OUTPATIENT CARE OF THE POSTPARTUM WOMAN AND HER BABY Sarah Gopman,

OUTPATIENT CARE OF THE POSTPARTUM WOMAN AND HER BABY Sarah Gopman, MD Associate Professor Dept. of Family and Community Medicine University of New Mexico July 1, 2015

Learning/Practice Objectives Screen for and treat postpartum depression Evaluate and treat postpartum thromboembolic disease Recognize and treat endomyometritis, c-section wound infections, and perineal wound complications Manage breastfeeding difficulties Evaluate and manage newborn hyperbilirubinemia

Screening for and Treatment of Postpartum Depression

A postpartum patient at risk for depression Josie is a 25 y/o woman cared for by you since she was 19 H/o major depressive d/o, including hospitalization for suicide attempt age 17 Intermittently on SSRI, stopped two months prior planned pregnancy, did well with cognitive behavioral therapy during pregnancy Had a term NSVD of a healthy baby and is breastfeeding

What type of mood disorders occur in the postpartum period? Postpartum/baby “blues” 40-80% of women affected Feeling overwhelmed Irritability Tearfulness Exhaustion Trouble falling or staying asleep Usually resolves by two weeks postpartum Increased risk of developing full postpartum depression

What type of mood disorders occur in the postpartum period? Postpartum depression 10-20% of women affected Greatest risk is first 12 weeks after delivery, but risk persists for one year Symptoms last more than 14 days

What are postpartum depression symptoms? Tearfulness, sad or flat affect, irritability, mood instability Feeling inadequate, guilty, overwhelmed Sleep and appetite disturbance Intense worries or obsessive thoughts re. harm to the baby Difficulty concentrating or making decisions Lack of interest in the baby, family or activities Poor bonding Thoughts of death or suicide Somatic symptoms: HA, CP, palpitations, numbness, hyperventilation

How is postpartum psychosis characterized? 1-2 in 1000 women affected Agitation and anger Anxiety/Paranoia Insomnia/Delirium/Confusion Mania (hyperactivity, elated mood) Suicidal or homicidal thoughts Auditory hallucinations (about the baby, of a religious nature) Visual hallucinations (seeing or feeling “a presence” or “darkness”) Delusions and commands to harm the infant (not just an obsessive thought) EMERGENCY: PSYCHIATRIC HOSPITALIZATION NECESSARY

What is the risk of suicide in the postpartum period? “Suicides account for up to 20% of all postpartum deaths and represent one of the leading causes of peripartum mortality.” (2005 in Archives of Women’s Mental Health)

What is different about postpartum depression versus depression at other times of life? Sleep deprivation is the norm postpartum Strong societal expectations about maternal happiness postpartum 50% of postpartum depression goes undiagnosed Postpartum depression affects mothers, children, partners, and families

How does maternal depression relate to pregnancy outcomes? Maternal effects Low weight gain Increased use of cigarettes, alcohol, other substances Ambivalence regarding the pregnancy Neonatal/infant effects Increased preterm birth Low birth weight Higher cortisol levels (sustained through adolescence)

How does postpartum depression affect maternal behavior? Mothers who are depressed show Less affectionate behavior and impaired bonding Less response to infant cues More hostile/intrusive interactions with their infants Decreased rates of infant safety practices

What are the risks to children when postpartum depression goes untreated? Children of mothers with untreated depression exhibit More fussiness and colic Impaired emotional development: fewer positive facial expressions Poorer language development: less vocalization Difficulties with attention Decreased cognitive skills Increased risk for long-term behavioral problems Remission of maternal depression improves children’s mental and behavioral disorders Consider depression during pregnancy and postpartum as an exposure with associated risks for the infant!

When should you screen your patient for postpartum depression? Any routine infant or maternal postpartum visit Special visits scheduled for following up on hx of depression Example First newborn check at 2 or 3 days after d/c 2 weeks postpartum 4-6 weeks postpartum

What method will you use to screen her? Postpartum Depression Screening Scale 35-item Likert response scale (“Strongly Disagree” to “Strongly Agree”) Third grade reading level Completed by patient in 10 minutes Addresses seven areas Sleeping/Eating Disturbances Anxiety/Insecurity Emotional Lability Cognitive Impairment Loss of Self Guilt/Shame Contemplating Harming Oneself

What method will you use to screen her? Edinburgh 10-item Postnatal Depression Scale self-report scale (“Yes, most of the time” to “No, not at all”) Each item scores 0-3 points, max score 30, 10 is cutoff for depression Available in several languages Intended for use at 6-8 weeks postpartum, but validated for use at other times Completed by patient in 5 minutes Addresses symptoms of Inability to laugh Inability to look forward to things with enjoyment Blaming oneself unnecessarily Feeling anxious or worried Feeling scared or panicky Feeling that “things have been getting on top of me” Difficulty sleeping because of unhappiness Feeling sad or miserable Crying Thoughts of harming oneself

How do the two screening methods compare? Postpartum Depression Screening Scale For combined major and minor postpartum depression sensitivity 91% specificity 72% Edinburgh Postnatal Depression Scale For combined major and minor postpartum depression Sensitivity 68-80% Specificity 77%

Which antidepressants can be used while breastfeeding? Sertraline (Zoloft) currently favored SSRI during breastfeeding Short half-life Low or undetectable infant plasma levels More follow-up data on infant development Paroxetine (Paxil) and fluvoxamine (Luvox) also show low infant plasma levels Use following with caution in patients w/ prior good effect Fluoxetine (Prozac)--long half-life Citalopram (Celexa)--high breast milk concentration

What else do we know about antidepressant use while breastfeeding? Omega-3 fatty acids showed significant response rate in one open-label study Medication exposure to fetus via placental transfer is almost always greater than to the newborn via breastfeeding Most national guidelines recommend six months of treatment once depression is in remission

What are non-pharmacological options for treatment of postpartum depression? Cochrane Review: any psychosocial or psychological intervention, compared to usual postpartum care, is associated with reduction in risk of continued postpartum depression Breastfeeding may be somewhat protective against postpartum depression (oxytocin release?)

What are non-pharmacological options for treatment of postpartum depression? Cognitive Behavioral Therapy Good results w/ group approach 10-40% fail to complete full treatment (similar to pharmacotherapy) May have enduring effects not seen w/ pharmacotherapy (up to two years) Six sessions of non-directive counseling w/ child health nurses was more effective than routine primary care in Sweden Telephone-based peer support out-performed care as usual (five 30-minute conversations)

Back to your patient You see Josie frequently in clinic in the early postpartum period (newborn checkups and her own visit) At two weeks postpartum She describes low energy, worrying that she is not a good mom, difficulty sleeping, prolonged episodes of crying Denies SI/HI, hallucinations, etc. Is able to care for her baby but not enjoying it much You review options for treatment of postpartum depression, including risks of no treatment She elects to start medication Used sertraline with good effect previously, so you rx 50mg daily You see her in f/u in 2 weeks Feeling better, no mania, bonding with baby, but some sx’s persist You increase sertraline to 100mg daily and schedule her back in 2 weeks

How can her partner and family members help? Mothers without social support twice as likely to develop postpartum depression Among Latina women, those satisfied with marital/partner relationships showed lower risk of depressive sx’s postpartum Among high risk women, better social support quicker improvement in depressive sx’s Educate partner about signs of mania/hypomania: can be uncovered w/ use of SSRI. Also educate about the importance of treatment!

Evaluation and Treatment of Postpartum Thromboembolic Disease

How do patients with thromboembolic disease present in the postpartum period? Silvia is a 37 y/o G5P5 at 9 days s/p repeat c/s performed at 37 wks for pre-eclampsia She has a BMI of 43 She presents w/ increasing left leg pain and swelling for 2 days On exam, you note the left calf is 4cm larger in circumference than the right and is tender to palpation and slightly erythematous She has no dyspnea, tachypnea, or hypoxia

What are the risk factors for thromboembolic disease in the postpartum period? Age 35 BMI 30 Grand multiparity Fam hx of VTE/thrombophilia Bed rest Immobility for 4 days Pre-eclampsia Severe varicose veins Virtualmedicalcentre.com Cesarean delivery (OR 13.3, 95% CI 3.4-51.4)

What is the incidence of VTE in postpartum women? 0.5-3.0 per 1000 pregnancies Equal incidence in each trimester and postpartum 90% of DVTs in pregnancy are in the left leg PE is more frequent in the postpartum period than during pregnancy (RR 15.0, 95% CI 5.143.9)

How is VTE diagnosed in the postpartum period? Venous compression ultrasonography is the preferred test for dx of DVT 89-96% sensitive and 94-99% specific for symptomatic proximal LE DVT in non-pregnant patients Current spiral CT technology is comparable to pulmonary angiography in positive and negative predictive values for PE CT delivers more radiation to the breast than V/Q scan, which may be preferred in those w/ family hx of breast cancer

How is VTE treated in the postpartum period? Warfarin can be started at the same time as low molecular weight heparin or unfractionated heparin LMWH (1 mg/kg SC bid) or UFH (80 units/kg loading dose iv, then continuous iv infusion of 18 units/hour, or 17,500 units SC q12h) aPTT goal is 1.5-2.0 X upper limits of normal Continue LMWH or UFH until INR is 2.0-3.0 for 2 consecutive days Treat until 3-6 months post-diagnosis and for at least 6 weeks postpartum

Back to your patient Her risk factors are: age, c/s, pre-e, obesity Her LE doppler confirms left DVT She is appropriate for outpatient treatment Given LMWH 100mg SC in OBT Rx for bid LMWH is phoned to her pharmacy and emergency prior authorization is approved She also starts warfarin and is given a f/u appt in the Coumadin Clinic Is that okay for breastfeeding moms? Yes Should she be given prophylaxis in a subsequent pregnancy? Yes: She falls under the criteria of “no known thrombophilia with previous single episode of VTE associated with transient risk factor that was pregnancy- or estrogen-related.”

Endomyometritis, C-section Wound Infections, and Perineal Wound Complications

A postpartum woman with fever Delia is a 32 y/o G1P1, 7 days s/p c/s for failure to progress following induction for GDMA2 Complains of onset of fever and chills yesterday evening, resolved w/ ibuprofen overnight, recurrent this morning with temp 102 at home Reports her VB has increased slightly in the last 24h, notes a foul vaginal odor and some vague abdominal pain

How does postpartum endomyometritis present and what are the pathogens involved? Temp 38.0 (100.4), chills Uterine tenderness Foul lochia Lower abdominal pain Fundus soft instead of firm, sub-involuted (above umbilicus, excessive VB) Microbiology Usually mixture of 2-3 aerobes and anaerobes, including gram pos and neg; rarely GC/CT Rare but potentially lethal bacteria: clostridium sordellii, clostridium perfringens, strep or staph toxic shock

What are risk factors for postpartum endomyometritis? C/s most important Prolonged labor or ROM Lots of cervical exams Internal monitors in labor Manual placenta extraction Maternal DM or severe anemia BV or GBS colonization

How is postpartum endomyometritis evaluated and diagnosed? Physical exam Fever, tachycardia Uterine tenderness on abdominal or bimanual exam Look for findings associated with other causes of fever, such as surgical site infection, pelvic abscess, mastitis, UTI/pyelo, DVT/PE Rising neutrophil count w/ increased bands (WBCs commonly elevated in labor, but should not continue to rise postpartum) Blood cx GC/CT if not done prior, positive earlier in pregnancy, or patient at increased risk Imaging usually not indicated unless fever is persistent after 48-72h of abx or VB is heavy (fluid/debris/gas in uterus can be normal)

How is postpartum endomyometritis treated? Clindamycin 900mg iv q8h plus gentamicin 5mg/kg q24h (or 1.5mg/kg iv q8h), w/ 90-97% cure rate Treat until clinically improved and afebrile X 24-48h; further oral tx not required unless bacteremia present based on positive blood cx If fever persistent, add ampicillin, vs. change to ampicillin/sulbactam (Unasyn)1.5g iv q6h, which can also be used first-line Uterine suction currettage occasionally required to remove POCs shown on U/S (if not improving or bleeding heavy) In late postpartum endomyometritis (1-6 weeks postpartum and usually milder sx’s, 15% of all disease), amoxicillinclavulanate 875mg po bid X 7 days is acceptable

What if your patient presented with no fever, but increased pain at her c/s incision site? Risk factors for c/s wound infection similar to endomyometritis Wound appears erythematous and induration can be palpated Evaluate for seroma, hematoma, or abscess, including probing down to the fascia w/ a sterile cotton-tipped applicator if the wound opens Wound aspirate (rather than swab) for cx After drainage of an abcess/opening the wound, irrigate and pack w/ sterile gauze, w/ healing by secondary intention Antibiotics Cephalexin 500mg po qid X 7 days Clindamycin if MRSA suspected Both are fine for breastfeeding Close follow up is important amamasblog.com

How do postpartum patients with perineal laceration complications present? Tanya is a 20 y/o G1P1 s/p vacuum-assisted vaginal delivery for failure to descend and fetal intolerance of labor She had a second degree perineal laceration repaired She presents 3 days postpartum with perineal pain She reports a subjective fever at home, but is afebrile in your office, with no recent antipyretic use On perineal exam, no erythema, sutures appear intact, no foul-smelling discharge, external anal sphincter and rectovaginal septum intact, but a hematoma is noted of the left labia

What is the differential diagnosis and treatment for perineal pain postpartum? Labial/vaginal hematoma: incise, evacuate, and ligate the bleeding vessel(s) if continues to expand or appears infected; if stable and not large, may resorb spontaneously Williams Obstetrics, 23 Ed.

What is the differential diagnosis and treatment for perineal pain postpartum? Perineal infection Open any organized abscess (imaging may be required to assess for tracking of the abscess into deep tissues) Consider removing suture material Verify that a third or fourth degree laceration has not been overlooked Antibiotics (may require admission) Look for hemorrhoids and anal fissures, treat accordingly Discuss in private whether pressured/forced to have sex before completely healed

Back to your patient Delia has endomyometritis by hx and exam Admitted for iv gent and clinda Becomes afebrile after 18 hours of abx Tx’d until afebrile for 24h and no fundal tenderness, then abx d/c’d and observed for 24h off abx, remained afebrile Tanya has a 3 X 3 cm labial hematoma She states “that lump has been there since a few hours after the delivery” and “it’s the same size as yesterday” Vitals are normal There is no surrounding erythema or induration You elect conservative management, give precautions, and bring her back in 48h for re-examination

Management of Breastfeeding Difficulties

What types of breastfeeding difficulties do women encounter postpartum? Cassandra is a 28 y/o G1P1, 10 days s/p term NSVD Exclusively breastfeeding, 3 days of breast pain Nipple pain starts at latch and lasts entire feeding, plus shooting pains that radiate from nipple back into breast occurring w/ letdown and feeding No fevers, chills, or body aches Nipples and areolae are bright pink; cracks and fissures on both nipples; no other erythema, warmth, induration or fluctuance Baby appears to have oral thrush

How is breast candidiasis evaluated? Pain from intraductal yeast infections is often described as shooting and radiates from nipple to chest wall, and is out of proportion to the clinical exam Nipple/areola may appear shiny or flaky Skin scraping for microscopy Positive breast milk culture Often associated w/ other yeast infections in the infant, such as thrush or diaper area dermatitis There is not universal agreement among clinicians and researchers regarding the existence of this clinical entity

How is breast candidiasis treated? Blisstree.com Infant and mother treated Topical nystatin or gentian violet for infant Topical nystatin, miconazole, or ketoconazole for mother if infection seems to be cutaneous only (not intraductal) Another option is oral fluconazole (Diflucan) for mom, /baby (not FDA approved, but used frequently for moms) Mother: 400mg po on day one, then 200mg po daily X at least 10 days Infant: 6-12mg/kg po on day one, then 3-6mg/kg po daily X at least 10 days

What are the risk factors for mastitis? Most common in 2nd and 3rd weeks postpartum (75-95% occurring before infant is 3 mos of age) Poor breastfeeding technique Infant cleft lip/palate or short frenulum Cracked nipples Missed feeding(s) Nipple piercing Poor maternal nutrition Plastic-backed breast pads, tight bra Yeast infection Manual pump use Breastfeedingbasics.com

What interventions can decrease the risk of mastitis? Improve breastfeeding technique and latch Apply expressed breast milk or lanolin to nipples and areolae Treat yeast infections Consider frenotomy

How is mastitis diagnosed and treated? Localized, unilateral breast tenderness and erythema Fever, malaise, fatigue, body aches, headache Breast milk cultures rarely indicated, unless infection fails to respond to tx Most common organism is S. aureus Treat with antibiotics and improving breastfeeding technique Complete emptying of the breast is key, and breastfeeding should continue; this decreases risk of abscess

How is mastitis diagnosed and treated? Antibiotic choices Amox/clav 875 mg po bid Cephalexin 500 mg po qid Clindamycin 300 mg po qid Dicloxacillin 500 mg po qid TMP/SMX 160/800 mg po bid (avoid in mothers of infants 2mos or sick infants of any age) Duration of tx usually 10-14 days Abscess should undergo I&D or needle aspiration, w/ fluid sent for culture, and breastfeeding can usually continue

Another patient with breastfeeding difficulties Noemi is a 24 y/o G2P2 s/p NSVD at 36 weeks following spontaneous preterm labor Mother and infant discharged home at 2 days postpartum, w/ LATCH score of 7-8 Followed closely in clinic for infant weight gain Infant is now 6 weeks old, and mom returned to work 2 weeks ago Having a hard time pumping at work, and thinks milk supply is decreasing Baby’s grandma has been giving an ounce or two of formula, along w/ EMB, while mom at work

Why should we promote exclusive breastfeeding? Human milk provides Nutrients and energy for rapid growth and development Protective factors against infection Otitis media, diarrheal illness, upper respiratory infection Decreases pain and suffering Reduces lost work time for parents Chronic disease prevention Diabetes mellitus Celiac disease Childhood cancers Atopic disease Multiple sclerosis Inflammatory bowel disease

What are the costs of suboptimal breastfeeding in the U.S.? 2010 study by Bartlick and Reinhold, published in the journal Pediatrics Looked only at costs of pediatric diseases Used “2007 dollars” If 90% of US families breastfed exclusively for 6 months, the U.S. would save 13 billion and prevent 911 deaths At 80% compliance, savings would be 10.5 billion and 741 deaths

What are current breastfeeding recommendations? American Academy of Pediatrics and American Academy of Family Physicians 4-6 months exclusively Continue for at least 1 year World Health Organization 4-6 months exclusively Continue for at least two years

How can we help women maintain/increase breast milk production? Avoid introduction of formula Pump q 3h when away from baby Pump immediately after each feed Adequate rest, nutrition, and hydration for mother Have a “nurse-in” Natural products: mother’s milk tea, oatmeal, etc. Metoclopromide course for mom: 10 mg po tid X 10 days (or other regimens/drugs) Advocate for breastfeeding-friendly policies in your own workplace and community!

Evaluation and Management of Newborn Jaundice

A newborn at risk for hyperbilirubinemia Baby Girl T was delivered to a 40 y/o G1P0 at 35 6/7 wks GA via emergent c/s for fetal bradycardia occurring following combined spinal-epidural for planned external cephalic version in setting of PPROM and breech DOB 5-13-15 at 05:50, Apgars 3 & 9, L&D BW 2260g PPV at delivery, MBU for couplet care, MBU BW 2240g Initial bili 7.2 at 28 hours of life Coombs negative Exclusively breastfed D/c’d home day 3, f/u day 5 with bili of 20.3, wt 2120g

How is newborn jaundice evaluated in the outpatient setting? Is breast milk intake adequate? Insufficient intake decreased stool production increased reabsorption of bili from gut elevated unconjugated (indirect) bili Weight loss or insufficient gain? Poor urine or stool output? Persistent meconium stools? Elevated bili lethargy and poor feeding higher bili Inadequate intake dehydration, malnutrition, risk of kernicterus Often called “breastfeeding jaundice” but should be called “not-enough-breastfeeding jaundice”

How is newborn jaundice evaluated in the outpatient setting? Are there risk factors for hemolysis? Polycythemia Cephalohematoma or bruising at birth ABO incompatibility or Rh isoimmunization Red cell glucose metabolism enzyme deficiencies: pyruvate kinase Hereditary spherocytosis or other RBC membrane abnormalities

Could it be breast milk jaundice? What is that? Presents in the first or second week of life Can persist for up to 12 weeks Resolves spontaneously Incidence 36% in exclusively breastfed infants Hypothesized to involve a breast milk component that increases enterohepatic circulation of bilirubin Weight gain, stool/urine output, and physical exam should all be normal Total serum bili in breast milk jaundice alone should be 12 mg/dl Conjugated (direct) bili should be less than 1mg/dl

How can you be sure it’s just breast milk jaundice? If direct bili 1 but total bili is 12, additional evaluation is needed First r/o hemolysis: hct or hgb, reticulocyte count, coombs, peripheral smear Test for G6PD deficiency People of African, Asian, Latino, Mediterranean and Middle Eastern descent at higher risk 4.9% of world’s population affected: 12% of African American men, 4.3% of Asian American men X-linked, but can also affect females Risk of false negative test from larger amount of G6PD in young RBCs, more released w/ hemolysis—consider retesting when jaundice is resolved Review newborn metabolic screen results Consider parental bili levels for Gilbert’s Testing for all UGT 1A1 mutations is not readily available, but some are obtained w/ newborn metabolic screening

What does UGT 1A1 do and what are the associated mutations? UGT 1A1 (uridine diphosphate glucuronosyltransferase 1A1) hepatic enzyme that conjugates bilirubin After conjugation, bili travels to small intestine in bile Intestinal flora converts it to stercobilin Stercobilin is excreted in stool Beta-glucuronidase can deconjugate bili Deconjugated bili is absorbed by intestinal mucosa and returned to liver via portal circulation (enterohepatic circulation) UGT 1A1 mutations Crigler-Najjar type I: 1 in 1 million babies, no enzyme production, critically high bili, kernicterus and death if untx’d in newborn period, most die later in life of kernicterus; liver transplant is currative Crigler-Najjar type II: indolent course, elevated bili but below LL, responds to phenobarb which induces UGT 1A1 production Gilbert’s syndrome: 8% prevalence, eznyme levels 1/3 rd to 1/10th of normal, mild effect on bili but could be additive w/ another cause

What are some other non-hemolytic etiologies? Biliary atresia Neonatal hepatitis Galactosemia Hypothyroidism Pyloric stenosis Annular pancreas Duodenal or jejunal atresia Sepsis Medication exposures: ceftriaxone, dicloxicillin, sulphonamides

Our patient’s clinical course Date Time Bili Tx Level 5/14 09:45 7.2 10.5 Observe 5/15 07:00 10.0 13.2 Observe 5/16 06:00 13.8 15.5 2100 D/c home 5/18 08:45 20.3 18 2120 Admit for photo tx 5/18 21:00 15.0 18 5/19 08:30 10.7 18 5/22 10:45 14.1 5/28 09:15 18.0 (dir 0.4) 2330 MCH consulted, feed freq’ly, f/u for wt 6/1 15:45 17.8 (dir 0.4) 2410 F/u 4-7d 6/8 09:30 19.7 (dir 0.6) 2330 Wt loss noted, MCH consulted w/ plan to admit, PCP rec no admit, supplement w/ formula, G6PD, retic, repeat coombs. 6/9 15:15 16.2 (dir 0.5) 2380 On-call resident leaves vm for mom to go to Peds ED. Email communication b/w mom and PCP that Peds ED not needed. 2450 Got 30cc formula after each breast feed. 6/10 6/11 11:45 12.7 (dir 0.4) Weight Action Continue photo tx 2150 D/c photo tx and d/c home F/u in 6d Mom notified by PCP, continuing care at Pres per prior plan.

Phototherapy Guidelines

Newborn Jaundice Clinical Decision Making Pathway Preer GL, Philipp BL. Understanding and managing breast milk jaundice. Arch Dis Child Fetal Neonatal Ed (2010). doi:10.1136/adc.2010.184416

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References, continued Yonkers K, Wisner K, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. General Hospital Psychiatry. 31 (2009): 403-413. Payne J, Meltzer-Brody S. Antidepressant use during pregnancy: current controversies and treatment strategies. Clinical Obstetrics and Gynecology. Vol. 53, No. 3. 469-482. ACOG Practice Bulletin No. 92, April 2008. Use of Psychiatric Medications During Pregnancy and Lactation. Gjerdingen D., Yawn B. Postpartum depression screening: importance, methods, barriers, and recommendations for practice. Journal of the American Board of Family Medicine. May-June 2007. Vol. 20, No. 3. Preer GL, Philipp BL. Understanding and managing breast milk jaundice. Arch Dis Child Fetal Neonatal Ed (2010). doi:10.1136/adc.2010.184416