19 DECEMBER 2007 ISSUE

Problems seen in postnatal period

Anil Sharma

As pregnancy care has changed in New Zealand, the GP often finds that women with whom he or she has had little contact or rapport with during the pregnancy present in need of medical attention or advice after the birth.

Some of these problems are discussed here; postnatal depression is not included as it was covered very well recently in a “How to Treat” article by Kumeu GP William Ferguson (New Zealand Doctor, 26 September).

Postpartum pyrexia
Defined as a temperature greater than 38°C, this usually occurs within the first two weeks after birth and can be due to a variety of causes. Although most of the infections causing this will be of the genital tract or urinary system, a full general examination is necessary, including the chest, breasts, legs and bimanual palpation of the pelvic region. Appropriate cultures in addition to a high vaginal swab/endocervical swab and mid-stream urine (MSU) are indicated, eg, blood cultures and sputum.

In general, the uterus becomes a pelvic organ again by about 14 days postnatal and the lochia goes from red for the first three days to yellow, then white over the next 10 days and stays as such for a few weeks.

Endometritis is a common culprit and causes lower abdominal pain, offensive lochia and uterine tenderness. All but the mildest infections require hospital assessment and intravenous antibiotics and serious thought must be given to a hospital pelvic scan to look for retained products of conception. Currently, Augmentin is commonly used or a cephalosporin/erythromycin and metronidazole for penicillin-allergic women.

Endometritis and/or retained products of conception can also lead to secondary postpartum haemorrhage without pyrexia and appropriate management includes antibiotics (and evacuation of the uterus if retained products are unequivocally diagnosed by scan). Histology of the “products” should be requested to exclude gestational trophoblastic disease.

For breast infections, flucloxacillin is indicated early to prevent breast abscesses. Continued suckling or expressing of milk is important. In scenarios of postpartum pyrexia with no apparent cause, antibiosis is wise (unless a viral infection is likely).

Septic pelvic vein thrombophlebitis
This is secondary to pelvic infection and, although uncommon (around one in 1000 births), should be considered after the above has been excluded. Ongoing fever and pain should raise suspicions and management is hospital based initially.

Thromboembolism
The puerperium is the most hypercoagulable “stage” of pregnancy and, while I do not propose to discuss this topic which all GPs will be familiar with, it is included here to raise awareness in the postnatal woman with leg, groin or chest pain or lower limb oedema. Hospital referral may be indicated.
 
Drugs in pregnancy and lactation
One web-based resource relating to the safety of drugs in pregnancy and lactation is www.safefetus.com which allows for generic or brand name drug searches and gives graded results from category A (safest) to category X (known danger, contraindicated).

Conclusion
I hope the long term re-engagement of GPs into maternity care provision is not just a necessity due to the ongoing shortage and burnout of other providers. True family centred healthcare plays an important role in the wellness of our communities and (arguably) there is no better way to become involved than to take part in antenatal care. Time will tell whether this is a realistic prospect.

Anil Sharma is an obstetrician and gynaecologist at Waitemata DHB, with Birthright Obstetricians and in private gynaecological practice. His special interests are high-risk pregnancy, prolapse, urinary incontinence and menstrual disorders 

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