, heat, hardening, and pain) are similar and generally develop unilaterally. Puerperal mastitis is milk stasis- or infection-related inflammation of the mammary gland that peaks in incidence 2–3 weeks postpartum. The most common pathogens include Staphylococcus aureus at > 90%, more rarely coagulase-negative staphylococci, streptococci, Pseudomonas aeruginosa, and Escherichia coli (e119). Bacterial mastitis requires antibiotic therapy. Milk stasis-related mastitis also requires antibiotics to be started if there is no improvement after 24–48 h. Before starting calculated therapy (oral ß-lactamase-resistant penicillin [flucloxacillin 4 × 250–500 mg/day] or first- and second-generation cephalosporins [cephaclor 3 × 250–500 mg/day], in the case of penicillin allergy, macrolide antibiotics [clarithromycin 4 × 500 mg/day] or clindamycin 3 × 600 mg/day, Table 3) for at least 10–14 days), material should be obtained for microbiological analysis (e117, e123). In the case of resistance to treatment > 2 weeks, histological investigation is mandatory to exclude inflammatory breast cancer (e126). In all breast disorders during the lactation period, regular emptying of the breast, manually or mechanically if necessary, is essential alongside an evaluation of the causes (e127). Adjunctive analgesia with acetaminophen (500–1500 mg/day) or ibuprofen (800–1 600 mg/day) can be given, as well as warming the breast before/cooling the breast after breastfeeding (e128). Between 4 and 11% of cases of mastitis develop into an abscess, which should undergo fine-needle aspiration while the patient is on concurrent antibiotic therapy. If the abscess persists or findings are extensive, surgical incision with drainage and irrigation is performed (e129). Weaning is not necessary in breast disorders during breastfeeding and should be avoided above all in the case of stasis-related disorders and in the acute phase. An exception here is the rare bilateral mastitis due to group B ß-hemolytic streptococci: in addition to pausing breastfeeding, the infant should receive simultaneous antibiotic therapy (e53). Another rare special form is candida infection of the milk ducts. Fungal mastitis is a common cause of treatment-refractory nipples that are painful during breastfeeding, with a burning pain radiating deep into the breast (e130), often without external signs of inflammation. Pathogen detection can be challenging. Treatment with oral fluconazole (initially, 2 × 100–200 mg/day) continues until symptoms resolve (usually for 1 or more weeks), then reduced to 1 × 100–150 mg/day for a few more days (e120). To prevent re-infection, the infant must also be treated (oral gel for infants 4 × daily) (e131).

Mental disorders in the puerperium

The spectrum of mental disorders in the puerperium ranges from mild low mood and adjustment disorders to severe psychoses. Typical clinical pictures include depressive and anxiety disorders, post-traumatic stress disorder, eating disorders, and personality disorders (e132).

For depressive disorders, a prevalence of 6.5%–16% is reported (e132– e134), whereby the data in the literature vary and often do not distinguish between major and minor depression. A systematic review published in 2005 describes a point prevalence for major depression in high-income countries of 3.1%–4.9% during pregnancy and of 4.7% in the first 3 months postpartum (for minor depression, 11%, and 13%, respectively) (e135). The incidence in low-income countries is likely to be higher (e132, e136). In addition to pre-existing mental disorders or depressive syndromes (e137– e140), the following are considered to be important risk factors: difficult psychosocial situations (domestic violence [e140, e141]), negative life events/low levels of social support (e137– e140), migrant background (e142) and/or low social status (e137, e138, e140, e143), pregnancy/birth complications, and a positive family history (e137– e139); having said that, depression can also occur in patients with no pre-existing conditions or risk factors (e132, e144). The differentiation between what can be considered “normal stress” and a manifest mental disorder is a difficult one to make. It is assumed that only 20%–50% of women with depressive symptoms in the puerperium report these to their physician or midwife (e145– e148). The Edinburgh postnatal depression scale (EDPS) is a widely used screening tool that has been translated into numerous languages (e149).

The mildest form of depressive disorder that is not a mental illness in the proper sense is the so-called “baby blues.” According to ICD-10, this is not a distinct diagnostic entity, but is classified instead as “postpartum depression, not otherwise specified” (e150). Therefore, this term applies only to those cases that do not meet the definition for any other mental disorder (e151). A systematic review published in 2020 reported a prevalence of “baby blues” of between 13.7% and 76.0% (e152). These maternity blues usually peak after a few days, with an improvement generally seen within 2 weeks. Important treatment measures for mild depressive episodes include support in caring for the infant and ensuring adequate sleep.

Postpartum depression meets the DSM-5 and ICD-10 criteria for a manifest depressive disorder. By definition, onset is within the first 4–6 weeks after birth, with the initial manifestation tending to occur later compared to the “baby blues” and, thus, following discharge from the maternity unit. ICD-10 makes a distinction between mild, moderate, and severe depressive episodes (e153). Postpartum depression differs little in terms of symptoms from non-pregnancy-related depression (e132). If a patient fulfills the criteria for depression, treatment should be initiated by a psychiatrist, since possible suicidality needs to be ruled out and drug treatment initiated if necessary. An important aspect of the care of patients with mental illness is to assess whether the infant’s well-being is at risk; this should be done by a psychiatrist.

The prevalence of anxiety disorders in the puerperium is reported to be between 9% and 17.1% (e154– e156), showing little difference from that outside of pregnancy/breastfeeding; it is also unclear what effect pregnancy and the puerperium have on the course of anxiety disorders (e132).

Post-traumatic stress disorder (PTSD) can occur either after pregnancy-related events (including events in previous pregnancies) or after non-pregnancy-related trauma. The prevalence in high-income countries is estimated to be 1–2% (e157). The true rate may be higher, given that often only pregnancy-related trauma are recorded (rate otherwise, 6%–8%) (e158).

Patients with eating disorders often appear to go into remission during pregnancy, although symptoms nevertheless re-emerge in a large proportion of women some time after pregnancy and the puerperium (e159).

Severe psychiatric disorders such as psychosis, schizophrenia, and bipolar disorders are rare in the puerperium, although the exact prevalence is unknown and it is unclear whether it differs from that outside of pregnancy. A large epidemiological study conducted in the United States reported the incidence of psychotic disorders and bipolar disorders in the puerperium to be 0.5% and 2.9%, respectively (e154). Pregnancy and childbirth represent major life changes and, as such, an important potential trigger for manic episodes and psychosis, which have a considerable impact on maternal–infant morbidity and mortality, as well as on the mother–child relationship (e160). Compared to postpartum depression, psychotic disorders tend to be short-term and are of comparatively sudden onset within the first 2 weeks, and usually within the first 1–3 days after birth (e161) (ebox).

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Only one answer is possible per question. Please select the answer that is most appropriate.

Question 1

Mrs Miller is scheduled to give birth by cesarean section in the 34th GW due to severe pre-eclampsia. For how long should postpartum seizure prophylaxis with i.v. magnesium be continued?

1. Up to 6 h following delivery

2. Up to 12 h following delivery

3. Up to 24 h following delivery

4. Up to 48 h following delivery

5. Until blood pressure normalizes

Question 2

In the presence of which pre-existing disease does postpartum thyroiditis occur particularly frequently?

1. Pre-existing lipedema

2. Psoriasis

3. Ulcerative colitis

4. Type-1 diabetes mellitus

5. Crohn‘s disease

Question 3

What is the risk of thrombosis in the puerperium if the patient has a history of previous thrombosis?

1. 1–2.5%

2. 5–15.5%

3. 15.6–30%

4. 35–40.5%

5. 46–60%

Question 4

What is a characteristic feature of postpartum urinary incontinence?

1. The inability to spontaneously micturate 2 h following delivery

2. A residual urine volume of at least 300–350 mL following spontaneous micturition

3. It affects 50–60% of all women following childbirth

4. Age peak in women over 40 years

5. Frequently occurs following operative vaginal delivery

Question 5

Which measure is shown to reduce the risk of postpartum endometritis?

1. Manual removal of the placenta during cesarean section

2. Routine curettage of the uterine cavity during cesarean section

3. Treatment of vaginal colonization with Candida albicans at the beginning of the pregnancy

4. Prophylactic antibiotic administration during cesarean section

5. Regular administration of anti-inflammatory drugs during the first 48 h postpartum

Question 6

What, on the basis of the existing medical history, should arouse suspicion of A streptococcal infection in the puerperal woman?

1. Slow-onset lymphadenitis postpartum

2. An infection in the pharyngeal region of the 2-year-old sibling

3. Pre-existing bacterial vaginosis

4. Pre-existing autoimmune disease

5. Gradual disease onset 6 days following delivery

Question 7

What is a risk factor for a hypertensive disorder of pregnancy?

1. Kidney disease

2. Premature rupture of membranes

3. Immobilization

4. Hashimoto‘s thyroiditis

5. Marfan syndrome

Question 8

What is a characteristic correlate in the diagnosis of Sheehan syndrome?

1. Empty sella on MRI

2. Detection of a degenerative intramedullary lesion

3. Diaphragma sellae that is painful on palpation

4. Presence of Wernicke–Korsakow psychosis

5. Subcortical substance loss

Question 9

How long does physiological postpartum uterine involution to the original size of approximately 50 g usually take?

1. 1–2 Weeks

2. 3–4 Weeks

3. 5–6 Weeks

4. 7–8 Weeks

5. 9–10 Weeks

Question 10

What is a risk factor for thrombosis/embolism in the puerperium?

1. BMI < 20 kg/m2

2. Excessive physical activity

3. Gingivitis

4. Primiparity

5. Stillbirth in the current pregnancy

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eBOX. Risk factors for mental disorders in the puerperium (excluding psychoses) (modified from [e132]).

Pre-existing mental illness or depressive syndromes (e137– e140); OR 5.1–5.6 (e137)

• Difficult psychosocial situations:

  • Domestic violence (e140, e141); OR 2.11–6.75 (e137)

  • Negative life events (e137– e140)

  • Low level of social support (e137– e140);

  • lack of support from the partner OR 2.0–9.4 (e137)

  • Migrant background (e142)

  • Low social status (e137, e138, e140, e143) OR 2.1–13.2 (e137)

  • Unplanned pregnancy OR 1.6–8.8 (e137)

  • Pregnancy/birth complications (e135– e137)

  • Positive family history (e135– e137)