Consider: Sepsis, infection, anemia, diabetic ketoacidosis (if diabetic)

Vital sign changes may alert to shock, including the shock index (SI).

Headache, visual changes

Atelectasis (temporary suboptimal inflation of dependent lung regions): Common in the first 1 to 2 days postoperatively, improves with upright positioning, ambulation, and deep breathing.

Pneumonia (community or hospital-acquired, aspiration): Often associated with febrile morbidity, may or may not be associated with oxygen desaturation or cough. Aspiration pneumonia or pneumonitis should be high on the differential in any patient who vomits during surgery (not uncommon after regional analgesia owing to hypotension), who is highly sedated without a secured airway, or who requires general endotracheal analgesia, especially emergently, when the stomach may not be empty.

Pulmonary edema (cardiogenic or noncardiogenic): Upon identification of pulmonary edema, echocardiogram is recommended to distinguish between the two.

Pulmonary embolism: Signs and symptoms may be subtle and mimic other pathologic entities; therefore, a high index of suspicion and prompt evaluation is warranted. These include mild shortness of breath, cough, chest pressure/pain, tachycardia, calf tenderness, swelling, or leg pain. Deep venous thrombosis (DVT) of the lower extremities or small, subtle pulmonary embolism may herald a larger, submassive, or massive embolism that may follow and be life-threatening.

Transfusion-related lung injury

For most cardiac complications, it is important to optimize and maintain physiologic parameters. Consultation and team-based management with critical care and cardiology colleagues are recommended. Monitor electrolytes and aim to maintain potassium near 4.0 mmol/L and magnesium at or near 2.0 mg/dL whenever possible. Consider providing supplemental oxygen as needed to maintain SaO₂ ≥94%.

Diagnosis often relies upon physical examination (edema, cardiac heart sounds, and rhythm), electrocardiogram (EKG), echocardiogram (transthoracic and/or transesophageal), rhythm monitor (telemetry, 24-hour event monitor), and blood tests.

The differential includes, but is not limited to:

Ileus/small bowel obstruction: See the section below for detailed information about diagnosis and management of small bowel obstruction.

Bowel injury (acute or delayed): Bowel injury should be identified and repaired immediately if seen at surgery. If bowel contents are seen at surgery, immediately call in for surgical repair. Delayed bowel injury may follow severe bowel obstruction, toxic megacolon (marked dilatation of the colon ≥10 cm in diameter on x-ray), or thermal injury to the bowel. Abdominal pain, distension, nausea/vomiting associated with fever, and marked elevation of white blood cell count should alert the clinician to a possible bowel injury. Free air in the abdomen on imaging may reflect normal changes following the laparotomy required for cesarean. A new appearance of free air on repeat imaging, however, is more concerning. A bowel series with contrast that shows spillage of contrast is diagnostic and prompts immediate surgical intervention.

Hemoperitoneum: Abdominal pain, distension, and early or advances stages of shock may be present. See the section below for more detailed information.

Retroperitoneal hematoma: Abdominal or flank pain, fundal diversion to one side, and early or advanced stages of hemorrhagic shock may be present.

Urinary tract infection: May occur in up to 1% of patients who have an indwelling catheter, which is routinely placed to drain the bladder for cesarean delivery. Urinalysis and culture are recommended.

Bladder or ureteral injury: May be identified immediately at the time of surgery, as a delayed injury (such as a thermal injury). Delayed injury may present with acute pain, ileus, increase in serum creatinine, and the appearance of intra-abdominal fluid on imaging (ultrasound or computed tomography [CT] with contrast). See also Chapter 4.11, “Urologic Injuries During Delivery,” for further details.

Vesicovaginal fistula, ureterovaginal fistula: Most commonly presents following a prolonged labor. May also develop postsurgically following cesarean hysterectomy, especially if the vaginal cuff is devitalized or if there is insufficient space between the vaginal cuff and bladder. Symptoms include leakage of urine from the vagina or urine dermatitis of the perineum. Please see Chapter 6.2, “Vaginal Fistula Repair,” for more information.

DVT: Unilateral limb edema, pain, common. Up to one-third of DVTs during pregnancy may originate in the pelvis. Venous Doppler is the first-line imaging modality. Anticoagulation should be started before imaging whenever there is a strong suspicion for DVT.

Superficial thrombophlebitis: This presents as painful, tender, and sometimes erythematous cording of superficial veins. Treatment usually consists of warm compresses, nonsteroidal anti-inflammatory medication for pain control. Antibiotic use may be considered if there are signs of infection. Patients at increased risk for DVT formation may be started on prophylactic Lovenox or heparin.

Localized infection at venipuncture site: Erythema, purulent exudates, warmth, and pain characterize a local infectious process. If sepsis is suspected, blood cultures should be sent. Removal of any remaining lines and antibiotics targeted for common skin pathogens are the usual first-line treatment.