Emergency Medicine Practice: Managing Postpartum Complications in The Emergency Department

MARCH 2022 | VOLUME 24 | ISSUE 3
Emergency Medicine Practice Evidence-Based Education • Practical Application
CLINICAL CHALLENGES:
• What are the history and physical
examination findings that point
to life-threatening postpartum
complications?
• When are advanced imaging, ECG,
and laboratory studies needed?
• When should ob/gyn, neurology,
and cardiology consultation be
obtained?
Authors
Nicole Yuzuk, DO
Ultrasound Director, Core Faculty, St. Joseph’s
University Medical Center, Paterson, NJ
Joseph Bove, DO
Emergency Physician, St. Joseph’s University
Medical Center, Paterson, NJ
Riddhi Desai, DO
Department of Emergency Medicine, St.
Joseph’s University Medical Center, Paterson, NJ
Managing Postpartum
Peer Reviewers
Complications in the
Jennifer Beck-Esmay, MD, FACEP
Emergency Department
Associate Professor of Emergency Medicine;
Assistant Residency Director, Mount Sinai n Abstract
Morningside-West; Icahn School of Medicine at Postpartum patients may present to the emergency department
Mount Sinai, New York, NY with complaints ranging from minor issues, requiring only
Elizabeth Leenellett, MD, FACEP patient education and reassurance, to severe, life-threatening
Associate Professor and Vice Chair, Department complications that require prompt diagnosis and multidisciplinary
of Emergency Medicine, University of Cincinnati consultation and management. At times, vague presentations or
College of Medicine, Cincinnati, OH
overlapping conditions can make it difficult for the emergency
clinician to recognize an emergent condition and initiate proper
Prior to beginning this activity, see “CME treatment. This issue reviews the major common emergencies
Information” on page 22. that present in postpartum patients, by chief complaint, including
hemorrhage, infection, pre-eclampsia, eclampsia, headache, and
cardiopulmonary conditions, and reviews the most recent evidence
and guidelines.
For online access, scan with your

smartphone camera or QR code reader app:
This issue is eligible for CME credit. See page 22. EBMEDICINE.NET
Case Presentations
A woman 3 weeks’ post partum presents with gradually worsening cough and severe shortness of
breath…
• Early on Sunday morning, a 33-year-old woman presents with gradually worsening cough and shortness
of breath that is so severe that if she takes more than 4 steps, she has to sit down to catch her breath.
• Her blood pressure in triage is 185/115 mm Hg, she is tachycardic with a heart rate of 120 beats/min,
CASE 1
and she is tachypneic and speaking in short phrases. Her temperature is 37°C, and her oxygen satura-
tion is 95%.
• She has no past medical history, and states she had an uncomplicated delivery of twin boys 3 weeks
ago via cesarean delivery. On physical examination, there is jugular venous distension, crackles
bilaterally, and lower extremity edema. Her abdomen is soft and nontender.
• You wonder why her blood pressure is so high and whether her high blood pressure is related to her
shortness of breath...
A man brings his wife into the ED for altered mental status 2 weeks after having a baby…
• The patient is wheeled into the resuscitation room for evaluation. The husband states she has been
intermittently confused and at times thinks she is still pregnant, despite caring for the newborn.
• On examination, she is afebrile, her blood pressure is 190/110 mm Hg, and heart rate is 98 beats/min.
CASE 2
She is moving all extremities, but has global weakness and is oriented only to herself and her husband.
• Her husband states that she had an uneventful vaginal delivery 2 weeks prior, after a normal pregnancy.
He also reports she had been complaining of a pressure-like headache for the past 2 days, for which
she had been taking acetaminophen 650 mg every 8 hours, with temporary improvement.
• After obtaining a bedside blood sugar (which is normal), she starts to seize on the stretcher. Your dif-
ferential is long, and includes stroke and drug overdose, but you also wonder whether this could be ec-
lampsia. With so many possibilities, you consider what the best pharmacologic intervention would be...
A 25-year-old woman with headache, blurry vision, and right arm numbness presents after delivering
a baby 3 days ago…
• She reports having had an epidural with her recent vaginal delivery, and thought her symptoms may be
CASE 3
related to that.
• Her blood pressure is 135/90 mm Hg; heart rate, 85 beats/min; temperature, 36.5ºC; and oxygen
saturation 99% on room air. She has decreased sensation to pinprick throughout her right upper
extremity, but otherwise the neurologic exam is normal.
• A “Code Stroke” is activated, and she is sent for a noncontrast head CT; however, you know that a
negative CT does not rule out stroke and wonder whether she will need a more extensive evaluation...
n Introduction only to the mother, but also to the newborn baby.

The postpartum period can be a difficult time for Up to 6 weeks‘ postpartum, patients may present
some patients. In addition to the challenges of taking with various complaints, such as abdominal pain,
care of a newborn, there are many complications that wound complications, persistent vaginal bleeding,
can potentially arise after delivery. A retrospective breast pain, fever, hypertension, chest pain, shortness
study that included 26,074 pregnancies noted that of breath, and neurologic symptoms. At times, the
20% of these patients had complications such as vague presentations or overlapping conditions
gestational diabetes, gestational hypertension, make the diagnosis and management challenging.
and/or pre-eclampsia, and approximately 25% of A thorough history of present illness should focus
them were evaluated at least once in the emergency on obstetric- and gynecologic-related questions
department (ED) for postdelivery complications.1 It to elicit the diagnosis of potential complications
is imperative that emergency clinicians be aware of such as postpartum pre-eclampsia, cerebral venous
these complications and not minimize a new mother’s thrombosis, pulmonary embolus, hemorrhage,
complaints. Sending a postpartum patient home headache, and infection.
without a proper diagnosis can be detrimental not
MARCH 2022 • www.ebmedicine.net 2 ©2022 EB MEDICINE

This issue of Emergency Medicine Practice pro- challenges of taking care of a newborn, including
vides a systematic approach to evaluating postpartum sleepless nights and stress, there are dangerous
patients using the most recent evidence from the etiologies, including cerebral venous thrombosis
literature and American College of Obstetricians and and intracranial hemorrhage (ICH). In a prospective
Gynecologists (ACOG) guidelines. study of 985 postpartum patients with headache,
the most common etiologies were tension/migraine
and musculoskeletal, thus highlighting the challenge
n Critical Appraisal of the Literature of avoiding bias in these patients.7 In another
PubMed MEDLINE® was searched for articles in retrospective study that included 95 postpartum
the English language with the keyword postpartum women, 10% of patients were found to have a
combined with emergencies, cardiomyopathy, more severe diagnosis, including cerebral venous
hemorrhage, infections, hypertension, pre-eclampsia, thrombosis, hemorrhage, or mass.8 Postpartum
eclampsia, HELLP syndrome, and headache. The patients are at higher risk for dangerous etiologies
search was initially limited to articles from the past of headaches secondary to their coagulopathic state
10 years, and to the publication types of randomized and incidence of hypertensive disorders.
controlled trials, systematic reviews, or meta-analyses. Postpartum stroke can be either hemorrhagic
The Cochrane Library was searched for references, (usually from a ruptured aneurysm or vascular
as was the American College of Physicians Journal malformation) or ischemic/thrombotic (likely
Club, the Database of Abstracts and Reviews of secondary to cerebral venous thrombosis or pre-
Effects (DARE) Health Technology Assessment, and eclampsia/eclampsia).9 ICH is one of the most feared
United Kingdom’s National Health Service Economic complications in postpartum patients because of the
Evaluation database. There were 4 ACOG Practice high mortality rate, and the risk for ICH is highest
Bulletins found to be relevant. There were no in the postpartum period. Identifiable risk factors
published guidelines on the emergent management include advanced age, Black race, hypertensive
of postpartum complications by the American disorders, coagulopathy, and smoking.10 A final cause
College of Emergency Physicians. Additional relevant of a postpartum headache warranting recognition
papers in the bibliographies of the articles were is a post–dural puncture headache. This can be
also reviewed. There is not a body of high-quality seen in as many as 16% of postpartum patients with
literature, such as randomized controlled trials, to headaches.8 These headaches are thought to be
support most practices in emergency management related to the loss of cerebrospinal fluid (CSF) into the
of the postpartum patient; the literature tends to be dural space, causing loss of intracranial CSF volume.
primarily lower quality evidence, such as prospective
cohort studies and retrospective studies. Fever and Infection
Causes of postpartum fever include wound infection,
mastitis, and endometritis. Wound infection can
n Etiology and Pathophysiology vary, depending on the type of delivery (vaginal vs
Hemorrhage cesarean). Mastitis is most common within the first
Postpartum hemorrhage may be characterized as 3 months of breastfeeding and is reported to occur
early (primary postpartum hemorrhage), occurring in 2% to 10% of breastfeeding women.11 Mastitis
in the first 24 hours post partum; or late (secondary is usually a result of inadequate breast emptying,
postpartum hemorrhage) when occurring 24 hours leading to clogged ducts and inflammation. Cracked
to 12 weeks post partum.2 It is defined by ACOG as nipples, which can be caused by a poor infant latch,
blood loss >1000 mL or blood loss with symptoms are also known to cause mastitis. Lastly, endometritis
and signs of hypovolemia.3 It is important to note that should also be on the differential of a postpartum
blood loss >500 mL is still abnormal and should be patient presenting to the ED with fever. Endometritis
investigated. The main cause of hemorrhage, seen in can begin during labor, as the vaginal flora can
60% to 80% of cases, is uterine atony.3,4 Unfortunate- migrate to the uterus. Cesarean delivery is considered
ly, attempts at establishing a risk-stratifying tool have the biggest risk factor for endometritis, especially
lacked sufficient sensitivity and specificity, so there is when it is performed after the onset of labor. Bacterial
not a universally accepted way to predict a postpar- vaginosis can also increase risk, causing endometritis
tum hemorrhage.4,5 Other notable causes of postpar- in patients undergoing cesarean delivery.12
tum hemorrhage include uterine rupture, lacerations,
coagulopathies, retained placenta, infections, and Pre-eclampsia/Eclampsia
vascular malformations.6 Pre-eclampsia is characterized by elevated blood
pressure (systolic blood pressure ≥140 mm Hg
Headache or diastolic blood pressure ≥90 mm Hg) after 20
Headaches are common in women in the postpartum weeks’ gestation, with clinical signs and laboratory
period, and although this can be secondary to the abnormalities involving the hematologic, renal,
GROUP SUBSCRIPTIONS: [email protected] 3 © 2022 EB MEDICINE. ALL RIGHTS RESERVED.

hepatic, pulmonary, and/or neurologic systems. If the The clinical features of pre-eclampsia are a direct
patient presents with features of pre-eclampsia and result of the generalized endothelial dysfunction it
new-onset seizures, a diagnosis of eclampsia is given. causes.17 The pathophysiology involves maternal as
(See Table 1.) well as placental factors. In early pregnancy, abnormal
Along with elevated blood pressure, proteinuria is implantation and the increase in placental mass can
a hallmark of pre-eclampsia. A random urine dipstick cause decreased placental perfusion, which activates
reading of 1+ is suggestive, but not diagnostic endothelial cells, initiating the coagulation cascade
of this criterion. If other quantitative measures and increasing vascular permeability. Hypertension
are not available, a urine dipstick reading of 2+ and coagulopathy result from chronic inflammation
is more suggestive of pre-eclampsia. Criteria for and endothelial dysregulation, causing aberrancies
pre-eclampsia with severe features includes severe in vascular tone and increase in antiangiogenic
blood pressure elevation (systolic blood pressure factors. Proteinuria and edema are findings from this
>160 mm Hg or diastolic blood pressure >110 mm increased vascular permeability. Headache, seizures,
Hg on 2 occasions, 4 hours apart, in addition to visual changes, abdominal pain, and fetal growth
the renal, hepatic (thrombocytopenia), pulmonary, restriction are the sequelae of endothelial dysfunction
and neurologic criteria for pre-eclampsia.13 From an in the vasculature of target organs, such as the brain,
emergency medicine standpoint, a blood pressure of liver, kidney, and placenta.
160/110 mm Hg is considered severe hypertension Although patients without pregnancy
in pregnancy, and treatment with antihypertensives complications can present with de novo postpartum
should be initiated without waiting for obstetrics/ pre-eclampsia and eclampsia, certain risk factors
gynecology (ob/gyn) specialist input. have been identified. A 2016 meta-analysis of cohort
Pre-eclampsia and eclampsia complicate up to studies included ≥1000 patients and evaluated the
8% of pregnancies globally.13 For many years, the fo- risk for pre-eclampsia in relation to common clinical
cus of pre-eclampsia has traditionally been on hyper- risk factors assessed at ≤16 weeks of gestation (total
tension, because hypertensive emergencies result in of 92 studies, more than 25 million pregnancies). The
the maternal morbidity associated with this condition. highest rate of pre-eclampsia occurred in women with
However, hypertension is just one of the clinical mani- antiphospholipid syndrome (17%), and the highest
festations, and there is not strong evidence to show relative risk of pre-eclampsia occurred in women
that treating hypertension prevents pre-eclampsia.14 with a past history of the disease (12%).18 Other
An asymptomatic postpartum patient with elevated prominent risk factors included chronic hypertension,
blood pressure may not always require treatment. pregestational diabetes, prepregnancy BMI >30
Pre-eclampsia is likely due to an excessive kg/m2, multifetal pregnancy, and use of assisted
maternal inflammatory response to pregnancy.15 reproductive technology.19 Nonwhite women had
Obesity increases the likelihood of pre-eclampsia higher recurrence risk.16 A retrospective study in
by inducing chronic inflammation and endothelial women with singleton pregnancies found that
dysfunction, which induces the microangiopathic maternal age ≥40 years was also associated with
features of pre-eclampsia. A retrospective cohort increased risk of pre-eclampsia.19
study showed that the patient’s prepregnancy
body mass index (BMI) appeared to have a strong HELLP Syndrome
association with the risk for incident pre-eclampsia in HELLP stands for Hemolysis, Elevated Liver enzymes,
the first or second pregnancy.16 Low Platelet count. The specific criteria for diagnosis
can be seen in Table 2. The pathogenesis in HELLP
syndrome is somewhat unclear and often occurs with
pre-eclampsia; however, when there is inadequate
Table 1. Criteria for the Diagnosis of trophoblast invasion, placental ischemia results.
Postpartum Pre-eclampsia13 Subsequently, the endothelium is activated, which
• Systolic blood pressure ≥140 mm Hg
or
• Diastolic blood pressure ≥90 mm Hg
plus Table 2. Criteria for the Diagnosis of
New onset of 1 or more of the following:
• Protein/creatinine ratio >0.3 in a random urine specimen
HELLP Syndrome20
• Thrombocytopenia (platelets <100,000/mcL) • Microangiopathic hemolytic anemia
• Serum creatinine >1.1 or doubling of creatinine concentration in the • Schistocytes (helmet cells) on peripheral smear
absence of other renal disease • Platelet count ≤100,000/mcL
• Liver transaminases at least twice the upper limit of normal • Aspartate aminotransferase >70 IU/L
• Pulmonary edema • Lactate dehydrogenase ≥600 IU/L, bilirubin ≥1.2 mg/dL
• New-onset and persistent headache that is not accounted for by other
diagnoses and not responding to usual doses of analgesics Abbreviations: HELLP, hemolysis, elevated liver enzymes, low platelet
• Visual symptoms count.

initiates the coagulation cascade. Platelets release n Differential Diagnosis
thromboxane A and serotonin, causing vasospasm, There is a wide range of postpartum complications,
platelet aggregation, and persistent endothelial so the differential diagnosis should be tailored to the
disruption that leads to inflammation, hypertension, chief complaint. For a patient presenting with acute-
and proteinuria.21 The consumption of platelets onset shortness of breath or chest pain, pulmonary
causes thrombocytopenia. The red blood cells embolus must always be at the top of the differential,
break down while passing through platelet- and but other diagnoses of concern include heart failure,
fibrin-rich capillaries, causing microangiopathic a pre-existing cardiomyopathy, myocardial infarction,
hemolytic anemia, leading to microvascular injuries coronary artery dissection, and symptomatic anemia
of multiple organ systems. An ischemic-reperfusion from a potential hemorrhage.25,30 In patients present-
injury initiates the liver damage in HELLP syndrome. ing with elevated blood pressure and/or neurologic
It is hypothesized that the cascade ceases when the complaints, pre-eclampsia, eclampsia, and HELLP
fetus is delivered.21 Another hypothesis is that HELLP syndrome should all be considered; many times they
syndrome involves the complement cascade and is a manifest together. If the patient has abdominal pain
systemic inflammatory disorder that may be treatable with an elevated blood pressure, additional consid-
without emergent delivery of the fetus. erations may include hypertensive emergency, acute
fatty liver of pregnancy, thrombotic thrombocytope-
Peripartum Cardiomyopathy nic purpura, hemolytic uremic syndrome, pancreatitis,
Peripartum cardiomyopathy (PPCM) affects patients hepatitis, cholecystitis, and appendicitis. For a patient
primarily in the postpartum period, but it can be presenting with headache, the more dangerous eti-
present at any time from the last month of pregnancy ologies such as cerebral venous thrombosis, intracra-
to 5 months after delivery.23-26 (See Table 3.) nial hemorrhage, and stroke should always be high
McNamara et al found 98/100 (98%) of patients on the differential. If the patient received an epidural,
were diagnosed postpartum,23 and Goland et al the clinician should also consider the possibility of a
found 140/182 (77%) were diagnosed postpartum.24 post–dural puncture headache. (See Table 4.)
PPCM remains a diagnosis of exclusion and is mainly
characterized by a left ventricular ejection fraction
<45%, though the diagnosis can be made with values
exceeding 45%.22,26 In the United States, the disease
Table 4. Differential Diagnoses for
is rare, but increasing, with an incidence of 1 in 968 Postpartum Headache8,31-33
live births.27 Signs and Symptoms Possible Diagnosis
The mechanisms underlying PPCM have not been
Focal neurologic findings and/or signs of Cerebral venous sinus
elucidated but are related to several factors including intracranial hypertension; symptoms are thrombosis
Black race, multiparity, and advanced maternal usually progressive
age.22,26 Pre-eclampsia is 4 times more prevalent Acute onset of focal neurologic deficits Acute ischemic stroke
in those with PPCM (22% vs 5%).27 However, more
than 90% of pre-eclampsia patients do not develop Elevated blood pressure + proteinuria, Pre-eclampsia
visual disturbances, nausea, abdominal
PPCM, which supports the notion that pre-eclampsia
pain
is not required for its development.28 Pre-eclampsia
Visual complaints, papilledema that may Idiopathic intracranial
with acute pulmonary edema can be distinguished be worse with Valsalva, abnormal mental hypertension
from PPCM primarily by a maintained left ventricular status or neurologic examination
ejection fraction. Shared mechanisms have been Isolated Horner syndrome, headache +/- Carotid or vertebral
postulated, with the understanding that additional neck pain; other neurologic findings artery dissection
factors beyond pre-eclampsia alone can precipitate
Fever, leukocytosis, meningismus, altered Central nervous system
the cardiac dysfunction seen in PPCM.28 mental status infection
Headache with thunderclap onset, Subarachnoid
meningismus; may have focal neurologic or intracranial
findings hemorrhage
Headache exacerbated by standing; history Post–dural puncture
of epidural anesthesia at delivery or post–spinal
Table 3. Criteria for the Diagnosis of anesthesia headache
Peripartum Cardiomyopathy29 Headache in a patient with history of Migraine headache

migraines; symptoms of usual migraine
• Development of heart failure in the last month of pregnancy or within
5 months of delivery Headache with a “pressing” or “tight“ Tension headache
• Absence of an identifiable cause for the heart failure sensation; bilateral, mild to moderate;
• Absence of recognizable heart disease prior to the last month of worsens as day progresses
pregnancy
• Left ventricular systolic dysfunction www.ebmedicine.net

n Prehospital Care sure, suspect eclampsia, and provide a loading dose
Prehospital providers should obtain a thorough of magnesium sulfate in addition to antihypertensive
medical and obstetric history, focusing on the number medications. The adult dose of magnesium sulfate
of weeks the patient is postpartum, pregnancy is 4 to 6 grams IV over 20 minutes. If there will be an
complications experienced, and whether the patient extended transport time after administering the load-
received prenatal care. An accurate blood pressure ing dose, consider initiating a maintenance infusion
reading is essential, along with a detailed neurologic of 1 to 2 grams per hour. If the seizure activity does
and cardiovascular examination, and all information not resolve after initiating magnesium, then IV or
should be communicated to the ingoing hospital. intramuscular (IM) benzodiazepines can be adminis-
Depending on the stability of the patient and the tered.36 These patients should be transported rapidly
presenting complaint, it may be necessary to divert to a facility that has ob/gyn and intensive care unit
the postpartum patient to more specialized care (eg, (ICU) capabilities.
stroke center, cardiac catheterization center, ob/gyn
services, etc). Dyspnea and Chest Pain
For patients with shortness of breath and chest pain,
Postpartum Hemorrhage evaluation for hypertension and hypoxia is indicated.
Some postpartum patients may be stable for trans- If hypoxic, consideration should be given to pulmo-
port with monitoring of vital signs, but others may nary embolism or heart failure. After supplemental
require aggressive, immediate intervention. If a oxygen is provided, if the patient has evidence of
postpartum patient in a prehospital environment is lower extremity edema and rales on examination,
experiencing severe vaginal bleeding, check to see treat with nitrates and diuretics similar to the non-
if there is an external tear. If so, apply direct pressure pregnant patient. Noninvasive ventilation may be
to the area and then a dressing while transporting the utilized to decrease the work of breathing even in
patient to the hospital for definitive care. For patients patients without hypoxia. For patients with chest
who have just delivered out of hospital, if there is no pain, especially if the patient is hypertensive and pre-
evidence of external tear and the placenta has not eclampsia is suspected, an electrocardiogram (ECG)
yet been delivered, place one hand on the uterus should be obtained. Pre-eclampsia can predispose
and apply gentle traction to the umbilical cord to patients to cardiac ischemia or infarction secondary
deliver the placenta. If there are no external injuries to extreme vasoconstriction and multisystem organ
and the placenta has already been delivered, mas- involvement.35 If an ECG reveals ST-segment eleva-
sage the uterus until it is firm, as uterine atony is the tions or signs concerning for ischemia, it is important
most common cause of postpartum hemorrhage. If to relay this information to the emergency clinician,
oxytocin is available, consider prompt administration. as the patient may need to be transported to a center
The mother can also attempt to breastfeed, as this with cardiac catheterization capabilities.
will promote release of oxytocin and further contrac-
tion of the uterus to stop the bleeding. Encouraging Fever and Hypotension
the mother to empty her bladder may also help, as For patients presenting with signs and symptoms of
increased pressure of the bladder on the uterus can infection including fever, tachycardia, and hypoten-
result in uterine atony.34 If there is still profuse bleed- sion, consider supportive care with fluid administra-
ing, 1 gram of tranexamic acid intravenously (IV) over tion, as these patients may be septic secondary to a
10 minutes may be provided. The receiving hospital postpartum infection. Further history-taking to elicit
should be notified as soon as possible to allow the focal symptoms such as lower abdominal pain, odor-
ED to mobilize their team, prepare the resuscitation ous discharge, breast erythema, or incisional pain can
area, prepare for massive transfusion protocols, and be helpful in distinguishing the underlying cause of
notify consultants (ob/gyn and the medical intensiv- fever while transporting the patient.
ist) for prompt management and stabilization of the
patient once EMS arrives. If the patient is actively
bleeding, administer fluids and packed red blood n Emergency Department Evaluation
cells, if available. History
Because of the many complications that can be seen,
Altered Mental Status/Seizures there are many specific questions that must be asked
For patients who are altered, having seizures, or ob- of the postpartum patient. Start by learning the mode
tunded, airway protection is a priority.35 If the patient of delivery (vaginal or cesarean), date of delivery,
had a severe headache and is now obtunded, con- and the total number of pregnancies the patient has
sider transport to a stroke center and document the had. If the patient is hypertensive, inquire about a
pupillary size and reactivity prior to intubation to help history of hypertension or about any medications
the receiving center form a differential on arrival. For they were taking during pregnancy. Ask about chest
patients who are seizing, with elevated blood pres- pain, difficulty breathing, orthopnea, hemoptysis,

or leg edema. Abdominal pain, particularly right showing bilateral disc edema would suggest idio-
upper quadrant pain or epigastric pain, is important pathic intracranial hypertension. On the other hand,
to note, as this may be seen in HELLP syndrome. A if focal deficits, anisocoria, or a nonreactive pupil are
bleeding complaint warrants additional investigation present, the diagnosis should shift toward stroke and
into any coagulopathy concerns, as well as symptoms other intracranial pathologies.
of volume loss. If the patient reports a headache, Finally, examination of the abdomen may reveal
ask about associated symptoms such as vision focal tenderness, particularly in the right upper
changes and vomiting, which may suggest increased quadrant, as in HELLP syndrome.
intracranial pressure. Inquire whether the patient had
a history of headaches prior to pregnancy, a history
of pre-eclampsia, or epidural anesthesia for delivery. n Diagnostic Studies
When a patient presents with a fever or a complaint Hemorrhage
related to a possible infection, inquire whether the Clinical examination and vital signs will be most
newborn is breastfed or formula-fed. Ask about important in patients with postpartum hemorrhage,
breast erythema or pain, abdominal pain, and vaginal because the overwhelming majority of cases are due
discharge to help localize the source of the infection. to uterine atony, which has no standard laboratory
or imaging confirmatory tests.3,4 Intra-abdominal
Physical Examination or retroperitoneal bleeding may result in a delayed
The physical examination must be thorough. Vital diagnosis, so it is important to observe closely and
signs and hemodynamic stability provide the first recheck vital signs of any patient with suspicion for
objective clues toward making a diagnosis. bleeding. Hemoglobin level should be obtained, but
Is the patient tachycardic, hypertensive, and/or its value should not be relied upon, as acute changes
tachypneic? If so, look for jugular venous distension, in blood volume may not be reflected in the hemo-
pulmonary crackles, abnormal heart sounds, and leg globin.39,40 Physiologic changes during pregnancy,
edema. Maintain a high index of suspicion for heart including the increased plasma volume, may serve to
failure even if symptoms are developing gradually blunt the potential hemoglobin drop expected in the
and not acutely. Always consider PPCM in a dyspneic postpartum patient with blood loss of 500 to 1100
patient, because a delay in diagnosis has been mL. For example, about two-thirds of patients with
correlated with a high degree of morbidity and even 500 to 1000 mL of blood loss did not have a drop of
mortality.24 Pulmonary rales may also be present as hemoglobin ≥2 g/dL.40 Obtaining a fibrinogen level
part of a broader diagnosis of pre-eclampsia, since a may be considered, as lower levels may be predic-
sudden, severe increase in blood pressure can lead to tive of severe disease; however, its utility to serve
flash pulmonary edema in the pre-eclamptic patient. as a potential therapeutic target is in question. A
Is the patient hypertensive with all other vital 2020 systematic review that included 2 randomized
signs normal? Then postpartum hypertension moves controlled trials failed to show objective evidence of
higher on the differential; however, elevated blood improvement in outcomes in postpartum hemorrhage
pressure should always be considered pre-eclampsia with early fibrinogen replacement.41 A final diagnostic
until proven otherwise. aid that may be useful is ultrasound. This modality
Is the patient febrile and hypotensive? The pa- can help in making the diagnosis in certain scenarios,
tient may be in septic shock due to retained products such as the identification of retained placental tissue.
or another infectious etiology. If the delivery was
cesarean, examine the wound for erythema or puru- Headache
lent discharge to localize a source. A breast examina- In the postpartum patient presenting with headache,
tion may show erythema or tenderness suggestive of pre-eclampsia should always be at the top of the dif-
mastitis, while a pelvic examination can be performed ferential. A hypertensive patient who has delivered
to assess for vaginal discharge and uterine tenderness within the prior 6 weeks should be evaluated imme-
suggesting endometritis. diately with the standard pre-eclampsia workup that
Alternatively, hypotension noted may not includes laboratory work and urinalysis to assess for
be infectious in origin and could be from blood proteinuria. For a normotensive patient in whom pre-
loss anemia. Carefully inspect the skin color and eclampsia has been ruled out, after a thorough his-
conjunctiva for pallor that can help identify the tory and physical examination has been performed,
cause of the hypotension. A pelvic examination in the emergency clinician must decide whether further
the postpartum patient may be useful to localize a workup and imaging is appropriate. Patients present-
postpartum hemorrhage, as it may help to dictate ing with abnormalities on neurologic examination,
further management.37,38 altered mental status, or meningeal signs will require
A thorough neurologic examination is essential, further evaluation that may include advanced imag-
especially in patients with symptoms of headache. ing, laboratory studies, and/or lumbar puncture. A
A headache with an ophthalmological examination lumbar puncture may be indicated in the ED if there

is suspicion for subarachnoid hemorrhage despite a asking about clogged ducts and how effectively the
normal noncontrast head computed tomography (CT) newborn is emptying the breast can be helpful. If
scan, or if the patient is febrile/altered and meningitis underlying fluctuance is palpated or if there is no
and/or encephalitis is suspected. improvement with antibiotics, an ultrasound may be
For postpartum patients presenting with signs needed to assess for breast abscess.11 Endometritis is
and symptoms of stroke, follow the standard stroke another clinical diagnosis, indicated by the presence
protocols and obtain an immediate noncontrast of fever, uterine/abdominal pain or tenderness with-
CT scan of the head. Further imaging, such as CT out another identifiable cause, or purulent drainage
angiography/perfusion may also be of benefit to from the uterus. Consider further imaging if pelvic
rule out dissection and assess for any large-vessel abscess or retained products are suspected.
occlusions. For patients with ICH, further imaging,
such as CT angiography, may be necessary, since as Cardiopulmonary Complaints
many as 77% of these may be related to aneurysm.9 Imaging Studies
For patients presenting with acute-onset head- Postpartum patients presenting with cardiopulmo-
ache and neuro-ophthalmological symptoms, be nary complaints require diagnostic testing. The most
concerned for cerebral venous thrombosis; however, useful study for assessing a postpartum patient with
the noncontrast CT may be normal in up to two-thirds cardiopulmonary complaints is transthoracic echo-
of these patients.42 The radiologist should be noti- cardiogram.45 (See Figure 1.) For clinicians skilled in
fied of the concern and should focus on looking for a point-of-care ultrasound (POCUS), the use of bedside
hyperdensity of the cortical vein or dural sinus. Given ultrasound should be considered, especially in any un-
that a standard CT of the brain is normally nondiag- stable patient with undifferentiated dyspnea. POCUS
nostic, CT venography and/or magnetic resonance can be used to rapidly assess a patient for findings of
(MR) venography may be of added benefit. MR imag- heart failure, such as reduced ejection fraction, B-lines,
ing (MRI) is considered the gold standard for diag- pleural effusions, and/or dilated inferior vena cava.
nosis of cerebral venous thrombosis, given its higher In addition, POCUS can reveal alternative diagnoses,
sensitivity, but in a study of 25 patients, CT with CT such as right ventricular dilation and dysfunction, which
venography (as compared to angiography) had a could be suggestive of a pulmonary embolism.
95% sensitivity and 90% specificity.43 Additionally, a Nearly all cases of PPCM will have a reduced left
recent meta-analysis looking at CT venography and ventricular ejection fraction of <45%. These findings
MR venography concluded that both imaging modali- can mimic those of a dilated cardiomyopathy, but
ties have a high level of diagnostic accuracy, although PPCM may be distinguished by noting a younger
showing a lower sensitivity (79%) with
CT along with CT venography as op-
posed to MRI with MR venography.44 Figure 1. Peripartum Cardiomyopathy on
Given the lack of access to MRI in Echocardiogram
some EDs and the time it takes to
obtain these studies, CT in conjunc-
tion with CT venography can be con-
sidered if MRI is not readily available.
Fever and Infection

Common postpartum infections,
which include wound infection, mas-
titis, and endometritis, are primarily
clinical diagnoses, and further imag-
ing modalities are rarely warranted.
For detection of infection at the
cesarean incision or vaginal lacera-
tion site, often all that is necessary is
a good physical examination. Further A B
imaging, such as CT scan, is reserved
for cases where a deeper infection View A: Apical 3-chamber view showing a patient with postpartum cardiomyopathy with a large
is suspected, such as an abscess. thrombus attached to the apex (arrow).
Mastitis can also be diagnosed clini- View B: Apical 2-chamber view showing the thrombus protruding into the left ventricular cavity
cally, looking for any areas of red- (arrow).
Abbreviations: Ao, aorta; LA, left atrium; LV, left ventricle.
ness, swelling, or inflammation of the Reprinted from Revista Portuguesa de Cardiologia. Volume 33, Issue 9. Regayip Zehir, Can
breasts. Often, fever and myalgias Yucel Karabay, Gonenc Kocabay, et al. An unusual presentation of peripartum cardiomyopathy:
precede inflammatory changes, so recurrent transient ischemic attacks. Page 561. Copyright 2014, with permission from Elsevier.

patient who is in the postpartum time period.22 n Treatment
Chest x-ray should be ordered in a fashion similar Treatment of Hemorrhage
to the nonpregnant patient with cardiopulmonary For patients with massive postpartum hemorrhage,
complaints, looking for pulmonary vascular conges- the major treatment options include administration
tion, pleural effusions, or an enlarged heart.46 of uterotonic agents (such as oxytocin), uterine
tamponade, tranexamic acid, blood transfusions,
Electrocardiogram pelvic artery embolization, and hysterectomy.5,51 The
ECGs remain a cornerstone of the evaluation of emergency clinician should manage the patient in
any patient presenting with chest pain or shortness consultation with obstetric and surgical colleagues,
of breath, and this is also true for the peripartum because multiple treatment modalities may be
patient. ECG interpretation will be similar to the needed simultaneously.
approach to a patient presenting with symptoms Less-invasive maneuvers and interventions, such
of acute coronary syndromes (ACS). The ECG will as uterine massage, should be tried initially. (See
be helpful in ruling out alternative diagnoses (eg, Figure 2.) Administration of uterotonic agents can
ST-segment elevation myocardial infarction) rather also be started. Dosages for the more common
than diagnosing PPCM; however, ECG has shown pharmacologic uterotonic agents are:5
some promise in helping to prognosticate and may • Oxytocin 10 U IV followed by an infusion of
be useful to help provide some reassurance to up to 10 U/hr to sustain contractions/control
patients. For instance, in a study of 88 women with hemorrhage or 10 units IM if it is difficult to
PPCM, a normal ECG correlated with a left ventricular obtain IV access
ejection fraction ≥50% (84% vs 49%, P = .001) and • Misoprostol 600 to 1000 mcg orally, sublingually,
survival at 1 year (100% vs 85%, P = .01).47 Findings of or rectally once
left atrial enlargement should raise concern, as they • Methylergonovine 0.2 mg IM every 2 to 4 hours
portend a lower left ventricular ejection fraction at 1 • 15-methyl PGF2a 0.25 mg IM every 15 to 90
year as well as higher mortality.47 minutes, 8 doses maximum
Laboratory Studies Obstetric consultation in conjunction with use of

Troponins, along with ECGs, are standard in the uterotonic agents is warranted because no agent has
workup of a patient with cardiac complaints; however, demonstrated superiority and multiple agents can
there is no specific biomarker that can confirm PPCM, be combined in rapid succession while preparing for
leaving assessment for cardiac injury or ACS as the more-invasive measures.52
main utility of troponin.22 Whether pregnancy is a An intrauterine balloon may be considered if
risk factor for myocardial infarction is not known, bleeding continues. Procedurally, antiseptic should
but it is a rare event, given that pregnant patients be used to cover the area, followed by the use
are generally young. Certainly, in the somewhat of forceps to insert the intrauterine device above
older patient (age >35 years), suspicion should be the internal os. A Bakri balloon can be inflated
increased, and troponin testing should be used to
account for the increased risk for myocardial infarction
in this age group.48,49 Figure 2. Bimanual Uterine Massage
NT-proBNP (N-terminal pro B-type natriuretic
peptide) and BNP testing may be helpful in diagnos-
ing heart failure; they have similar performance.45
Although results should always be interpreted with
caution, in pregnant and postpartum patients with a
BNP <100 pg/mL or NT-proBNP <70 pg/mL, heart
failure can be ruled out. Higher levels require clinical
correlation, as the marker can be elevated in a num-
ber of processes both cardiac and noncardiac.50
Other Studies
Endomyocardial biopsy is not helpful in diagnosing
PPCM. Although it is not routinely recommended,
it can be useful to help diagnose myocarditis.25
Similarly, there are limited data on cardiac MRI for
PPCM, and it should be reserved for the stabilized
Reprinted by permission from Springer Science+Business Media New
patient for whom an alternative diagnosis, such as
York: Springer Nature. Megan Kwasniak, Anton A Wray, Joseph A.
myocarditis, is being considered.22,25 Tyndall. Management of primary postpartum hemorrhage. In: Atlas of
Emergency Medicine Procedures, Latha Ganti, ed. © Copyright 2016.

approximately 500 mL, while a Sengstaken-Blakemore Treatment of Cerebral Venous Thrombosis
esophagogastric tube, with approximately 500 mL The treatment of cerebral venous thrombosis
volume, is an option. A single Foley catheter, which includes anticoagulation. Concurrent hemorrhage or
may hold a maximum of 80 mL, is not recommended, hemorrhagic conversion can occur with this condition,
as it may obscure bleeding, giving false reassurance but the benefit often outweighs the risk, and this is
that bleeding has subsided.53 A meta-analysis not always a contraindication. The goal of treatment
described overall uterine balloon tamponade success is to recanalize the thrombosed vein and prevent
at 85.9% (95% confidence interval, 83.9-87.9%).54 other thrombi from forming or embolizing (eg, deep
Tranexamic acid, an antifibrinolytic agent, showed vein thromboses or pulmonary emboli).
some promise in a multinational randomized, double- Although few data are available on this topic,
blind controlled trial of more than 20,000 women.51 2 randomized controlled trials that included a total
Death due to postpartum hemorrhage was 1.5% in of 79 patients showed benefit with IV heparin and
the tranexamic acid group versus 1.9% in the placebo subcutaneous low-molecular-weight heparin (LMWH)
group (P = .045). There was a stronger benefit in the compared to placebo. The overall consensus for
subgroup of those who received tranexamic acid cerebral venous thrombosis treatment is anticoagula-
within 3 hours, with mortality rates of 1.2% compared tion.57,58 One study suggested increased efficacy of
to 1.7% (P = .008) in the placebo group. Therefore, LMWH when compared to heparin, so if there are no
tranexamic acid may be most beneficial if it is used as contraindications to LMWH (eg, renal failure) and no
soon as possible after bleeding is first identified. In invasive procedures are planned that would require
accordance with the trial, 1 gram of tranexamic acid rapid reversal, this is likely the superior option.59
IV over 10 minutes may be repeated if bleeding con- It is generally taught that acute ICH is a
tinues for 30 minutes or restarts within 24 hours. contraindication to anticoagulation; however, this
is not always the case with patients presenting
Treatment of Headache with cerebral venous thrombosis. In the previously
Although not usually life-threatening, postpartum mentioned trials, 34 of the 79 patients had an
headaches can be debilitating, and maximizing treat- intracerebral hemorrhage upon presentation.57,58
ment options can help patients return home and When looking at these patients, those randomized
care for their newborns. Treatment of postpartum to receive heparin did not have any evidence of new
headaches will depend on the underlying cause. For intracerebral hemorrhage, while 3 of the patients in
patients presenting with benign headache etiologies, the placebo group did develop one. In the de Bruijn
standard headache treatments, including nonsteroidal study, of the 15 patients with hemorrhage prior to
anti-inflammatory drugs (NSAIDs) and acetamino- treatment, none had any secondary worsening.57 The
phen, can be initiated; both are safe for breastfeed- European Federation of Neurologic Societies has
ing mothers. stated in their guidelines that an ICH associated with
For patients presenting with symptoms consistent cerebral venous thrombosis is not a contraindication
with post–dural puncture headache, the treatment for heparin therapy.60 These treatment decisions will
depends on the severity of symptoms. Patients be made in conjunction with specialty care clinicians,
with mild post–dural puncture headache (defined but it is important to recognize that, despite ICH,
as the ability to perform daily activities and tolerate anticoagulation may still be recommended to
an upright position) can have a trial of conservative improve outcomes.
treatment that includes bed rest as needed, hydration, For patients with continued decline or no im-
and oral analgesics. There is very little high-quality provement with anticoagulation, further treatment
evidence for various medications for post–dural options such as endovascular therapy or mechanical
puncture headache, but in addition to standard over- thrombectomy can be considered. There are limited
the-counter medications, caffeine can be considered. data for these procedures and, at this time, no proven
In a randomized controlled trial of 40 patients, benefit. These are discussed further in the “Contro-
reduction of headache severity at 4 hours was reported versies and Cutting Edge” section, on pages 12-13.
with 300 mg of caffeine, but no significant difference
was found at 24 hours.55 Treatment of Infection
If more-severe symptoms of post–dural puncture Treatment for Mastitis
headache are present, including a patient’s inability For patients presenting with signs and symptoms
to care for their baby, anesthesiology consultation suggestive of mastitis, supportive care should be
should be obtained for an epidural blood patch. In a encouraged in the first 12 to 24 hours, including cool
2010 systematic review of 86 patients across 3 studies, compresses, NSAIDs, and continued breastfeeding
it was shown that an epidural blood patch reduced or pumping.61 If symptoms persist, antibiotics are
the intensity and length of headache compared to indicated and should be targeted against the most
conservative treatment.56 common pathogen, Staphylococcus aureus. Patients
started on antibiotics should continue breastfeed-

ing and be reassured that the antibiotic choice made deliveries, and should be suspected if erythema is
by the physician is compatible with breastfeeding. noted around the surgical site in the presence of
Studies on antibiotics for mastitis are limited, but one fever. Antibiotic therapy should focus on common
observational study found that efficient breast-emp- pathogens, including Streptococcus in the early
tying improved mastitis in 50% of patients. This was postpartum period and Staphylococcus epidermidis
increased to 96% with the addition of antibiotics.62 or S aureus, Enterococcus faecalis, or Escherichia
If the patient has no risk factors for methicillin- coli for wounds that become infected later on.65
resistant Staphylococcus aureus (MRSA), dicloxacillin Consultation with ob/gyn should be considered for
(500 mg orally 4 times per day) or cephalexin (500 mg any patient presenting with any postpartum infection
orally 4 times per day) can be started. If the patient to ensure the patient has appropriate follow-up with
is allergic to these options, clindamycin (300 mg 4 the treatment plan and resolution of symptoms.
times per day) can be used.63 If MRSA is suspected,
the treatment of choice includes clindamycin (300 mg Treatment for Pre-eclampsia/Eclampsia and
4 times per day) or trimethoprim-sulfamethoxazole HELLP Syndrome
(1 DS [double strength] tablet 2 times per day). Postpartum patients can present with new-onset high
Note that trimethoprim-sulfamethoxazole should blood pressure, pre-eclampsia, eclampsia, or HELLP
be avoided if the patient is breastfeeding an infant syndrome without prior history. Blood pressure >160
who is G6PD-deficient or an infant who is jaundiced, mm Hg systolic or >110 mm Hg diastolic is consid-
ill, stressed, premature, or <60 days old. For severe ered severe hypertension. The blood pressure should
infections, IV vancomycin is recommended, and be rechecked within 15 minutes. If it remains elevat-
culture of breast milk may be necessary to identify ed, antihypertensive medications should be adminis-
the causative pathogen and further guide inpatient tered. It is essential to treat severe high blood pres-
antibiotic choice.11 sure to prevent life-threatening sequelae. Sudden,
If there is no improvement in a patient on elevated blood pressure can result in stroke, heart
antibiotics within 48 to 72 hours, the clinician should failure, renal failure, and/or myocardial ischemia.13
consider breast abscess in the differential and For those with gestational hypertension with severe
an ultrasound should be performed to assess for features and pre-eclampsia with severe features or
fluid collection. If an abscess is identified, needle eclampsia, magnesium sulfate should also be given.
aspiration or incision and drainage are indicated. First-line antihypertensive therapy is beta
blockers; labetalol 10 to 20 mg IV can be given
Treatment for Endometritis as a first dose. However, this nonselective beta
For patients presenting with symptoms suggestive of blocker should be avoided in patients with asthma
endometritis, antibiotic therapy will depend on the or pre-existing heart conditions such as heart failure,
patient’s group B Streptococcus (GBS) status, given bradycardia, or atrioventricular block. Labetalol has
increasing resistance of this organism to clindamycin. the quickest onset of action (1-2 minutes) relative to
For patients who are GBS-negative, IV clindamycin other antihypertensives given to patients with pre-
and gentamicin should be started. If the patient is eclampsia and eclampsia.
known to be GBS-positive, either IV ampicillin can be Hydralazine and nifedipine are second-line
added to this regimen or ampicillin-sulbactam can be antihypertensives that can be used. Hydralazine can
used as monotherapy. If the patient’s symptoms are be given as 5 mg IV or IM, then escalated to 5 to 10
mild, consideration of oral therapy can be given, with mg IV if blood pressure remains elevated after 20 to
either amoxicillin/clavulanic acid (875 mg 2 times per 40 minutes. Hydralazine must be given cautiously,
day) or metronidazole (500 mg 2 times per day) plus as it can result in hypotension after large doses; it is
either doxycycline (100 mg 2 times per day) or levo- recommended to give a maximum of 20 mg, total.
floxacin (500 mg 1 time per day).64 There should be Nifedipine can be given orally at 10 to 20 mg, and
improvement within 24 to 48 hours of antibiotic use. repeated in 20 minutes if the blood pressure remains
elevated. Its onset of action is 5 to 10 minutes.13
Treatment for Wound Infection For women who are breastfeeding, beta blockers
Wound infection treatment will depend on whether such as labetalol, metoprolol, and propranolol are
the patient had a vaginal or cesarean delivery. For first-line because they have the least transfer into
patients who underwent episiotomy and/or vaginal breast milk. Calcium-channel blockers are also
laceration repair, the physical examination should safe. ACE inhibitors enter breast milk at low levels;
identify whether the wound has any dehiscence however, neonates can become hypotensive and
or cellulitis. For patients with granulation tissue oliguric. Thiazides are known to reduce breast milk
developing, all that may be necessary is good wound volume and suppress lactation, but are safe at 50 mg
care and monitoring for improvement. Antibiotics are or less daily.66
usually indicated only if concurrent cellulitis is seen.
The risk for wound infection is higher in cesarean

Treatment of Seizure at higher risk for thromboembolic complications;
Seizures in eclampsia are self-limited in most cases. the literature recommends anticoagulation when the
For seizing patients who are eclamptic, therapy ejection fraction is <35%.69-71 Clinicians should take
includes giving magnesium sulfate, not only for into consideration the potential teratogenic effects
the cessation of the current seizure, but to prevent of warfarin and the risk for postpartum hemorrhage.5
recurrent seizures. It is crucial to provide supportive Otherwise, dosing and therapy selection is equivalent
therapy by assessing the airway, status of breathing, to nonpregnant patients.
and circulation. Patients should be placed on a
monitor, provided supplemental oxygen therapy as
needed, and the head of the bed should be elevated n Special Populations
to mitigate the risk for aspiration. Special consideration should be given to the needs
A Cochrane review that included 15 trials of the breastfeeding mother. Although the majority
involving 11,444 women revealed that there was of medications are safe while breastfeeding, the
a significant reduction in mortality and recurrent clinician must be attuned to and proactively address
seizures in women with eclampsia when magnesium the breastfeeding mother’s concerns. The emergency
sulfate was administered.67 As a result, magnesium clinician should make sure not to withhold certain
sulfate is the drug of choice in eclamptic patients. medications or wrongly tell a patient to “pump and
Eclamptic patients should be given a loading dose dump” if it is not necessary. Also, the emergency
of magnesium sulfate 4 to 6 grams IV followed by a clinician should recognize that during the postpartum
maintenance dose of 1 to 2 grams per hour. If the period, a nursing mother must frequently empty her
patient has recurrent seizures, they can be given breasts, usually at least every 3 hours. If the newborn
another 2 to 4 grams IV over 5 minutes.13 Often, an is not in the ED to breastfeed, a breast pump should
infusion of magnesium sulfate at 2 grams per hour be available during the workup and treatment to
should follow the initial IV bolus. Patients in status prevent complications such as engorgement, supply
epilepticus or experiencing recurrent seizures despite issues, clogged ducts, and mastitis.
being fully loaded with magnesium should be treated The majority of over-the-counter medications
with lorazepam, up to 10 mg, and a midazolam or are safe for breastfeeding mothers, including acet-
propofol infusion, if needed. aminophen and NSAIDs, which are frequently given
for pain and/or fever. Antibiotics, such as those used
Treatment of HELLP Syndrome for mastitis and endometritis, are also generally safe
For treatment of HELLP syndrome, it is thought that for lactating mothers. However, trimethoprim-sulfa-
corticosteroids may play a role in disrupting the methoxazole should be avoided for breastfeeding
proinflammatory features of the disease. A Cochrane mothers with infants in the following scenarios: the
review looking at corticosteroid use that included first 2 months of life, due to the risk for hyperbilirubi-
550 women found no difference in risk of maternal nemia; in infants with G6PD-deficiency; and in infants
death and severe maternal morbidity with their use. who are premature, acutely ill, or jaundiced.72
The only difference noted was that the patients in If imaging is deemed necessary, these may
the corticosteroid group had an increased platelet include CT or MRI with IV contrast. Studies have dem-
count after therapy. In the ED, corticosteroids are not onstrated that <0.04% of gadolinium contrast and
administered when HELLP syndrome is suspected, <0.01% of iodinated contrast are excreted into breast
as the evidence is insufficient.68 Supportive therapy milk.73,74 These amounts are less than the actual
and close monitoring for sequelae such as acute weight-based doses given directly to infants, so ces-
respiratory distress syndrome, pulmonary edema, liver sation of breastfeeding after contrast administration is
failure, and renal injury are warranted. not routinely recommended.75
Treatment of Peripartum Cardiomyopathy

Diagnosing PPCM in the ED is difficult, so the goal n Controversies and Cutting Edge
should be to maintain a high level of suspicion and Endovascular Therapies for Cerebral Venous
communicate your concerns to both ob/gyn and Thrombosis
cardiology, since the patient‘s care will require a mul- The mainstay of treatment for cerebral venous throm-
tidisciplinary approach. Overall treatment strategies bosis includes anticoagulation; however, patients who
for PPCM should be similar to those for nonpregnant show neurologic decline despite treatment may be
heart failure patients. Aside from typical nitrates and candidates for endovascular therapy. Data are limited
diuretics, telemetry monitoring is important because and, at this time, do not show a definitive benefit. A
these patients are at risk for arrhythmias, including 2010 systematic review looked at patients undergo-
atrial fibrillation and ventricular tachycardias. Addi- ing endovascular treatment to assess safety of this
tionally, their depressed ejection fraction and the pro- intervention. Of the 156 patients studied, 12 patients
coagulant effects of the peripartum period put them died after endovascular thrombolysis and 15 had a

major episode of bleeding. Of the patients with major n Disposition
bleeding complications, 12 developed ICH and 7 Ultimately, patient disposition will depend on the
of these patients died.76 This was deemed nonneg- working diagnosis. The management of postpartum
ligible, so the risks and benefits of performing this patients can be complex, and they should be treated
procedure should be weighed carefully. with a multidisciplinary approach. Most patients
A 2015 systematic review looking at mechanical suspected of having a more severe diagnosis, includ-
thrombectomy found 84% of patients had a good ing PPCM, eclampsia/HELLP syndrome, or cerebral
outcome and a high recanalization rate (95%). The venous thrombosis will require admission to a moni-
authors concluded that it was a reasonably safe tored bed and prompt consultation with ob/gyn and
procedure; however, the majority of studies included other subspecialties including cardiology, neurology,
were retrospective case reports and case series, and critical care. Patients with pre-eclampsia without
possibly causing publication bias and therefore severe features may be able to be discharged home
underrepresenting poor outcomes.77 safely after discussion with their ob/gyn if the patient
Cerebral venous thrombosis remains a challeng- has close follow-up for weekly maternal evaluations
ing condition to treat, with limited high-quality data; and blood work.
consultation with neurology, neurosurgery, and/or in- As with any disease process, sometimes a more
terventional radiology is recommended to decide the serious complication may not manifest on initial
best course of treatment for the postpartum patient. presentation. Therefore patients, including those
diagnosed with benign headache etiologies or minor
Thromboelastography for Postpartum postpartum infections, should be given clear return
Hemorrhage precautions and schedule close follow-up with their
Rapid assessment of hemostasis is essential to primary care provider and ob/gyn.
allow for the detection of coagulopathies and
improve patient outcomes in the postpartum
hemorrhaging patient. Thromboelastography may n Summary
be useful to help guide the emergency clinician The postpartum period is a time of excitement
and the multidisciplinary team to treat these and exhaustion for new parents, but symptoms of
complex coagulopathies. Randomized controlled postpartum complications should always be taken
trials are difficult to perform in bleeding, critically seriously by the emergency clinician. A thorough
ill obstetric patients, and sufficient evidence is history and physical examination will point to the
currently lacking. Future prospective studies are correct diagnostic pathway. Vital signs should be
needed to demonstrate patient-oriented outcomes reviewed carefully, especially for hypertension, as pre-
that will help guide physicians in the application of eclampsia can occur up to 6 weeks postpartum and
thromboelastography to this patient cohort.78 is sometimes overlooked. Special attention should be
paid to patients presenting with hypoxia, abnormal
HELLP Syndrome Treatment neurologic findings, or fever in order to not miss
Given the limited utility of medications in HELLP syndrome, PPCM, cerebral venous thrombosis, or an infectious
some experimental medications have been identified. process. Laboratory testing and imaging studies will
In a case report of a patient with HELLP syndrome, a be patient-dependent, but can help aid in diagnosis
patient was treated with eculizumab, a targeted inhibitor and management, especially if the presenting
of complement protein C5. The patient had “marked diagnosis is unclear. Treatment should be focused
clinical improvement and complete normalization of on stabilizing the mother and getting necessary
laboratory parameters” after having HELLP syndrome.79 consultants on board promptly. Ensure that adequate
Further studies are necessary to evaluate such treatment in accommodations are made for breastfeeding
postpartum patients with HELLP syndrome. mothers, such as bringing a breast pump to the
bedside and verifying and communicating that
Bromocriptine for Peripartum medication selections will allow the mother to
Cardiomyopathy continue breastfeeding. The emergency clinician
Although the treatment for PPCM largely follows the should always consider discussing the case with ob/
treatment for the nonpregnant heart failure patient, gyn and other consultants, as needed, to help identify
bromocriptine, which blocks prolactin, is being the best disposition and ensure close follow-up.
studied as a potential therapy that may interfere with
the pathogenesis of PPCM and be an adjunct to the
current treatment regimen. Evidence is mainly from
outside the United States and is insufficient at this
time, but bromocriptine could be a future therapeutic
in this high-risk patient population.71,80,81

Case Conclusions
For the 3 weeks’ post partum woman who presented with gradually worsening cough and severe
shortness of breath…
Chest x-ray revealed that this patient had pulmonary edema. You treated her with IV nitroglycerin, and
CASE 1
her blood pressure improved to 160/90 mm Hg. You also administered 40 mg of IV furosemide. On re-
evaluation, her heart rate was sinus rhythm in the 80s, and her oxygen saturation was 97% on room air. Her
blood pressure remained elevated, requiring a nitroglycerin infusion. CBC, CMP, uric acid level, urinalysis,
and LDH were normal. An ECG revealed T-wave inversions in the lateral leads, and her troponin and BNP
levels were significantly elevated. Bedside echocardiogram revealed moderately reduced ejection fraction
of 35%, making a diagnosis of PPCM likely, and this was confirmed after she was admitted to the ICU.
For the woman who presented with altered mental status and then began to seize…
You gave the patient an IV bolus of 4 g of magnesium sulfate, followed by a 2 g/hr magnesium sulfate
CASE 2
infusion, and the seizure ceased. You then provided labetalol 20 mg IV to initiate blood pressure management
and immediately took the patient to CT. Her CT head was negative for acute intracranial abnormalities. Her
labs revealed an elevated urine/protein-creatinine ratio of 0.5, transaminitis, and thrombocytopenia. These
findings, in addition to the patient’s headache, altered mental status, and seizures were consistent with
eclampsia. You consulted ob/gyn and neurology, and the patient was admitted to the ICU.
For the woman with headache, blurry vision, and right arm numbness who presented after delivering
a baby 3 days previously…
You noted that this patient’s noncontrast head CT was normal, and you explained the results to her and
her husband. She was relieved, and started to get dressed to go home. You went on to explain to her that,
CASE 3
unfortunately, even though her initial imaging test was negative, she had features on history and exam that
were concerning for a more serious diagnosis, such as stroke or cerebral venous thrombosis. You explained
to her that she would need to be admitted for MRI/MR venography and specialty consultation. She was very
worried, because she was breastfeeding her newborn, but you reassured her that you would have a breast
pump brought to the bedside and make sure all of the medications she received were safe. Ultimately, she
received MR venography, which confirmed the diagnosis of cerebral venous thrombosis.
n Time- and Cost-Effective Strategies tional medications for post–dural puncture head-
• Bedside emergency ultrasound for suspected ache (eg, caffeine), emergency clinicians should
PPCM may reduce delays in diagnosis. On arrival counsel patients appropriately. Lifestyle modifica-
of an acutely dyspneic patient, perform a cardiac tions (eg, oral hydration) should be encouraged,
and pulmonary examination. Look for decreased and discussion about readily available medica-
contractility of the heart, bilateral B-lines, pleural tions, such as ibuprofen and acetaminophen,
effusions, and a plethoric inferior vena cava. should be initiated.
• Appropriate antibiotic choice is important for pa- • It is important to communicate early on with
tients presenting with infectious postpartum com- the ob/gyn team when a patient with suspected
plications. For patients with less severe infections, pre-eclampsia or HELLP is being evaluated in the
oral antibiotics are preferred. IV antibiotics should ED. In some cases, a patient has a low likelihood
be reserved for patients with more severe infec- of pre-eclampsia (eg, a single high reading on
tion or those who are exhibiting signs of sepsis. arrival) and resources may be used unnecessarily.
• For patients at locations where MRI is not read- A cost-effective strategy to avoid unnecessary ad-
ily available or if there will be a significant delay, mission/observation to the labor and delivery unit
consideration should be made for CT/CT venog- is to wait for all of the results of the pre-eclamp-
raphy, given that some studies suggest similar sia/HELLP workup. If the patient is hemodynami-
sensitivities. The benefits and risks of radia- cally stable, the blood pressure is well-controlled
tion exposure and time to diagnosis should be in the ED, and the workup is negative, then the
weighed on a case-by-case basis. patient may be discharged with close ob/gyn
• Given the lack of high-quality evidence for addi- follow-up in 12 to 24 hours.

Risk Management Pitfalls for Managing
Postpartum Complications
1. “The patient never had a history of pre- 6. “The patient had a normal noncontrast
eclampsia during her pregnancy, so I did not head CT, so it couldn’t be a cerebral venous
think to consider it in the postpartum period.” thrombosis.” Normal noncontrast CT of the brain
Postpartum hypertensive disorders do not need cannot rule out cerebral venous thrombosis. If
to be a continuation of antenatal or gestational clinical suspicion is high, further imaging such
hypertensive disorders—they can be new as MRI/MR venography for cerebral venous
diagnoses after delivery. It is crucial to recognize thrombosis should be pursued.
and treat high blood pressure early to avoid
complications or sequelae. 7. “I placed a Foley catheter, and the postpartum
patient’s vaginal bleeding seemed to improve.
2. “I decided to discharge the patient with mildly I’m not sure why she suddenly became
elevated blood pressure, prior to hearing back hemodynamically unstable and continued to
from the ob/gyn consultant.” Do not discharge decline.” Placing a Foley catheter is likely to just
a patient with pre-eclampsia unless the ob/gyn obscure bleeding rather than control it. Use of a
team has been consulted and agrees. It may Bakri balloon is best.53
sometimes be hard to differentiate underlying
hypertension from pre-eclampsia/eclampsia, and 8. “The patient’s blood pressure was normal, so I
ob/gyn can be helpful in making this distinction. doubt there is a significant amount of hemor-
It is also important to ensure the patient has rhage.” Do not rely solely on the blood pressure
adequate follow-up and does not need further for patients with postpartum hemorrhage. Hypo-
monitoring in the hospital. tension is a late finding that may not occur until
more than 25% of a patient’s blood volume has
3. “The patient had her baby 3.5 weeks ago, so been lost.39 Timely diagnosis and early interven-
I didn’t even consider pre-eclampsia in the tion may prevent shock and death.
differential for her elevated blood pressure.”
Pre-eclampsia can occur up to 6 weeks after 9. “The patient had shortness of breath that I
delivery; be sure to keep this on the differential attributed to anxiety as a new parent. I didn’t
when evaluating postpartum patients who do not even consider PPCM.” Do not mistake vague
present to the ED within 1 to 2 weeks of delivery. fatigue or shortness of breath for anxiety in the
postpartum patient. A bedside echocardiogram
4. “Even though the blood pressure was elevated can provide useful information and help obtain
at 175/110 mm Hg, I thought it was okay to the correct diagnosis early in the ED visit.
wait until I consulted ob/gyn to start blood
pressure medications.” Severe pre-eclampsia 10. “My patient presenting for miscarriage has
requires aggressive blood pressure control with a history of PPCM from her last pregnancy,
labetalol, hydralazine, and/or nifedipine; it may with continued symptoms. She asked me
also require prophylactic magnesium sulfate. if it was okay to continue trying for more
Therapies should not be delayed pending the children, but I didn’t know what the best
ob/gyn consult. answer was.” Patients with PPCM, and especially
those with continued reduced left ventricular
5. “The patient presented with only a mild ejection fraction, should not be encouraged to
headache. I assumed that was the reason for have future pregnancies. This can lead to heart
her increase in blood pressure, and therefore failure progression or relapse and eventual death.
it couldn’t have been pre-eclampsia.” Pre- There may be opportunities to address this and
eclampsia should always be on the differential for begin these conversations in the ED, as pregnant
patients presenting with a peripartum headache patients frequent the ED for other issues.80
in the ED. Even if the blood pressure is only
transiently elevated, further workup may be
warranted in the ED, especially if the patient has
no prior history.

n References therapy for mild to moderate hypertension during pregnancy.
Cochrane Database Syst Rev. 2018;10(10):CD002252. (Review
Evidence-based medicine requires a critical appraisal article)
of the literature based upon study methodology 15. Redman CWG, Sacks GP, Sargent IL. Preeclampsia: an exces-
and number of subjects. Not all references are sive maternal inflammatory response to pregnancy. Am J
equally robust. The findings of a large, prospective, Obstet Gynecol. 1999;180(2):499-506. (Review article)
randomized, and blinded trial should carry more 16. Boghossian NS, Yeung E, Mendola P, et al. Risk factors differ
weight than a case report. between recurrent and incident preeclampsia: a hospital-based
cohort study. Ann Epidemiol. 2014;24(12):871-877. (Cohort
To help the reader judge the strength of each study; 26,613 patients)
reference, pertinent information about the study, 17. Roberts JM, Taylor RN, Goldfien A. Clinical and biochemi-
such as the type of study and the number of patients cal evidence of endothelial cell dysfunction in the pregnancy
in the study is included in bold type following the syndrome preeclampsia. Am J Hypertens. 1991;4(8):700-708.
references, where available. The most informative (Review article)
references cited in this paper, as determined by 18. Bartsch E, Medcalf KE, Park AL, et al. Clinical risk factors
the authors, are noted by an asterisk (*) next to the for pre-eclampsia determined in early pregnancy: system-
atic review and meta-analysis of large cohort studies. BMJ.
number of the reference. 2016;353:i1753. (Systematic review and meta-analysis of
large cohort studies; 5,356,688 patients)
1. Harris A, Chang HY, Wang L, et al. Emergency room utilization
19. Khalil A, Syngelaki A, Maiz N, et al. Maternal age and ad-
after medically complicated pregnancies: a Medicaid claims
verse pregnancy outcome: a cohort study. Ultrasound Obstet
analysis. J Womens Health (Larchmt). 2015;24(9):745-754. (Ret-
Gynecol. 2013;42(6):634-643. (Retrospective; 76,158 patients)
rospective population-based cohort study; 26,074 patients)
20. ACOG Practice Bulletin. Diagnosis and management of pre-
2. Menard MK, Main EK, Currigan SM. Executive summary of the
eclampsia and eclampsia. Number 33, January 2002. American
reVITALize initiative. Obstet Gynecol. 2014;124(1):150-153.
College of Obstetricians and Gynecologists. Int J Gynaecol
(ACOG executive summary)
Obstet. 2002;77(1):67-75. (Consensus report)
3. Nyfløt LT, Sandven I, Stray-Pedersen B, et al. Risk factors for
21. Stojanovska V, Zenclussen AC. Innate and adaptive immune
severe postpartum hemorrhage: a case-control study. BMC
responses in HELLP syndrome. Front Immunol. 2020;11:667-
Pregnancy Childbirth. 2017;17(1):17. (Case control study;
667. (Review article)
3123 patients)
22. Ersbøll AS, Damm P, Gustafsson F, et al. Peripartum cardiomy-
4. Bateman BT, Berman MF, Riley LE, et al. The epidemiology
opathy: a systematic literature review. Acta Obstet Gynecol
of postpartum hemorrhage in a large, nationwide sample of
Scand. 2016;95(11):1205-1219. (Systematic review)
deliveries. Anesth Analg. 2010;110(5):1368-1373. (Descriptive
study; 25,654 patients) 23. McNamara DM, Elkayam U, Alharethi R, et al. Clinical outcomes
for peripartum cardiomyopathy in North America: results of the
5. Practice Bulletin No. 183: postpartum hemorrhage. Obstet
IPAC Study (Investigations of Pregnancy-Associated Cardiomy-
Gynecol. 2017;130(4):e168-e186. (Practice bulletin)
opathy). J Am Coll Cardiol. 2015;66(8):905-914. (Prospective
6. Lew G, Pulia M. Emergency childbirth. In: Roberts J, Hedges J, cohort; 100 cases)
Custalow C, eds. Clinical Procedures in Emergency Medicine.
24. Goland S, Modi K, Bitar F, et al. Clinical profile and predictors
6th ed. 2013:1313-1318. (Textbook chapter)
of complications in peripartum cardiomyopathy. J Card Fail.
7.* Goldszmidt E, Kern R, Chaput A, et al. The incidence and etiol- 2009;15(8):645-650. (Retrospective review; 182 patients)
ogy of postpartum headaches: a prospective cohort study. Can
25. Bauersachs J, König T, Meer P, et al. Pathophysiology, diagno-
J Anaesth. 2005;52(9):971-977. (Prospective cohort study;
sis and management of peripartum cardiomyopathy: a position
985 patients) DOI: 10.1007/BF03022061
statement from the Heart Failure Association of the European
8. Stella CL, Jodicke CD, How HY, et al. Postpartum head- Society of Cardiology Study Group on peripartum cardiomy-
ache: is your work-up complete? Am J Obstet Gynecol. opathy. Eur J Heart Fail. 2019;21(7):827-843. (Review article)
2007;196(4):318. (Retrospective chart review; 95 patients)
26. Kolte D, Khera S, Aronow WS, et al. Temporal trends in
9. Dias MS, Sekhar LN. Intracranial hemorrhage from aneurysms incidence and outcomes of peripartum cardiomyopathy in the
and arteriovenous malformations during pregnancy and the United States: a nationwide population-based study. J Am
puerperium. Neurosurgery. 1990;27(6):855-865. (Retrospective Heart Assoc. 2014;3(3):e001056. (Population based retrospec-
chart review; 154 patients) tive study; 34,219)
10. Meeks JR, Bambhroliya AB, Alex KM, et al. Association of 27. Bello N, Rendon ISH, Arany Z. The relationship between pre-
primary intracerebral hemorrhage with pregnancy and the eclampsia and peripartum cardiomyopathy: a systematic review
postpartum period. JAMA Netw Open. 2020;3(4):e202769. and meta-analysis. J Am Coll Cardiol. 2013;62(18):1715-1723.
(Cohort-crossover study; 3,314,945 patients) (Systematic review and meta-analysis; 979 patients)
11.* ACOG Committee Opinion no. 361: breastfeeding: maternal 28. Stone JH. HELLP syndrome: hemolysis, elevated liver enzymes,
and infant aspects. Obstet Gynecol. 2007;109(2, Part 1):479. and low platelets. JAMA. 1998;280(6):559-562. (Case report)
(Practice bulletin)
29. Demakis JG, Rahimtoola SH, Sutton GC, et al. Natural course of
DOI: 10.1097/00006250-200702000-00064
peripartum cardiomyopathy. Circulation. 1971;44(6):1053-1061.
12. Newton ER, Prihoda TJ, Gibbs RS. A clinical and microbiologic (Prospective cohort; 27 patients)
analysis of risk factors for puerperal endometritis. Obstet Gyne-
30.* American College of Obstetricians and Gynecologists’
col. 1990;75(3 Pt 1):402-406. (Retrospective; 607 patients)
Presidential Task Force on Pregnancy and Heart Disease and
13.* Gestational hypertension and preeclampsia: ACOG Practice Committee on Practice Bulletins—Obstetrics. ACOG Practice
Bulletin, Number 222. Obstet Gynecol. 2020;135(6):e237-e260. Bulletin No. 212: pregnancy and heart disease. Obstet Gyne-
(Practice guidelines) col. 2019;133(5):e320-e356. (Practice bulletin)
DOI: 10.1097/AOG.0000000000003891 DOI: 10.1097/AOG.0000000000003243
14. Abalos E, Duley L, Steyn DW, et al. Antihypertensive drug 31. Winston AW, Norman D. Late postpartum eclampsia coincident

with postdural puncture headache: a case report. AANA J. 50. Potter LR, Yoder AR, Flora DR, et al. Natriuretic peptides: their
2003;71(5):371-372. (Case report) structures, receptors, physiologic functions and therapeutic ap-
32. Tanguay JJ, Allegretti PJ. Postpartum intracranial hemorrhage plications. Handb Exp Pharmacol. 2009(191):341-366. (Review
disguised as preeclampsia. Am J Emerg Med. 2008;26(2):247. article)
e245-e247. (Case report) 51.* WOMAN Trial Collaborators. Effect of early tranexamic acid
33. Savage H, Harrison M. Central venous thrombosis misdiag- administration on mortality, hysterectomy, and other morbidi-
nosed as eclampsia in an emergency department. Emerg Med ties in women with post-partum haemorrhage (WOMAN): an
J. 2008;25(1):49-50. (Case report) international, randomised, double-blind, placebo-controlled
trial. Lancet. 2017;389(10084):2105-2116. (Randomized
34. Queensland Ambulance Service. Clinical practice guidelines:
double-blind placebo-controlled trial; 20,021 patients)
obstetrics/secondary post-partum haemorrhage. 2021. Ac-
DOI: 10.1016/S0140-6736(17)30638-4
cessed February 10, 2022. Available at: www.ambulance.qld.
gov.au/docs/clinical/cpg/CPG_Secondary%20postpartum%20 52. Likis FE, Sathe NA, Morgans AK, et al. AHRQ Comparative Ef-
haemorrhage.pdf (Clinical practice guidelines) fectiveness Reviews. Management of Postpartum Hemorrhage.
Rockville (MD): Agency for Healthcare Research and Quality
35. Dalton A, Limmer D, Mistovich JJ, et al. Advanced Medical Life
(US); 2015. (US government agency report)
Support: A Practical Approach to Adult Medical Emergencies.
3rd ed: Pearson; 2006. (Textbook) 53. Swaminathan A. Post-partum hemorrhage. 2018. Accessed
February 10, 2022. https://rebelem.com/post-partum-hemor-
36. Lim K-H. Preeclampsia. Medscape. 2018. Accessed February
rhage/ (Review blog)
10, 2022. Available at: www.emedicine.com/emerg/topic480.
htm (Website) 54. Suarez S, Conde-Agudelo A, Borovac-Pinheiro A, et al. Uterine
balloon tamponade for the treatment of postpartum hemor-
37. Linden JA, Grimmnitz B, Hagopian L, et al. Is the pelvic ex-
rhage: a systematic review and meta-analysis. Am J Obstet
amination still crucial in patients presenting to the emergency
Gynecol. 2020;222(4):293.e291-293. (Systematic review; 4729
department with vaginal bleeding or abdominal pain when an
patients)
intrauterine pregnancy is identified on ultrasonography? A ran-
domized controlled trial. Ann Emerg Med. 2017;70(6):825-834. 55. Camann WR, Murray RS, Mushlin PS, et al. Effects of oral
(Randomized control trial; 202 patients) caffeine on postdural puncture headache. A double-blind,
placebo-controlled trial. Anesth Analg. 1990;70(2):181-184.
38. Seymour A, Abebe H, Pavlik D, et al. Pelvic examination is un-
(Randomized controlled trial; 40 patients)
necessary in pregnant patients with a normal bedside ultra-
sound. Am J Emerg Med. 2010;28(2):213-216. (Prospective 56. Boonmak P, Boonmak S. Epidural blood patching for prevent-
comparative study; 50 patients) ing and treating post-dural puncture headache. Cochrane Data-
base Syst Rev. 2010 Jan 20;(1):CD001791 (Cochrane review; 9
39. Bonnar J. Massive obstetric haemorrhage. Best Pract Res Clin
studies, 379 participants)
Obstet Gynaecol. 2000;14(1):1-18. (Review article)
57. de Bruijn SF, Stam J. Randomized, placebo-controlled trial of
40. Anger H, Durocher J, Dabash R, et al. How well do postpartum
anticoagulant treatment with low-molecular-weight heparin for
blood loss and common definitions of postpartum hemorrhage
cerebral sinus thrombosis. Stroke. 1999;30(3):484-488. (Ran-
correlate with postpartum anemia and fall in hemoglobin? PLoS
domized controlled trial; 59 patients)
One. 2019;14(8):e0221216. (Review article)
58. No authors listed. Heparin treatment in sinus venous thrombo-
41. Zaidi A, Kohli R, Daru J, et al. Early use of fibrinogen replace-
sis. Lancet. 1991;338(8775):1153-1154. (Randomized con-
ment therapy in postpartum hemorrhage—a systematic review.
trolled trial; 20 patients)
Transfus Med Rev. 2020;34(2):101-107. (Systematic review;
299 patients) 59.* Misra UK, Kalita J, Chandra S, et al. Low molecular weight
heparin versus unfractionated heparin in cerebral venous
42. Leach JL, Fortuna RB, Jones BV, et al. Imaging of cerebral ve-
sinus thrombosis: a randomized controlled trial. Eur J Neurol.
nous thrombosis: current techniques, spectrum of findings, and
2012;19(7):1030-1036. (Randomized controlled trial; 66 pa-
diagnostic pitfalls. Radiographics. 2006;26(suppl_1):S19-S41.
tients) DOI: 10.1111/j.1468-1331.2012.03690.x
(Review article)
60. Einhaupl K, Stam J, Bousser MG, et al. European Federation
43. Wetzel SG, Kirsch E, Stock KW, et al. Cerebral veins: compara-
of Neurological Societies. EFNS guideline on the treatment of
tive study of CT venography with intraarterial digital subtraction
cerebral venous and sinus thormbosis in adult patients. Eur J
angiography. AJNR Am J Neuroradiol. 1999;20(2):249-255.
Neurol. 2010;17(10):1229-1235. (Review article)
(Comparative study; 25 patients)
61. Spencer JP. Management of mastitis in breastfeeding women.
44.* Xu W, Gao L, Li T, et al. The performance of CT versus MRI
Am Fam Physician. 2008;78(6):727-731. (Review article)
in the differential diagnosis of cerebral venous thrombosis.
Thromb Haemost. 2018;118(06):1067-1077. (Meta-analysis; 62. Thomsen AC, Espersen T, Maigaard S. Course and treatment
4595 patients) DOI: 10.1055/s-0038-1642636 of milk stasis, noninfectious inflammation of the breast, and
infectious mastitis in nursing women. Am J Obstet Gynecol.
45. Daniels LB, Maisel AS. Natriuretic peptides. J Am Coll Cardiol.
1984;149(5):492-495. (Randomized controlled trial; 213 pa-
2007;50(25):2357-2368. (Review article)
tients)
46. Ker JA, Soma-Pillay P. NT-proBNP: when is it useful in obstetric
63. Breastfeeding challenges: ACOG Committee Opinion, Number
medicine? Obstet Med. 2018;11(1):3-5. (Review article)
820. Obstet Gynecol. 2021;137(2):e42-e53. (Committee opin-
47. Honigberg MC, Elkayam U, Rajagopalan N, et al. Electrocardio- ion)
graphic findings in peripartum cardiomyopathy. Clin Cardiol.
64. Dalton E, Castillo E. Post partum infections: a review for the
2019;42(5):524-529. (Observational study; 88 patients)
non-OBGYN. Obstet Med. 2014;7(3):98-102. (Review article)
48. James AH, Jamison MG, Biswas MS, et al. Acute myocardial in-
65. Martens MG, Kolrud BL, Faro S, et al. Development of wound
farction in pregnancy: a United States population-based study.
infection or separation after cesarean delivery. Prospective
Circulation. 2006;113(12):1564-1571. (Retrospective chart
evaluation of 2,431 cases. J Reprod Med. 1995;40(3):171-175.
review; 859 patients)
(Prospective study; 2431 patients)
49. Petitti DB, Sidney S, Quesenberry CP Jr, et al. Incidence of
66. Lenfant C, National Education Program Working Group. Work-
stroke and myocardial infarction in women of reproductive age.
ing group report on high blood pressure in pregnancy. J Clin
Stroke. 1997;28(2):280-283. (Case control study; 581 patients)
Hypertens (Greenwich). 2001;3(2):75-88. (Review article)

67. Duley L, Gülmezoglu AM, Henderson-Smart DJ, et al. Mag-
nesium sulphate and other anticonvulsants for women with
21 ANNUAL
st
pre-eclampsia. Cochrane Database Syst Rev. 2010 Nov
10;2010(11):CD000025. (Cochrane review; 15 trials, 11,444
patients)
68. Woudstra DM, Chandra S, Hofmeyr GJ, et al. Corticosteroids
for HELLP (hemolysis, elevated liver enzymes, low platelets) syn-
drome in pregnancy. Cochrane Database Syst Rev. 2010 Sep
8;(9):CD008148. (Cochrane review; 11 trials, 550 patients)
69. Kido K, Guglin M. Anticoagulation therapy in specific car-
diomyopathies: isolated left ventricular noncompaction and
peripartum cardiomyopathy. J Cardiovasc Pharmacol Ther.
2018;24(1):31-36. (Systematic review)
IN EMERGENCY MEDICINE 70. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA
guideline for the management of heart failure: a report of the
June 22-26, 2022 American College of Cardiology Foundation/American Heart
Association Task Force on practice guidelines. Circulation.
LIVE IN-PERSON 2013;128(16):e240-e327. (Practice guideline)
71. Davis MB, Arany Z, McNamara DM, et al. Peripartum cardiomy-
opathy. J Am Coll Cardiol. 2020;75(2):207-221. (Review article)
72. Trimethoprim-sulfamethoxazole. Drugs and Lactation Database
J
(LactMed). Accessed February 10, 2022. Available at: https://
oin us in Ponte Vedra for the 21st Clinical
www.ncbi.nlm.nih.gov/books/NBK501289/ (Review article)
Decision Making in Emergency Medicine 73. Kubik-Huch RA, Gottstein-Aalame NM, Frenzel T, et al. Gado-
conference! The nation’s most renowned pentetate dimeglumine excretion into human breast milk dur-
experts will cover topics critical to improving ing lactation. Radiology. 2000;216(2):555-558. (Observational
study; 20 patients)
patient outcomes in your ED, including critical 74. Webb JAW, Thomsen HS, Morcos SK. The use of iodinated and
care, cardiac emergencies, and trauma. gadolinium contrast media during pregnancy and lactation. Eur
Radiol. 2004;15(6):1234-1240. (Guideline)
75. Bettmann MA. Frequently asked questions: iodinated contrast
Earn up to 32 AMA PRA Category 1 CreditsTM agents. Radiographics. 2004;24(suppl_1):S3-S10. (Review
article)
For more information and to register risk-free: 76. Dentali F, Squizzato A, Gianni M, et al. Safety of thrombolysis in
cerebral venous thrombosis. A systematic review of the litera-
www.ClinicalDecisionMaking.com ture. Thromb Haemost. 2010;104(5):1055-1062. (Systematic
review; 15 studies, 156 patients)
EB Medicine subscribers receive $100 off 77. Siddiqui FM, Dandapat S, Banerjee C, et al. Mechani-
the regular in-person registration rate with cal thrombectomy in cerebral venous thrombosis. Stroke.
2015;46(5):1263-1268. (Systematic review; 185 cases)
coupon code EB2022! 78. Amgalan A, Allen T, Othman M, et al. Systematic review of
viscoelastic testing (TEG/ROTEM) in obstetrics and recommen-
We are committed to providing a COVID-safe dations from the women’s SSC of the ISTH. J Thromb Haemost.
2020;18(8):1813-1838. (Systematic review; 32,817 patients)
environment for learning. The expectation 79. Lokki AI, Haapio M, Heikkinen-Eloranta J. Eculizumab treatment
is that all who attend in-person will be fully for postpartum HELLP syndrome and aHUS--case report. Front
vaccinated and boosted; proof of vaccination Immunol. 2020;11:548. (Case report)
80. Hilfiker-Kleiner D, Haghikia A, Nonhoff J, et al. Peripartum
is required to enter the conference room. cardiomyopathy: current management and future perspectives.
Masks and distancing will be required. Eur Heart J. 2015;36(18):1090-1097. (Review article)
81. Jha N, Jha AK. Peripartum cardiomyopathy. Heart Fail Rev.
2021;26(4):781-797. (Review article)

n CME Questions 6. Which agent, especially when given within 3
Current subscribers receive CME credit hours of postpartum hemorrhage, has been
absolutely free by completing the shown in a double-blind randomized controlled
following test. Each issue includes 4 AMA trial to reduce death due to hemorrhage?
PRA Category 1 CreditsTM, 4 ACEP a. Oxytocin
Category I credits, 4 AAFP Prescribed b. Tranexamic acid
credits, or 4 AOA Category 2-A or 2-B credits. c. Platelets
Online testing is available for current and archived d. Normal saline
issues. To receive your free CME credits for this
issue, scan the QR code below with your 7. The preferred treatment for cerebral venous
smartphone or visit www.ebmedicine.net/E0322 thrombosis includes:
a. Aspirin
b. Low-molecular-weight heparin
c. Endovascular therapy
d. Heparin
8. Which of the following is the first-line

antihypertensive medication for a postpartum
1. What is the primary cause of postpartum patient with suspected pre-eclampsia?
hemorrhage? a. Calcium-channel blocker (nifedipine)
a. Uterine atony b. Beta blocker (labetalol)
b. Vaginal laceration c. ACE inhibitor (lisinopril)
c. Coagulopathy d. Peripheral arterial vasodilator (hydralazine)
d. Retained placenta
9. Which therapy is superior to benzodiazepines
2. Which of the following is included in the and phenytoin in the treatment of eclamptic
criteria for diagnosing HELLP syndrome? patients?
a. Transaminases >50 U/L a. Oxytocin
b. Platelets <100,000/mcL b. Normal saline boluses
c. Normal bilirubin levels c. Ketamine
d. Decreased lactate dehydrogenase d. Magnesium sulfate
3. In what time frame do most patients with 10. A 33-year-old woman 2 weeks’ postpartum
postpartum cardiomyopathy (PPCM) typically presents to the ED with blurred vision,
present to the ED? elevated blood pressure, and protein/
a. Up to 1 year postdelivery creatinine ratio of 0.5. She exhibits seizure-
b. Only within the first 2 weeks postdelivery like activity, and the symptoms resolve 2
c. The last month of pregnancy to within 5 minutes after administration of magnesium
months postdelivery sulfate IV and diazepam IV. The patient is
d. Up to 6 months postdelivery stabilized in the ED, but requires a titratable
beta blocker infusion to manage her blood
4. What is the gold standard diagnostic test for pressure. To which location should the
diagnosis of cerebral venous thrombosis? patient’s disposition be?
a. CT noncontrast of brain a. Discharge home with urgent ob/gyn follow-
b. MRI noncontrast of brain up.
c. MR venography b. Admit to medical floor under neurology
d. CT venography service with ob/gyn consult.
c. Admit to the ICU with ob/gyn consult.
5. What is the most useful diagnostic study to d. Place in observation unit with neurology
help determine whether a patient has PPCM? consult.
a. Electrocardiogram
b. Troponin
c. Transthoracic echocardiogram
d. Brain natriuretic peptide (BNP)

Clinical Pathway For Management of the
Postpartum Patient With a Headache
Does the patient have

elevated blood pressure?
(≥140 mm Hg systolic
or ≥90 mm Hg diastolic)
YES NO
Go to “Clinical Pathway for the Postpartum Does the patient have altered mental
Patient with Elevated Blood Pressure,” status, papilledema, or an abnormal
page 21 neurologic examination?
YES NO
• Consider lumbar puncture in patients for Did the patient have epidural anesthesia
whom meningitis, encephalitis, or SAH for delivery and now symptoms of
is a consideration (Class I) post–dural puncture headache?
• Check glucose, obtain CBC and
metabolic profile YES NO
• Obtain CT of brain
• Consider further imaging, eg, CTV/
MRV, if cerebral venous thrombosis is
suspected
• Consult neurology and ob/gyn
• Admit to hospital
(Class II)
Consult anesthesia for consideration of • Treat headache with analgesics

epidural blood patch treatment (Class II) (Class II)
• Consider further imaging and/or
neurology consult if alternative diagnosis
such as cerebral venous thrombosis is
suspected despite normal neurologic
examination (Class I)
• Consider lumbar puncture in patients for
whom meningitis, encephalitis, or SAH
is a consideration (Class I)
• Refer to primary care physician or
ob/gyn for follow-up if deemed to be low-
risk for dangerous etiology of headache
Abbreviations: CBC, complete blood cell (count); CT, computed tomography; ob/gyn, obstetrics and gynecology; SAH, subarachnoid hemorrhage.
For Class of Evidence Definitions, see page 21.

Clinical Pathway for Management of the
Postpartum Patient With Elevated Blood Pressure
(Systolic ≥140 mm Hg, Diastolic ≥90 mm Hg)
Does the patient have a headache,

nausea, abdominal pain,
or blurry vision?
YES NO
Obtain CBC, urinalysis, urine protein/ Recheck blood pressure.

creatinine ratio, complete metabolic Is it still elevated?
panel, and LDH
• Is there confirmed pre-eclampsia based YES NO
on diagnostic criteria (see below)
or
• Is there high suspicion for pre-
eclampsia?
YES NO
Administer Refer for follow-up with primary care

• Administer IV labetalol (10-20 mg), IV
• Magnesium sulfate (4-6 grams IV bolus physician or ob/gyn in 1-2 days for
hydralazine (5 mg), or PO nifedipine
followed by an infusion) repeat blood pressure check
(10-20 mg) (Class II)
PLUS • Consult ob/gyn
• Labetalol 10 mg IV or hydralazine 5
mg IV
(Class I)
• Consult ob/gyn for admission Diagnostic Criteria for Pre-Eclampsia
• If hemodynamically unstable or if there • Systolic blood pressure ≥140 mm Hg
is neurologic deficit, consult ICU or
• Diastolic blood pressure ≥90 mm Hg
plus
New onset of 1 or more of the following:
• Administer IV labetalol (10-20 mg), IV • Protein/creatinine ratio >0.3 in a random urine specimen
hydralazine (5 mg), or PO nifedipine • Thrombocytopenia (platelets <100,000/mcL)
(10-20 mg) (Class II) • Serum creatinine >1.1 or doubling of creatinine concentration in the
• Consult ob/gyn absence of other renal disease
• Liver transaminases at least twice the upper limit of normal
• Pulmonary edema
Abbreviations: CBC, complete blood cell (count); ICU, intensive care unit; • New-onset and persistent headache that is not accounted for by other
IV, intravenous; LDH, lactate dehydrogenase; ob/gyn, obstetrics and diagnoses and not responding to usual doses of analgesics
gynecology; PO, orally. • Visual symptoms
Class of Evidence Definitions

Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I Class II
• Always acceptable, safe • Safe, acceptable Class III Indeterminate
• Definitely useful • Probably useful • May be acceptable • Continuing area of research
• Proven in both efficacy and effectiveness • Possibly useful • No recommendations until further
Level of Evidence: • Considered optional or alternative research
Level of Evidence: • Generally higher levels of evidence treatments
• One or more large prospective studies • Nonrandomized or retrospective stud- Level of Evidence:
are present (with rare exceptions) ies: historic, cohort, or case control Level of Evidence: • Evidence not available
• High-quality meta-analyses studies • Generally lower or intermediate levels • Higher studies in progress
• Study results consistently positive and • Less robust randomized controlled trials of evidence • Results inconsistent, contradictory
compelling • Results consistently positive • Case series, animal studies, • Results not compelling
consensus panels
• Occasionally positive results
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2022 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

CME Information
In upcoming issues of Date of Original Release: March 1, 2022. Date of most
Emergency Medicine Practice recent review: February 10, 2022. Termination date: March
1, 2025.
Accreditation: EB Medicine is accredited by the Accredi-
tation Council for Continuing Medical Education (ACCME) to provide
DECEMBER 2021 | VOLUME 23 | ISSUE 12
continuing medical education for physicians. This activity has been
planned and implemented in accordance with the accreditation require-
Emergency Medicine Practice Evidence-Based Education • Practical Application
ments and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for
CLINICAL CHALLENGES: a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should
• What are the common and less-
common signs and symptoms of claim only the credit commensurate with the extent of their participa-
acute aortic syndromes?
• When should you use radiography,
tion in the activity.
and when are CT or MRI
recommended? Specialty CME: Included as part of the 4 credits, this CME activity is
• How should blood pressure and
heart rate be controlled in patients
with aortic dissection?
eligible for 1 pharmacology CME credit, subject to your state and institu-
Authors
tional requirements.
Anthony Hackett, DO, FACEP,
FAAEM, FRSM
ACEP Accreditation: Emergency Medicine Practice is approved by
Attending Physician, CHI St. Joseph Regional
Hospital; Clinical Assistant Professor of
Emergency Medicine and Clinical Clerkship
the American College of Emergency Physicians for 48 hours of ACEP
Director, Texas A&M University School of
Medicine, Bryan-College Station, TX
Case courtesy of Associate Professor Frank Gaillard, Radiopaedia.org, rID: 9068
Category I credit per annual subscription.
Jonathan Stuart, DO, MS Thoracic Aortic Syndromes
Assistant Professor of Emergency Medicine,
Uniformed Services University, Bethesda, MD;
in The Emergency AAFP Accreditation: The AAFP has reviewed Emergency Medicine
Practice, and deemed it acceptable for AAFP credit. Term of approval is
Critical Care Fellow, University of Washington,
Seattle, WA
Douglas L. Robinson, DO, MS

Department: Recognition
Medical Director, 3rd Battalion, 75th Ranger
Regiment, Fort Benning, GA; Assistant Professor
and Management from 07/01/2021 to 06/30/2022. Physicians should claim only the credit
commensurate with the extent of their participation in the activity.
of Emergency Medicine, Mercer University
School of Medicine, Columbus, GA n Abstract
Acute aortic syndromes include aortic dissection, penetrating
atherosclerotic ulcer, and intramural hematomas, but aortic
Peer Reviewers
Daniel Eraso, MD
dissection is the most common and the deadliest. This review
summarizes the latest evidence on developing a differential for
• 4.00 Enduring Materials, Self-Study AAFP Prescribed Credit(s)-
Assistant Professor, Department of Emergency
Medicine, University of Florida College of
Medicine–Jacksonville, Jacksonville, FL
aortic dissection when common complaints, such as chest pain,
abdominal pain, and syncope are also present. Recent evidence Managing Postpartum Complications in the Emergency Department
on the optimal uses of emergency department imaging studies
Trevor Pour, MD
Assistant Professor of Emergency Medicine,
and risk stratification tools are reviewed, along with special
considerations in the management of penetrating atherosclerotic
AOA Accreditation: Emergency Medicine Practice is eligible for 4
Category 2-A or 2-B credit hours per issue by the American Osteopathic
Associate Program Director, Emergency
Medicine Residency, Icahn School of Medicine at
ulcer and intramural hematoma. Pharmacologic therapies for
Mount Sinai, New York, NY managing hemodynamic parameters and shock, and indications
Association.
for operative intervention are also reviewed, along with cutting-
Prior to beginning this activity, see “CME
Information” on page 26. edge diagnostic and treatment options on the horizon.
For online access, scan with your

smartphone camera or QR code reader app:
Needs Assessment: The need for this educational activity was deter-
This issue is eligible for CME credit. See page 26. EBMEDICINE.NET
mined by a practice gap analysis; a survey of medical staff, includ-
ing the editorial board of this publication; review of morbidity and
mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation
responses from prior educational activities for emergency physicians.
• Meningitis and Encephalitis Target Audience: This enduring material is designed for emergency medi-
cine physicians, physician assistants, nurse practitioners, and residents.
• Skin and Soft-Tissue Infections Goals: Upon completion of this activity, you should be able to: (1) identi-
fy areas in practice that require modification to be consistent with current
• Cardiac Valve Emergencies evidence in order to improve competence and performance; (2) develop
strategies to accurately diagnose and treat both common and critical ED
presentations; and (3) demonstrate informed medical decision-making
based on the strongest clinical evidence.
CME Objectives: Upon completion of this article, you should be able to:
(1) list the elements of a thorough history and examination for patients
in the postpartum period and describe how they relate to emergent
postpartum complications; (2) describe the diagnostic workup for each
of the most common postpartum complications; and (3) outline the
safest and most cost-effective treatment plans for common postpartum
Group discounts for you complications.
and your colleagues Discussion of Investigational Information: As part of the activity, faculty
may be presenting investigational information about pharmaceutical
products that is outside Food and Drug Administration approved label-
ing. Information presented as part of this activity is intended solely as
EB Medicine offers budget-friendly discounts for continuing medical education and is not intended to promote off-label
group practices, hospitals and medical systems, use of any pharmaceutical product.
academic medical centers, and other institutions Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity,
balance, independence, transparency, and scientific rigor in all CME
with 5 or more clinicians. Our variety of formats, activities. All faculty participating in the planning or implementation of
CME tracking, and customized reporting makes a CME activity are expected to disclose to the participants any relevant
financial relationships and to assist in resolving any conflict of interest
EB Medicine the resource both administrators and that may arise from the relationship. In compliance with all ACCME
clinicians will value and trust. accreditation requirements and policies, all faculty for this CME activ-
ity were asked to complete a full financial disclosure statement. The
information received is as follows: The authors, Dr. Nicole Yuzuk, Dr.
For more information, contact Dana Stenzel, Joseph Bove, Dr. Riddhi Desai; the peer reviewers, Dr. Jennifer Beck-
Account Executive, at [email protected] Esmay, Dr. Elizabeth Leenellett; the Editor-in-Chief, Dr. Andy Jagoda;
the Associate Editor-in-Chief, Dr. Kaushal Shah; and the Research Edi-
or 678-336-8466, ext. 120, or visit tors, Dr. Aimee Mishler, and Dr. Joseph Toscano, report no relevant
www.ebmedicine.net/groups financial relationships with ineligible companies.
Commercial Support: This issue of Emergency Medicine Practice did
not receive any commercial support.
To learn more or subscribe, visit Earning Credit: Go online to www.ebmedicine.net/CME and click on
www.ebmedicine.net/EMPinfo the title of the test you wish to take. When completed, a CME certificate
will be emailed to you.
Hardware/Software Requirements: You will need a Macintosh or PC
with Internet capabilities to access the website.
Additional Policies: For additional policies, including our statement of
conflict of interest, source of funding, statement of informed consent,
and statement of human and animal rights, visit http://www.ebmedicine.
net/policies.

The Emergency Medicine Practice Editorial Board
EDITOR-IN-CHIEF Daniel J. Egan, MD Charles V. Pollack Jr., MA, MD, Scott D. Weingart, MD, FCCM
Harvard University Affiliated Emergency FACEP, FAAEM, FAHA, FACC, FESC Professor of Emergency Medicine; Chief,
Andy Jagoda, MD, FACEP Medicine Residency, Massachusetts General EM Critical Care, Stony Brook Medicine,
Professor and Chair Emeritus, Department Hospital/Brigham and Women's Hospital, Clinician-Scientist, Department of Stony Brook, NY
of Emergency Medicine; Director, Center Boston, MA Emergency Medicine, University of
for Emergency Medicine Education and Mississippi School of Medicine, Jackson MS RESEARCH EDITORS
Research, Icahn School of Medicine at Marie-Carmelle Elie, MD
Mount Sinai, New York, NY Associate Professor, Department of Ali S. Raja, MD, MBA, MPH Aimee Mishler, PharmD, BCPS
Emergency Medicine & Critical Care Executive Vice Chair, Emergency Medicine, Emergency Medicine Pharmacist, Program
ASSOCIATE EDITOR-IN-CHIEF Medicine, University of Florida College of Massachusetts General Hospital; Professor Director, PGY2 EM Pharmacy Residency,
Medicine, Gainesville, FL of Emergency Medicine and Radiology, Valleywise Health, Phoenix, AZ
Kaushal Shah, MD, FACEP Harvard Medical School, Boston, MA
Assistant Dean of Academic Advising, Vice Nicholas Genes, MD, PhD Joseph D. Toscano, MD
Chair of Education, Professor of Clinical Clinical Assistant Professor, Ronald O. Robert L. Rogers, MD, FACEP, Chief, Department of Emergency Medicine,
Emergency Medicine, Department of Perelman Department of Emergency FAAEM, FACP San Ramon Regional Medical Center, San
Emergency Medicine, Weill Cornell School Medicine, NYU Grossman School of Assistant Professor of Emergency Medicine, Ramon, CA
of Medicine, New York, NY Medicine, New York, NY The University of Maryland School of
INTERNATIONAL EDITORS
Medicine, Baltimore, MD
EDITORIAL BOARD Michael A. Gibbs, MD, FACEP Peter Cameron, MD
Professor and Chair, Department of Alfred Sacchetti, MD, FACEP
Saadia Akhtar, MD, FACEP Academic Director, The Alfred Emergency
Emergency Medicine, Carolinas Medical Assistant Clinical Professor, Department of
Associate Professor, Department of and Trauma Centre, Monash University,
Center, University of North Carolina School Emergency Medicine, Thomas Jefferson
Emergency Medicine, Associate Dean for Melbourne, Australia
of Medicine, Chapel Hill, NC University, Philadelphia, PA
Graduate Medical Education, Program
Director, Emergency Medicine Residency, Andrea Duca, MD
Steven A. Godwin, MD, FACEP Robert Schiller, MD
Mount Sinai Beth Israel, New York, NY Attending Emergency Physician, Ospedale
Professor and Chair, Department of Chair, Department of Family Medicine,
Papa Giovanni XXIII, Bergamo, Italy
Emergency Medicine, Assistant Dean, Beth Israel Medical Center; Senior Faculty,
William J. Brady, MD
Simulation Education, University of Florida Family Medicine and Community Health, Suzanne Y.G. Peeters, MD
Professor of Emergency Medicine and
COM-Jacksonville, Jacksonville, FL Icahn School of Medicine at Mount Sinai, Attending Emergency Physician, Flevo
Medicine; Medical Director, Emergency
New York, NY Teaching Hospital, Almere, The Netherlands
Management, UVA Medical Center; Joseph Habboushe, MD MBA
Operational Medical Director, Albemarle Scott Silvers, MD, FACEP
Assistant Professor of Clinical Emergency Edgardo Menendez, MD, FIFEM
County Fire Rescue, Charlottesville, VA Medicine, Department of Emergency Associate Professor of Emergency Medicine, Professor in Medicine and Emergency
Medicine, Weill Cornell School of Medicine, Chair of Facilities and Planning, Mayo Clinic, Medicine; Director of EM, Churruca Hospital
Calvin A. Brown III, MD
New York, NY; Co-founder and CEO, Jacksonville, FL of Buenos Aires University, Buenos Aires,
Director of Physician Compliance,
MDCalc Argentina
Credentialing and Urgent Care Services, Corey M. Slovis, MD, FACP, FACEP
Department of Emergency Medicine, Eric Legome, MD Professor and Chair Emeritus, Department Dhanadol Rojanasarntikul, MD
Brigham and Women's Hospital, Boston, Chair, Emergency Medicine, Mount Sinai of Emergency Medicine, Vanderbilt Attending Physician, Emergency Medicine,
MA West & Mount Sinai St. Luke's; Vice Chair, University Medical Center, Nashville, TN King Chulalongkorn Memorial Hospital;
Academic Affairs for Emergency Medicine, Faculty of Medicine, Chulalongkorn
Peter DeBlieux, MD Ron M. Walls, MD
Mount Sinai Health System, Icahn School of University, Thailand
Professor of Clinical Medicine, Louisiana Professor and COO, Department of
Medicine at Mount Sinai, New York, NY
State University School of Medicine; Chief Emergency Medicine, Brigham and Stephen H. Thomas, MD, MPH
Experience Officer, University Medical Keith A. Marill, MD, MS Women's Hospital, Harvard Medical School, Professor & Chair, Emergency Medicine,
Center, New Orleans, LA Associate Professor, Department of Boston, MA Hamad Medical Corp., Weill Cornell
Emergency Medicine, Harvard Medical Medical College, Qatar; Emergency
Deborah Diercks, MD, MS, FACEP, CRITICAL CARE EDITORS
School, Massachusetts General Hospital, Physician-in-Chief, Hamad General Hospital,
FACC
Boston, MA William A. Knight IV, MD, FACEP, Doha, Qatar
Professor and Chair, Department of
Emergency Medicine, University of Texas Angela M. Mills, MD, FACEP FNCS Edin Zelihic, MD
Southwestern Medical Center, Dallas, TX Associate Professor of Emergency Medicine
Professor and Chair, Department of Head, Department of Emergency Medicine,
and Neurosurgery, Medical Director, EM
Emergency Medicine, Columbia University Leopoldina Hospital, Schweinfurt, Germany
Advanced Practice Provider Program;
Vagelos College of Physicians & Surgeons,
Associate Medical Director, Neuroscience
New York, NY
ICU, University of Cincinnati, Cincinnati, OH
CEO: Stephanie Williford

Director of Finance & Analytics: Robin Wilkinson
Publisher: Suzanne Verity
Director of Editorial Quality: Dorothy Whisenhunt, MS
Direct all inquiries to: Senior Content Editor & CME Director: Erica Scott
Phone: 678-366-7933 Content Editor: Cheryl Belton, PhD, ELS
Fax: 770-500-1316 Digital Editor & Project Manager: Angie Wallace
Editorial Assistant: Erin Mooney, MA
5600 Spalding Drive, Unit 921697 CME Coordinator: Kristen Raynor, MEd
Norcross, GA 30010-1697 Customer Service Representative: Kandis Slater
Peachtree Corners, GA 30092 Account Executive: Dana Stenzel
E-mail: [email protected] Director of Marketing: Anna Motuz, MBA
Website: www.ebmedicine.net Email Marketing Specialist: Joshua Devou, MBA
Database Administrator: Jose Porras
ISSN info and disclaimer:
Emergency Medicine Practice (ISSN Print: 1524-1971, ISSN Online: 1559-3908, ACID-FREE) is published monthly (12 times per year) by EB Medicine
(5600 Spalding Drive, Unit 921697, Norcross, GA 30010-1697). Opinions expressed are not necessarily those of this publication. Mention of products
or services does not constitute endorsement. This publication is intended as a general guide and is intended to supplement, rather than substitute,
professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials
contained herein are not intended to establish policy, procedure, or standard of care. Copyright © 2022 EB Medicine. All rights reserved. No part of
this publication may be reproduced in any format without written consent of EB Medicine. This publication is intended for the use of the individual
subscriber only and may not be copied in whole or part or redistributed in any way without the publisher’s prior written permission.

Points & Pearls
QUICK READ
Managing Postpartum
Complications in the
Emergency Department
MARCH 2022 | VOLUME 24 | ISSUE 3
Points
Pearls
• Postpartum patients can present, without prior
history, with new-onset high blood pressure, • Postpartum complications have a wide dif-
pre-eclampsia, or HELLP syndrome up to 6 weeks ferential and often overlapping symptoms.
after delivery. The diagnostic criteria for postpar- Diagnosis is tailored to the chief complaint,
tum pre-eclampsia are noted in Table 1. with the history and physical examination hav-
• Blood pressure >160 mm Hg systolic or >110 ing primary importance.
diastolic is considered severe; recheck in 15 • Signs and symptoms on the differential for
minutes. If it remains elevated, antihypertensive postpartum headache are noted in Table 4.
therapy should be initiated; first-line therapy is • Treatment of postpartum complications
beta blockers. often requires a multidisciplinary approach.
• For eclamptic patients who are seizing, therapy Early consultation with ob/gyn, neurology,
includes a magnesium sulfate loading dose of cardiology, and/or interventional radiology is
4-6 grams IV, followed by a maintenance dose of recommended.
1-2 grams/hr. Patients experiencing recurrent sei- • For postpartum hemorrhage, uterotonic
zures may need additional doses or an infusion. agents can be administered and uterine
• Diagnostic criteria for HELLP syndrome are noted massage performed. Ob/gyn consultation
in Table 2. Therapy is typically supportive; evi- is recommended, as multiple agents can be
dence for corticosteroid use is insufficient.68 combined while preparing for more-invasive
• Up to 10% of postpartum patients with headache measures, if needed.
have been found to have a more severe diagno- • Hemoglobin levels may not reflect blood vol-
sis, such as cerebral venous thrombosis, hemor- ume accurately; observe vital signs closely in
rhage, or mass,8 secondary to the coagulopathic bleeding patients.39,40
state in pregnancy and hypertensive disorders.
• Patients who present with headache with neu-
rologic abnormalities, altered mental status, or
meningeal signs require advanced imaging and/ x-ray can identify vascular congestion, pleural effu-
or lumbar puncture. sions, or enlarged heart.
• As many as 77% of patients with cerebral venous • Fever can be indicative of wound infection, mas-
thrombosis may have a normal CT;42 radiology titis, or endometritis, which can be diagnosed on
should be notified if there is concern for ICH. CT history and physical examination. Fever and hypo-
venography can be considered if MRI is not read- tension may point to sepsis.
ily available. • The majority of over-the-counter medications and
• Post–dural puncture headache may be seen in antibiotics are safe for breastfeeding mothers;
up to 16% of patients with headache.8 If symp- however, trimethoprim-sulfamethoxazole should
toms are severe and not relieved by rest and oral be avoided when the infants are (1) <60 days old;
analgesics, anesthesiology consult should be (2) G6PD-deficient; or (3) premature, acutely ill, or
obtained for possible epidural blood patch. jaundiced.
• Peripartum cardiomyopathy (PPCM) can occur up • Advise patients given antibiotics that improvement
to 5 months after delivery, and is mainly character- should be seen within 24-72 hours (depending on
ized by left ventricular ejection fraction <45%. Cri- the drug), and to return if there is no improvement.
teria for diagnosis of PPCM are noted in Table 3. • Ensure that patients discharged are given explicit
• Bedside ultrasound can be used to assess a return precautions, that obstetric follow-up has
patient with cardiopulmonary complaints, includ- been arranged, and the patient and baby have
ing heart failure and pulmonary embolism. Chest good home care arranged.

Emergency Medicine Practice: Managing Postpartum Complications in The Emergency Department

Uploaded by

Copyright:

Available Formats

Emergency Medicine Practice: Managing Postpartum Complications in The Emergency Department

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Emergency Medicine Practice: Managing Postpartum Complications in The Emergency Department

Uploaded by

Copyright:

Available Formats

MARCH 2022 | VOLUME 24 | ISSUE 3

Emergency Medicine Practice Evidence-Based Education • Practical Application

For online access, scan with your

n Introduction only to the mother, but also to the newborn baby.

MARCH 2022 • www.ebmedicine.net 2 ©2022 EB MEDICINE

GROUP SUBSCRIPTIONS: [email protected] 3 © 2022 EB MEDICINE. ALL RIGHTS RESERVED.

MARCH 2022 • www.ebmedicine.net 4 ©2022 EB MEDICINE

Peripartum Cardiomyopathy29 Headache in a patient with history of Migraine headache

GROUP SUBSCRIPTIONS: [email protected] 5 © 2022 EB MEDICINE. ALL RIGHTS RESERVED.

MARCH 2022 • www.ebmedicine.net 6 ©2022 EB MEDICINE

GROUP SUBSCRIPTIONS: [email protected] 7 © 2022 EB MEDICINE. ALL RIGHTS RESERVED.

Fever and Infection

MARCH 2022 • www.ebmedicine.net 8 ©2022 EB MEDICINE

Laboratory Studies Obstetric consultation in conjunction with use of

GROUP SUBSCRIPTIONS: [email protected] 9 © 2022 EB MEDICINE. ALL RIGHTS RESERVED.

MARCH 2022 • www.ebmedicine.net 10 ©2022 EB MEDICINE

GROUP SUBSCRIPTIONS: [email protected] 11 © 2022 EB MEDICINE. ALL RIGHTS RESERVED.

Treatment of Peripartum Cardiomyopathy

MARCH 2022 • www.ebmedicine.net 12 ©2022 EB MEDICINE

GROUP SUBSCRIPTIONS: [email protected] 13 © 2022 EB MEDICINE. ALL RIGHTS RESERVED.

MARCH 2022 • www.ebmedicine.net 14 ©2022 EB MEDICINE

GROUP SUBSCRIPTIONS: [email protected] 15 © 2022 EB MEDICINE. ALL RIGHTS RESERVED.

MARCH 2022 • www.ebmedicine.net 16 ©2022 EB MEDICINE

GROUP SUBSCRIPTIONS: [email protected] 17 © 2022 EB MEDICINE. ALL RIGHTS RESERVED.

MARCH 2022 • www.ebmedicine.net 18 ©2022 EB MEDICINE

8. Which of the following is the first-line

GROUP SUBSCRIPTIONS: [email protected] 19 © 2022 EB MEDICINE. ALL RIGHTS RESERVED.

Does the patient have

Consult anesthesia for consideration of • Treat headache with analgesics

MARCH 2022 • www.ebmedicine.net 20 ©2022 EB MEDICINE

Does the patient have a headache,

Obtain CBC, urinalysis, urine protein/ Recheck blood pressure.

Administer Refer for follow-up with primary care

Class of Evidence Definitions

GROUP SUBSCRIPTIONS: [email protected] 21 © 2022 EB MEDICINE. ALL RIGHTS RESERVED.

Douglas L. Robinson, DO, MS

For online access, scan with your

MARCH 2022 • www.ebmedicine.net 22 ©2022 EB MEDICINE

CEO: Stephanie Williford

GROUP SUBSCRIPTIONS: [email protected] 23 © 2022 EB MEDICINE. ALL RIGHTS RESERVED.

MARCH 2022 • www.ebmedicine.net 24 ©2022 EB MEDICINE

You might also like