# Clinical Cases: Postpartum Period

## Case 1: Postpartum Hemorrhage Due to Uterine Atony

### Clinical Image
![Postpartum Hemorrhage](case_01_image.jpg)
*Source: [Wikipedia - Postpartum bleeding](https://en.wikipedia.org/wiki/Postpartum_bleeding) - CC BY-SA 4.0*

### Case Presentation
A 32-year-old G4P4 woman has just delivered a 4.1 kg infant vaginally after oxytocin augmentation for a prolonged labor lasting 18 hours. The placenta delivers spontaneously 10 minutes after delivery. Within 30 minutes postpartum, the nurse notes heavy vaginal bleeding with clots. Estimated blood loss is already 800 mL. The uterus is palpated and found to be soft and "boggy" above the umbilicus rather than firm and contracted. Vital signs show heart rate 105 bpm and blood pressure 100/65 mmHg. The diagnosis is postpartum hemorrhage secondary to uterine atony. Bimanual uterine massage is initiated immediately. Oxytocin infusion is increased, and methylergonovine (Methergine) 0.2 mg IM is administered (after confirming the patient is not hypertensive). The uterus remains poorly contracted. Misoprostol 800 mcg is given rectally. Tranexamic acid 1 gram IV is administered. With aggressive uterotonic therapy and continued massage, the uterus becomes firm. Total blood loss is estimated at 1500 mL. The patient receives 2 units of packed red blood cells. Hemoglobin the following day is 8.5 g/dL. She is discharged on day 2 with oral iron supplementation and does well at her postpartum visit.

### Key Learning Points
- Uterine atony is the most common cause of postpartum hemorrhage (PPH), accounting for approximately 70% of cases; risk factors include overdistension (macrosomia, polyhydramnios, multiple gestation), prolonged labor, chorioamnionitis, and oxytocin use
- The "4 T's" framework for PPH causes: Tone (atony), Tissue (retained products), Trauma (lacerations), and Thrombin (coagulopathy)
- First-line management includes uterine massage and uterotonic agents: oxytocin, methylergonovine (contraindicated in hypertension), carboprost (contraindicated in asthma), and misoprostol
- Tranexamic acid given within 3 hours of delivery reduces PPH-related mortality and should be considered early in management

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## Case 2: Postpartum Endometritis

### Clinical Image
![Endometritis](case_02_image.jpg)
*Source: [Wikipedia - Endometritis](https://en.wikipedia.org/wiki/Endometritis) - CC BY-SA 3.0*

### Case Presentation
A 28-year-old G1P1 woman is postoperative day 2 following cesarean delivery for arrest of dilation. Her labor had been prolonged, with rupture of membranes 28 hours before delivery, multiple cervical examinations, and internal fetal monitoring. She develops fever to 38.8°C with chills. She reports lower abdominal pain and foul-smelling lochia. Physical examination reveals uterine tenderness on palpation and purulent cervical discharge. Laboratory studies show WBC 18,000/μL with left shift. The diagnosis is postpartum endometritis. Blood and endometrial cultures are obtained. Empiric IV antibiotic therapy with clindamycin 900 mg IV every 8 hours plus gentamicin 5 mg/kg IV daily is initiated. By 48 hours, she remains febrile. Ampicillin 2 g IV every 6 hours is added to the regimen to cover enterococcus. Within 24 hours of adding ampicillin, she becomes afebrile. Antibiotics are continued until she has been afebrile for 24-48 hours. She is discharged on hospital day 5 without need for oral antibiotics and recovers fully.

### Key Learning Points
- Endometritis is the most common cause of puerperal fever; cesarean delivery is the strongest risk factor (5-10x higher risk than vaginal delivery), especially with labor and ruptured membranes
- Other risk factors include prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, internal monitoring, and chorioamnionitis
- The classic antibiotic regimen is clindamycin plus gentamicin; if no improvement in 48 hours, ampicillin is added to cover enterococcus
- Endometritis is a polymicrobial infection involving vaginal flora including anaerobes, gram-positive cocci, and gram-negative rods

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## Case 3: Postpartum Depression

### Clinical Image
![Postpartum Depression](case_03_image.jpg)
*Source: [Wikipedia - Postpartum depression](https://en.wikipedia.org/wiki/Postpartum_depression) - CC BY-SA 4.0*

### Case Presentation
A 30-year-old G1P1 woman presents for her 6-week postpartum visit. She delivered a healthy infant vaginally without complications. During the visit, she appears tearful and withdrawn. On questioning, she reports persistent sadness, difficulty bonding with her infant, feelings of worthlessness as a mother, severe fatigue despite the baby sleeping through the night, poor appetite, and difficulty concentrating. She initially experienced "baby blues" after delivery but her symptoms have progressively worsened over the past month rather than improving. She denies suicidal ideation or thoughts of harming her infant but admits to intrusive thoughts that something bad will happen to the baby. The Edinburgh Postnatal Depression Scale (EPDS) score is 18 (scores above 10 suggest possible depression). The diagnosis is postpartum depression. The patient is referred for psychiatric evaluation. She is started on sertraline 50 mg daily (chosen for its favorable profile during breastfeeding with minimal transfer into breast milk). She is also referred for cognitive behavioral therapy. At follow-up 8 weeks later, her symptoms have significantly improved, she is bonding well with her infant, and her EPDS score has decreased to 6.

### Key Learning Points
- Postpartum depression affects 10-15% of women and is distinguished from "baby blues" (50-80% of women, resolves by 2 weeks) by persistence and severity of symptoms
- Risk factors include history of depression or anxiety, inadequate social support, stressful life events, and previous postpartum depression
- The Edinburgh Postnatal Depression Scale (EPDS) is the recommended screening tool; scores above 10 warrant further evaluation
- SSRIs (particularly sertraline due to low breast milk transfer) are first-line pharmacotherapy; combination with psychotherapy is most effective