Postpartum Urinary & GI Complications

Urinary & GI Postpartum Complications

• Postpartum (PP) complications linked to the urinary system stem from the body's changes and stresses during pregnancy, labor, and delivery
• These complications potentially affect the kidney, bladder, urethra, or other parts of the urinary tract

Urinary Retention

• Urinary retention occurs when the bladder cannot empty completely
• Nerve damage, swelling in the perineal area, or the effects of epidural anesthesia may cause urinary retention
• Difficulty urinating, feeling the urge but being unable to pass urine, and discomfort or pain in the bladder area describes possible symptoms
• Risk factors include epidural anesthesia, prolonged labor, vaginal tearing, and having a large baby
• Treatment is usually intermittent, but a PP catheter might be required, depending on the severity

Urinary Incontinence

• Involuntary urine leakage defines urinary incontinence
• Pregnancy and childbirth can cause pelvic floor muscle weakening and related urinary incontinence
• Leaking urine when coughing, sneezing, laughing, or during physical activity describes symptoms
• Vaginal delivery (especially with a large baby), multiple pregnancies, advanced maternal age (AMA), and obesity increase risk
• Treatment includes pelvic floor therapy to strengthen the pelvic floor muscle

Bladder Injuries

• Accidental bladder injuries can happen during a difficult or traumatic delivery
• Use of forceps or a C-section increases risk of bladder injuries
• Symptoms include blood in the urine, lower abdomen pain, difficulty urinating, and sometimes inability to urinate
• C-section delivery, difficult vaginal delivery, and prolonged labor also increase risk
• Varying treatments will depend on the severity of damage

Urinary Tract Infection (UTI)

• Postpartum UTIs are common due to urinary stasis, catheterization during labor, and hormonal changes
• Frequent urges to urinate, pain or burning during urination, cloudy or foul-smelling urine, and lower abdominal discomfort are possible symptoms
• The use of a catheter during labor, vaginal delivery, C-section, and a history of UTIs all can increase risk
• Treatment focuses on antibiotics to which the identified bacteria is susceptible

Hematuria

• Blood in the urine can occur after childbirth due to trauma to the urinary system
• Symptoms include pink or red-tinged urine and possible pain during urination
• Risk factors involve vaginal or C-section delivery, especially with a traumatic birth
• Inconsistent symptoms require further investigation

Pelvic Floor Dysfunction

• Childbirth-related weakening or damage to the pelvic floor muscles, which support the bladder and other organs, leads to bladder control and pelvic health issues
• Symptoms include urinary incontinence, pelvic heaviness, or pain
• Vaginal delivery, especially with multiple births or a large baby, can cause pelvic floor dysfunction
• Pelvic floor physical therapy, including Kegel exercises to increase muscle strength, is a treatment

Gastrointestinal Complications

• GI and rectal system complications are prevalent post-partum
• These can be managed with medical treatment, pelvic floor exercises, and physical therapy

Constipation

• Childbirth factors, which include hormonal shifts, dehydration, dietary changes, pain medication, and physical strain, can lead to constipation
• The pressure exerted on the pelvic floor during delivery contributes to bowel dysfunction
• Infrequent bowel movements (Less than three times a week), hard or dry stools, bloating, straining, discomfort during bowel movements describes some symptoms
• Risk factors involve pain medication (opioids), low-fiber diet, inactivity during the PP period, pelvic floor dysfunction, and dehydration
• Treatment involves fiber supplements, early ambulation, hydration, and OTC stool softeners, while laxative use is not advised

Hemorrhoids

• Swollen blood vessels in the rectal area, which can develop during pregnancy and worsen during labor due to straining and pressure contribute to hemorrhoids
• Symptoms include pain, itching, or bleeding around the anus, especially during or after bowel movement, as well as swelling and discomfort in the rectal area
• Risk factors involve vaginal delivery (especially prolonged or with a large baby), constipation, pushing for long periods during labor, and increased intra-abdominal pressure
• Increasing dietary fiber, topical analgesics with corticosteroids, and OTC medications such as witch hazel and local anesthetics are some treatments

Postpartum Hemorrhage, Anemia and Hematoma

• Delayed Postpartum Hemorrhage refers to excessive vaginal bleeding after the immediate postpartum period, typically from 24 hours to 12 weeks after delivery

Causes of Delayed PP Hemorrhage

• Retained placenta fragments or subinvolution of the placental bed cause delayed hemorrhage
• Less common causes include endometritis, uterine atony, or trauma

Diagnosis and Treatment of PP Hemorrhage

• TVUS helps detect retained placental products and a physical exam should be conducted
• Treatment focuses on uterine compression and bimanual fundal massage
• Broad-spectrum antibiotics if the cause is determined to be an infection
• Removal of placental fragments utilizing dilation, suction, or curettage
• Surgical removal if necessary

Anemia

• Childbirth and delivery results in blood loss and varies based on delivery circumstances
• Iron deficiency is responsible for 95% of anemias in pregnancy
• CDC defines anemia in the third trimester as a hemoglobin (Hgb) concentration less than 11g/dL or a hematocrit (Hct) less than 33%
• Preventative measures for anemia focus on 60 mg/day of elemental iron supplementation during pregnancy and the PP period
• Treatment can take the form of PO 300 mg ferrous sulfate (with 60mg of elemental iron) supplementation TID during a minimum of three months
• Co-administration with citric juice aids in absorption
• IV iron infusion may be necessary in severe cases to rapidly increase iron stores, which is preferred over IM injections

Vulvar Hematoma

• Delivery trauma and perineal surgical repairs can cause blood to collect on the perineum, leading to tissue swelling
• Symptoms include palpable pain and tenderness that typically manifests by unilateral symptoms
• Patients can present with tachycardia, low blood pressure, and pallor; shock, altered mental status, and decreased urinary output may also be indicated in severe cases
• Diagnosis involves a physical examination, CT imaging, and blood tests
• Conservative management involves ice packs and pain management, while surgical options include ligation of the affected blood vessel, wound packing, and broad-spectrum antibiotics

Postpartum Hypertension

• Women with pre existing hypertension and preeclampsia during pregnancy have a continued risk of developing eclampsia up to 6 weeks postpartum
• Re-admission typically occurs within eight days of delivery
• Common symptoms include a headache and vision changes
• Severe BP ranges and seizure activity suggest a progression to eclampsia
• Management includes oral anti-hypertensive medications for mild to moderate presentations and magnesium sulfate for severe cases
• These women are at higher risk for chronic diseases such as CVD, stroke, and T2DM, especially those who deliver preterm with FGR and/or stillbirth
• Telemonitoring BP and VS programs are being investigated to lower maternal mortality and morbidity rates

Endometritis

• Bacteria, part of the normal vaginal flora, causes this polymicrobial infection
• Causes can be vaginal exams during labor and other surgical manipulations during surgery that enters the upper genital tract, peritoneal cavity, & the blood stream
• Signs and symptoms typically appear in the first 24-72 hours, but can be present up to 6 weeks pp
• Uterine Tenderness can be a sign
• Elevated temperature ( 100.4 degrees or greater), chills, tachycardia, uterine tenderness, pelvic pain, elevated WBC
• Cesarean section, young age, low socioeconomic status, extended duration of labor and ruptured membranes, multiple vaginal exams, pre-existing infections of the lower genital tract can put the patient at risk
• Antibiotics are the most common treatment for Endometritis

Thromboembolic Disorders

Thromboembolic Disorders in Pregnancy

• Superficial Thrombophlebitis
• Deep Vein Thrombosis (DVT)
• Pulmonary Embolism (PE)
• Pathogenesis, clinical findings, diagnosis, prevention, and treatment plans are recommended for review

Postpartum Mood Disorders

It is recommended to review PP Blues, PP Depression, and PP Psychosis with knowledge of safe treatment plans during breastfeeding

Postpartum Infection

• Occurs at the site of episiotomy, perineal lacerations, or c/s incision
• Pain, purulent or serosanguineous discharge, odor, and poor healing indicate a potential wound
• Higher risks exist for patients who have poro surgical techniques, low socioeconomic status, and obesity Skin flora (s. aureus, aerobic streptocci)

Mastitis

• One or both breasts are typically tender unilateral, erythematous, and engorged as indicated on physical exam
• Sudden onset symptoms present for 2-5 days or peaking on days 2-3 indicate potential for the patient having breast
• Nipple, positioning, latching, and feedings can also lead to concern

Overview of Mental Health

SSRIs, SNRIs, Tricyclic Antidepressants, Bupropion, Benzodiazepines, Lithium, and Antiepileptic drugs can all have different effects and side effects on a pregnant or post-partum patient

Other Aspects to Watch in PPD

• Patients may be sad and irritable
• Assess what actions are possible in each action plan
• High potential for women to have a loss of appetite
• Patients want to ensure that it is right to breast feed
• Ensure that you also help with the other members of the family, and ensure everyone is able to manage together