Elizabeth J. Corwin, PhD, RN, CNP,
and Megan Arbour, MS, CNM

ABSTRACTThe aim of this article is to review
postpartum fatigue, especially as it
relates to the occurrence andpathophysiology of three common
postpartum conditions known tocontribute to fatigue: anemia, infection/inflammation, and thyroid
dysfunction. Fatigue is an unrelenting condition that affects physicaland mental health, and it has implications for everyday activities,
motivation, and social interactions.
Although individuals of all ages
and both genders are at risk fordeveloping fatigue, postpartum fatigue is particularly challenging,
because the new mother has demanding life tasks to accomplish
during this period of time. Postpartum fatigue may impact postpartum maternal role attainment andmay place a woman at increased
risk for postpartum depression. Although several treatable physiological conditions common during the
postpartum period are known toincrease fatigue, none of these
conditions is a part of the usual assessment of healthy postpartum
women. For many women, subtle
fatigue may develop, linger orworsen, and even lead to depression, with both the woman andher care provider unaware.
Key Words: Postpartum fatigue;
Anemia; Hypothyroid; Inflammation; Postpartum depression; Evidence-based practice.
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In Western countries, the most common cause of aneostpartum fatigue is a debilitating condition that may
mia during pregnancy and the postpartum period is ironhave an impact on a new mother’s ability to care for
deficiency. Daily iron demand increases nearly 10-fold
her child (Troy, 2003). It also may delay a woman’s refrom the start of a pregnancy to term (Milman, 2006).
turn to functional status in the areas of household, social,
However, less than 25% of women start their pregnancies
employment, and self-care responsibilities (Troy, 2003; Mcwith iron stores sufficient to meet requirements, and only
Queen & Mander, 2003) and increase her risk of postpar5% increase their iron intake sufficiently during pregnantum depression (PPD) (Corwin, Brownstead, Barton,cy to make up that difference (Milman, 2006). This
Heckard, & Morin, 2005). Although fatigue likely exists onmeans that even with iron supplementation, by term aa continuum, the percentage of women who identify fatigue
large number of pregnant women are iron depleted, if not
as a significant symptom is estimated to increase from 20%
frankly anemic. Full compliance with iron recommendapreconceptionally to 50% to 64% among women immeditions during pregnancy is rare, with less than 30% of
ately postpartum (Lee & Zaffke, 1999). In one of the first
women fully compliant and an equal percentage denying
studies about this topic, Affonso, Lovett, Paul, and Sheptak
any iron supplementation during pregnancy (Nordeng,(1990) reported that nearly 70% of the women in theirEskild, Nesheim, Aursnes, & Jacobsen, 2003).
study acknowledged elevated fatigue 1 to 2 weeks postparDuring the postpartum period, iron deficiency contintum compared to nonpregnant women, with 40% continuues or worsens for a significant percentage of women.
ing to report elevated levels 12 weeks later. For many
Milman, Bergholt, Keld-Erik, Eriksen, and Graudal
women, lingering fatigue is a serious problem. In one study,(1999) found that 8 weeks after an uncomplicated delivamong a sample of 436 mothers, 44% rated postpartum faery, 16% of women not receivtigue as their second most freing supplemental iron during
quent complaint (to breast probpregnancy were iron deficient,lems) at 1 month postpartum; at 3Iron deficiency anemia isand 12% had frank iron defiand 6 months postpartum, fatigue
ciency anemia. Of women who
was the third most frequent comcommon during pregnancy
used iron supplementation conplaint (after respiratory and sexual
sistently during pregnancy (66problems) (Gjerdingen, Froberg,
and the postpartum period,
mg daily), 3% were iron defiChaloner, & McGovern, 1993).
cient and 1.6% were anemic. In
especially in young and lowThree Common
a study of low-income women,
incomewomen,
andis
Bodnar, Cogswell, and Scanlon
Contributors to(2002) reported postpartum
Postpartum Fatigue
linked to postpartum fatigue
iron deficiency prevalence rates
Postpartum fatigue is often seenof 12.7%, 12.4%, and 7.8% at
and poor health outcome.
as an inevitable consequence of
0 to 6, 7 to 12, and 13 to 24
the transition to motherhood.
months postpartum, respectiveAlthough it is true that situaly. Postpartum women in thetional factors, such as 24-hour infant care and caring forlowest income group (poverty index ratio <130%) wereother children in the home, may contribute to fatigue
four times more likely to be anemic at 0 to 6 months and(McQueen & Mander, 2003), physical conditions that inthree times more likely to be anemic at 6 to 12 months
crease postpartum fatigue also exist. These conditions inpostpartum, compared to more affluent women.
clude anemia, infection/inflammation, and thyroid dysIron deficiency anemia is linked to postpartum fatigue
function, all of which are amenable to evidence-based inand other poor health outcomes. In one study, women withterventions.
low Hb levels (<12 g/dL) at 3 months postpartum weremore likely to have postpartum fatigue (Lee & Zaffke,1999). Besides fatigue, anemia is associated with irritability,
Anemiaapathy, and an inability to concentrate. Interestingly, Beck
Anemia is defined as a hemoglobin (Hb) concentration lessand Indman (2005) identified each of these factors as comthan the established cutoff delineated by the World Healthmon presentations of PPD. Treatment of iron deficiency aneOrganization (WHO) for a particular population. The latest
mia in the postpartum period is straightforward but first reWHO report on anemia in pregnancy (WHO, 1992) estiquires diagnosis. Currently, the Centers for Disease Control
mates that 43% of nonpregnant women of reproductive age
and Prevention (CDC, 1998) recommend anemia screening
in developing countries, and 12% in industrialized countries,
at 4 to 6 weeks postpartum only for women who were diagare anemic; these estimates rise to 56% and 18%, respecnosed as anemic in the third trimester, who had experienced
tively, by the third trimester of pregnancy. After childbirth,
excessive blood loss during delivery, or whose pregnancies
Hb levels fall slightly during the first 24 hours because of
had resulted in a multiple birth. Other women are generally
blood loss and then rise over the next 2 to 5 days. Hb
not tested for anemia after discharge unless they are symptoshould return to the normal nonpregnant range by 7 days
matic. Symptoms of iron deficiency anemia, however, are of(Milman, 2006).

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Postpartum infection and postpartum thyroid deficiency
may go undetected and contribute to lingering fatigue.

ten subtle, especially if the anemia has developed over a prolonged period. Even women who suffer excessive blood loss
during or after delivery and are known to be severely anemic (Hb <9 mg/L), are typically sent home only with instructions to take iron. In a search of standard postpartum
guidelines, we were unable to identify anticipatory guidance
recommendations regarding the high level of fatigue these
women should expect to experience (CDC, 1998).
Evidence-Based Intervention for Anemia
A clear, evidence-based intervention would be to identify, via anurse-initiated telephone call, women who—when asked—report that they are experiencing a high level of postpartum fatigue. In our previous work, we have identified a score of >6
on a well-validated postpartum fatigue screening tool, theModified Fatigue Symptom Checklist (Pugh, Milligan, Parks,
Lenz, & Kitzman, 1999), administered on day 14 postpartum
as above the normal range and indicative of severe postpartum fatigue (Corwin et al., 2005). Using this or a different
tool or simply asking questions, screening for significant fatigue could be accomplished in a few minutes. Any woman
who complains of severe fatigue at 2 weeks postpartum
should be scheduled for an appointment, at which time sheshould be screened for anemia by obtaining (at a minimum) a
test of Hb concentration or hematocrit. If the woman is nototherwise ill, a low Hb or hematocrit would allow for a presumptive diagnosis of iron deficiency anemia, and treatment
could be initiated. All other postpartum women could be tested in the same manner for anemia at the 6-week postpartum
visit. Treatment for anyone found to be anemic should include
dietary advice regarding increased consumption of foods richin iron, iron therapy, and anticipatory guidance regarding
managing fatigue. Iron therapy involves iron administeredorally at a dose between 60 and 120 mg/day (in divided doses) for at least 6 months (CDC, 1998). Follow-up laboratory
analyses are required to evaluate treatment success. An increase in reticulocytes should be detectible within 7 to 10 days
after initiation of oral iron therapy. Hb levels should begin torise within 3 days, showing a maximum response by 4 weeks.
An increase in Hb concentration of >1 g/dL or in hematocritof >3% at 4 weeks confirms the diagnosis of iron deficiency
anemia. With treatment, postpartum iron deficiency anemia
should resolve within 12 weeks. Women who do not respondto iron therapy by 4 weeks should be evaluated for othercauses of anemia.
Infection/Inflammation

Postpartum infection includes infections that occur in the firstdays after delivery (e.g., postpartum endometritis) and infections that may develop weeks after delivery (e.g., infectious
mastitis). As with most infections, postpartum infections activate the immune system, resulting in inflammation and theJuly/August 2007

production of proinflammatory cytokines. The exact incidence of postpartum infection is difficult to ascertain because
most infections occur after hospital discharge. In one large
study that included screening ambulatory medical records,
emergency room reports, and pharmacy records of morethan 2,800 women within 1 month of giving birth, the postpartum infection rate was 6%, with rates varying from 5.5%
after vaginal delivery to 7.4% after cesarean section (Yokoe
et al., 2001). The most common types of postpartum infection are endometritis, urinary tract infection, and mastitis(Yokoe et al., 2001). Other common sites include the vagina,
vulva, perineum, and cervix. Obstetrical history regarding
type of delivery, length of labor after rupture of membranes,internal fetal monitoring, manual removal of the placenta,
catheterization during labor, and breastfeeding highlights
women at greatest risk. Risk of infection is also increased for
women with diabetes, HIV, or other immune deficiencies(Lehtovirta et al., 2005) and for obese women (Usha Kiran,Hemmadi, Bethel, & Evans, 2005). Infection can be diagnosed based on physical findings, including fever, foulsmelling vaginal discharge, pain on urination, and tendernessof uterus, abdomen, or breasts. Laboratory screenings include wound, cervical, breast milk, and urinary cultures.
Proinflammatory cytokines drive and mediate the immune response and are known to cause systemic symptoms,
including fatigue. Although endometritis and mastitis often
present with other more severe symptoms, including fever
and pain, some infections (including urinary tract infection[UTI] and subclinical mastitis) may present with fatigue as
the primary complaint in postpartum women. Postpartum
women are susceptible to UTI for several months because of
persistent postpartum ureteral dilation and vesicoureteral reflux. Likewise, mastitis may develop at any time in awoman who is breastfeeding.
Currently, there are no studies correlating either subclinical or frank infection and postpartum fatigue. Groer et al.
(2005) did identify a relationship between postpartum fatigue and self-report of respiratory infection, although participants’ report of infection was not objectively confirmed.
Common sites for postpartum infection, such as the breasts,
uterus, vagina, vulva, perineum, or cervix, were not specifically addressed by the researchers. Focusing on inflammation and fatigue in the postpartum period, however, previous work from our laboratory found that postpartum fatigue was positively correlated with increased urinary interleukin-1 beta in healthy women (Corwin, Bozoky, Pugh, &Johnston, 2003). In this study, none of the women were
known or suspected to be suffering from an infection, however, and no cultures were performed.
Evidence-Based Intervention for Infection/Inflammation
Given the frequent occurrence of infection in the postpartum
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period and the established association between infection, inflammation, and fatigue, a second evidenced-based intervention to reduce postpartum fatigue would be to evaluate all
women for infection at the 6-week postpartum visit. This assessment should be done with the caveat that two groups ofwomen should be screened earlier than 6 weeks: women athigh risk for postpartum infection because of obstetrical orother factors and any woman scoring as significantly fatigued over the phone at 2 weeks postpartum. In addition to
obtaining an accurate history and completing a focused
physical exam at the 6-week visit, obtaining a urine culture
and complete blood count with differential may identify
women with infection. Anticipatory guidance for all women
after childbirth that alerts them to subtle symptoms of infection (including symptoms that may develop months later) is
another important intervention. Treatment would include
the appropriate antibiotic therapy and a follow-up appointment to test for cure. Certain antibiotics, including the sulfonamides and quinolones, should be avoided in womenbreastfeeding their infants. Antibiotic prophylaxis for all
women after cesarean section is recommended (Smaill &Hofmeyr, 2002).
Thyroid Dysfunction

The thyroid gland produces the hormones thyroxine (T4)and tri-iodothyronine (T3) in response to thyroid-stimulating hormone (TSH) released from the anterior pituitary gland. TSH in turn, is produced in response to stimulation by the hypothalamic hormone, thyrotropin releasing hormone (TRH), which is itself secreted in response to multiple metabolic signals. In healthy individuals, negative feedback among all thyroid hormones ensures that serum levels of TRH, TSH, T3, and T4 remain
within a narrow range. Women with clinical hypothyroidism demonstrate elevated serum TSH levels in conjunction with reduced T4 (and to a lesser extent, T3); patients with subclinical hypothyroidism demonstrate elevated TSH levels in conjunction with normal levels of T4(American Association of Clinical Endocrinologists[AACE], 2002). Total or free T3 levels are not considereddiagnostic for hypothyroidism.
Most women without pre-existing hypothyroidism remain euthyroid during pregnancy, although de novo development of hypothyroidism during pregnancy does occur at
an incidence rate of approximately 2.5% (Lazarus, 2003).
After giving birth, between 1.1% and 16.7% (mean prevalence 7.5%) of previously well women develop a condition
called postpartum thyroiditis (PPT). Classic PPT is a subclinical condition characterized by the transient occurrence ofhyperthyroidism, followed by hypothyroidism beginning (onaverage) at 19 weeks postpartum and resolving by 1 year
(Stagnaro-Green, 2004). This pattern of hyperthyroidism
followed by hypothyroidism and then recovery is not universal, however. In a longitudinal study of 640 women, Lucas et al. (2005) found that among the 7.8% who developed
PPT, 42% experienced only hypothyroidism without preceding hyperthyroidism. Of those women, 56% ultimately de218

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veloped persistent hypothyroidism over the next several
years (8.1 ± 2.2).
Risk factors for PPT include diabetes mellitus, a personalor family history of autoimmune disease, and a history of
thyroid disease or goiter. Women positive for antithyroid
peroxidase antibodies (antiTPOAb), a standard prenatal
screening assay run early in gestation, are at an especiallyhigh risk (Lazarus, 2003). Most women with PPT, however,
have no identifiable risk factors.
Evidence-Based Intervention for Thyroid Dysfunction
Clinical diagnosis of hypothyroidism in postpartum womenis difficult because many of the symptoms—including fatigue and depressed mood—are nonspecific during thistime. Although measuring thyroid hormone levels is not
generally recommended for all postpartum women,
women who are known to be at high risk or suffering
symptoms, including depression or severe fatigue, may
benefit from screening. Especially likely to be undiagnosed
without screening are women who suffer from subclinicalhypothyroidism and whose symptoms, including fatigue,
may be mild although still significant compared to euthyroid persons. In the Colorado Thyroid Disease Prevalence
Study, significant symptoms were reported by nearly 30%
of women with untreated subclinical hypothyroidism,
with 18% of the respondents specifically identifying fatigue as a significant complaint (Canaris, Manowitz,
Mayor, Ridgway, & Chester, 2000). Again, a telephone
call at 2 weeks postpartum for self-report of fatigue may
identify women who need to be evaluated for early-onset
hypothyroidism; at each subsequent appointment, fatigue
should be re-evaluated.
To differentiate between relatively common symptomsof the postpartum period and hypothyroidism, the AACE
and others recommend asking postpartum women about
symptoms more specifically associated with hypothyroidism (but not the postpartum period), such as dry
skin, aches and pains, hoarseness, goiter, fluid retention,
forgetfulness, and constipation (AACE, 2002). Screening
tests recommended for postpartum women include a sensitive measurement of TSH level, free or total T4 level,
and antiTPOAbs. The AACE also recommended that thediagnosis of clinical or subclinical hypothyroidism beconsidered and assessed in all patients with depression.
Currently, there are no studies available that correlate thedevelopment of postpartum hypothyroidism with postpartum fatigue.
Women who are diagnosed with overt hypothyroidism
are treated with a high-quality levothyroxine. Althoughmanagement for each woman should be individualized,
the usual mean replacement dose is 1.6 mg/kg/day.
Women should be reassessed after an interval of at least 6
weeks and treatment titrated as necessary. Treatment ofsubclinical hypothyroidism is controversial, with reports
identifying and denying clear benefits (Chu & Crapo,2002). None of the studies on the effectiveness of treating
subclinical hypothyroidism have been conducted on postJuly/August 2007

partum women, however, for whom fatigue might be amore disabling and distressing symptom than for others.

Interactive Effects of Physiological
Factors on Postpartum Fatigue
Each of these physiological factors commonly identified ascontributing to fatigue—anemia, infection, and thyroid dysfunction—may occur together in the postpartum period andmay even synergize. For example, it is known that the inflammatory response can lead to iron deficiency, an occurrence believed to be an evolutionary response that serves todeny bacteria and other microbes access to the high iron levels required for their survival (Weiss, 2005). At the sametime, anemia may reduce immune function and increase therisk of infection (CDC, 1998). Likewise, most causes of hypothyroidism, including PPT, are autoimmune in nature,
driven by a proinflammatory cytokine immune response. Finally, iron deficiency anemia is associated with lower circulating levels of thyroid hormone, perhaps a result of diminished functioning of the iron-dependent enzyme thyroid peroxidase (TPO) required for the incorporation of iodide into
the thyroglobulin molecule (Zimmermann & Kohrle, 2002).
Thus, these three conditions have the potential to coexist
and augment a woman’s fatigue. To date, no studies havelooked at any synergistic effects of these conditions in postpartum women.

Linking Postpartum Fatigue and PPD
We and others have suggested that postpartum fatigue is asignificant risk factor for PPD (Troy, 2003; Corwin et al.,2005). Moreover, each of the conditions discussed in this article as a potential contributor to fatigue in postpartum
women has been linked on its own to the development of
PPD. For example, as part of a larger study, we identified
postpartum anemia as a significant risk in the developmentof depression (Corwin, Murray-Kolb, & Beard, 2003). Other studies on the relationship of postpartum anemia and depression have produced mixed results, indicating that more
research is required. No studies are available to indicate thatwomen with postpartum infections are at increased risk ofdeveloping depression. A limited number of studies, however, link the presence of elevated proinflammatory mediators
and PPD (Maes et al., 2000).
The evidence regarding dysfunctional thyroid function
postpartum and PPD is also limited. Although postpartum
hypothyroidism may contribute to depression, most womenwith PPD have normal thyroid hormone levels. A study by
Lucus, Pizarro, Grenada, Salinas, and Sanmarti (2001) reported results from a sample of 641 women, 11% of whomdeveloped postpartum thyroid dysfunction—defined as
overt or subclinical hyperthyroidism—between 1 and 3
months postpartum and/or overt or subclinical hypothyroidism between 3 and 6 months postpartum. In this study,
none of the women developed PPD, although the authors
did not identify rates of depression in women suffering hypothyroidism alone.
July/August 2007

Suggested Clinical Implications
Nurses should consider implementing the followinginterventions:• Placing a “red flag” in a woman’s prenatal record if she
is known in advance to be especially susceptible toconditions associated with postpartum fatigue.
• Encouraging any woman with a particular risk to returnfor a 2-week postpartum visit for appropriate screening
for anemia, infection/inflammation, and thyroid dysfunction.
• Screening all other women for severe fatigue via a 2week postpartum nurse-initiated telephone call, using
the Modified Fatigue Symptom Checklist.
• Asking women about their fatigue.
• Treating anyone found to be anemic with dietaryadvice, iron therapy, and anticipatory guidance regarding managing fatigue.
• Evaluating all women for infection at the 6-week postpartum visit and evaluating women with fatigue earlier.
• Evaluating thyroid function in women who are at highrisk for depression or fatigue.

Clinical Practice Implications
Postpartum anemia, infection/inflammation, and altered thyroid function are decidedly amenable to evidenced-based interventions, provided they are first diagnosed. Healthcare
providers, including clinic and office nurses, nurse practitioners, and midwives, are in a position to (a) place a “redflag” in a woman’s prenatal record if she is known in advance to be especially susceptible to any of these conditions
based on previous medical history, (b) review those red flags
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Nurses can instituteinterventions, such as 2-week
postpartum assessment for
fatigue and physiologicalsymptoms, and help women
get treatment for fatigue.
and any others that develop during delivery before the discharge of a new mother and her infant, (c) encourage any
woman with a particular risk to return for a 2-week postpartum visit for appropriate screening, and (d) screen allother women for severe fatigue via a 2-week postpartum
telephone call, encouraging women identified as severely fatigued to come in for an appointment as soon as possible.
For these recommendations to be implemented, all the
stakeholders in women’s health (including women’s and pediatric healthcare providers and insurance providers) must
agree that postpartum fatigue and depression carry emotional and economic expenses that make prevention not only
advisable but also cost-effective. Documenting cost effectiveness, in turn, requires well-designed interventions evaluatedby evidence-based research. Finally, all new mothers should
receive anticipatory guidance on recognizing the signs andsymptoms that suggest anemia, infection, or thyroid abnormality and how to prevent and respond to severe postpartum fatigue (Troy, 2003). By these means, clinicians will bebetter able to assist new mothers in meeting their role demands and may reduce their risk of developing PPD. ✜Elizabeth J. Corwin is an Associate Professor, College ofNursing, The Ohio State University, Columbus. She can bereached via e-mail at Corwin.56@osu.edu
Megan Arbour is a Graduate Teaching Associate, College
of Nursing, The Ohio State University, Columbus.
The authors deny any conflict of interest or financial
arrangement with any companies or institutions that may
benefit from the findings presented in this article.
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