Pathological puerperium: challenges and complications of the postpartum period

INTRODUCTION

The puerperium is the period from the third stage of labor until six to eight weeks after delivery.(1,2,3,4,5,6) Approximately 200 000 to 300 000 women die annually due to complications during this time, and the leading causes are postpartum hemorrhage, puerperal infections, and psychological disorders, such as depression.(7,8,9,10) Despite the increasing attention to the puerperium, there are still significant challenges that affect the well-being of women,(11,12,13,14) mainly due to the underestimation of symptoms and the lack of adequate care for them.(15,16,17,18) Thus, the difficulties of underdiagnosis, lack of medical access, little or no support network, and inadequate psychological care lead to more relevant complications of pathological puerperium.(19,20)

This research guide's hypothesis is that early identification and effective intervention for pathological puerperium complications can significantly improve health outcomes for women and their babies. The objective is to analyze and explore the main challenges and complications of the pathological puerperium, proposing a model that facilitates more appropriate and timely postpartum care. Through this research, we seek to contribute to the improvement of clinical practices and increase awareness of the importance of comprehensive postpartum care.

METHODS

This research was a comprehensive literature review of various literature and studies on the pathological puerperium. Databases such as PubMed and SciELO, as well as manuals and treatises on gynecology and obstetrics, will help identify the risk factors and the main complications associated with this period.

The search was on postpartum women < 20 years: this group faces risks associated with physical immaturity and less maternal experience, as well as economic and emotional factors that increase the likelihood of complications. Puerperal women > 35 years: advanced age is related to a higher risk of gestational and puerperal pathologies, as well as an increase in the rate of inductions and cesarean sections, especially in nulliparous women. These women may also present conditions such as diabetes and hypertension, increasing morbidity and mortality. Puerperal women in general: specific risk factors and prenatal and postnatal conditions influencing the puerperium will be evaluated.

It is essential to highlight that the types of delivery: both cesarean sections and vaginal deliveries will be considered. Recent articles were used: studies published between 2014 and 2023 that dealt with pathological puerperium will be included, as well as literature addressing pathophysiological complications and clinical management. Articles that were excluded from the study: articles that did not address pathological puerperium, studies of women with previous surgeries, as they could complicate the identification of pathologies; paid articles, research on women with very extreme maternal age (<15 or >45 years), for specific conditions that do not represent the general population, studies with approach to pregnancies with gestational age <28 weeks, focused on advanced complications, articles of women with severe pathologies (heart failure, renal failure), sources with incomplete data that compromise the integrity of the study.

Identifying and analyzing these factors will benefit health professionals and patients, improving the understanding and care of the pathologic puerperium.

RESULTS

The findings obtained from the literature review on the pathologic puerperium were used to evaluate risk factors and the main complications associated with this critical period.

A total of 28 articles were reviewed, using 21, plus the obstetric literature: Williams and Rezende, which explained the risk factors and complications and included puerperal women, population by age groups. It was observed that 60 % of the participants were under 20 years of age, which suggests a high incidence of adolescent pregnancies. This group did not enter the study because of their physical immaturity, i.e., they have not yet completed their physical development and also have less maternal experience, as well as the relationship with economic and emotional factors, which increase the chances of challenges and complications.

On the other hand, 30 % belonged to the group of women older than 35 years. This group often presents greater complications since this age is more associated with a greater chance of gestational and puerperal pathology, so it is also associated with more medical inductions, a higher rate of cesarean sections, and pathologies such as diabetes and hypertension.(1)

It is essential to highlight that several risk factors contributing to pathological puerperium were identified. In particular, a significant prevalence of complications was recorded, including:

Postpartum hemorrhage: 25 % of women presented this complication, being one of the leading causes of maternal mortality (21) and it is responsible for 30 % of all maternal deaths in developing countries. In this context, the main complications related to bleeding are uterine hypotonia and atony, laceration of the tract, retained placenta or placental debris, hematomas, and uterine inversion

Intraparenchymal hematoma with active bleeding: a 41-year-old woman on her third postpartum day begins with a headache and right hemiparesis. A large left hemispheric intraparenchymal hematoma is identified on cranial computed tomography without intravenous contrast (a). After contrast administration, contrast extravasation is observed within the hematoma (b, circle) as a sign of active bleeding.

Postpartum infections: 15 % of women experienced infections, which may derive from inadequate hygienic conditions or complications during delivery. The main ones are endometritis, episiotomy infection, and infection of the abdominal wall.(3) It is important to note that mammary alterations may also be a complication associated with fever in the postpartum period.

Endometritis: a 37-year-old woman in the second week of postpartum with persistent fever and pelvic pain. The computed tomography (a) shows an enlarged uterus with abundant hypodense content and gas, greater than expected for the second postpartum week. Clinical correlation is essential; image ''b'' belongs to another asymptomatic patient, and hypodense content and gas bubbles are observed in the endometrial cavity as a normal finding.

Psychological disorders: 20 % of the women reported problems such as depression and anxiety, which highlights the need for mental health care since these numbers are increasing every year, and it is a little-discussed problem.(4,16,22)

The type of delivery also influences complications and challenges, mainly when the diagnosis is late.

Vaginal deliveries: they presented postpartum hemorrhage in 10 % of the cases, with infections in 5 % and psychological disorders in 15 %.(5,4)

Cesarean sections: complications were higher, with postpartum hemorrhage 40 %, infections 30 %, and psychological distress 25 %.(2) These results suggest that cesarean sections, although often necessary, may be associated with an increased risk of complications.

Infection of surgical wound in cesarean delivery, the patient was 22 days postoperative, had skin and subcutaneous cellular tissue involvement, called necrotizing fasciitis, and the patient evolved to a picture of puerperal sepsis. Case report retrieved from Gynecol. Obstet. mex. vol.86 no.8 Mexico City Aug. 2018: Necrotizing fasciitis in the surgical wound. A case report finding of the review was that 70 % of women did not receive adequate postpartum care; that is, critical deficiency in the health system, and lack of follow-up can lead to an increase in complications.(3) Thus, there is an urgent need to implement more rigorous and accessible care protocols for women in the puerperium once care protocols and education for health professionals would provide a solid basis for discussion on the interventions needed to address the challenges in the pathological puerperium and, mainly, aiming to decrease the risks, complications, and challenges is these women.(10)

DISCUSSION

The puerperium is a critical period for maternal health, where early identification of risk factors and complications is essential to improve outcomes. This analysis reveals that the main complications of pathological puerperium include postpartum hemorrhage, puerperal infections, breast alterations, thromboembolic diseases, and psychiatric disorders. When related to the main risk factors: maternal age (women younger than 20 years and older than 35 years), parity (primiparous women may have different risks compared to multiparous women), type of delivery: cesarean deliveries have a higher risk of infections and complications compared to vaginal deliveries, duration of labor: prolonged labor may increase the risk of hemorrhage and trauma, Medical factors(history of diseases: conditions such as diabetes mellitus, hypertension, heart disease and coagulation disorders) and infections during pregnancy: the presence of previous infections may predispose to puerperal infections: pregnancy may predict problems in the puerperium. Postpartum hemorrhage: puerperal hemorrhage is the leading cause of maternal mortality worldwide, accounting for 30 % of deaths in developing countries.(2,4,9,16,19,21) The most common causes are uterine hypotonia, tract lacerations, and retained placental debris. Evidence suggests that an accurate clinical diagnosis and proper management using uterotonics and tamponade techniques are crucial to reducing mortality.(6,9) It is essential to highlight that in Argentina, although arterial hypertension is the leading cause of maternal death, hemorrhage continues to be a significant concern.

Puerperal infections: these infections, especially endometritis, are significant factors of morbidity.(1,21) Research confirms that cesarean sections increase the risk of infections, especially in contexts of malnutrition and lack of prenatal care. One measure shown to reduce puerperal infection is the prophylactic administration of antibiotics, i.e., it effectively reduces the incidence of postoperative infections. Breast alterations: breast complications, such as lactational stasis and fissures, affect the physical and emotional well-being of mothers; once, in some cases, because of pain, they stop breastfeeding and suffer even more, feel unable to nourish their child and contribute to the process of postpartum depression. Thus, education on breastfeeding techniques and timely treatment are essential to prevent serious infections such as mastitis and emotional problems that can be caused.

Thromboembolic diseases: Deep vein thrombosis and pulmonary embolism pose a considerable risk. Since symptoms can be mistaken for regular physiological changes, it is therefore crucial that physicians maintain a high index of suspicion and make appropriate diagnoses. Early anticoagulation can be lifesaving and should be part of the management strategy in women with identifiable risk factors.

Psychiatric disorders: postpartum depression is a growing problem associated with stressors and hormonal changes. Mothers who face traumatic events during pregnancy or who lack social support are particularly vulnerable. A multidisciplinary approach that includes mental health assessment as part of comprehensive postpartum care is required. Appropriate care can mitigate the impact of these disorders on mother and baby. In conclusion, this research highlights the complexity of the pathological puerperium and the interrelationship of its risk factors, complications, and postpartum challenges. A proactive approach that includes education, early diagnosis, and comprehensive treatment is crucial to improving maternal health outcomes and quality of life during pregnancy and in the puerperium. In addition, more studies are needed to evaluate effective interventions in each of these aspects since the best treatment is the prevention of the pathology, i.e., identifying risk factors, comprehensive care, and early diagnosis.

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