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7 Changes andPotential Complications During Puerperium
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rst 6 weeks after delivery and that this rate
occurs at a lower rate in the following 6months,
by which time you should have returned to your
prepregnancy weight.
7.3.10 System Cardiovascular
The peripartum is a period in which sudden
hemodynamic changes occur, which imposes on
the maternal organism an ability to adapt, which
is dependent on the existence or not of previous
cardiac pathology. In the presence of this, the
volume and/or pressure overload can lead to situations as serious as acute lung edema [2].
– Cardiac output: At the time of delivery, there
is an increase in cardiac output of about 60%,
mainly at the expense of increased stroke volume. Consequently, there will also be an
increase in blood pressure.
– Plasma volume: In the immediate postpartum
period, the increase in plasma volume (blood
volume) is even greater due to the return to the
blood circulation present in the uterine circulation, the increased venous return to the right
heart (sudden decompression of the inferior
vena cava), and the mobilization of extravascular uid. The increase in blood volume thus
seems to counterbalance blood loss at delivery
(about 500 mL at vaginal delivery and
1000mL at cesarean section).
considered normal, mainly at the expense of
granulocytes and without deviation to the left.
Lymphopenia is also frequently seen [2].
– Hemostasis: The coagulation system is acti-
vated at the time of delivery. From the rst
hours, there is a consumption of platelets and
clotting factors, which aims to promote the
buffering of uterine hemorrhage. In about
48h, the clotting factors are practically nor-
mal [2].
7.4 Risk Factors forPostpartum
Complications
The main complications in the puerperium are
essentially related to maternal comorbidities, previous or acquired during the pregnancy, as well
as aspects associated with childbirth and
delivery.
Briey, they can be organized into antepartum
and intrapartum/postpartum factors (Table 7.1)
[2, 3].
Particularly in relation to the mode of delivery, cesarean section alone is the main risk factor
for puerperal complication. In this procedure,
there is a higher rate of maternal morbidity and
mortality compared to vaginal delivery and there
are several complications that result from it,
which include endometritis, postpartum hemorrhage, pelvic thrombophlebitis, septic shock, etc.
As a general rule, cardiac output and plasma
volume return to the prepregnancy level in about
2weeks.
7.3.11 System Hematological
– Erythrocytes: There are no signicant differ-
ences, unless the delivery has been accompa-
nied by increased blood loss. Hemoglobin
concentration returns to prepregnancy levels
in approximately 6weeks [2].
– Leukocytes: During labor, leukocytosis occurs
which persists or increases in the rst week of
puerperium. Values up to 25,000leuc/mL are
Table 7.1 Antepartum and intrapartum and postpartum
risk factors
Risk factors for puerperal complications
Antepartum Intra- and postpartum
Low socioeconomic and
educational level
Absence or poor prenatal
surveillance
Poor nutrition
Immunosuppressive therapy
Obesity
Hypertension is a risk factor
too
Anemia
Poor personal hygiene
Lower genital tract
infections
Premature rupture of
membranes
Chorioamnionitis
Cesarean
Dystocic childbirth
Prolonged labor
Multiple vaginal
touches
Internal fetal
monitoring
Postpartum
hemorrhage
Birth canal trauma
Breast ssures
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In several studies, a relative risk of 5–30 times
for some complications is described.
7.5 Life-Threatening Postpartum
Complications
7.5.1 Headache
Most puerperal headaches do not reect severe
pathology, since they are the result of a combination of factors, which include hormonal and psychological changes, fatigue, sleep deprivation,
and irregular dietary habits. In those submitted to
neuro-axis anesthesia, headache may be secondary to several vasoactive drugs previously used
[2–4].
However, other entities, although rarer, are
given.
Table 7.2 Puerperal headache conditions
Conditions Association
Preeclampsia
of late onset
Stroke Associated with focal neurological
Headache after
dura mater
puncture
Primary
headache
Alarm signs in headaches
Sudden-onset headache (“worst headache in life”)
Headache de novo, especially “migraine type”
Modication of the usual headache characteristics
(e.g., pain, pattern, intensity)
Headache in anticoagulated patient or with
hemorrhagic dyscrasia
Headache in an immunocompromised patient or with
neoplasia
Headache associated with fever or manifestations
suggestive of CNS pathology
Headache that does not respond to analgesic
medication
Particularly if hypertension and in
the rst 48h after delivery. It is also
possible to appear a few weeks after
delivery
decits de novo
In normotensive women and with
neuro-axis analgesia. Usually in the
rst 48h after the procedure, which
worsens with the orthostatic position
and with the elevation of the head of
the bed. Relief with decubitus and
rest
Women with previous headache,
with exactly the same characteristics
7.5.2 Seizure
7.5.2.1 Preeclampsia/Eclampsia
In most cases, seizures in pregnancy, childbirth,
and puerperium arise in the context of preeclampsia/eclampsia. In the postpartum period, seizures
usually appear in the rst 48 h, although they
may appear later. Prevention and treatment
(Table7.3) involve performing therapy with magnesium sulfate [2, 3].
Severe hypertension of recent-onset, underlying cases of preeclampsia/eclampsia, particularly
wherein BP ≥160 and/or 110mmHg, is indicated
to be treated immediately (Table7.4), under penalty of serious maternal cardiovascular complications, such as AMI and stroke.
The goal in the puerperium is to obtain a BP
≤140 and/or 90 mmHg. Alpha-methyldopa, in
view of its association with postpartum depression, should be passed over to other drugs,
namely inhibitors of the renin-angiotensinaldosterone system and calcium channel
antagonists.
Table 7.3
eclampsia
1ª Line: Magnesium sulfate
Loading
dose
Manutention
dose
Booster dose 2g EV during
2ª Line: Diazepam
Loading
dose
Manutention
dose
Prevention and treatment of seizures in
4g EV in
20–30min
(bolus)
2–3g/h
(rhythm
50–75mL/h)
10–15min
(additional
bolus)
5mg EV
5mg each
5min (max.
20mg)
Therapeutic levels:
4–8mEq/L
Toxicity if >8mEq/L
+/− abolition of the
rotulian reex,
depression,
awareness, diplopia,
muscle paralysis,
respiratory arrest,
prolongation of the
QRS on the ECG
Antidote: 1g 10%
calcium gluconate
(10mL EV in
3–4min)
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Table 7.4
Acute treatment Manutention treatment Contraindications
Labetalol: 20mg (bolus EV) and
duplicate the dose at each 20min (max.
200mg)
Nifedipine: 10mg (repeat 10mg after
30min)
Hydralazine: 5mg (bolus EV) and
repeating the dose at each 20min (max.
20mg)
Nitroglycerin: 5mcg/min and repeating
the dose at each 5min (max. 100mcg)
Sodium nitroprusside: 0.25mcg/kg/min
and duplicate the dose at each 5min (max.
10mcg/kg/min)
hypertension during pregnancy and preeclampsia/eclampsia should collect urine for proteinuria
and measure the TA to be able to reclassify the
situation. Approximately 12% of women with
hypertension in pregnancy can develop chronic
hypertension.
7.5.2.2 Epilepsy
The incidence of seizures in the puerperium does
Blood pressure control in severe preeclampsia and eclampsia
50–400mg/6h (max.
600mg/day)
10–20mg 6h (max.
60mg/day)
3–7mg/h (max. 200mg/
day)
<4h (fetotoxicity due to
cyanide accumulation)
At 6 weeks postpartum, all women with
Congestive heart failure, maternal
bradycardia, coronary heart disease, aortic
stenosis, and asthma
Congestive heart failure, severe asthma,
and intestinal obstruction
Heart disease, coronary disease, and
tachycardia
Hypertensive encephalopathy
Table 7.5
Pathology Other clinical manifestations
Pulmonary
thromboembolism
Peripartum
cardiomyopathy
Panic disorder Palpitations, trembling, feeling
Musculoskeletal
pathology
Causes of dyspnea and/or chest pain
Hemoptysis
Cough, orthopnea, paroxysmal
nocturnal dyspnea,
hemoptysis, and MI edema
of imminent death
Pain with movement and
breathing (more in inspiration)
not appear to be higher in women with a history
of epilepsy. However, it is important to recognize
signicant changes in the pharmacokinetics of
antiepileptics in the postpartum period, which
potentiates phenomena of toxicity to these agents.
Serum monitoring of the concentration of these
drugs assumes an important role at this stage
[2–4].
dystocic births (suction cup and forceps) and episiotomy [2, 4]. Usually, there is talk of a vulvar
painful syndrome, which is accompanied by
edema and erythema and which analytically leads
to leukocytosis. If complicated by infection by
group A streptococcus or necrotizing fasciitis,
broad-spectrum antibiotic therapy is mandatory.
In the case of necrosis, surgical debridement may
even be necessary.
7.5.3 Dyspnea andChest Pain
Dyspnea and chest pain appear in the context of
heart and/or lung diseases. Although there are
several possible causes (Table7.5) in the postpartum period, the two most clinically relevant are
pulmonary thromboembolism and peripartum
cardiomyopathy.
7.5.4 Vulvar Edema
Vulvar edema is a consequence of trauma existing during childbirth, which is associated with
7.6 Non-Life-Threatening
Postpartum Complications
7.6.1 Diculty inUrination
andUrinary Retention
Urinary retention in the postpartum period is
dened by the inability to have urination for more
than 6h, either spontaneously or after removal of
the bladder catheter (placed in the cesarean section) [2, 4]. In this denition, it is also assumed
that the residual post-voiding volume is at least
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150 mL after spontaneous voiding. The cause
seems to be related to the pudendal nerve injury.
The risk factors involved include epidural
analgesia, primiparity, dystocic delivery, and episiotomy [2–4].
Clinical manifestations are variable. The
patient may be asymptomatic, as she may have
pain, burning, pollakiuria, urinary urgency or
hesitation, hypogastric pain, weak or intermittent
urinary stream, and/or incomplete bladder
emptying.
Treatment involves intermittent bladder catheterization. Prophylactic antibiotic therapy is not
necessary. The role of anticholinergics such as
physostigmine and rivastigmine is limited.
The prognosis is usually good, since it is a
self-limited condition, which resolves within
1week.
7.6.2 Incontinence
Urinary and/or fecal incontinence are relatively
common conditions in the immediate postpartum
period. These are of multifactorial etiology,
although the most frequently described causes
are lacerations of the respective sphincters at the
time of delivery [2, 4]. Pelvic oor ultrasound
plays an important role in the assessment of this
type of dysfunction. Early pelvic paviment physiotherapy is determinant as a incontinence
recovery.
In most cases, a progressive improvement is
noted in subsequent weeks. If complaints persist,
it will be necessary to discuss the various options
for diagnosis and treatment that are most appropriate for each case.
7.6.3 Hemorrhoids
Hemorrhoids are frequent in pregnancy and in
the puerperium, and it seems that in this last
phase they become more symptomatic. This
problem affects approximately one-third of
women. The treatment of symptomatic hemorrhoids (pruritus, pain, hemorrhage, or prolapse)
involves the use of topical anesthetics, corticoste-
roids, oral laxatives, fecal emollients, and vasoactive agents [2, 4].
7.6.4 Foul-Smelling Lochia
A strong and unpleasant odor in the postpartum
period is more often related to decient intimate
hygiene, which may be underlying bacterial vaginosis. Do not forget to review the birth canal, regarding a possible compress forgotten at the time of
suturing the laceration or episiotomy [2, 4].
Strong and unpleasant odor accompanied by
fever and brownish lochia (chocolate brown)
should make you think of endometritis.
7.6.5 Symptomatic Venous
Insuciency oftheLower
Limbs
In pregnancy, there are several factors that promote venous distension and occurrence of edema,
namely the increase in venous pressure due to the
mechanical pressure of the pregnant uterus on the
lower pelvic and vena cava, the myorelaxant effect
of progesterone when contributing to the decreased
venous vascular resistance, as well as the hydrodynamic obstruction caused by the high pressure of
the venous ow of the uterine circulation. Here,
stasis and endothelial injury may predispose to the
appearance of supercial thrombophlebitis or even
deep venous thrombosis.
After delivery, with a reduction in pressure
below the diaphragm, there is an adjustment that
may involve only partial improvement of venous
insufciency, since the vascular structural alteration has already occurred.
The improvement of symptoms involves elevation of the lower limbs, physical exercise, compression stockings, and bioavonoids.
7.6.6 Thromboembolism
Thromboembolism is an important cause of postpartum mortality and morbidity in the Western
world. This term refers to all phenomena of vas-
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133
cular occlusion at the venous level, which will
include deep vein thrombosis, pulmonary embolism, supercial thrombophlebitis, and septic pelvic thrombophlebitis [2, 4].
Risk factors for thrombotic events can be
organized schematically into three groups, which
are part of the so-called Virchow triad (Fig.7.6).
Hypercoagulability, one of the elements of this
triad and which has been present since pregnancy,
is even more pronounced in the puerperium due
to the release of thromboplastin with the discharge. Thus, in the puerperium, we speak of a
6–8 times higher risk for thrombotic events.
The diagnosis of thrombotic events is suspected, often inferred from the following clinical
manifestations (Table7.6) [2]:
LA
RA
LV
RV
Fig. 7.6 Virchow triad
Embolus
Thrombus
Venous valve
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Table 7.6
Thrombotic events Clinical manifestations Treatment
Supercial
thrombophlebitis
Pelvic septic
thrombophlebitis
Deep venous
thrombosis
Pulmonary embolism – Sudden-onset dyspnea
Clinical manifestations of thrombotic events
– Inammatory signs (heat, ushing, edema,
and pain) in a vascular area of the limb
Isolated fever or associated abdominal pain,
which does not yield to antibiotic therapy
– Abdominal pain (more frequent in FID,
related to thrombosis of the right ovarian vein)
Pain, redness, edema, and swelling of the limb
– Pain on palpation and sensation of
“hardened” cord in the affected vascular path
– Positive Homans sign (pain in the twin
region with limb dorsiexion)
– Chest pain, of a pleuritic nature, and
hemoptysis (in small and peripheral pulmonary
infarcts)
– Syncope, seizures, and other changes in the
state of consciousness
– Tachypnea, tachycardia, hypotension
– Signs of right-heart failure
– Rest, elevation of the limb, and
application of local heat
– Nonsteroidal anti-inammatory
drugs (topical or systemic) and
analgesics
– Elastic compression stockings
– Low-molecular-weight
unfractionated heparin in prophylactic
dose
– Surgery (if no response to previous)
Low molecular weight unfractionated
heparin in therapeutic dose
– Surgery (if no response to previous)
– Unfractionated and low molecular
weight heparin in therapeutic dose
– Surgery (if no response to previous)
The prophylaxis and treatment of thromboembolism in the situations described above are summarized in Table7.7 [2].
7.6.7 Fever andPuerperal
Infections
The increase in body temperature in the rst 24h
of the puerperium is a normal nding. The cause
is not fully known, although the most plausible
hypothesis is related to the woman’s endocrinemetabolic response to the stress of childbirth. It
usually has spontaneous resolution [2, 4].
A feverish condition, on the other hand, can be
dened as a body temperature above 38°, lasting
more than 48h, in the rst 10days of the puerperium, excluding the rst 24h [2].
Take a Note
The absence of fever does not mean the
absence of infection. Likewise, a feverish
spike, especially in the rst 24h, is not a
sign of infection.
Fever is not a single parameter of infection and should be carefully evaluated in
order to understand whether or not it
deserves investigation.
The rate of infection in the puerperium is
approximately 5–7%, with higher rates in those
undergoing cesarean section [4]. However, it is
believed that the actual prevalence remains
underestimated, given the various limitations of
epidemiological surveillance systems.
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Table 7.7
lism [2]
Unfractionated heparin
80 UI/kg bolus, followed by the continuous infusion
18 UI/kg/h
Low-molecular-weight heparin
Weight in early pregnancy
Enoxaparin 40mg
Dalteparin 5.000
Tinzaparin 175 UI/
Unfractionated heparin
5.000 UI 2×/day
Low-molecular-weight heparin
Weight in early pregnancy
Enoxaparin 20mg
Dalteparin 2.500
Tinzaparin 3.500
Prophylaxis and treatment of thromboembo-
<50kg 50–90kg>90kg high risk
2×/day
UI 2×/
day
kg 1×/
day
< 50 Kg50-90 Kg> 90 Kghigh risk
1×/day
UI 1×/
day
UI 1×/
day
60mg
2×/day
6.000
UI 2×/
day
175 UI/
kg 1×/
day
40mg
2×/day
5.000
UI 2×/
day
4.500
UI 1×/
day
80mg
2×/day
8.000
UI 2×/
day
175 UI/
kg 1×/
day
40mg
2×/day
5.000
UI 2×/
day
4.500
UI 2×/
day
1 UI/
day ×
weigh
(Kg)
10.000
UI 2×/
day
175 UI/
kg 1×/
day
0.5–1mg/
kg 2×/day
50–100
UI/kg 2×/
day
4.500 UI
2×/day
Most febrile infectious processes in the puerperium are caused by infection of the lower genital
tract [2]. In a schematic way, we can consider:
1. Uterus infections and appendages
2. Surgical wound infections (abdominal or
perineal)
3. Breast infections (mastitis and breast
abscesses)
4. Infections from other locations (e.g., urinary
infections)
7.6.7.1 Infection oftheUterus
andAdnexa
Endometritis seems to be the precursor event in
all infectious processes involving the uterus and
the appendages, so it is important to recognize
the diagnosis early in this phase [2].
Endometritis refers to the infection of the
decidua, which can extend to the myometrium
(endomyometritis) or affect the parametrium
(parametritis) [2].
It is currently the most frequent cause of fever
in the rst 10days postpartum.
The etiology of endometritis is polymicrobial,
with an ascending pathway of infection [4].
It often appears between the fourth and the
fth day. Symptoms include high fever, underinvolved uterus, and painful on palpation and
mobilization, with soft consistency and purulent
discharge and a foul smell [2].
Take a Note
Etiology of endometritis: polymicrobial
(Gram positive, negative, anaerobic, and
Mycoplasma). Chlamydia is related to
late endometritis (more than 1 week
postpartum).
Brumm triad: uterus with three charac-
teristics (underinvolved + soft + painful).
The complications of endometritis are related
to the extension of the infectious process to the
pelvic and peritoneal cavities, which include
parametritis, salpingitis, peritonitis, abscess,
necrotizing fasciitis, and septic shock. Pelvic
thrombophlebitis can also be one of the
complications.
The diagnosis can be complemented with an
analytical evaluation, blood cultures, urine culture, and pelvic ultrasound.
The indicated treatment (Table 7.8) [2] is to
carry out IV antibiotics that must be maintained
until at least 48h after the patient becomes apyretic and asymptomatic.
7.6.7.2 Surgical Wound Infections
(Abdominal or Perineal)
Surgical Wound Infections
They usually result from injuries and bruises that
are contaminated by skin microorganisms [2]
(vaginal ora in the case of episiorrhaphy).
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Table 7.8 Antibiotic scheme recommended in
endometritis
Clindamycin 900mg 8/8h EV+Gentamicin
1.5mg/kg 8/8h EV
Or
Ceftriaxone 1g 12/12h EV+Metronidazole
500mg 12/12h EV
+
Azithromycin 500mg/day EV (2days) or doxycycline
100mg 12/12h PO (7days) (suspected Chlamydia
infection and/or late endometritis)
+
Ampicillin 2g 6/6h EV (sepsis or Enterococcus
infection suspected)
After apyrexia and clinical improvement, the patient
can be discharged with amoxicillin + clavulanic acid
875/125mg 12/12h PO, for 10days
In refractory cases, add ampicillin (diagram above)
The infection can occur in the rst month
after delivery and is classied as supercial
(skin and/or subcutaneous tissue involvement)
or deep (involvement of the fasciae and muscle
planes).
The agents involved are B-hemolytic
Streptococcus group A and B, S. aureus, S. epi-
dermidis, E. coli, and Proteus mirabilis [2].
Clinical manifestations can be fever, local
pain, heat, redness, edema, abscess formation,
and drainage of purulent exudate.
The wound should be washed, preferably with
0.9% SF drained, opened, or even debrided in the
presence of foreign or necrotic material.
Treatment involves antibiotics (see Table7.9)
[2]. Whenever possible, collect purulent exudate
for direct and cultural microbiological
examination.
The wound that is complicated by a bruise or
infection may suffer dehiscence. The approach
involves cleaning, drainage, disinfection, and
antibiotics. Second intention healing or need for
resuscitation may be considered.
7.6.7.3 Breast Infections (Mastitis
andBreast Abscess)
Mastitis is an infectious process, acute or chronic,
which can affect breast tissues (skin, subcutaneous, or glandular tissue) [2].
Acute puerperal mastitis is the most common
form of mastitis [2]. Most often, it appears in the
Table 7.9
infections
Supercial infection
Clindamycin 300mg 8/8h PO or cefuroxime 500mg
12/12h PO or amoxicillin + Ac. Clavulanic
875/125mg 12/12h PO
Deep infection
Opening, cleaning, debridement, and antibiotic
therapy
Hospitalization criteria: deep infection,
immunosuppression, diabetes mellitus, severe anemia,
non-patent oral route, inability to comply or
therapeutic failure with the oral regimen, and sepsis
It will be indicated: clindamycin 900mg 8/8h
EV+gentamicin 3–5mg/kg/day EV or amoxicillin +
Ac. Clavulanic 875/125mg 6/6h EV
Apyrexia and clinical improvement, possibility of
discharge with oral antibiotic indicated for supercial
infection
Antibiotic recommended for surgical wound
rst 6weeks postpartum and is caused by saprophytic microorganisms in the skin: S. aureus, S.
epidermidis, B-hemolytic group B Streptococcus
[2, 4].
These microorganisms enter the breast parenchyma from ssures around the nipples, most of
the time resulting from the inadequate grip of the
newborn and/or breast engorgement.
The risk factors described [2, 4] include primiparity, age under 25years, breast engorgement,
nipple ssure, previous episode of mastitis, direct
trauma to the breasts, infant’s rhinopharynx
infection, poor hygiene, and nipple
abnormalities.
The clinical manifestations are fever and other
classic signs of inammation, associated with
breast engorgement and with the possibility of
adenopathies.
The treatment of patients involves the use of
analgesics, antipyretics, adequate breast suspension (suitable bra), frequent and complete breast
emptying, and antibiotic therapy (Table7.10) [2].
For severe infection, culture material should be
collected.
Breastfeeding must be maintained in both
breasts, and the infant must start with the unaffected one. If difcult, emptying should be done
by manual or mechanical expression.
The breast abscess corresponds to a purulent
collection in the breast parenchyma.
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Table 7.10 Recommended treatment for mastitis
Conservative measures (symptomatic relief)
Analgesic/antipyretic
Antipyretics
Local ice
Complete breast emptying at <4-h intervals
Oral antibiotics (10–14days)
Flucloxacillin 500mg 6/6h
Dicloxacillin 500mg 6/6h
Cephalexin 500mg 6/6h
Clindamycin 300mg 6/6h (if allergic to penicillin)
Abscess drainage
If uctuation is present, otherwise adopt previous
measures
It will be indicated: clindamycin 900mg 8/8h
EV+gentamicin 3–5mg/kg/day EV or amoxicillin +
Ac. Clavulanic 875/125mg 6/6h EV
Apyrexia and clinical improvement, possibility of
discharge with oral antibiotic indicated for supercial
infection
The treatment of abscess involves the institution of antibiotics (see Table7.10) and surgical drainage in the presence of uctuation.
Drainage is done using a radial incision and as
far away as possible from the areola in order to
preserve the galactophorous ducts and consequently lactation.
sient, and self-limiting. However, in a small percentage, it can progress to depression. At this
stage, the woman demonstrates liking the newborn and seems motivated to maintain breastfeeding. Psychotherapy is the main weapon in
preventing the evolution of this pathology to
something more serious.
7.6.10 Postpartum Depression
About 10% of women develop symptoms of
depression within 4–8 weeks after delivery [2].
The diagnosis is made according to the DSM-V
criteria.
The main risk factors appear to be a history of
depression or anxiety disorder during pregnancy,
a family history of depression, teenage pregnancy, poor social and family support, and traumatic events during pregnancy [2, 4].
In major depression, there is interference with
personal functioning, that is, the woman becomes
unable to carry out her usual tasks.
Five or more of the following symptoms
should be present daily for most of the day for at
least 2weeks [5]:
7.6.8 Postpartum Psychiatric
Disorders
Changes in mood in the puerperium [2, 4] are frequent and of a transitory nature. Psychological
support for women thus becomes extremely
important in this phase, which is known to be
highly vulnerable in order to avoid the negative
consequences of some psychiatric pathologies,
namely postpartum blues, postpartum depression, and psychosis puerperal.
7.6.9 Postpartum Blues
Postpartum blues affect about 60% of women
depending on the criteria used, appear in the rst
10days after delivery, and are characterized by
depressed mood, emotional lability, easy crying,
insomnia, and irritability [2]. In contrast to
depression, it appears to be more benign, tran-
1. At least one symptom is either depressed
mood or anhedonia
2. Changes in appetite or weight
3. Insomnia or hypersomnia
4. Psychomotor agitation or retardation
5. Fatigue or loss of energy
6. Feeling of guilt or worthlessness
7. Difculty with thinking, concentration, or
making decisions
8. Suicidal ideation or suicidal attempts
In women with a history of postpartum depression, there is a 25% risk of recurrence in subsequent pregnancy.
7.6.11 Postpartum Psychosis
This is a serious delusional condition, often
accompanied by hallucinatory activity in the second to third months of puerperium [2].
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F. Cordeiro and M. Gomes-Ferreira
Table 7.11
Risk Very low Low High
Antidepressants Sertraline, paroxetine, duloxetine, citalopram,
Benzodiazepines Lorazepam
Mood stabilizers Carbamazepine
Antiepileptics Carbamazepine
Antipsychotics Quetiapine
APILAM (Association for the Promotion of and Scientic and Cultural Research into Breastfeeding) [6]
symptoms present in major depression. In the disease phase itself, delusional thinking arises, almost
always dominated by the belief that the child has a
malformation or is dead, or that they are not married and that the newborn does not belong to them
[2, 5]. Hallucinations, predominantly visual and
auditory, are also present in 25% [2].
as well as the child, hospitalization is often indicated. It is considered a psychiatric emergency, in
which treatment with antidepressants and eventually antipsychotics should be started.
Psychotherapy has its role essentially after the
Drugs and their risk of excretion in breast milk
escitalopram, venlafaxine mirtazapine,
uvoxamine nortriptyline
Midazolam
Oxazepam
Valproate
Valproate
Risperidone
Olanzapine
Paliperidone
The prodrome includes previously described
In this pathology, due to the risk for the mother
Fluoxetine,
bupropion
Diazepam
Alprazolam
Clonazepam
Triazolam
Estazolam
Flumazenil
Lamotrigine
Asenapine
Lamotrigine
Haloperidol
Droperidol
Promethazine
Chlorpromazine
Aripiprazole
Asenapine
Reboxetine
Bromazepam
Flurazepam
Lithium
Ziprasidone
and functional impact, and the patient’s preference. Among the various treatment options, we
have cognitive behavioral therapy, interpersonal
therapy, and pharmacological therapy [4].
The main concerns with pharmacological
treatment are related to the possibility of drugs
and/or their metabolites being excreted in breast
milk and thus having consequences in the newborn. In addition to the possibility of inducing
short-term toxicity, they can also have an effect
on neurodevelopment.
Table 7.11 lists the drugs and their risk of
excretion in breast milk, so that a safer choice can
be made.
acute phase and is directed to the conict areas
identied in the assessment.
Regarding the prognosis, it is known that
7.7 Neuropathy
women who present this clinical picture have a
higher risk of developing depression and bipolar
affective disorder [5].
It affects about 1% of postpartum women [2].
The most frequent condition is mononeuropathy, and the nerves frequently affected are the
femoral skin, femoral nerve, peroneal nerve,
7.6.12 Treatment ofPsychiatric
Disorders
lumbosacral plexus, sciatic nerve, and obturator
nerve [2]. Nerve damage occurs by compression,
stretching, transection, or vascular injury.
The choice of treatment will depend on several
factors, including history of psychiatric illness,
singularity of the symptoms and signs, severity
Neuropathic symptoms rarely occur following
neuraxial anesthesia, as in hematoma or epidural
abscess.
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