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<h1>Normal and Abnormal Puerperium</h1>
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Updated: Jul 22, 2016
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 Author: Christine Kansky, MD; Chief Editor: Christine
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Overview
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<h2>Overview</h2>
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<p>Puerperium is defined as the time from the delivery of the placenta
through the first few weeks after the delivery. This period is usually considered
to be 6 weeks in duration. By 6 weeks after delivery, most of the changes of
pregnancy, labor, and delivery have resolved and the body has reverted to the
nonpregnant state.</p>
<p>An overview of the relevant anatomy and physiology in the postpartum
period follows.</p>
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<h3>Uterus</h3>
<p>The pregnant term uterus (not including baby, placenta, fluids, etc)
weighs approximately 1000 g. In the 6 weeks following delivery, the uterus recedes
to a weight of 50-100 g.</p>
<p>Immediately postpartum, the uterine fundus is palpable at or near the
level of the maternal umbilicus. Thereafter, most of the reduction in size and
weight occurs in the first 2 weeks, at which time the uterus has shrunk enough to
return to the true pelvis. Over the next several weeks, the uterus slowly returns
to its nonpregnant state, although the overall uterine size remains larger than
prior to gestation.</p>
<p>The endometrial lining rapidly regenerates, so that by the seventh day
endometrial glands are already evident. By the 16th day, the endometrium is
restored throughout the uterus, except at the placental site.</p>
<p>The placental site undergoes a series of changes in the postpartum
period. Immediately after delivery, the contractions of the arterial smooth muscle
and compression of the vessels by contraction of the myometrium ("physiologic
ligatures") result in hemostasis. The size of the placental bed decreases by half,
and the changes in the placental bed result in the quantity and quality of the
lochia that is experienced.</p>
<p>Immediately after delivery, a large amount of red blood flows from the
uterus until the contraction phase occurs. Thereafter, the volume of vaginal
discharge (lochia) rapidly decreases. The duration of this discharge, known as
lochia rubra, is variable. The red discharge progressively changes to brownish red,
with a more watery consistency (lochia serosa). Over a period of weeks, the
discharge continues to decrease in amount and color and eventually changes to
yellow (lochia alba).<sup>
 [<a
onclick="showToolTip(this,'references-layer','1')"
href="javascript:void(0);">1</a>] </sup>The period of time the lochia can last
varies, although it averages approximately 5 weeks.<sup>
href="javascript:void(0);">2</a>] </sup></p>
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<p>The amount of flow and color of the lochia can vary considerably. Fifteen
percent of women have continue to have lochia 6 weeks or more postpartum. Often,
women experience an increase in the amount of bleeding at 7-14 days secondary to
the sloughing of the eschar on the placental site. This is the classic time for
delayed postpartum hemorrhages to occur.</p>
<h3>Cervix</h3>
<p>The cervix also begins to rapidly revert to a nonpregnant state, but it
never returns to the nulliparous state. By the end of the first week, the external
os closes such that a finger cannot be easily introduced.</p>
<h3>Vagina</h3>
<p>The vagina also regresses but it does not completely return to its
prepregnant size. Resolution of the increased vascularity and edema occurs by 3
weeks, and the rugae of the vagina begin to reappear in women who are not
breastfeeding. At this time, the vaginal epithelium appears atrophic on smear. This
is restored by weeks 6-10; however, it is further delayed in breastfeeding mothers
because of persistently decreased estrogen levels.</p>
<h3>Perineum</h3>
<p>The perineum has been stretched and traumatized, and sometimes torn or
cut, during the process of labor and delivery. The swollen and engorged vulva
rapidly resolves within 1-2 weeks. Most of the muscle tone is regained by 6 weeks,
with more improvement over the following few months. The muscle tone may or may not
return to normal, depending on the extent of injury to muscle, nerve, and
connecting tissues.</p>
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<h3>Abdominal wall</h3>
<p>The abdominal wall remains soft and poorly toned for many weeks. The
return to a prepregnant state depends greatly on maternal exercise.</p>
<h3>Ovaries</h3>
<p>The resumption of normal function by the ovaries is highly variable and
is greatly influenced by breastfeeding the infant. The woman who breastfeeds her
infant has a longer period of amenorrhea and anovulation than the mother who
chooses to use formula. The mother who does not breastfeed may ovulate as early as
27 days after delivery. Most women have a menstrual period by 12 weeks; the mean
time to first menses is 7-9 weeks.</p>
<p>In the breastfeeding woman, the resumption of menses is highly variable
and depends on a number of factors, including how much and how often the baby is
fed and whether the baby's food is supplemented with formula. The delay in the
return to normal ovarian function in the lactating mother is caused by the
suppression of ovulation due to the elevation in prolactin. Half to three fourths
of women who breastfeed return to periods within 36 weeks of delivery.</p>
<h3>Breasts</h3>
<p>The changes to the breasts that prepare the body for breastfeeding occur
throughout pregnancy. Lactogenesis, which is the development of the ability to
secrete milk, occurs as early as 16 weeks gestation. The placenta supplies high
levels of circulating progesterone which activates mature alveolar cells in the
breast to secrete small amounts of milk. After delivery of the placenta, there is a
rapid decline in progesterone which triggers the onset of milk production and
subsequent swelling, or engorgement, of breasts in the postpartum period. The
colostrum is the liquid that is initially released by the breasts during the first
2-4 days after delivery. High in protein content and antibody rich, this liquid is
protective for the newborn. The colostrum, which the baby receives in the first few
days postpartum, is already present in the breasts, and suckling by the newborn
triggers its release. The process, which begins as an endocrine process, switches
to an autocrine process; the removal of milk from the breast stimulates more milk
production. Over the first 7 days, the milk matures and contains all necessary
nutrients in the neonatal period. The milk continues to change throughout the
period of breastfeeding to meet the changing nutritional demands of the baby.</p>
<p>Lactation is the process of continued secretion of copious milk.
Lactation requires regular removal of milk (ie breast emptying) which triggers
prolactin release from the anterior pituitary gland. It also requires nipple
stimulation (ie suckling) which triggers oxytocin from the posterior pituitary
gland. Oxytocin release after tactile stimulation of the nipple-areolar
complex causes myoepithelial cells of the breasts to contract, which forces milk
into the alveolar lumens and then into the ducts, prior to moving out through
the nipple. If the mother is not breastfeeding, the absence of milk removal leads
to elevated intramammary pressure as the milk accumulates within the alveolar
lumen. Alveolar distention restricts blood flow to the alveoli and interferes
with milk production. Additionally, the increase in pressure triggers an inhibitor
of lactation (FIL) which decreases prolactin levels and triggers mammary involution
within 2-3 weeks.</p>
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<h2>Routine Postpartum Care</h2>
<p>The immediate postpartum period most often occurs in the hospital
setting, where the majority of women remain for approximately 2 days after a
vaginal delivery and 3-4 days after a cesarean delivery. During this time, women
are recovering from their delivery and are beginning to care for the newborn. This
period is used to make sure the mother is stable and to educate her in the care of
her baby (especially the first-time mother). While still in the hospital, the
mother is monitored for blood loss, signs of infection, abnormal blood pressure,
contraction of the uterus, and ability to void. There is also attention to Rh
compatibility, maternal immunization statuses and breastfeeding.</p>
<h3>Vaginal delivery</h3>
<p>After a vaginal delivery, most women experience swelling of the perineum
and consequent pain. This is intensified if the woman has had an episiotomy or a
laceration. Routine care of this area includes ice applied to the perineum to
reduce the swelling and to help with pain relief. Conventional treatment is to use
ice for the first 24 hours after delivery and then switch to warm sitz baths.
However, little evidence supports this method over other methods of postpartum
perineum treatment. Pain medications are helpful both systemically as nonsteroidal
anti-inflammatory drugs (NSAIDs) or narcotics and as local anesthetic spray to the
perineum.</p>
<p>Hemorrhoids are another postpartum issue likely to affect women who have
vaginal deliveries. Symptomatic relief is the best treatment during this immediate
postpartum period because hemorrhoids often resolve as the perineum recovers. This
can be achieved by the use of corticosteroid creams, witch hazel compresses, and
local anesthetics in addition to a bowel regimen that avoids constipation.</p>
<p>Tampon use can be resumed when the patient is comfortable inserting the
tampon and can maintain it without discomfort. This often takes longer for the
woman who has had an episiotomy or a laceration than for one who has not. The
vagina and perineum should first be fully healed, which takes several weeks.
Tampons must be changed frequently to prevent infection.</p>
<h3>Cesarean delivery</h3>
<p>The woman who has had a cesarean delivery understandably will experience
post-op pain at the abdominal incision. This, too, can be treated with heat or ice
to the incision site, abdominal binder support, and use of systemic pain
medication. Activities of daily living should be resumed as tolerated but without
unnecessary delay.</p>
<h3>Sexual intercourse</h3>
<p>Sexual intercourse may resume when bright red bleeding ceases, the vagina
and vulva are healed, and the woman is physically comfortable and emotionally
ready. Physical readiness varies greatly among women but may take several weeks.
Birth control is important to protect against pregnancy because the first ovulation
is very unpredictable.</p>
<h3>Patient education</h3>
<p>Substantial education takes place during the hospital stay, especially
for the first-time mother. The mother (and often the father) is taught routine care
of the baby, including feeding, diapering, and bathing, as well as what can be
expected from the baby in terms of sleep, urination, bowel movements, and
eating.</p>
<p>Providing education, support, and guidance to the breastfeeding mother is
especially important during this time. Multiple international and national
government health agencies including The World Health Organization (WHO), the
American Academy of Pediatrics (AAP), the American College of Obstetricians and
Gynecologists (ACOG), and the United States Preventive Services Task Force
recommend exclusive breastfeeding for the first six months of life. In 1991 The
World Health Organization (WHO) and the United Nations Children�s Fund (UNICEF)
launched a global program called The Baby-Friendly Hospital Initiation (BFHI) that
aims to increase the numbers of infants who are exclusively breastfed worldwide.
The BFHI program developed �Ten Steps to Successful Breastfeeding� which are
evidence-based practices which are recommended for health care facilities to
implement in an effort to protect, promote, and support breastfeeding. More than
152 countries now qualify as �Baby-Friendly� by the standards set forth under the
BFHI protocol which can be found at the WHO Baby-friendly Hospital Initiative
website<sup>
href="javascript:void(0);">3</a>] </sup>:
http://www.who.int/nutrition/topics/bfhi/en/. </p>
<p>Breastfeeding is neither easy nor automatic. It requires much effort on
the part of the mother and her support team. Breastfeeding should be initiated as
soon after delivery as possible; in a normal, uncomplicated vaginal delivery
breastfeeding is possible almost immediately after birth. Encourage the mother to
feed the baby every 2-3 hours (at least while she is awake during the day) to
stimulate milk production. Long feedings are unnecessary, but they should be
frequent. Milk production should be well established by 36-96 hours. Lactation
consultants have special training in breast feeding support and are an important
resource for new mothers.</p>
<p>In women who choose not to breastfeed, the care of the breasts is quite
different. Care should be taken not to stimulate the breasts in any way in order to
prevent milk production. Ice packs applied to the breasts and the use of a tight
brassiere or a binder can also help to prevent breast engorgement. Acetaminophen or
NSAIDs can alleviate the symptoms of breast engorgement (eg, tenderness, swelling,
fever) if it occurs. Bromocriptine was formerly administered to suppress milk
production; however, its use has diminished because it requires 2 weeks of
administration, does not always work, and can produce adverse reactions.</p>
<p>For excellent patient education resources, visit eMedicineHealth's <a
href="http://www.emedicinehealth.com/collections/CO1602.asp"
target="_blank">Pregnancy Center</a>. Also, see eMedicineHealth's patient education
articles <a href="http://www.emedicinehealth.com/Articles/18320-1.asp"
target="_blank">Postpartum Perineal Care</a>, <a
href="http://www.emedicinehealth.com/articles/39063-1.asp" target="_blank">Birth
Control Methods</a>, <a href="http://www.emedicinehealth.com/articles/35411-1.asp"
target="_blank">Birth Control Overview</a>, <a
href="http://www.emedicinehealth.com/articles/37658-1.asp" target="_blank">Birth
Control Spermicides</a>, and <a
href="http://www.emedicinehealth.com/articles/12156-1.asp"
target="_blank">Breastfeeding</a>.</p>
<h3>Discharge instructions</h3>
<p>The new mother should be given discharge instructions and
expectations/precautions to consider once leaving the hospital. The most important
information is who and where to call if she has problems or questions. She also
needs details about resuming her normal activity. Instructions vary, depending on
whether the mother has had a vaginal or a cesarean delivery and any comorbidities
that may have been part of her care.</p>
<p>The woman who has had a vaginal delivery may resume all physical
activity, including using stairs, riding or driving in a car, and performing
muscle-toning exercises, as long as she experiences no limiting pain or discomfort.
The key counseling is to progressively resume normal activity while being mindful
of the common fatigue and exhaustion experienced while caring for a newborn.
Pregnancy, labor, delivery, and care of the newborn are strenuous and stressful,
and the mother needs sufficient rest to recover. The woman who has had a cesarean
delivery must be more careful about resuming some of her activities in the
postoperative period. She must avoid overuse of her abdomen until her incision is
well healed in order to prevent an early surgical complications. Women are
typically scheduled for a routine comprehensive postpartum evaluation between 4 to
6 weeks after delivery. Earlier postpartum follow-up is recommended in women at
high risk of postpartum complications who require problem-oriented visits for
closer management of hypertensive issues, postpartum depression, wound infections,
lactation difficulties, or comorbidities that require postpartum medication changes
(i.e. seizure disorder, diabetes).<sup>
href="javascript:void(0);">4</a>] </sup>The postpartum visit is also an important
time to identify the patient�s primary care provider and communicate any
recommendations for follow-up on ongoing medical problems or pregnancy-related
issues. This better facilitates the patient�s transfer of care and helps optimize
maternal health during the interconception period.</p>
<p>Unfortunately, there is a poor attendance rate at scheduled postpartum
visits, with approximately 40% of individuals missing their follow-up appointment.
Several strategies for increasing attendance include discussing the importance of
this visit during prenatal care, scheduling postpartum visits before hospital
discharge, using technology to send reminders to patients about their
appointment.<sup>
<p>A comprehensive postpartum visit includes evaluation of the patient�s
physical and psychological well-being, review of vaccination history, review of
cervical cancer screening history, and discussion about future fertility desires
with appropriate contraception counseling. Depression screening is recommended at
least once during the perinatal period with a validated instrument, such as the
Edinburgh Postnatal Depression Scale.<sup>
href="javascript:void(0);">4</a>, <a onclick="showToolTip(this,'references-
layer','5')" href="javascript:void(0);">5</a>] </sup> The Edinburgh Postnatal
Depression scale is a 10-item self-report questionnaire that includes symptoms of
both anxiety and depression with exclusion of constitutional symptoms of mood
disorders (i.e. change in sleep and eating patterns) that tend to be common in the
postpartum period. It is recommended that providers who screen for depression have
resources to initiate treatment and provide resources for those who screen positive
for postpartum depression.</p>
<p>For women with gestational diabetes, the postpartum period is an
important time to screen for impaired glucose tolerance or Diabetes Mellitus Type
2. The Fifth International Workshop on Gestational Diabetes Mellitus
recommends that women with GDM undergo a 75-g, 2 hour oral glucose tolerance test
between 6-12 weeks <em>postpartum.</em><sup>
href="javascript:void(0);">6</a>] </sup><em> </em>Approximately one third of
women with GDM will have diabetes or impaired glucose metabolism at postpartum
screening. These individuals should be appropriately counselled on lifestyle
interventions or medical management options (i.e. metformin, insulin) to optimize
their glycemic control. Those who have a normal postpartum glucose tolerance test
should be appropriately counselled that there is still a 7 fold risk of developing
type 2 diabetes later in life and up to 50% of women with GDM will develop diabetes
over 20 years after her pregnancy.<sup>
href="javascript:void(0);">6</a>] </sup> Therefore the American Diabetes
Association (ADA) recommends patients with GDM and normal results of postpartum
screening have repeat testing every 3 years because of the increased risk of
developing diabetes in the future.<sup>
<p> Contraception options should be discussed before the mother leaves
the hospital. Although she may not be ready to decide about which method to
initiate, she should be educated about the options that are safe based on any
medical comorbidities and consistent with her future fertility desires. It is
important to initiate contraception during the postpartum period to prevent
unintended pregnancy and reduce the risks associated with pregnancies of short
birth intervals; specifically, when the interconception interval is less than 6
months there is a greater incidence of subsequent pregnancies with low birth weight
and preterm birth.<sup>
<p>A systemic review of ovulation and menses in nonlactating women found
that although most women begin ovulation at least 6 weeks postpartum, with mean day
of first ovulation occurring 45-94 days postpartum, a limited number ovulate
sooner.<sup>
href="javascript:void(0);">8</a>] </sup>Two studies reporting earliest day of first
ovulation reported it occurring on days 25 and 27 postpartum, emphasizing the need
for early postpartum contraception discussion and method initiation to decrease the
risk of pregnancy soon after delivery.</p>
<p>Many options are available, as follows:</p>

<ul>

<li>
<div class="topbullet">
<p>Natural methods can be used in highly motivated couples, to include
the use of monitoring the basal body temperature and the quality and quantity of
the cervical mucus to determine what phase of the menstrual cycle the woman is in
and if it is safe to have intercourse.</p>
</div></li>

<li>
<p>Barrier methods of contraception, such as condoms, are widely
available, as are vaginal spermicides. Condoms are available over-the-counter,
while diaphragms and cervical caps must be fitted.</p>
</div></li>

<li>
<p>Hormonal methods of contraception are numerous. Combined estrogen-
progestin agents are taken daily by mouth or monthly by injection. Progestin-only
agents are available for daily intake or by long-acting injections that are
effective for 12 weeks.</p>
</div></li>

<li>
<p>Intrauterine devices can be placed immediately post partum (after
delivery of the placenta) or after uterine involution occurs typically 4-6 weeks
after delivery. Immediate postpartum insertion is associated with an increased risk
of expulsion, approximately 24%. Immediate insertion is contraindicated in those
with any postpartum infection including peripartum chorioamnionitis, endometritis
or puerperal sepsis.<sup>
</div></li>

<li>
<p>Permanent methods of birth control (ie, tubal ligation, vasectomy) are
options for those who are certain they do not desire more children.</p>
<p>The CDC has published �The United Stated Medical Eligibility Criteria
for Contraceptive Use (US MEC)� which are evidence-based guidelines that assist
health care providers in recommending a safe of contraceptive method for an
individual based on medical comorbidities<em><a
href="https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5904a1.htm?s_cid=rr5904a1_w"
target="_blank">.</a></em><sup>
href="javascript:void(0);">10</a>] </sup>Recommendations are provided using a 4-
point categorical grading system which takes into account an individual�s risks of
using certain contraceptive agents depending on their medical comorbidities.
Specifically, �category 1� identifies a contraception that is safe for use in a
patient without restriction versus a �category 4� designation which represents an
unacceptable health risk to an individual and should therefore be avoided based on
their medical history.</p>
<p>The US MEC should be utilized for patients in the postpartum period in
order to select the safest contraception option at time of discharge from delivery.
The risk for a venous thromboembolism, or a blood clot, is highest among women in
the first 21 days postpartum. and declines gradually until returning to a woman�s
baseline risk at around 42 days postpartum.<sup>
href="javascript:void(0);">11</a>] </sup>Therefore, in women who are less than 21
days postpartum, combined hormonal contraceptives are a category 4 option and not
recommended due to the unacceptable health risk in immediate postpartum patients.
After that time, combined hormonal contraceptives may be considered without
restriction based on an individual�s nursing method and/or other medical risk
factors for complications. Among women who are breastfeeding within the first
postpartum month, combined hormonal contraception is considered a category 3 option
because of possible association on breastfeeding duration and success.
Alternatively, progestin-only hormonal methods such as the minipill, depo
medroxyprogesterone acetate injections, intrauterine device and Nexplanon implant
can be safely initiated immediately postpartum even in those women who are
breastfeeding (category 1 and 2).</p>
</div></li>
</ul>
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<h2>Hemorrhage</h2>
<p>Postpartum hemorrhage is defined as excessive blood loss during or after
the third stage of labor. The average blood loss is 500 mL at vaginal delivery and
1000 mL at cesarean delivery. Since diagnosis is based on subjective observation,
it is difficult to define clinically.</p>
<p>Objectively, postpartum hemorrhage is defined as a 10% change in
hematocrit level between admission and the postpartum period or the need for
transfusion after delivery secondary to blood loss.<sup>
<p>Early postpartum hemorrhage is described as that occurring within the
first 24 hours after delivery. Late postpartum hemorrhage most frequently occurs 1-
2 weeks after delivery but may occur up to 6 weeks postpartum.</p>
<h3>Etiology</h3>
<p>Early postpartum hemorrhage may result from uterine atony, retained
products of conception, uterine rupture, uterine inversion, placenta accreta, lower
genital tract lacerations, coagulopathy, and hematoma. Causes of late postpartum
hemorrhage most commonly include retained products of conception, infection,
subinvolution of placental site, and coagulopathy.</p>
<p>Uterine atony and lower genital tract lacerations are the most common
causes of postpartum hemorrhage. Factors predisposing to uterine atony include
overdistension of the uterus secondary to multiple gestations, polyhydramnios,
macrosomia, rapid or prolonged labor, grand multiparity, oxytocin administration,
intra-amniotic infection, and use of uterine-relaxing agents such as terbutaline,
magnesium sulfate, halogenated anesthetics, or nitroglycerin. In uterine atony,
lack of closure of the spiral arteries and venous sinuses coupled with the
increased blood flow to the pregnant uterus causes excessive bleeding.</p>
<p>Active management of the third stage of labor with administration of
uterotonics before the placenta is delivered (oxytocin still being the agent of
choice), early clamping and cutting of the umbilical cord, and traction on the
umbilical cord have proven to reduce blood loss and decrease the rate of postpartum
hemorrhage.</p>
<p>Lower genital tract lacerations, including cervical and vaginal
lacerations (eg, sulcal tears), are the result of obstetrical trauma and are more
common with operative vaginal deliveries, such as with forceps or vacuum
extraction. Other predisposing factors include macrosomia, precipitous delivery,
and episiotomy.</p>
<h3>Incidence</h3>
<p>Vaginal delivery is associated with a 3.9% incidence of postpartum
hemorrhage.<sup>
href="javascript:void(0);">12</a>] </sup>Cesarean delivery is associated with a
6.4% incidence of postpartum hemorrhage. Delayed postpartum hemorrhage occurs in 1-
2% of patients.</p>
<h3>Morbidity and mortality</h3>
<p>In the United States, postpartum hemorrhage is responsible for 5% of
maternal deaths. Other morbidities associated with hemorrhage include the need for
blood transfusions and/or subsequent surgical interventions that may lead to future
infertility.</p>
<h3>History</h3>
<p>The antepartum or early intrapartum identification of risk factors for
postpartum hemorrhage allows for advanced preparation and possible avoidance of
severe sequelae.</p>
<p>Every patient must be interviewed upon admission to the labor floor.
Request information about parity, multiple gestation, polyhydramnios, previous
episodes of postpartum hemorrhage, history of bleeding disorders, and desire for
future fertility.</p>
<p>Note the use of prolonged oxytocin administration, as well as the use of
magnesium sulfate during the patient's labor course.</p>
<p>Simulation training for postpartum hemorrhage management and standardized
management protocols (including massive transfusion protocols) are now part of many
resident training and hospital safety programs.</p>
<h3>Physical</h3>
<p>Patients with postpartum vaginal bleeding that is persistent or greater
than anticipated should be urgently evaluated in order to identify the etiology of
bleeding and facilitate appropriate interventions. This can be done simultaneously
with initiation of any resuscitative measures in order to maintain hemodynamic
stability. Additional personnel should be called to bedside in order to facilitate
urgent evaluation of a patient with inappropriate postpartum bleeding. Initial
assessment should include review of vital signs with careful note of any signs of
hypovolemia including tachycardia, hypotension, tachypnea, low oxygen saturation,
and oliguria. A thorough physical exam including abdominal exam (incision check and
uterine tone), vaginal exam, and rectal examination should be performed to localize
any laceration that is the source of bleeding. It is important to obtain IV access
in any patient with concerning bleeding or unstable vital signs. Preferably a
patient will have two large bore catheters in this situation to aid in the
administration of blood products, fluids, and medications. Supplemental
oxygenation by a high-flow face mask (10 to 15 liters/minute) improves oxygen-
carrying capacity and delivery. The anesthesiology team should also be aware
of any patient with a postpartum hemorrhage to better assess the patient�s airway,
breathing, and indication for intubation.</p>
<h3>Workup</h3>
<p>It is important to check a hemorrhaging patient's complete blood count
and coagulation studies (fibrinogen, prothrombin time/activated partial
thromboplastin time) to exclude resulting anemia or coagulopathy, which may require
further treatment with blood products. It is also important that any patient
admitted to the labor and delivery unit have an active blood sample (type and
screen) available if the need for urgent transfusion arises. A �clot
observation test� has been used to detect coagulation problems prior to the
return of laboratory studies; specifically 5 mL of blood is observed in a red top
tube. If clotting occurs within 8-10 minutes and the clot remains intact, the
patients fibrinogen stores are likely adequate and functioning. When a patient
requires multiple units of blood products, electrolytes should also be monitored
serially with immediate treatment of any abnormalities. Hyperkalemia and low levels
of ionized calcium are the most common electrolyte disturbances; if untreated the
patient is at risk for depressed cardiac function and possible cardiac arrest.
A multidisciplinary team approach involving intensive care specialists is
often required for patient management in severe cases.</p>
<h3>Treatment</h3>
<p>Initial therapy may include supplemental oxygenation, identification and
repair of obstetric lacerations, bimanual uterine massage for atony, manual sweep
to remove any retained products of conception or blood clots from the uterus, and
administration of uterotonic agents. Ultrasonography can aid in identifying
retained products prior to bimanual exam especially in the patient without regional
anesthesia. If retained products of conception are noted despite manual removal, a
uterine curettage may be necessary to control hemorrhage.</p>
<p>The most common cause of immediate postpartum hemorrhage is atony;
therefore uterotonic agents should be readily available for quick access and prompt
administration in order to control bleeding. Dilute oxytocin infusion (10-40U in
1000mL of lactated ringer solution [LRS] or isotonic sodium chloride solution) is
an effective uterotonic agent for both prevention and treatment of a postpartum
hemorrhage. Routine postpartum administration of oxytocin is recommended as a key
measure in active management of the third stage of labor to reduce the average risk
of maternal hemorrhage at birth and possibly shorten the third stage of labor.<sup>
href="javascript:void(0);">13</a>] </sup>The rate of oxytocin administration can be
increased to correct uterine atony however rapid infusion of high-dose oxytocin can
be associated with significant risk of cardiovascular collapse. If IV access is not
obtained, 10 units of oxytocin is appropriate. Additionally, if poor uterine tone
is noted at time of cesarean section, 10 unites of intrauterine oxytocin may be
administered directly into the myometrium.</p>
<p>If uterine atony persists, alternative uterotonic agents should be
considered. These include methylergonovine (ie Methergine), carboprost tromethamine
(15 methyl-PG2alpha, Hemabate), or misoprostol (PGE1). Carboprost tromethamine
(methylergonovine) is administered as an injection of 250mcg in 20mL normal saline
intramuscularly; it may be administered at least 15 minutes apart for eight total
doses. Methylergonovine 0.2mg is administered intramuscularly every two to four
hours. It is important to consider contraindications to certain uterotonics when
using pharmacotherapy to control bleeding. For example, carboprost
tromethamine should not be given to individuals with asthma and methylergonovine is
contraindicated in hypertension.</p>
<p>Misoprostol may be administered sublingually, orally, or rectally for
postpartum hemorrhage treatment. Vaginal administration in the setting of
postpartum hemorrhage is not recommended due to impaired absorption. The optimum
dose depends on route of misoprostol administration because of varying rates of
absorption and time to peak concentration. Although misoprostol is a less effective
than the injectable uterotonics for postpartum hemorrhage treatment, it is commonly
used in low resource settings because of its widespread availability, low cost,
ease of storage (i.e. heat stable) and ease of administration.<sup>
href="javascript:void(0);">14</a>] </sup>The 2010 Monte Carlo study reported 70%
reduction in mortality among 10,000 women delivering at home in rural India with a
$6 incremental cost per disability-adjusted life year (DALY).<sup>

<ul>

<li>
If postpartum bleeding secondary to atony is not responsive to
pharmacologic therapy, additional interventions should be considered such as
uterine tamponade. Uterine tamponade, which is an effective intervention for
postpartum hemorrhage related to atony or bleeding of the lower uterine segment,
can be achieved by several means:

<ul class="topbullet-para">

<li>Uterine packing is now considered safe and effective therapy for the
treatment of postpartum hemorrhage.<sup>
href="javascript:void(0);">16</a>] </sup>Gauze soaked with 5,000 units of thrombin
in 5mL of sterile saline is carefully but firmly packed in the uterine cavity using
a sponge stick to achieve tamponade. Use prophylactic broad spectrum antibiotics
and concomitant oxytocin with this technique. The timing of removal of the
packing is controversial, but most physicians favor 24-36 hours. This treatment is
successful in half of patients. If unsuccessful, it still provides time in which
the patient can be stabilized before other surgical techniques are employed.</li>

<li><p>A Foley catheter with a large bulb (#24 Foley catheter with a 30
mL balloon or a Sengstaken-Blakemore tube) can be used as an alternative to uterine
packing.<sup>
href="javascript:void(0);">17</a>] </sup>.This tamponading technique can be highly
effective, is inexpensive, requires no special training, and may prevent the need
for surgery.</p></li>

<li><p>A Bakri tamponade balloon is a silicone fluid-filled balloon that
may also provide control of uterine bleeding in cases where other interventions
have failed. A deflated silicone balloon is inserted into the uterus and then
filled to a recommended volume of 500cc to allow the balloon to adapt to the
configuration of the uterine cavity.<sup>
href="javascript:void(0);">18</a>] </sup> The Bakri balloon is connected to a
24 French silicone catheter which allows drainage of the uterine cavity for
measurement of ongoing bleeding. Maximum intrauterine time is 24 hours but it may
be removed prior to this time.</p></li>

<li><p>Uterine artery embolization, which is performed under local
anesthesia, is a minimally invasive technique performed by trained interventional
radiologists.<sup>
href="javascript:void(0);">19</a>] </sup>The success rate is greater than 90%.<sup>
href="javascript:void(0);">20</a>] </sup>This procedure is believed to preserve
fertility.<sup>
layer','19')" href="javascript:void(0);">19</a>] </sup>Complications are low (6-7%)
and include fever, infection, and nontarget embolization. In patients at high risk
for postpartum hemorrhage, such as those with placenta previa, placenta accreta,
coagulopathy, or cervical pregnancy, the catheter can be placed prophylactically
prior to delivery.<sup>
href="javascript:void(0);">20</a>] </sup></p></li>

<li><p>The B-Lynch suture technique<sup>
href="javascript:void(0);">21</a>] </sup>: A suture is passed through the anterior
uterine wall in the lower uterine segment approximately 3 cm medial to the lateral
edge of the uterus. The suture is wrapped over the fundus 3�4 cm medial to the
cornual and inserted into the posterior uterine wall again in the lower uterine
segment approximately 3 cm medial to the lateral edge of the uterus and brought out
3 cm medial to the other edge of the uterus. The suture is wrapped over the fundus
and directed into and out of the anterior uterine wall parallel to the previous
anterior sutures. The uterus is compressed in an accordion-like fashion and the
suture is tied across the lower uterine segment. The B-Lynch suture technique and
other compression suture techniques are operative approaches to postpartum
hemorrhage that have proven to preserve fertility.<sup>
layer','23')" href="javascript:void(0);">23</a>] </sup>As practitioners become
proficient in this technique, it may be considered before uterine artery or
hypogastric artery ligation and hysterectomy.</p></li>
</ul>
</div></li>
</ul>
<p>When conservative therapy fails, the next step is surgery with either
bilateral uterine artery ligation or hypogastric artery ligation. Uterine artery
ligation is thought to be successful in 80-95% of patients. If this therapy fails,
hypogastric artery ligation is an option however most obstetricians have little to
no experience with this technique. This approach is technically difficult and is
only successful in 42-50% of patients.<sup>
href="javascript:void(0);">24</a>] </sup>Instead, stepwise devascularization of the
uterus is now thought to be the next best approach, with possible ligation of the
utero-ovarian and infundibulopelvic vessels.<sup>
<p>When all other therapies fail, emergency hysterectomy is often a
necessary and lifesaving procedure.</p>
<h3>Perineal Lacerations</h3>
<p>Lacerations are a common sequelae of vaginal childbirth due to strain on
the perineum and pelvic floor muscles, with 53-79% of women sustaining some type of
laceration during a vaginal delivery.<sup>
href="javascript:void(0);">26</a>] </sup>Perineal lacerations are distinct from an
episiotomy which is a purposeful surgical incision of the posterior aspect of the
vagina in order to enlarge the perineum for childbirth during the second stage of
labor. An epidemiologic study in 2012 reported approximately 12% of vaginal births
included an episiotomy.<sup>
<p>Perineal tears are classified into four categories depending on the depth
of tissue involvement. First degree lacerations involve superficial injury to the
skin and subcutaneous perineal tissue or vaginal epithelium only. Second degree
lacerations extend into the musculature of the perineal body, including the deep
and superficial transverse perineal muscles, the bulbocavernosus muscle, and the
pubococcygeus muscle. Obstetric anal sphincter injuries (OASIS), which are third
and fourth degree perineal lacerations are considered more severe forms of
obstetric tears. Third degree lacerations extend beyond the muscles and involve the
anal sphincter. There are three subdivisions of a third degree tear depending on
degree of involvement of the external and/or internal anal sphincter. Specifically
less than 50% of the external anal sphincter is torn in a 3A tear. In a 3b tear,
greater than 50% of the external anal sphincter is torn. A 3c tear includes
complete rupture of the external anal sphincter as well as involvement of the
internal anal sphincter. Lastly, a fourth degree laceration is an injury involving
the entire anal sphincter complex as well as the anal epithelium. Any deep perineal
laceration noted after a delivery warrants a thorough evaluation including a
digital rectal exam to improve the diagnosis of OASIS. Approximately 4% of women
have a clinically recognized OASIS immediately after time of vaginal
delivery<em>.</em><sup>
href="javascript:void(0);">26</a>] </sup>Other tears after childbirth include
periclitoral, periurethral, and labial lacerations; these should only be repaired
to achieve hemostasis or to correct distorted anatomy. Additionally, lacerations to
the vulva, vagina, and cervix also occur and should be repaired based on clinical
assessment of bleeding or distorted anatomy.</p>
<p>Those who had an OASIS are at greatest risk of complications from
lacerations including include pain, bleeding and/or hematoma formation, localized
infection (20%), and wound breakdown (25%).<sup>
href="javascript:void(0);">26</a>] </sup>Immediate care of OASIS includes pain
control and avoidance of constipation with a prescribed bowel regimen. These
individuals should have early and consistent follow up in the postpartum period to
evaluate wound healing and any development of anal incontinence. In
individuals with a severe perineal laceration, the absolute risk of OASIS in a
subsequent pregnancy is approximately 3%. Moreover, 67-90% of women with a previous
OASIS have a subsequent vaginal delivery.<sup>
href="javascript:void(0);">26</a>] </sup>It is reasonable to offer a cesarean
delivery in those who sustained an OASIS in the following circumstances: women with
anal incontinence after delivery, women who had further complications including
wound infection or need for repeat laceration repair, women who experienced
psychological trauma due to significant laceration tear at time of delivery.
However, those who desire a cesarean delivery should be appropriately counseled on
the increased morbidity of this mode of delivery compared to a vaginal
delivery.</p>
</div>
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</div>
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</div>
</div>
</div>
<h2>Infections</h2>
<h3>Prevention</h3>
<p>Delivery by cesarean section is the single most important risk factor for
postpartum maternal infection. In the absence of antimicrobial prophylaxis, women
who have a cesarean delivery have a five to 20-fold greater chance of a postpartum
infection compared to those who delivery vaginally<em>.</em><sup>
href="javascript:void(0);">28</a>] </sup>Therefore ACOG recommends the routine
administration of prophylactic antibiotics in women undergoing cesarean
section.<sup>
href="javascript:void(0);">29</a>] </sup>In a large Cochrane review of 95 studies
including over 15,000 women who had cesarean deliveries, there was a 60-70%
reduction in postpartum complications after the use of prophylactic antibiotics
including wound infection and endometritis.<sup>
<p>The American College of Obstetricians and Gynecologist recommend a single
dose of a targeted antibiotic, such as a first-generation cephalosporin, as first-
line antimicrobial prophylaxis in women undergoing a cesarean section due to its
narrow spectrum of activity, efficacy, and low cost<em>.</em><sup>
href="javascript:void(0);">29</a>] </sup><em> </em>Guidelines set forth by
the Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of
America (IDSA), the Surgical Infection Society (SIS), and the Society for
Healthcare Epidemiology of America (SHEA) recommend cefazolin 2 grams for
patients .</i><sup>
<p>In those individuals with a severe allergy to penicillin or cephalosporin
(ie a history of anaphylaxis, angioedema, respiratory distress or urticarial
reaction) a combination of clindamycin (900mg) with an aminoglycoside (ie
gentamicin 5mg/kg IV) is recommended for broad coverage antibiotic
prophylaxis.<sup>
layer','30')" href="javascript:void(0);">30</a>] </sup>The prophylactic agent
should be administered within 60 minutes prior to skin incision to ensure adequate
drug tissue levels; in emergent cases when this is not possible antibiotic
administration should occur as soon as possible after the start of the cesarean
delivery.<sup>
href="javascript:void(0);">29</a>] </sup>Compared to multidose therapy, single-dose
antibiotic administration is preferred because it just as effective with a
reduction in costs, associated toxicity and risk of colonization with resistant
organisms.</p>
<h3>Endometritis</h3>
<p>Endometritis is an ascending polymicrobial infection. The causative
agents are usually normal vaginal flora or enteric bacteria.</p>
<h3>Etiology</h3>
<p>Endometritis is the primary cause of postpartum infection. The most
common organisms are divided into 4 groups: aerobic gram-negative bacilli,
anaerobic gram-negative bacilli, aerobic streptococci, and anaerobic gram-positive
cocci. Specifically, <em>Escherichia coli, Klebsiella pneumoniae,</em> and
<em>Proteus</em> species are the most frequently identified organisms.</p>
<p>Endometritis occurring on postpartum day 1 or 2 most frequently is caused
by group A streptococci. If the infection develops on day 3 or 4, the causative
organism is frequently enteric bacteria, most commonly <em>E coli,</em> or
anaerobic bacteria. Endometritis that develops more than 7 days after delivery is
most frequently caused by <em>Chlamydia trachomatis.</em> Endometritis following
cesarean delivery is most frequently caused by anaerobic gram-negative bacilli,
specifically <em>Bacteroides</em> species.</p>
<p>Known risk factors for endometritis include cesarean delivery, young age,
low socioeconomic status, prolonged labor, prolonged rupture of membranes, multiple
vaginal examinations, placement of an intrauterine catheter, preexisting infection
or colonization of the lower genital tract, twin delivery, and manual removal of
the placenta. It has also been shown that manual removal of the placenta at
cesarean delivery increases the incidence of endometritis.</p>
<h3>Incidence</h3>
<p>Endometritis complicates less than 3% of all vaginal deliveries. Cesarean
delivery is the most important risk factor for development of postpartum
endometritis and therefore significantly increases the risk of endometritis after
delivery, particularly when performed after the onset of labor and without
antibiotic prophylaxis. Among women who receive standard antibiotic prophylaxis
prior a cesarean section delivery in the absence of labor, the frequency of
postpartum endometritis is 1.7%; this increases to 11% in patients have a cesarean
delivery after the onset of labor and 28% in those who do not receive antibiotic
prophylaxis after the onset of labor that resulted in a cesarean section.<sup>
<p>Following 48-72 hours of intravenous antibiotic therapy, 90% of women
clinically improve. Fewer than 2% of patients develop life-threatening
complications such as septic shock, pelvic abscess, or septic pelvic
thrombophlebitis.<sup>
<h3>History</h3>
<p>A patient may report any of the following symptoms: fever, chills, lower
abdominal pain, malodorous lochia, increased vaginal bleeding, anorexia, and
malaise.</p>
<h3>Physical</h3>
<p>A focused physical examination is important and should include vital
signs, an examination of the respiratory system, breasts, abdomen, perineum, and
lower extremities. A patient with endometritis typically has a fever of 38�C or
greater, tachycardia, and fundal tenderness. Some patients may develop mucopurulent
vaginal discharge, whereas others have scant and odorless discharge.</p>
<h3>Differential diagnosis</h3>
<p>See the list below:</p>

<ul>

<li>
<p>Urinary tract infection</p>
</div></li>

<li>
<p>Acute pyelonephritis</p>
</div></li>

<li>
<p>Lower genital tract infection</p>
</div></li>

<li>
<p>Wound infection</p>
</div></li>

<li>
<p>Atelectasis</p>
</div></li>

<li>
<p>Pneumonia</p>
</div></li>

<li>
<p>Thrombophlebitis</p>
</div></li>

<li>
<p>Mastitis</p>
</div></li>

<li>
<p>Appendicitis</p>
</div></li>
</ul>
<h3>Workup</h3>

<ul>

<li>
<p>Laboratory tests: The appropriate tests for a febrile postpartum
patient may include a CBC count with differential, urinalysis, urine culture, and
blood cultures.</p>
</div></li>

<li>
<p>Imaging: If a respiratory process is high on the differential, obtain
a chest radiograph.</p>
</div></li>
</ul>
<h3>Treatment</h3>
<p>Treatment of endometritis is with intravenous antibiotics. Parenteral
antibiotics are usually stopped once the patient is afebrile for 24-48 hours,
tolerating a regular diet, and ambulating without difficulty.<sup>
href="javascript:void(0);">32</a>] </sup>In general, an extended course of oral
antibiotics has not been found to be beneficial,<sup>
href="javascript:void(0);">33</a>] </sup>although 2 exceptions have been noted. In
patients who respond quickly to intravenous antibiotics and who desire early
discharge, a short course of oral antibiotics may be substituted for continued
intravenous therapy. The other exception includes patients with staphylococcal
bacteremia requiring an extended period of treatment.</p>
<p>Broad spectrum coverage with a combination of clindamycin and gentamicin
is a commonly used and highly effective regimen for the treatment of endometritis
with a cure rate of greater than 90%<em>.</em><sup>
href="javascript:void(0);">34</a>] </sup>Clindamycin is typically administered as
900 mg intravenously every eight hours. The most cost efficient and convenient
gentamycin regimen is extended interval dosing of gentamicin with 5mg/kg every 24
hour, however 1.5mg/kg every 8 hours is also an acceptable regimen with equal
efficacy. Gentamicin should be avoided in those with impaired renal function;
instead reasonable alternative regimens include ampicillin-sulbactam (1.5g every 6
hours) or clindamycin and a second-generation cephalosporin. Ampicillin-sulbactam
should also be considered in regions with a significant clindamycin resistant B.
fragilis.<sup>
href="javascript:void(0);">35</a>] </sup>Ampicillin (or vancomycin for patients
with a penicillin allergy) should be considered when the patient does not respond
to the initial therapy of gentamicin and clindamycin to cover Enterococcus
faecalis, which may be the cause of up to 25% of postpartum endometritis
infections.<sup>
href="javascript:void(0);">36</a>] </sup>In a Cochrane review of endometritis
treatment regimens, there were significantly more treatment failure rates in those
treated with a regimen with poor activity against penicillin-resistant anaerobic
bacteria as compared to those treated with a regimen with coverage against
penicillin-resistant anaerobic bacteria with no difference in side effects.<sup>
<h3>Urinary Tract Infections</h3>
<p>A urinary tract infection (UTI) is defined as a bacterial inflammation of
the bladder or urethra. Greater than 105 colony-forming units from a clean-catch
urine specimen or greater than 10,000 colony-forming units on a catheterized
specimen is considered diagnostic of a UTI.</p>
<h3>Etiology</h3>
<p>Risk factors for postpartum UTI include cesarean delivery, forceps
delivery, vacuum delivery, tocolysis, induction of labor, maternal renal disease,
preeclampsia, eclampsia, epidural anesthesia, bladder catheterization, length of
hospital stay, and previous UTI during pregnancy.<sup>
<p>The most common pathogen is <em>E coli.</em><sup>
href="javascript:void(0);">38</a>] </sup>In pregnancy, group B streptococci are a
major pathogen. Other causative organisms include <em>Staphylococcus saprophyticus,
E faecalis, Proteus,</em> and <em>K pneumoniae.</em></p>
<h3>Incidence</h3>
<p>Postpartum bacteruria occurs in 3-34% of patients, resulting in a
symptomatic infection in approximately 2% of these patients.</p>
<h3>History</h3>
<p>A patient may report frequency, urgency, dysuria, hematuria, suprapubic
or lower abdominal pain, or no symptoms at all.</p>
<h3>Physical</h3>
<p>On examination, vital signs are stable and the patient is afebrile.
Suprapubic tenderness may be elicited on abdominal examination.</p>

<ul>

<li>
<p>Acute cystitis</p>
</div></li>

<li>
<p>Acute pyelonephritis</p>
</div></li>
</ul>
<h3>Workup</h3>
<p>Appropriate laboratory tests include urinalysis, urine culture from
either a clean-catch or catheterized specimen, and CBC count.</p>
<h3>Treatment</h3>
<p>Treatment is started empirically in uncomplicated infection because the
usual organisms have predictable susceptibility profiles. When sensitivities are
available, use them to guide antimicrobial selection. Treatment is with a 3- or 7-
day antibiotic regimen.<sup>
href="javascript:void(0);">37</a>] </sup>Commonly used antibiotics include
trimethoprim/sulfamethoxazole, ciprofloxacin, and norfloxacin. Amoxicillin is often
still used, but it has lower cure rates secondary to increasing resistance of <em>E
coli.</em> The quinolones are very effective but are considerably more expensive
than amoxicillin and trimethoprim/sulfamethoxazole and should not be used in
breastfeeding mothers.</p>
<h3>Mastitis</h3>
<p>Mastitis is defined as inflammation of the mammary gland.</p>
<h3>Etiology</h3>
<p>Milk stasis and cracked nipples, which contribute to the influx of skin
flora, are the underlying factors associated with the development of mastitis.
Mastitis is also associated with primiparity, incomplete emptying of the breast,
and improper nursing technique. The most common causative organism, isolated in
approximately half of all cases, is <em>Staphylococcus aureus</em>.<sup>
href="javascript:void(0);">39</a>] </sup>Other common pathogens include
<em>Staphylococcus epidermidis, S saprophyticus, Streptococcus viridans,</em> and
<em>E coli.</em></p>
<h3>Incidence</h3>
<p>In the United States, the incidence of postpartum mastitis is 2.5-
3%.<sup>
layer','39')" href="javascript:void(0);">39</a>] </sup>Mastitis typically develops
during the first 3 months postpartum, with the highest incidence in the first few
weeks after delivery.</p>
<p>Neglected, resistant, or recurrent infections can lead to the development
of an abscess, requiring parenteral antibiotics and surgical drainage. Abscess
development complicates 5-11% of the cases of postpartum mastitis and should be
suspected when antibiotic therapy fails.</p>
<p>The diagnosis of mastitis is solely based on the clinical picture.</p>
<h3>History</h3>
<p>Fever, chills, myalgias, erythema, warmth, swelling, and breast
tenderness characterize this disease.</p>
<h3>Physical</h3>
<p>Focus examination on vital signs, review of systems, and a complete
examination to look for other sources of infection. Typical findings include an
area of the breast that is warm, red, and tender. When the exam reveals a tender,
hard, possibly fluctuant mass with overlying erythema, a breast abscess should be
considered.</p>

<ul>

<li>
<p>Mastitis</p>
</div></li>

<li>
<p>Breast abscess</p>
</div></li>

<li>
<p>Cellulitis</p>
</div></li>
</ul>
<h3>Workup</h3>
<p>No laboratory tests are required. Expressed milk can be sent for
analysis, but the accuracy and reliability of these results are controversial and
aid little in the diagnosis and treatment of mastitis.</p>
<h3>Treatment</h3>
<p>Milk stasis sets the stage for the development of mastitis, which can be
treated with moist heat, massage, fluids, rest, proper positioning of the infant
during nursing, nursing or manual expression of milk, and analgesics.</p>
<p>When mastitis develops, penicillinase-resistant penicillins and
cephalosporins, such as dicloxacillin or cephalexin, are the drugs of choice.
Erythromycin, clindamycin, and vancomycin may be used for infections that are
resistant to penicillin. Resolution usually occurs 48 hours after the onset of
antimicrobial therapy. Lactation efforts should continue and the milk is still safe
for newborn ingestion.</p>
<h3>Wound Infection</h3>
<p>Wound infections in the postpartum period include infections of the
perineum developing at the site of an episiotomy or laceration, as well as
infection of the abdominal incision after a cesarean birth. Wound infections are
diagnosed on the basis of erythema, induration, warmth, tenderness, and purulent
drainage from the incision site, with or without fever. This definition can be
applied both to the perineum and to abdominal incisions.</p>
<h3>Etiology</h3>
<p>Perineal infections: Infections of the perineum are rare. In general,
they become apparent on the third or fourth postpartum day. Known risk factors
include infected lochia, fecal contamination of the wound, and poor hygiene. These
infections are generally polymicrobial, arising from the vaginal flora.</p>
<p>Abdominal wound infections: Abdominal wound infections are most
frequently the result of contamination with vaginal flora. However, <em>S
aureus,</em> either from the skin or from an exogenous source, is isolated in 25%
of these infections.<sup>
href="javascript:void(0);">41</a>] </sup>Genital <em>Mycoplasma</em> species are
commonly isolated from infected wounds that are resistant to treatment with
penicillins.<sup>
href="javascript:void(0);">42</a>] </sup>Known risk factors include diabetes,
hypertension, obesity, treatment with corticosteroids, immunosuppression, anemia,
development of a hematoma, chorioamnionitis, prolonged labor, prolonged rupture of
membranes, prolonged operating time, abdominal twin delivery, and excessive blood
loss.</p>
<h3>Incidence</h3>
<p>The incidence of perineal infections is 0.35-10%. The incidence of
incisional abdominal wound infections is 3-15% and can be decreased to
approximately 2% with the use of prophylactic antibiotics.</p>
<p>The most common consequence of wound infection is increased length of
hospital stay or hospital readmission. About 7% of abdominal wound infections are
further complicated by wound dehiscence. More serious sequelae, such as necrotizing
fasciitis, are rare, but patients with such conditions have a high mortality
rate.</p>
<h3>History</h3>
<p>Patients with perineal infections may complain of an inordinate amount of
pain, malodorous discharge, or vulvar edema.</p>
<p>Abdominal wound infections develop around postoperative day 4 and are
often preceded by endometritis. These patients present with persistent fever
despite antibiotic treatment.</p>
<h3>Physical</h3>
<p>Perineal infections: An infected perineum often looks erythematous and
edematous and may be accompanied by purulent discharge. Perform an inspection to
identify hematoma, perineal abscess, or stitch abscess.</p>
<p>Abdominal wound infections: Infected incisions may be erythematous, warm,
tender, and indurated. Purulent drainage may or may not be obvious. A fluid
collection may be appreciated near the wound, which, when entered, may release
serosanguineous or purulent fluid.</p>
<h3>Workup</h3>
<p>The diagnosis of wound infection is often made based on the clinical
findings. Serial CBC counts with differentials may be helpful, especially if a
patient does not respond to therapy as anticipated. CT imaging of the abdomen may
be indicated if an abscess is suspected after a cesarean delivery.</p>
<h3>Treatment</h3>
<p>Perineal infections: Treatment of perineal infections includes
symptomatic relief with NSAIDs, local anesthetic spray, and sitz baths. Identified
abscesses must be drained, and broad-spectrum antibiotics may be initiated.</p>
<p>Abdominal wound infections: These infections are treated with antibiotics
as well as drainage and inspection of the fascia to ensure that it is intact.
Antibiotics may be used if the patient is afebrile.</p>
<p>Most patients respond quickly to the antibiotic once the wound is
drained. Antibiotics are generally continued until the patient has been afebrile
for 24-48 hours. Patients do not require long-term antibiotics unless cellulitis
has developed. Studies have shown that closed suction drainage or suturing of the
subcutaneous fat decreases the incidence of wound infection when the subcutaneous
tissue is greater than 2 cm in depth.<sup>
layer','44')" href="javascript:void(0);">44</a>] </sup></p>
</div>
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<h2>Septic Pelvic Thrombophlebitis</h2>
<p>Septic pelvic thrombophlebitis is defined as venous inflammation in the
abdomen/pelvis with thrombus formation. It is associated with fevers and is
unresponsive to antibiotic therapy.</p>
<h3>Etiology</h3>
<p>Bacterial infection of the endometrium seeds organisms into the venous
circulation, which damages the vascular endothelium and in turn results in thrombus
formation. The thrombus acts as a suitable medium for proliferation of anaerobic
bacteria. Ovarian veins are often involved because they drain the upper half of the
uterus. When the ovarian veins are involved, the infection is most often
unilateral, involving the right more frequently than the left. Occasionally, the
thrombus has been noted to extend to the vena cava or to the left renal vein.
Ovarian vein involvement usually manifests within a few days postpartum. Disease
with later onset more commonly involves the iliofemoral vein.</p>
<p>Risk factors include low socioeconomic status, cesarean birth, prolonged
rupture of membranes, and excessive blood loss.</p>
<h3>Incidence</h3>
<p>Septic pelvic thrombophlebitis occurs in 1 of every 2000-3000 pregnancies
and is 10 times more common after cesarean birth (1 per 800) than after vaginal
delivery (1 per 9000).<sup>
href="javascript:void(0);">45</a>] </sup>The condition affects less than 1% of
patients with endometritis.</p>
<p>Septic thrombophlebitis may result in the migration of small septic
thrombi into the pulmonary circulation, resulting in effusions, infections, and
abscesses. Only rarely is a thrombus large enough to cause death.</p>
<h3>History</h3>
<p>Septic pelvic thrombophlebitis usually accompanies endometritis. Patients
report an initial improvement after an intravenous antibiotic is initiated for
treatment of the endometritis. The patient does not appear ill. Patients with
ovarian vein thrombosis may describe lower abdominal pain, with or without
radiation to the flank, groin, or upper abdomen. Other symptoms include nausea,
vomiting, and bloating. Frequently, patients with enigmatic fever are asymptomatic
except for chills.</p>
<h3>Physical</h3>
<p>Vital signs demonstrate fever greater than 38�C and resting tachycardia.
If pulmonary involvement is significant, the patient may be tachypneic and
stridulous. On abdominal examination, 50-70% of patients with ovarian vein
thrombosis have a tender, palpable, ropelike mass extending cephalad beyond the
uterine cornu.</p>

<ul>

<li>
<p>Ovarian vein syndrome</p>
</div></li>

<li>
<p>Pyelonephritis</p>
</div></li>

<li>
<p>Appendicitis</p>
</div></li>

<li>
<p>Broad ligament hematoma</p>
</div></li>

<li>
<p>Adnexal torsion</p>
</div></li>

<li>
<p>Pelvic abscess</p>
</div></li>

<li>
<p>Enigmatic fever</p>
</div></li>

<li>
<p>Drug fever</p>
</div></li>

<li>
<p>Viral syndrome</p>
</div></li>

<li>
<p>Collagen vascular disease</p>
</div></li>

<li>
<p>Pelvic abscess</p>
</div></li>
</ul>
<h3>Workup</h3>

<ul>

<li>
<p>Important laboratory studies included urinalysis, urine culture, and
CBC count with differential.</p>
</div></li>

<li>
<p>Imaging: CT scan and MRI are the studies of choice for the diagnosis
of septic pelvic thrombophlebitis.<sup>
layer','46')" href="javascript:void(0);">46</a>] </sup>MRI has 92% sensitivity and
100% specificity, and CT imaging has a 100% sensitivity and specificity for
identifying ovarian vein thrombosis. These imaging modalities are capable of
identifying both ovarian vein and iliofemoral involvement.</p>
</div></li>
</ul>
<h3>Treatment</h3>
<p>The standard therapy after diagnosis of septic pelvic thrombophlebitis
includes anticoagulation with intravenous heparin to an aPTT that is twice normal
and continued antibiotic therapy. A therapeutic aPTT is usually reached within 24
hours, and heparin is continued for 7-10 days. In general, long-term
anticoagulation is not required. Antibiotic therapy is most commonly with
gentamicin and clindamycin. Other choices include a second- or third-generation
cephalosporin, imipenem, cilastin, or ampicillin and sulbactam. All of these
antibiotics have a cure rate of greater than 90%. Initially, it was thought that
patients defervesce within 24-28 hours.<sup>
href="javascript:void(0);">47</a>] </sup>More recent studies show that it takes 5-6
days for the fevers to resolve.<sup>
<p>In a 1999 prospective randomized study, women who were treated with
heparin in addition to antibiotics responded no faster than patients treated with
antibiotics alone.<sup>
href="javascript:void(0);">45</a>] </sup>These findings do not support the empiric
practice of heparin therapy for septic pelvic thrombophlebitis and raise the
question of whether a new standard protocol should be developed.<sup>
</div>
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</div>
<h2>Endocrine Disorders</h2>
<p><strong>Prevalence and Types </strong> Postpartum thyroid
dysfunction can occur any time in the first postpartum year. Clinical or laboratory
dysfunction occurs in 5-10% of postpartum women and may be caused by primary
disorders of the thyroid, such as postpartum thyroiditis (PPT) and Grave's disease,
or by secondary disorders of the hypothalamic-pituitary axis, such as Sheehan
syndrome and lymphocytic hypophysitis.<sup>
<h3>Postpartum Thyroiditis</h3>
<p>PPT is a transient destructive lymphocytic thyroiditis occurring within
the first year after delivery.</p>
<h3>Etiology</h3>
<p>PPT develops 1-8 months postpartum and is an autoimmune disorder in which
microsomal antibodies of the thyroid play a central role. PPT has 2 phases:
thyrotoxicosis and hypothyroidism.</p>

<ul>

<li>
<p>Thyrotoxicosis occurs 1-4 months postpartum and is always self-
limited. The condition is caused by the increase release of stored hormone as a
result of disruption of the thyroid gland.</p>
</div></li>

<li>
<p>Hypothyroidism arises between the fourth and eighth month
postpartum.</p>
</div></li>
</ul>
<p>Risk factors for development of PPT include a positive antithyroid
antibody test finding, history of PPT, and family or personal history of other
thyroid or autoimmune disorders.</p>
<h3>Incidence</h3>
<p>Approximately 4% of women develop transient thyrotoxicosis in the
postpartum period. Of these, 66-90% return to a euthyroid state; 33% progress to
hypothyroid. Approximately 2-8% of women develop hypothyroidism in the postpartum
period. A third of these patients experience transient thyrotoxicosis, whereas 10-
30% go on to develop permanent thyroid dysfunction.</p>
<p>Patients with high antithyroid antibody levels during pregnancy,
multiparity, and history of spontaneous abortions are at high risk for permanent
hypothyroidism. Having developed PPT, these women are at significant risk for
recurrent disease after subsequent pregnancies.<sup>
<h3>History</h3>
<p>Patients with thyrotoxicosis may report fatigue, palpitations, heat
intolerance, tremulousness, nervousness, and emotional lability. Patients in the
hypothyroid phase often complain of fatigue, dry skin, coarse hair, cold
intolerance, depression, and memory and concentration impairment. Because many of
these symptoms are mild and nonspecific and are often associated with the normal
postpartum state, PPT may go undiagnosed.</p>
<h3>Physical</h3>
<p>On examination, a patient may have tachycardia, mild exophthalmos, and a
painless goiter.</p>
<h3>Workup</h3>
<p>The first laboratory test to be performed should be the thyroid-
stimulating hormone (TSH) test.<sup>
href="javascript:void(0);">51</a>] </sup>TSH is decreased during the thyrotoxicosis
stage and increased during the hypothyroid phase. If the TSH level is abnormal,
check thyroid stimulating antibodies, free thyroxine index (FTI), and radioactive
iodine uptake (RIU) in order to distinguish this disorder from Graves disease. In
PPT, RIU is low, thyroid-stimulating antibodies are undetectable, and FTI is high.
Referral to an endocrine specialist is appropriate.</p>
<p>A thorough, cost-effective screening test for PPT does not exist;
therefore, limit screening to high-risk patients such as those with previous PPT or
other autoimmune disorders.<sup>
<h3>Treatment</h3>
<p>No treatment is available to prevent PPT.<sup>
<p>Thyrotoxicosis phase: No treatment is required for the thyrotoxicosis
phase unless the patient's symptoms are severe. In this case, a beta-blocker is
useful. For example, propranolol can be started at 20 mg every 8 hours and can be
doubled if the patient remains symptomatic. Propylthiouracil (PTU) has no role in
the treatment of PPT because the disorder is caused by the release of hormone from
the damaged thyroid and is not secondary to increased synthesis and secretion.</p>
<p>Hypothyroid phase: Since the hypothyroid phase of PPT is often transient,
no treatment is required unless necessitated by the patient's symptoms. Treatment
is with thyroxine (T4) replacement. T4 is most often given for 12-18 months, then
gradually withdrawn. The starting dose is 0.05-0.075 mg, which may be increased by
0.025 mg every 4-8 weeks until a therapeutic level is achieved.</p>
<h3>Postpartum Graves Disease</h3>
<p>Postpartum Graves disease is not as common as PPT, but it accounts for
15% of postpartum thyrotoxicosis. Similar to classic Graves disease, postpartum
Graves disease is an autoimmune disorder characterized by diffuse hyperplasia of
the thyroid gland caused by the production of antibodies to the thyroid TSH
receptor, resulting in increased thyroid hormone production and release. No
clinical features distinguish postpartum Graves disease from Graves disease in
other settings; therefore, diagnosis and management of this disorder is beyond the
scope of this article (see <a href="http://emedicine.medscape.com/article/120619-
overview">Graves Disease</a>).</p>
<h3>Lymphocytic Hypophysitis</h3>
<p>Lymphocytic hypophysitis is a rare autoimmune disorder causing pituitary
enlargement and hypopituitarism, leading to a decrease in TSH and to
hypothyroidism. Symptoms include headache, visual field deficits, difficulty
lactating, and amenorrhea. Diagnosis requires histopathologic examination. Most
patients do not require transsphenoidal hypophysectomy, so diagnosis is based on
history, physical, diagnostic imaging, and the temporal relationship to pregnancy.
Identification of the disorder becomes clearer as the pituitary reverts to its
normal size and recovers some of its normal function. During the acute phase of
this disease, hormone replacement is often necessary.</p>
<h3>Sheehan Syndrome</h3>
<p>Sheehan syndrome is the result of ischemia, congestion, and infarction of
the pituitary gland, resulting in panhypopituitarism caused by severe blood loss at
the time of delivery. Patients have trouble lactating and develop amenorrhea, as
well as symptoms of cortisol and thyroid hormone deficiency. Treatment is with
hormone replacement in order to maintain normal metabolism and response to
stress.</p>
</div>
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<h2>Psychiatric Disorders</h2>
<p>Three psychiatric disorders may arise in the postpartum period:
postpartum blues, postpartum depression (PPD), and postpartum psychosis. The
American College of Obstetricians and Gynecologist recommend that patients are
screened at least once for depression and anxiety symptoms during the perinatal
period using a standardized, validated tool.<sup>

<ul>

<li>
<p>Postpartum blues is a transient disorder the lasts hours to weeks and
is characterized by bouts of crying and sadness.</p>
</div></li>

<li>
<p>PPD is a more prolonged affective disorder that lasts for weeks to
months. PPD is not well defined in terms of diagnostic criteria, but the signs and
symptoms do not differ from depression in other settings. Anxiety is a prominent
feature of perinatal mood disorders while other �common� symptoms of depression
such as changes in sleep, appetite, and libido may be normal in the setting of
pregnancy</p>
</div></li>

<li>
<p>Postpartum psychosis occurs in the first postpartum year and refers to
a group of severe and varied disorders that elicit psychotic symptoms.</p>
</div></li>
</ul>
<h3>Etiology</h3>
<p>The specific etiology of these disorders is unknown. The current view is
based on a multifactorial model. Psychologically, these disorders are thought to
result from the stress of the peripartum period and the responsibilities of child
rearing. Other authorities ascribe the symptoms to the sudden decrease in the
endorphins of labor and the sudden fall in estrogen and progesterone levels that
occur after delivery. Low free serum tryptophan levels have been observed, which is
consistent with findings in major depression in other settings. Postpartum thyroid
dysfunction has also been correlated with postpartum psychiatric disorders.</p>
<p>Risk factors include undesired pregnancy, feeling unloved by mate, age
younger than 20 years, unmarried status, medical indigence, low self-esteem,
dissatisfaction with extent of education, economic problems with housing or income,
poor relationship with husband or boyfriend, being part of a family with 6 or more
siblings, limited parental support (either as a child or as an adult), and past or
present evidence of emotional problems. Women with a history of PPD and postpartum
psychosis have a 50% chance of recurrence. Women with a previous history of
depression unrelated to childbirth have a 30% chance of developing PPD.</p>
<h3>Incidence</h3>
<p>Perinatal depression includes any depressive episode that occurs during
pregnancy or in the first 12 months after delivery.</p>

<ul>

<li>
<p>Approximately 50-70% of women who have given birth develop symptoms of
postpartum blues.</p>
</div></li>

<li>
<p>PPD occurs in 1 of 7 women or approximately 10-15% of new
mothers.<sup>
</div></li>

<li>
<p>The incidence of postpartum or puerperal psychosis is 0.14-0.26%.</p>
</div></li>
</ul>
<p>Psychiatric disorders can have deleterious effects on the social,
cognitive, and emotional development of the newborn.<sup>
layer','55')" href="javascript:void(0);">55</a>, <a
layer','57')" href="javascript:void(0);">57</a>] </sup>These ailments can also lead
to marital difficulties.</p>
<h3>History</h3>

<ul>

<li>
<p>Postpartum blues is a mild, transient, self-limited disorder that
usually develops when the patient returns home. It commonly arises during the first
2 weeks after delivery and is characterized by bouts of sadness, crying, anxiety,
irritation, restlessness, mood lability, headache, confusion, forgetfulness, and
insomnia.</p>
</div></li>

<li>
<p>PPD: Patients suffering from PPD report insomnia, lethargy, loss of
libido, diminished appetite, pessimism, incapacity for familial love, feelings of
inadequacy, ambivalence or negative feelings toward the infant, and an inability to
cope. Consult a psychiatrist when PPD is associated with comorbid drug abuse, lack
of interest in the infant, excessive concern for the infant's health, suicidal or
homicidal ideations, hallucinations, psychotic behavior, overall impairment of
function, or failure to respond to therapeutic trial.</p>
</div></li>

<li>
<p>Postpartum psychosis: The signs and symptoms of postpartum psychosis
typically do not differ from those of acute psychosis in other settings. Patients
with postpartum psychosis usually present with schizophrenia or manic depression,
which signals the emergence of preexisting mental illness induced by the physical
and emotional stresses of pregnancy and delivery.</p>
</div></li>
</ul>
<h3>Treatment</h3>

<ul>

<li>
<p>Postpartum blues, which has little effect on a patient's ability to
function, often resolves by postpartum day 10; therefore, no pharmacotherapy is
indicated. Providing support and education has been shown to have a positive
effect.</p>
</div></li>

<li>
<p>PPD generally lasts for 3-6 months, with 25% of patients still
affected at 1 year. PPD greatly affects the patient's ability to complete
activities associated with daily living.</p>

<ul>

<li><p>Supportive care and reassurance from healthcare professionals and
the patient's family is the first-line therapy for patients with PPD.<sup>
href="javascript:void(0);">58</a>] </sup>Research on pharmacological treatment for
PPD is limited because postpartum women are often excluded from large clinical
trials.<sup>
href="javascript:void(0);">54</a>] </sup>Empirically, the standard treatment
modalities for major depression have been applied to PPD.</p></li>

<li><p>First-line agents include selective serotonin reuptake inhibitors
(SSRIs) or secondary amines. Studies on these drugs show that they can be used by
nursing mothers without adverse effects on the infant. LactMed
(https://www.nlm.nih.gov/pubs/factsheets/lactmedfs.html) can be referenced for up
to date safety considerations. </p></li>

<li><p>Consider electroconvulsive therapy for patients with PPD because
it is one of the most effective treatments available for major depression.
Treatment is recommended for 9-12 months beyond remission of symptoms, with
tapering over the last 1-2 months.</p></li>
</ul>
</div></li>

<li>
<p>Postpartum psychosis: Treatment of postpartum psychosis should be
supervised by a psychiatrist and should involve hospitalization as it is a medical
emergency. Specific therapy is controversial and should be targeted to the
patient's specific symptoms. Patients with postpartum psychosis are thought to have
a better prognosis than those with nonpuerperal psychosis. Postpartum psychosis
generally lasts only 2-3 months.</p>
</div></li>

<li>
<p>Secondary to the overlap between the normal sequelae of childbirth and
the symptoms of PPD, the former is often underdiagnosed.<sup>
href="javascript:void(0);">53</a>] </sup>Screening for PPD increases the
identification of women suffering from this disorder.<sup>
href="javascript:void(0);">53</a>] </sup>The Edinburgh Postnatal Depression Scale
has proven to be an effective tool for this type of screening.<sup>
layer','60')" href="javascript:void(0);">60</a>, <a
href="javascript:void(0);">61</a>] </sup>This scale consists of 10 self-reported
items that takes the patient less than 5 minutes to complete. This scale excludes
constitutional symptoms of depression, such as changes in sleeping patterns that
are common in pregnancy and postpartum period. It requires little extra time, is
available in 50 languages, and is acceptable to both patients and
physicians.<sup>
layer','62')" href="javascript:void(0);">62</a>] </sup> Other screening
instruments include the Patient Health Questionnaire 9, the Beck Depression
Inventory, and the Center for Epidemiologic Studies Depression Scale.<sup>
</div></li>
</ul>
<p>Screening with a standardized instrument should be concomitant with
clinical assessment of a patient's psychosocial wellbeing and support in the
postpartum period. It is important that physicians who utilize screening methods
are prepared on how to manage those with perinatal depression. Management may
include pharmacotherapy, referral to behavioral health resources, and closer follow
up in the postpartum period.</p>
<p> </p>
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<h6>References</h6>
</div>

<div class="modal-content">
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Author
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<p><strong>Christine Kansky, MD</strong> Resident Physician, Department
of Obstetrics and Gynecology, Virginia Commonwealth University School of
Medicine<br><br>Disclosure: Nothing to disclose.</p>

Coauthor(s)
</div>
<p><strong>Christine Isaacs, MD</strong> Associate Professor, Department
of Obstetrics and Gynecology, Division Head, General Obstetrics and Gynecology,
Medical Director of Midwifery Services, Virginia Commonwealth University School of
Medicine<br><br>
Christine Isaacs, MD is a member of the following
medical societies: <a xmlns:qnafn="http://www.webmd.com" href="http://www.acog.org"
target="_blank">American College of Obstetricians and
Gynecologists</a><br><br>Disclosure: Nothing to disclose.</p>
Specialty Editor Board
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<p><strong>Francisco Talavera, PharmD, PhD</strong> Adjunct Assistant
Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-
Chief, Medscape Drug Reference<br><br>Disclosure: Received salary from Medscape for
employment. for: Medscape.</p>

Chief Editor
</div>
<p><strong>Christine Isaacs, MD</strong> Associate Professor, Department
of Obstetrics and Gynecology, Division Head, General Obstetrics and Gynecology,
Medical Director of Midwifery Services, Virginia Commonwealth University School of
Medicine<br><br>
Christine Isaacs, MD is a member of the following
medical societies: <a xmlns:qnafn="http://www.webmd.com" href="http://www.acog.org"

Additional Contributors
</div>
<p><strong>Michail Spiliopoulos, MD</strong> Clinical Assistant
Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences, Temple
University Hospital<br><br>
Michail Spiliopoulos, MD is a member of the
following medical societies: <a xmlns:qnafn="http://www.webmd.com"
href="http://www.acmg.net" target="_blank">American College of Medical Genetics and
Genomics</a>, <a xmlns:qnafn="http://www.webmd.com" href="http://www.acog.org"
<p><strong>Dimitrios Mastrogiannis, MD, PhD, MBA,
FACOG</strong> Associate Professor, Department of Obstetrics, Gynecology and
Reproductive Sciences, Director of Obstetrics and Maternal-Fetal Medicine, Director
of Labor and Delivery, Temple University School of Medicine<br><br>
Dimitrios Mastrogiannis, MD, PhD, MBA, FACOG is a
member of the following medical societies: <a xmlns:qnafn="http://www.webmd.com"
href="http://www.acog.org" target="_blank">American College of Obstetricians and
Gynecologists</a>, <a xmlns:qnafn="http://www.webmd.com" href="http://www.aium.org"
target="_blank">American Institute of Ultrasound in Medicine</a>, <a
xmlns:qnafn="http://www.webmd.com" href="http://ama-assn.org"
target="_blank">American Medical Association</a>, <a
xmlns:qnafn="http://www.webmd.com" href="http://www.flmedical.org"
target="_blank">Florida Medical Association</a>, <a
xmlns:qnafn="http://www.webmd.com" href="http://www.smfm.org"
target="_blank">Society for Maternal-Fetal Medicine</a>, <a
xmlns:qnafn="http://www.webmd.com" href="http://sma.org" target="_blank">Southern
Medical Association</a>, <a xmlns:qnafn="http://www.webmd.com"
href="http://www.aagl.org" target="_blank">AAGL</a>, <a
xmlns:qnafn="http://www.webmd.com" href="http://www.socrei.org"
target="_blank">Society for Reproductive Endocrinology and
Infertility</a><br><br>Disclosure: Nothing to disclose.</p>
Acknowledgements
</div>
<p xmlns:qnafn="http://www.webmd.com">The authors and editors of Medscape
Reference gratefully acknowledge the contributions of previous authors Karin Witt,
MD, Natali Franzblau, MD, FACOG, Guillermo M Guzman, MD, and John P O'Grady, MD,
MA, to the development and writing of this article.</p>
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