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MRCOG PART 2 SBAs and EMQs

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Essay 302 - Post-partum mental illness

Posted by s  C.
SC

a) I would initially try to calm the patient down in a quiet room and explore her fears and concerns. I would inform her that we take such allegations seriously and will investigate any misconduct. I would try and gain her trust and build a rapport.

I would also ask about her general physical wellbeing in order to obtain a history. I would enquire if she had been getting enough sleep. I would ask if she had any symptoms of a urinary tract infection such as dysuria or frequency. I would ask if she had a cough and if it was productive of sputum as pneumonia can present with acute confusion.

I would ask about her past medical history looking for a history of mental and physical disorders. Patients with a history of post natal depression, bipolar disease, schizophrenia, puerperal psychosis can present with acute confusion. Patients with a past medical history of endocrine disorders such as hypo or hyperthyroidism can also present with acute confusion.

I would take an obstetric history to identify any postnatal problems in her previous pregnancy such as puerperal psychosis and bipolar disorder are particular risk of recurrence.

I would ask about her drug history, particularly if she had any opiate analgesia following her caesarean, and what the doses and frequency were. I would ask if she had a history of alcohol abuse or illicit drug use as withdrawal can present with acute confusion.

I would take a blood sample for a full blood count to exclude leucocytosis associated with infection; urea and electrolytes as hypnatraemia can cause confusion; thyroid function tests as hypo or hyperthyroidism can cause confusion, and liver function tests and gamma GT can be deranged in alcohol withdrawal.

For completion, I would try and ascertain her normal behaviour by asking her partner or relatives about what she is normally like.

I would ensure that she is nursed in a side room which is good lighting. I would ask a member of staff to stay in the rooom with her to offer her suuport and reassurance. I would try and ensure that the same members of staff are involved with her care to avoid further confusion and aggravation.

I would inform the consultant obstetricinan and psychiatric team of her condition and our concerns that it could be puerperal psychosis. I would also inform that investigations into an organic cause had been requested.

If she becomes aggresive, it may be necessary to sedate her using haloperidol 1mg intramuscularly. If she is deemed to be at risk of harming herself or her baby, she will require sectioning under the Mental Health Act.

b) Factors that increase the risk of post-partum mental illness include a past medical history of psychiatric conditions such as bipolar disease or puerperal psychosis. Individuals with such a history have the highest chance of relapse in the 1st 2 weeks postnatally.

Patients with a history os postnatal depression particularly severe postnatal depression are at increased risk of recurrence in a subsequent pregnancy.

Risk of suicide is increased in a patient with a previous family history of bipolar disease or suicide.

Increasing patient awareness of these conditions could reduce the interval of onset of symptoms to seeking help. The Edinburgh Postnatal Depression Score is a validated tool for assessing if a woman requires more detailed assessment of her mood.

Risks can be minimised by planning postpartum care in a multidisciplinary approach involving the GP, midwife, health visitor, obstetrician and community psychiatric nurse and psychiatrist if necessary. Clear communication should be maintained between all individuals responsible for her care. If a midwife is concerned she about mental illness she should refer the patient directly to the psychiatric team. The psychiatric team should accept direct referrals from a midwife.

Those at risk of suicide, have severe postnatal depression or puerperal psychosis should be admitted to a mother and baby unit for treatment. Separation of the baby from the mother should be avoided where possible.

Mood stabilisers such as lithium should not be stopped without consultation with a psychiatrist. Breastfeeding should be avoided to avoid risks of lithium to the baby.

Tricyclic antidepressants should be avoided to reduce the risk of cardiotoxicity if taken as an oversdose.

Posted by Shalini  M.
Sh
a)I would begin by empathetically calming the patient and would try to counsel her and build a rapport with her by assuring her everyone around her is for her safety.Also whether she is getting enough sleep or adequate pain relief is experienced and address her anxieties.Also details of support from family need to be elicited that could be worrying her.A detailed history should then be enquired about past history of psychiatric illness or family history of the same in first degree relative as either predispose the women to develop post-partum mental illness.Any evidence of infection like fever,urinary complaints should be asked for.Any history of drug intake like opiate overdose should be asked and checked for.Review records for notes on any history of psychiatric disorders and GP should be contacted for any such history.Any previous child in child protection services should be enquired into.A psychiatric evaluation should be arranged by a Psychiatrist and selective serotonin reuptake inhibitors can be prescribed like venlafexine,paroxetine.She should be transferred to mother and baby unit for further care.There is no need to seperate mother and baby and breast feeding should be encouraged.The lady should be counselled and constant emotional support be provided.The partner should be counselled and advised to offer extended support.
b)Any past history of psychiatric illness in the lady or in the first degree relatives is an important pridisposing factor for subsequent postpartum development of psychiatric illness.Any history of recreational drug abuse and alcohol intoxication can predispose to the same.Any previous child in child protection services or the lady being on at risk register is also an important factor.
The risk can be minimised by effective communication between GP,midwife abd obstetric care teams of any significant past or family history.This communication should be independent of the lady and not thru her.Such women should be under constant supervision of community midwives and also social service workers.management of such women should always involve detailed counselling and explanation of the problem to the couple and a management plan should be agreed upon.management should be multidisciplinary involving obstetrician,psychiatrist,social services and named midwife.Any history of domestic violence should be appropriately asked for local referral strategies decided to appropriate experts.
Posted by Sameena M.
22 year old woman becomes acutely confused and believes that the staff are trying to harm her baby 48 hours after delivery by emergency caesarean section for slow progress in labour. (a) Describe your initial assessment and treatment of the patient [12 marks]. (b) Discuss the factors that are associated with an increase in the risk of post-partum mental illness and how this risk can be minimised [8 marks]
answer:
take history of any psychiatric problems in part or in present pregnancy.check if she is on any antipsychotics or antidepressents and and has she received them in correct doses.check for other medications that can cause confusion and dellusions.check that she has slept well as lack of sleep can present like this.ask about other symptoms of mental illness like anorexia,low mood,tearfull,hallucinations,anhedonia,lack of interest in baby.ask for any past renal or liver problems to rule out conditions like hepatic encephalopathy.check her temp,BP, Pulse and sao2. try to rule out post natal confusional states and acute anxiety.
as she is presenting 48hrs after delivery,is confused and has hallucinations my initial diagonosis will be postnatal psychosis.
i will make sure she had all her medications if she is already on antipsychotics.send blood sample for fbc,lfts,and u&es.
inform perinatal psychiatric team if available,or general adult psychiatry team and request psychiatirst to review her for assessment medication and ?addmission to mother baby unit.Keep the mother baby unit informed.patient is at a risk of suicide and infanticide so arrange for 1:1 care till reviewed by psyciatrist and further plan made.
Risks of post natal psychosis are:past history of acute depression,past history of post natal psychosis(50% recurrence risk),family history of bipolar disorder or postnatal psychosis.
Risk factors for postnatal deppression are:childhood incident,lack of support,family history of mental illness,chronic problems in family,unwanted pregnancy,past history of psychiatric problems.
post natal mental illness can be decreased by early identification and treatment of high risk patients,by good communication between obstetricians gps midwifes and psychiatrists,by establishing perinatal psychiatric units.There is a role of prophalactic medication for postnatal psychosis.it is started on first postnatal day (eg,lithium) in the patients with history of postnatal psychosis.
patient should be asked few qs about mental health in her first contact antenatally and postnatally and if any concerns referred to psychiatric team.
patients with iud should not be encouraged to hold the babies.
single formal debriefing in case of traumatic deliveries should be avoided and support given and patient encouraged to seek support from family and friends
Posted by Johnson  O.
A/
I would call for help from senior obstetrician, midwives and junior doctor, because she may become violent and wanting to injure herself, her baby or staffs. I would calm her down and ask the reason why she think somebody will take her baby from her.
Her antenatal notes would be reviewed for any previous history of mental illness, any family history of mental illness. Her regular medication would be checked for any psychiatry medication. Any history of medical condition like diabetic with insulin injection, to rule out hypoglycemia. I would ask her about history of vomitting, fever and neck pain to exclude meningitis or peuperal sepsis.
Her temperature and pulse would be measured, they may be high in peuperal sepsis. Blood pressure would be checked for hypo or hypertension.
IV access and blood would be obtained for full blood count. White blood cell count and CRP would be raised in infection. Random blood sugar to exclude hypoglycemia. Liver function test, urea and electrolyte test would be performed. If temperature is above 38centigrade, blood culture would be requested.
Her treatment would depend on findings and diagnosis. IV antiboitic according to unit protocol if infection suspected. IV fluids in dehydration. If the diagnosis is peuperal psychosis, I would liase with the psychiatrist with special interest in peuperal psychosis. She may require transfer to mother and baby unit. Brestfeeding would be encouraged except if there is danger to the baby. Her family would be kept informed about her care and the intervention. I would complete incident form.
B/
Personal and family history of mental illness are risk factors for post mental illness. It is important to identify thes risk factors during pre-conception or antenatal booking clinic. Risk assessment form for all antenatal women to identify those at risk . This would allow early identification and intervention.
Failure of compliance of psychiatry medication during pregnancy because of fear of teratogenicity. This can be minimized by appropriate counselling about the medication, the implication of stopping it. Benefit and side effect of it. It important to liase with specialist and give monotherapy with lowest effective dose. Ensure that the medication is continued during pregnancy and peuperium.
Where in doubt about care of suspected mental illness, it is important to involve the psychiatrist at early stage.
Appropriate counselling with family support would help minimize the risk. Training of staffs in identifying high risk group. Audit of unit protocol on mangement is important.
Posted by H H.
There should be local guidelines and protocols in any maternity hospital to deal with these emergency situations .These should be regularly rehearsed and audited for best safety of patient.
The priorities in this situation are to the protection of patient from self harm , protection of her baby and safeguard to the staff. Suicide formed the 2nd leading cause of indirect causes of maternal mortality in the latest confidential enquiry into maternal deathes.
I should call for help and a multidisciplinary team ,formed of midwives ,psychiatrist ,pediatrician and senior obstetrician is organized.
I should know that in absence of psychiatrist permission ,the patient can not be detained.
The patient is approached in a sympathetic manner ,better by her midwife and calmed up. I should go through her notes for a cause that may have caused her mental confusion eg , see to drugs she took ,illicit drugs, anesthetic drugs as a cause . Would see if she had a medical illness in her pregnancy that may have relapsed or aggrevated eg, thyrotoxicosis or systemic lupus erythmatosus. Would consider electrolyte disturbances or thromboembolism . If patient can be approached pulse, BP ,temp(fever causing hallucinations) , respiratory rate , neck exam (goitre) , neurological exam. Would take bloods for FBC, urea and electrolytes ,liver function tests , drug levels in serum if medications were given.
If all data were free ,would consider post partum psychosis. A psychiatrist help in treatment is of value. Patient is dealt with in mother and baby unit.Care of her cesarean section wound done as usuall. Patient may be given antipsychotic medications and so breast feeding avoided. She should be followed up after disharge and GP informed.


B) Prim parity , young age at pregnancy , and fear of responsibility or commitment will increase the risk .These will be handeled by proper antenatal clases and after delivery by teaching how to deal with the baby and joining young parents clubs with adequate support from social worker .
Support from social services regarding housing . See to the support given to her from her partner and family.
Conditions that would lead to mental confusion like ,electrolyte disturbances, hypoglycemia , thyroiditis , and thyrotoxicosis should be managed properly with the her of the proper specialist.
Patients with drug abuse should be managed properly during antenatal care with the help of social services and methadone replacement advised.
The use of Edinburagh post partum depression score can give an idea of those who will develop post partum depression.
The risk can be further minimized , if there are protocols and guidelines that are regularly audited . Incident reporting and risk management will tell us where we went wrong in management of a case ,so that after the risk is analysed , systems are put for risk control.
The maternity dashboard should contain an item regarding the risk of post partum mental illness so that if amber colour is seen on it, measures are taken.
Posted by milad A.
I would initially reassure her and try to cam her down, ask whether she had good sleep and ensure present of family member for support as conditions such as blues and acute panic disorder usually respond well. I will assess her concentration and her ability to give medial history. However, in her acute confusion I will review her antenatal note, medical records, and caesarean section note and take a history from her partner or one of family member. Particularly I will enquire about her previous history of psychiatry illness, particular in pregnancy, or postpartum and also about family history of bipolar or postpartum psychosis as presence of this history put her as risk of puerperal psychosis. From antenatal note I will check for her attendances, whether pregnancy was planned history of drug and alcohol abuse past medical history such as hypothyroidism.
I will assess her level of consciousness, self care and check for pulse, temperature, blood pressure and respiratory rate as acute confusion sate can mistaken as psychosis and also check if she is continent for urine and faeces as woman with both puerperal confusion sate and puerperal psychosis can be disinherited. I will encourage her for breast feeding and ensure presence of assistance for baby care. If there is concern regarding violence toward her baby I will ask for child protection services. I will inform senior obstetrician and ask for help from prenatal specialist psychiatrist for assess in diagnosis and prompt admission to preinatal psychiatry mother and baby unit if her diagnosis is puerperal psychosis.
b) Risk factors for puerperal psychosis is mainly personal history of puerperal psychosis or bipolar illness where chance of recurrence in next pregnancy is 1:2 and family history of postpartum psychosis or bipolar disorder gives risk of 1:3. Alternatively, postnatal depression risk factors are either personal history of unipolar or bipolar depression either postpartum or other time in her life will give risk of recurrence 1:2-1:3. Psychosocial factors are important risk factors for postnatal depression these include adverse experience in childhood, chronic live adversity and recent life illness. Lack of social support and ambivalence toward pregnancy are also risk factors. High level of anxiety in pregnancy this can be related to pregnancy itself as woman undergo IVF or had history of stillbirth are more prone to postnatal depression. Moreover, depression in pregnancy is risk factor for postnatal depression.
T o minimise the risk screening in first antenatal booking by sensitively ask about personal and family history of psychiatric illness. Refer high risk women to specialist psychiatrist where plan for postnatal management is written in advance and ensure multidisplinary approach involve obstetrician psychiatrist, specialist nurse, midwife and health visitor. The preventive measures would include drug prophylaxis (Lithium) for woman at risk of puerperal psychosis and close surveillance in the immediate postnatal period. Provision of antenatal service for woman with drug and alcohol abuse. social support services and organisation for woman who require that. High index of suspicion to detect woman at risk of home violence. Postnatal debriefing and review for women who experiences obstetric emergencies
Posted by Bee N.
A) A patient who is acutely confused and with paranoid delusion poses a psychiatric emergency and may constitute a source of harm to herself, baby, staff or other patients. I will call for help from specialist mental health team, consultant obstetrician. The patient should have at least two staff constantly looking after her initially to prevent harm to herself or her baby. She will require sedation with haloperidol. When she is calm and less confused, she will be approached in a sensitive and sympathetic manner,explaining need for further investigation and given reassurance. I will then check for pulse, blood pressure, temperature and oxygen saturation. Her delivery notes will be read to ensure no adverse events have occured at delivery and if so patient will be properly debriefed. I will enquire about current history of a low mood, loss of interest in events and presence of any suicidal ideation. I will ask about any symptom of hallucination which will further support the diagnosis of psychosis. I will enquire about any previous mental illness and if so if she is on any treatment for this. Acute withdrawal from treatment can precipitate an acute episode of psychosis. I will ask about family history of mental illness which predisposis the patient to pueperal psychosis. I will enquire about use of illicit drugs, some of which are psychotropic. I will enquire about her wish to breast feed and plans for contraception as both of this can be affected by treatment that would be offered.
I will then perform a full neurological examination as a space occupying lesion can present with delirium. Other investigation to rule out other causes of delirium would be blood for full blood count, C- reactive protein, electrolyte and urea, thyroid function test, liver function test (hepatic encephalopathy). Based on the result of these further imaging may be required such as magnetic resonance imaging of the head especially if this is a first episode of psychosis.
For a case of pueperal psychosis, early referral to specialist mental health and specialist perinatal mental health teams for further assessment is necessary. she will be best managed in a specialist mother and baby unit. Typical antipsychotics such as chlorpromazine are preferrable form of drug treatment. Atypical antipsychotics are better avoided such as olanzepine which may cause agranulocytosis in the neonate. Patient should be informed that drugs are present in breastmilk but do not cause significant harm to baby. Baby will need monitoring while this medications are taken for signs of sedation or withdrawal. long acting depot preparations should be avoided as it may cause delayed cholinergic side effects. Typical antipsychotics such as chlorpronmazine cause increased prolactin which may be a problem for woman who do not wish to breast feed.
Partner and relatives should be informed of need for patient support. GP should be informed for follow up. Anti psychotics interfere with hormanal contraceptives which are enzyme inhibitors.

B) Factors associated with increased risk include history of previous mental illness and/or family history of mental illness. Patients should therefore at booking be asked about these and care taken at each visit to enquire about possible development of psychiatric symptoms or mood changes.
Non compliance of treatment in those with psychiatric illness may aslo contribute. The reasons for non compliance such as un acceptable side effect should be addressed.
History of illicit drug use should be asked about and patients discouraged from use of such drugs. Majority of them are psychotropics.
Proper assessment of patients using objective scoring systems such as the Edinburgh depression scoring scale would help stratifying severity and appropriate referral made.
lack of early referral and involvement of specialist psychiatrics also contribute. Patients should be assessed for this early and there should be a low threshold for psychotherapy. Multidisciplinary involvement would ensure optimum management.
Lack of documentation will lead to omission of psychiatric symptoms and management plan.-There should be clear documentation of consultation with patient having mood problems or with psychiatric illness. Plan should also be clearly documented.
tTere should be a regular audit of unit protocols as well as easy assess of maternities to psychiatric referral and help. Patients with difficulties in social life should be granted social support and support groups recommended when necessary.
Posted by SANCHU R.
A 22 year old woman becomes acutely confused and believes that the staff are trying to harm her baby 48 hours after delivery by emergency caesarean section for slow progress in labour. (a) Describe your initial assessment and treatment of the patient [12 marks]. (b) Discuss the factors that are associated with an increase in the risk of post-partum mental illness and how this risk can be minimised [8 marks]
Her initial assessment would be to check her vital signs, PR, BP, Temp and RR and SATS since acute confusion can be due to hypoxia.
If they are normal, History would be elicited asking for history of tearfulness, history of insomnia, history of feeling low and history of loss of appetite to diagnose depression. Elation and irritability would suggest a bipolar disorder.
History of suicidal tendency or risk of harming the baby should be ruled out.
With a delusion that people are trying to harm her baby, History of other delusions and hallucinations should be asked for which would indicate puerperal psychosis.
History would be elicited asking for history of psychiatric problems in this pregnancy, past history and family history of psychiatric illness and for history of similar episodes of puerperal psychosis after previous deliveries.
Her social history should be explored. Her partner and her parents should be asked about her mental health issues since she may not be able to give all the relevant details.
The initial treatment would include talking through and acknowledging her problems and explaining that her delusions are wrong. She must be urgently referred and managed by the team which includes the specialist midwife, the psychologist and the psychiatrist who would offer her counselling and anti-psychotic drugs. Breast-feeding would be contraindicated with most of the drugs.
If her psychosis is severe, she should be isolated and be under
supervision. The baby should be brought under Child Protection with involvement of social services.
The partner and her parents should be involved in the care of the woman and the baby.
After complete post-operative recovery, she may be transferred to the mother and baby psychiatry unit for further management or can be managed at home if she has enough support with follow-up and continuation of care by the GP and the community psychiatry services.
b)Stillbirth, IUD, traumatic delivery predispose to postpartum mental health problems. The risk factors would be Adverse events in childhood, Long-standing and Recent adverse events, lack of social support, Anxiety and ambivalence towards pregnancy. Past history of psychiatric problems, history of puerperal psychosis
Family history of psychiatric disorders predispose a woman to post-partum mental illness.
Although all the risks are not completely preventable, the risks can be minimised by early identification and proper management.
Giving adequate emotional support to the woman during labour, especially when there are complications, debriefing the incident and offering counselling prevents post-traumatic stress disorder to certain extent.
Identifying risk factors at the time of booking can help us to suspect and diagnose problems and get expert help early. Ensuring adequate social support prevents this problem. Breast-feeding is encouraged to improve bonding

Posted by Akanksha G.
A 22 year old woman becomes acutely confused and believes that the staff are trying to harm her baby 48 hours after delivery by emergency caesarean section for slow progress in labour. (a) Describe your initial assessment and treatment of the patient [12 marks].
a) puerperal psychiatric disorders constitute the 2nd most common cause of indirect maternal deaths. the clinical scenario directs towards a diffrential diagnosis of acute anxiety or puerperal psychosis. this patient will be managed by a multidisciplinary team involving primary and secondary levels. apart from the obstetrician, a consultant puerperal psychiatrist, community psychiatric nurse, healthworkers, organisations for social support may be involved.
a review of the patients notes, and history from carers of the women to know personal history of psychiatric illness, a past history of puerperal psychosis (50% recurrence) puts the women at high risk of puerperal psychosis. a family history of bipolar affective disorder may be corroborative. a through genaral examination of pulse BP, respiration should rule out puerperal confusional states. acute anxiety in the postpartum ususlly responds well to reassurance, a calm professional manner and presence of family members. a psychiatric consultation should be arranged and mother admitted to mother and baby unit. the principles of further care would include, psychological and social support, drug therapy and follow up assessment by health visitors,midwives. drug theray would be with either lithium carbonate, tricyclic antidepressants, SSNRI, mood stabilizers. breast feeding is contraindicated when on lithium. in extreme cases electroconvulsive therapy may be required. psychological and social support would involve assisstance from emotional confidantes, female friends. social support organizations may have a beneficial effect. follow up support from community psychiatric nurse, healthvisitor,midwives may be helpful.
b)Discuss the factors that are associated with an increase in the risk of post-partum mental illness and how this risk can be minimised [8 marks]
low social support, poor marietal relationship, unplanned pregnancy, recent life events, unemployment, are associated with an increase in the risk of postpartum mental illness. other risk factors include past psychiatric illness especially bipolar disorder. a pst history of puerperal psychosis increases the risk by 50%. family history of bipolar affective disorders is also a risk factor for puerperal mental illness. prevention would involve, screening of women who are at high risk of peurperal mental illness. this involves using the edinburgh post natal depression scale (EPDS). using this a score of 10 in the general population is taken as a cutoff for a psychiatric assessment. a score of 9 is taken as possible depression and a score of 12 as probable depression. all women in the postnatal period can be screend with this method for early identification and repeated at 6 weeks and 3 months by health visitors. women who are at high risk of puerperal psychosis (past history of psychosis, past history of puerperal psychosis) may benefit from prophylactic drug treatment starting on day 1 postpartum.
Posted by robina K.
Psychiatric illnesses were identified as the the leading cause of indirect maternal death and the second commonest cause of maternal mortality.
The clinical situation suggests postnatal depression or puerperal psychosis and there is risk to the women of suicidal tendency, risk to the baby of harm, neglect and infant death(SIDS) and risk to the carer of violence, abuse and harm . A multidisciplinary approach should be arranged immediately involving consultant obstetrician, clinical psycologist , psychiatrist and specialist nurse. I will review her pregnancy and delivery notes to see note of any prenatal psychiatric illnesses, medication she was on, obstetric complications, induction of labour, analgesia, duration of labour and neonatal condition .Partner or relatives may be involved in taking informations . I will carefully approach the women and try to develop rapport if she is not agitated, ask about her problems like post op pain , breast engorgement and other symptoms like lack of sleep, insomnia, hallucinations , carefully and sensitively ask about relationship problems with partner and domestic abuse/ violence .A history of drug abuse and alcohol is taken she may have withdrawal symptoms . A low mood ,irritability, ambivalence about the baby and anxiety indicates postnatal depression .Disorientation, hallucinations, insomnia, talktiveness and agitation indicates psychosis.
Depending on the severity of clinical condition if mild and stable I will explain and reassure her about the safety of the baby , encourage and help her in breast feeding . I will make arrangement to transfer her to Mother and Baby care unit . Post natal depression is treated with tricyclic antidepressants and SSRIs (paroxetin) .If she is in a condition when approach to her is risky arrangements will be made to transfer her to psychiatric ward after cosultation with psychiatrist . Puerperal psychosis is treated with antipsycotic drugs and rarely electro convulsive therapy . I will also involve specialist perinatal care ,child protection agencies and social services if there is risk to the baby .After discharge from the hospital long term follow up is advised 6weeks to one year depending on the severity of her condition .G.P should be informed to arrrange follow up at home or at clinic and close liasion with psychiartic services should be established . Women should be referred to support groups like MAMA (meet a mum association ).Partner or other family members are councelled about her care.If there is risk of domestic violence I will involve social services to prevent her going in the same situation .
(B) Factors associated with increased postpartum mental illnesses are history of previous mental illness ,there is a recurrent risk of 50% if the women has antepartum or past partum depression in her previous pregnancy . Risk of post partum depression or other psychiatric illneses specially bipolar conditions and schizophrenia increases the risk of recurrence if she has these conditions antenataly .Depression and other psychiatric illnesses outside pregnancy also increases recurrent risk . History of mental disorders in first degree relatives also increases risk to about 25% . Poor socioeconomic conditions, leading to illhealth, anaemia may be a cause . Poor family support , relationship problems with partner ,domestic abuse/violence and housing problems may be associated factors .Other associated factors could be an unwanted pregnancy , very young and very old age lady ,Stressfull life events drug abuse like cocain, heroin and alcohol, and poor antenatal attendence .
To minimise the risks of postnatal mental illnesses strategies should be in place for primary, secondary and tertiary prevention. Primary prevention aims at awareness about psychiatric illnesses in general public through media and pamphlets .Identification of at risk women at G.P surgery during antenatal visits. There should be training in identification of such women and protocols should be in place for direct referral to psychiatrist .
Risk can be minimised in high risk women through parenthood classes ,awareness of partner ,ensuring family support and access to treatment facilities in case of need .
Secondary prevention aims at minimising the duration and severity of illness by instituting immediate treatment once it is diagnosed .The severity of any mental illness can be assessed reliably by using Edunburgh postnatal depression scale .
Whenever a psychiatric condition is diagnosed during or after pregnancy a multidisciplinary care should be provided and establishment of good communication should be ensured among G.P, clinical psycologist, psychiatrist, specialist nurse and family members .
Good family support, improving her socioeconomic conditions, councelling about her stressfull life events may help .
Posted by Asa A.
asa
a)Initial assessment of the women must be in the presence of a chaperone or family member for medicolegal purposes .Simple postnatal blues usually starts on the third day post partum and the patient will be responding well to assurance and retaing her consciousness and orientation . IF she is confused and non responding to assurance assessment will be impossible without detaining the woman under the mental health act. She could be dangerous to herself or the staff or her baby so safe approach is of utmost importance. The on call psychiatrist will be called .Confusion 48 hours postpartum could be due to physical or mental illness like encephalitis, meningitis, stroke ,electrolytes imbalance ,thyroid problems ,drug withdrawal and puerperal psychosis and acute panic attacks .Revising her notes for any past history of medical disease like SLE or thyroid or history of illicit drug intake will be done . Revising her medication chart may point to drug overdose that need to be stopped . Previous family history of bipolar depression increase the risk acute mental illness 30% . Personal history of previous or current bipolar illness , previous attacks of puerperal psychosis increase the risk to 50 % .Full assessment includes pulse ,BP, temp and focal neurological signs . Chest and heart lower limbs examination is essential. Her level of consciousness , orientation to time and place or the presence of delusions will be checked . Basal investigations FBC ,LFT. Urea&electrolytes ,clotting screen ,ECG will be done . Other tests will be done to proof or exclude physical illness as CT brain in case of clinical suspicion .
After exclusion of physical illness the patient will be cared for in a mother and baby unit as it is better to avoid placing her in general psychiatric ward .Joint care with psychiatrist will be done. The patient will receive major psychtropic drugs like lithium carbonate or haloperidol and mood stabilizers . Of special concern is the use of yhese drugs during breast feeding . Most of typical or atypical antipsychotic drugs pass into brast milk and cause harm to the infant . The most safe drug in the least effective dose should be prescribed or in divided doses to save the mother and baby bonds. If the patient is not responding or in the presence of catatonia electrocovulsive therapy will be instituted .
Plans for her care after discharge will include daily visits from the psychiatrist community nurse in the first two weeks as relapses may occur putting the woman at risk of hurting herself or her infant . Multidisciplinary care between her GP ,psychiatrist and psychologist is essential better in perinatal psychiatry clinic .
Special attention will be given to support her and her family and guiding them to support groups like home start or newpin is important . The risk of recurrence in future pregnancy is high so contraceptive advice is important taking into account drug interaction with her current medications.
b) Factors increasing the incidence of postpartum mental illness are either lack of recognition of those at risk during ANC or post partum while the risk is maximum . or lack of organization between responsible health personell .We must differentiate between postpartum simple blues and depression and postpartum psychosis . Social factors like economic problems , single mothers , social deprivation and lack of support or difficult labour or stillbirth ,unwanted pregnancy may increase the incidence of post partum blues or depression . Support during ANC and postnatally in the ward will help women get over their life difficulties . Support groups and simply giving the woman the chance to talk may help. Strategies like interpersonal psychotherapy or self help , or cognitive behavioral therapy will be given to those at risk . For every pregnant women this risk should be assessed through asking her about her mood or how things are doing at home and asking her if she needs any help . Special attention should be given to women with previous history of postpartum blues or depression .
The other category of patients are those with previous family or personal history of puerperal psychosis or bipolar mental disease .Special attention should be paid to this group because the risk is 30-50 % . The stigma of mental illness may prevent the woman from informing her midwife or GP about this history so integrated care between health personnel is essential . If a women is at risk or on treatment of mental illness this should be in all copies of her records . Some will advice starting prophylactic treatment in day 1 post partum . Informing the local mother and baby unit of her due date and also the local perinatal psychiatric clinic is preferable . Some women may stop their medicine once they know they are pregnant putting them into further risk , adjusting doses and psychotherapy is of great importance to avoid postpartum complications.
Posted by Manoj M.

M
(a) A history from the midwife looking after this patient to establish details of her present state as she may not be able to give an appropriate history and details of her antenatal care from her records. Details of outcome of delivery and state of her baby e.g. baby in neonatal unit may explain the reson for her present state.
History of adequate sleep may suggest sleep deprivation as the cause.
Any past history of mental illness like bipolar illness may suggest recurrance in post natal period, past history of previous pregnancy with mental illness or past history of treament for mental illness may suggest recurrance.
History of breathless or chest pain may suggest pulmonary embolism as the cause of her confusional state.
History of neurological symptoms e.g. weakness of extremities may suggest neurological vascular events.
History of any other medical disorders like cardiac diseases may suggest likely cause of her symptoms.
Her drug history may suggest previous treatment for mental illness and also any current treatment related confusional states e.g. with opiates use for pain relief.
Any family history of mental illness may also suggest likely post partum affective disorder.
Her social factors like alcohol or illicit drug abuse should be taken and her relationship with her partner to exclude domestic abuse. Her support at home may also suggest lack of support as the cause.
Examination including pulse, blood pressure, oxygen saturation and examination of respiratory, neurological and cardiovascular system ro exclude systemic causes of her present acute confusional state.
Examination of lower limbs to exclude any signs of DVT as may suggest likely cause of PE for her present state.
Based on initial examination findings, ECG if suggestive of cardiovascular problems including CXR to exclude respiratory causes.
Treatment is based upon initial clinical assessment, if suggestive of pulmonary embolism treatment with therapeutic dose heparin and organising objective testing.
Cardiovascular and respiratory condition will need treatment involving specialist input from multidisciplinary team with physicians, anaesthetist.
Mental illness will need proper communication with mental health team and if continued admission then on mother and baby unit.
Initial treament involves providing adequate support and help and addressing her current needs
Non medical options include cognitive behavoir therapy / interpersonal therapy.
she may need medical treatment with antipsychotics / mood stabilisers but this depends if she is breast feeding and using the mininmum possible dose in divided dosage to control her symptoms.
She will need regular follow up by mental health team and explained possible risk of recurrance in future pregnancy.

(b) A past history of mental illness like bipolar illness, past history of treatment under psychiatrist or a family history of mental illness may suggest increase risk for mental illness in post partum period.
Any current treatment during antenatal period for mental illness may suggest exacerbation in the post natal period.
Any one with suspected domestic violence and at risk should be properly ascertained as likely increased risk for mental illness.
Women on at risk register and with social problems like drug and alcohol are also at increased risk for mental health problems in post natal period.
Any one suspicious of mental illness from history should be ascertained at each visit with \'Whooley questionaire\' to identify at risk women to diagnose and to initiate treatment earlier.
Adequate support should be provided both antenatally and post natally and may need help from social services.
Emphasis on addressing partners and relatives for the need of adequate support at home and regular or increased visit by midwife and her care booked under obstetric consultant.
Antenatal education and support will also reduce the risk of post partum mental illness.
Organising service pathway with proper communication and referral with local perinatal mental health team will reduce the risk of mental health problems in postnatal period.
Posted by C P.
C.
(a)
Postpartum depressive illness has increase maternal morbidity and mortality. This is supported by CEMACH report. My approach will be very calm and supportive to this patient. First thing I will reassure the patient that her baby will be safe and no one will harm her baby and every one will try to look after her and her baby.
Further I will try to explore the history to find out the risk factors. Primip has more risk for developing post natal depression. Previous history of depressive illness out side pregnancy and postpartum depressive illness are common presentation. Her family support, financial support, her personal history need evaluation to identify whether these factors had contributed her symptoms.
In the history I will inquire about whether she had any systemic illness. Hypothyrodism may present as depressive illness. Specially throditis.
Her general examination, vital signs need monitoring to exclude any systemic illness.
Depends upon her systemic findings I will decide her investigations. If puerperal sepsis is suspected I will do FBC, CRP, blood culture, MSU, HVS or would swab. This will identify the focus of infection. LFT and RFT will be required as a base line because, in case if she is going to be started with any medication for depression.
Her symptoms appears that she is suffering from severe post natal depression. I will involve the perinatal psychiatric team. She should be treated in mother and baby unit where her physical and psychological health will be optimised.
Anti depressive is the treatment of choice. Progesterone thought to be beneficial in the past but there is no evidence to support this. Now this is considered this could cause depression. Estrogen thought to increase the sensitivity of serotonin receptors and this can be used as a treatment. However, it has its own risk on the postpartum mother.
If hypothyroidism is diagnosed endocrinologist will be involved and thyroxin should be started. More importantly she need supportive treatment.
(b)
Risk assessment, early diagnosis of the disease , early involving of the psychiatric team and training the junior doctors to diagnosis is mandatory to minimize the mental illness.
Previous history of postpartum psychosis, psychosis, or family history of psychosis has high risk of causing mental illness. Primiperous patients, who had lack of family support, financial support, domestic abuse and drug abuse can increase the risk of developing mental illness.
Risk assessment is the best way of preventing or minimizing the risk of developing mental illness. This can be done at pre conception clinic or in antenatal clinic by taking detail history. Communication with her family physician and her midwife is important because it will identify the high risk cases. Any suspicious cases should be followed up.
Whoever on any medication for depressive illness or for bipolar disease become pregnant should be managed by combined care with psychiatric team. She should be counselled about the important taking medication which outright the risk to the baby. Most of the mother try to stop the medication when they realise they are pregnant thinking this will harm the baby.
Posted by A A.
As patient is in acute confusion state, there may be a risk to mother,her baby and staff. Therefore I will make sure the presence of her partner/her family member and chaperon before her assessment. This will also reduce the risk of assault to staff and will make the environment comfortable for the woman. If there is immediate risk to the woman or her baby or medical staff, she might be detained under mental health act preferably in mother and baby unit and duty psychiatrist will be contacted immediately.I will review her obstetric notes for past medical history and mental health illness and will take history from the patient if possible. This is to rule out any medical illness like SLE, Hypothyroidisim, diabetes, previous psychosis and any stillbirth. Any intake of drugs (prescribed /nonprescribed), alcohol and drugs given in hospital. I will assess the mental condition of the patient whether she is oriented, have any hallucination, delusions or suicidal ideas. Whether her mood is elated,depressed or irritable.I will also enquire about headache, visual disturbance (SOL,embolism,CVA) chest pain, shortness of breath for pulmonary embolism.I will check her pulse, blood pressure, temperature, RR,SO2,cardiorespiratory ,abdominal examination, lower limbs and neurological examination to check for evidence of VTE, Sepsis, CVA/neurologic disorder. I will send FBC/CRP(for infection), LFTs(Liver dysfunction),Urea and Electrolytes and blood glucose and TFTs, if appropriate chest X-ray to rule out medical cause.If it is a medical it will be treated accordingly.In the absence of medical cause, puerperal psychosis is the most likely diagnosis(specially in the presence of previous history).women will be admitted to dedicated mother and baby unit in severe cases rather postnatal ward.Diagnosis will be explained to women and her partener. Treatment will be comprises of sigle or combination of drugs,ECT, psychological therapies and social interventions.The choice and dosage of the drug is influenced by breast feeding issue.These include anti-psychotic medicine like Haloperiodol, chlorpromazine or Olanzapine. Breastfeeding can be continued with these drugs provided the dosage is small and divided.Others are mood stabilizers like lithium carbonate but breast feeding is contraindicated because it results in infant lithium toxicity and floppy baby syndrome.Anticonvulsants can be used as mood stabilizers like Carbamazepine or sodium valproate, but infant should be monitored for excessive drowsiness and in case of sodium valproate for rashes. Tricyclic antidepressants can be given even in breast feeding mother for depression but woman should be monitored because it can cause mania.Psychological treatment involves counselling,cognitive behavioural therapy and inter-personal psychotherapy. Social support not only involves practical assistance and advise, but also emotional confidants,friends and people who improve self esteem. Electoconsulsive therapy ECT should be considered in severe cases.
PART B) The risk factors include previous history of psychiatric illness,during pregnancy, following child birth or outside pregnancy(50% recurrence in puerperal psychosis). A family history of psychosis, depressive illness also make person high risk. An ambivalence towards pregnancy and high level of anxiety during pregnancy is also a contributing factor. Some factors maintain the illness and can delay recovery. These include inadequate or inappropriate treatment particularly subtheraputic doses of drugs and failure to continue with drugs for 6months. An adverse experience in childhood, chronic adversity or recent life events (still birth, previous infant death, traumatic birth experience,IVF or any other stressful life events) and lack of social support can be maintaining factor.Preoneptional counselling of the woman with mental health problems with provision of adequate contraception to avoid unwanted pregnancy is an important step to minimize the risk.Whenever a women come in contact with health professionals in booking or postnatal period,Early identification of the woman should be done by asking the relevant psychiatric history (previous psychiatric disease and family history), severity,clinical presentation and treatment including inpatient management(or information given by GP in referral letter).All woman at high risk of developing sever post partum illness by virtue of the previous history should be seen by a specialist perenatal mental health team.A written management plan(covering pregnancy,labour and postoartum)should be formulated in the light of high risk of recurrence following the delivery and shared with GP,midwife,obstetrician, community and hospital perinatal mental health team,so a multidisciplinary approach. There should be good communication at all level and availability of clear referral channel from primary to secondary/tertiary care for women who require urgent assessment and treatment and follow up procedure for women who fail to attend the hospitalcare.Antipsychotic medication should not be discontinued or altered without a review of mental health team.In Postpartum period close surveillance and contact with the patient by specialist community perinatal nurse together with midwife and early admission to mother and baby unit(if required) should be done.Protocols for management of these women should be followed and audited regularly.




Posted by Lilantha W.
(a) This is a sign of post natal emergency. I attend to this patient immediately and call for help from senior midwives, consultant obstetrician, initially. I will be cautious about potential restless, agitated and aggressive behaviour of the patient. Whilst the diagnosis is made, initial management should be commenced. I take history from the patient, staff and the relatives as appropriate. I obtain further information from case notes as diagnosis of postnatal psychosis (primary or relapse) is most likely with a differential of delirium secondary to puerperal sepsis, meningitis, hypoglycaemia, uraemia, ketoacidosis, hypoxia drug overdose or withdrawal; confabulation secondary to hepatic or Wernike encephalopathy ; puerperal blues, depression, stroke, disorientation/illusion and finally, abuse. This can be an adverse effect of opiod or other recreational drug, therefore, I will carefully look into the drug history.

I will enquire the patient why she believes that her baby is being harmed by the staff. If it is not due to rational grounds, it is most likely a delusion or else it can be a false sense as a result of an illusion. I will get inputs from midwives and paediatricians about the wellbeing of baby.

Examination includes mental score questions (<6/10 significant) or MMSE to recognise level of confusion. Physical examination to look for signs of endomeritis, peritonitis, mastitis, meningitis pneumonia or focal neurological deficit. Signs of agitation, restlessness, confusion, sweating and tachypnoea is found in drug and alcohol withdrawals. Signs of self-neglect can be observed in depression. Mental state examination is vital to clarify whether or not this is a delusion in acute psychosis. Associated signs of hallucinations, anhidonia, loss of appetite, and early waking should be searched for. Her insight should be assessed along with deliberate self harm, suicidal and homicidal intent. Further assessment by a liaison psychiatrist’s is needed for this.

I will look for vital signs of tachycardia, hypo/hypertension, pyrexia, hypoxia, tachypnoea. A MEWS chart would be commenced if not on already. Urinalysis should be done to look for UTI or ketoneuria. Fluid balance chart would indicate possible negative balance. I will check her BMs immediately. Venous access will be obtained and blood is tested for FBC, U&E, LFT, Amylase, Mg, PO4, glucose, CRP. Blood cultures will be taken if temp>38 C. Arterial blood gas is indicated if oxygen saturations are low.

Treatment for a major postnatal psychiatric illness is best done in a specialised mother and baby care unit. This decision will be taken after discussion with psychiatrists. Until then, both mother and the baby will be observed closely and support will be provided for the mother especially to establish breast feeding. Acute psychosis should be treated with systemic antipsychotics initially. Electroconvulsive therapy might rarely be considered. Long term care is vital to achieve sustained remission and to decrease morbidity and mortality.

If an organic cause is found, she should be admitted to maternity high dependency unit. Underlying case should be rectified whilst providing supportive therapy, for example, re-hydration, correct electrolyte imbalance and maintaining euglycaemia. Careful monitoring of vital signs and functional state of the patient is important. Specialists opinion should be sought appropriately.

(b) History of mental illness is the most important risk factor of developing a post partum mental illness. Therefore, prompt treatment for the primary psychiatric illness and psychoprophylaxis will minimise post partum illness or relapse. Patient with a history of recent depression, bipolar affective disorder or schizophrenia are at the highest risk. Such patient should be followed up by a multi-disciplinary obstetric and psychiatry centre. Pre-conceptual counselling, maintaining required therapeutic levels of antipsychotic or antidepressants during antenatal period, treating relapse promptly is important achieving this. Drug compliance should be checked especially, peri-partum. Late recognition of psychiatric symptoms is a risk factor of developing a severe disease that can be minimised by vigilance.

Drug and alcohol abuse are common risk factors. When such a problem is recognised, the patient should be referred to a specialised centre for counselling and further management which includes detoxification, eg. introducing methadone for heroin addicts, alcohol detoxification.

Adverse psychosocial circumstances increase the risk of post partum psychiatric disease, eg. People in low socio-economic group and those who unemployed are more vulnerable. Providing maternity grant for all pregnant women would minimise this risk. Women experience domestic abuse/violence is a vulnerable. Asking about potential issues about high risk women will facilitate early recognition and management. People with difficult social circumstances, eg. Disabled children should be provided with proper social services care.

Pregnant women with other physical illness such as diabetes, liver disease and those had a difficult pregnancy, delivery, morbid baby, still birth and neonatal issues are more susceptible. A tight control of the condition and providing meticulous antenatal, intra partum and post partum care and support is needed to avoid these risks.
Posted by shipra K.
A) Initial assessment
The patient needs to be dealt in a sensitive and gentle manner. She should be made comfortable and a detailed history be taken from the patient (if possible)or from her relatives. A multidisciplinary approach followed which includes a psychiatrist,psychologist,midwife and obstetrician.
History should include duration of her symptoms, any suicidal or homicidal thoughts. Any other abnormal behaviour. Any complications during labour or caesarian?Excessive pain? (post traumatic stress disorder) Her notes should be reviewed. The medications she had received should be reviewed. Had she had adequate rest? Is she getting good family support?
Past history: Any psychiatric illness in past, any medication she had been on,. History of drug addiction? Drug withdrawal could lead to acute confusional states Any medical disorder like hypothyroidism, diabetes.
Obstetrical history:number of children? previous similar episode in previous pregnancy.
Socio economic history:does she have a good financial support.Post partum mental illness more common in women with a poor socioeconomic background.
Does her partner support her ,any history domestic abuse needs to be taken.
On examination Pulse rate ,blood pressure,temperature, respiratory rate noted.
Respiratory system ,cardiovascular system ,and neurological system should be carefully examined. Per abdominal examination done.Local perineal examination done note
for any PPH.
Investigation:
FBC,Renal function test ,blood urea serum creatinine,blood sugar(Hypoglycaemia can present withacute confusional states) , thyroid function tests,liver function test.blood gas analysis .
B)Risk factors for developing post partum psychosis include most importantly previous history of psychiatric illness, these patients need to be seen by both obstetrician and a psychiatrist during antenatal period and told to continue with medication if safe during pregnancy(patient often stop medication during pregnancy for fear of teratogenicity) like SSRI’s.but drugs like lithium need to be stopped and switched over to a safer medication.
Poor socio economic condition is another factor.An extra child puts an additional burden on the family and can precipitate mental illness.
Lack of rest lack of support from partner, domestic abuse is another factor. Good support from partner and hospital staff , counseling and help from support groups would be helpful
Other risk factors include teenage pregnancy primigravida patient.
A patient with previous history of postnatal depression and those high risk for depression should be evaluated on the Edinburgh postnatal depression scale for early detection of symptoms and early start of medication
Posted by Leen K.
LEEN
A 22 year old woman becomes acutely confused and believes that the staff are trying to harm her baby 48 hours after delivery by emergency caesarean section for slow progress in labour.

(a) Describe your initial assessment and treatment of the patient [12 marks].
Puerperal confusional states and puerperal psychosis (PP) both have early onset after delivery. It is important to distinguish between the two for appropriate treatment. A history of bipolar mental illness, family history of bipolar illness and/or previous history of PP are risk factors for developing PP. PP tends to present after the 3rd day after birth, and its progression and deterioration tends to be rapid. I would look out for lability of mood (swinging from severe depression to manic elation). I would also look out for delusions of grandeur. Women with PP may also have anxiety and irritability.

I would also check the woman for signs of infections and look out for any other causes for confusion. I would also look at her drug history (especially if she is a known user of illicit drugs - as she may be experiencing withdrawal symptoms or she may have ingested illicit drugs causing this confusional state). I would make sure her blood pressure, pulse, temperature and respiratory rate are checked (these tends to be normal in PP), and a physical examination looking for signs of infection. I would also perform blood tests for white cell count and CRP if infection is suspected. I would aso organise urine toxicology if illicit drug use is suspected. Infections should be treated appropriately if found.

Early recognition, diagnosis and treatment is important to prevent progression of her symptoms.

I would involve the psychiatric perinatal mental health team early if PP is suspected. If she indeed has PP, she should be treated in a specialist mother-baby psychiatric unit so that she can receive appropriate specialist care. \"Typical\" antipsychotics should be used rather than \"atypical\" ones if breastfeeding, due to more long term data availability. If she requires antidepressants, tricyclic antidepressants are safer to use if she is breastfeeding, compared to SSRI (selective seratonin receptor inhibitor). She should also be provided with psychological and social support at the same time and follow up in the community is important. PP tends to resolve within 2-8 weeks with appropriate treatment.


(b) Discuss the factors that are associated with an increase in the risk of post-partum mental illness and how this risk can be minimised [8 marks]

Predisposing factors includes personal history of mental illness, family history of severe mental illness (bipolar or unipolar depression) and a previous history of PP or severe depressive illness. Other risk factors are chronic adversity and recent life events, as well as adversity in childhood. The woman is more at risk of postpartum mental illness if she has a history of stillbirth, infant death or traumatic delivery in the past.

Screening (at booking, and ideally throughout the pregnancy) of these risk factors to identity women at high risk of postpartum mental illness and early involvement of the psychiatric mental health team if identified as high risk. These women should be given support in pregnancy and closely monitored after delivery for signs of developing mental illness.

Women who are deemed very high risk should be given antidepressants and/or antipsychotics, based on advice from the psychiatrics team, on day 1 after delivery to try prevent postpartum mental illness. Early intervention will improve treatment and management.
Posted by Nur Sakina K.
NSK

From A:
Symptoms suggestive of puerperal psychosis-mainly affective is elicited. Atypical features- mixed affective, disturbed behaviours and confusion also suggests psychosis. Red flag symptoms- suicidal ideation, self neglect and an intention to harm the baby raises the need for urgent psychiatric review. Screening for risk factors for mental illness- previous psychiatric illness (especially affective psychosis), previous puerperal psychosis/ depression and family history (1st or 2nd degree relatives) of bipolar disorder is vital to assess her risk of current and future episodes. This information may be obtained from her previous hospital admission notes, midwife, psychiatrist or gp. Previous medical history of severe hypothyroidism and current obstetrics history (severe postpartum hemorrhage, sepsis) is addressed to exclude organic causes of her presentation. Enquiry re breastfeeding intentions is important to ensure drugs safe for lactation given if needed.
An observation (blood pressure, pulse, temperature, respiration) is needed for baseline levels, assesses hemodynamic stability and to exclude sepsis or major haemorrhage. Other signs of hypothyroidism (fatigue, coarse skin, slow movements and speech, periorbital oedema) should be identified. Her mental status should be examined by a psychiatrist.
Baseline full blood count (anemia, elevated lecocytes), urea and electrolytes to exclude liver and renal derangements may help exclude organic pathology. These are usually normal in mental disorders.
If initial assessment suggests puerperal psychosis, lithium should be started in conjunction with input from the psychiatric team. Admission to specialized mother-baby unit for further observation and treatment is necessary. Treatment with combination antipsychotics, antidepressants or lithium may be required depending on specific presentation. Electroconvulsive therapy (ECT) is a rapidly effective and safe treatment. Supportive care for patient, baby and her family is vital during this crucial period.

From B:
Risk factors include previous puerperal psychosis or other psychiatric disorders. These women are deemed high risk of puerperal and non-puerperal future episodes. Poor social support, marital and lack of confiding relationships increases the risk of mental illness. Personal or family history (1st/2nd degree relatives) of bipolar disorder has been strongly linked with development of puerperal psychosis. Recent adverse life events (deaths, marital breakup), poor coping abilities to puerperal changes increases her risk of postpartum blues and mental illnesses. Other social factors-unwanted pregnancy, unemployment and not breastfeeding have been linked with the development of mental illness. Organic causes such as hypothyroidism may also have psychiatric presentations.
Identification of woman at risk pre pregnancy or at booking from history taking is vital. Women at high risk should further be reassessed at least twice antenatally and once during the postpartum period for development of mental illness. Optimising their social support, treatment and mental status before embarking pregnancy also minimises her risk. Multidisciplinary team input- obstetrician, midwife, psychiatrist and gp ensures a plan is in place to manage her during pregnancy and allows her to feel supported. Early referral to psychiatric team for counseling and social workers to assist in any social difficulties (housing, home help, and financial assistance) minimizes this risk. Provision of contact details and easy accessibility of support person in cases of crises is crucial. The couple should also be encouraged to attend antenatal classes to educate regarding changes and what to expect during the antenatal and puerperium. Postnatally, breastfeeding should be encouraged and input from the lactation consultant may be needed to promote successful breastfeeding for mother-baby bonding. Woman at high risk of postnatal mental illness can also be started on prophylactic antidepressants, lithium or antipsychotics antenatally and in the immediate postpartum period in conjunction with psychiatric input.
Posted by G. K.
A)
Inital assessment should include careful questioning regarding her grounds for such a belief and dispelling any misconceptions that may have arisen due to any misunderstanding.
During questioning the patient\'s mental wellbeing should be asessed by asking her questions regarding her orientation in time ,place and person.Also any agitation and hyperexcitability should be noticed on her part which is out keeping with her present situation. Explore any ideation regarding harm to herself or harm to her baby.
For her physical welllbeing assessment, it should be checked whether she has slept well or not since delivery ,because lack of sleep can cause an acute confusional state.Similarly she should be assesed for hydration status and pain control since both these conditions can add to or cause the present situation.
A quick look at her notes will tell us about her parity, any personal history of mental illness or family history of same especialy bipolar affective disorder.Check to see whether she had the same problems during her past pregnancy/pregnancies and whether she received treatment for same.
Further investigate by taking B.P, temperature ,blood for full blood count,and urea and electrolyted since high B.P, fever, anaemia and electrolyte imbalances can present with confusion respectively.Do urinalysis to rule out a urinary tract infection and send urine for culture and sensitivity.
Early Involvement of a perinantal psychiatrist is essential in establishing the diagnosis of a psychotic state.
Treatment
Treatment depends on trating the underlying cause such as adequate hydration if the patient is dehydrated, good pain relief and ensuring that the patient gets adequate sleep if she is unable to sleep by placing her in a quiet room.Care and support should be provided throughout in looking after her baby and her fears should be dispelled about the staff posing anyharm to her baby.
In the presence of infection such as UTI, she should be given antipyretics andbroad spectrum antibiotics intravenously until the cultures sensitivites become available.
If the patient has puerpeural psychosis, she should be placed ina specilalized mother and baby unit and commenced on antipsychotic medication right away after consultation with the perinatal psychiatrist team.Treatment options depend on whether te baby is being breast fed or not.If the babby is not being breast fed, lithium can be commenced.Other options include typical antipsychotics such as haloperidol and chlorpromazine and atypical antipsychotics such as risperidone, olanzapine and clozapine.
Atypical antipsychotics and lithium are not indicated for use in breast feeding women. It is recommended that they use typical antipsychotics only /combied witha mood stablizer anticonvulsant such as carbamazepine or sodium valproate.
B)
The factors which predipose to postpartum psychosis include:
Family history /personalof bipolar affective disorder/schizophrenia
Puerpeural psychosis ina previous pregnancy.

Risk factors regarding post partum depresion include:
personal history od depression.
past history of postnatal depression

Contibutary factors include:
single mother/unwanted pregnancy
deprived social background and lack of support at home.
abusive partner/history of domestic abuse
Alcohol and illicit drug abuse
recent advers life events

The risk of mental illness cen be minimized by screening for personal/family history of same during the booking visit by asking specific questions regrding personal and famillial metal illness.
Social history regarding drug and alcohol abuse,domestic violence, and lack of social support should be inquired into senstivelely.Women considered at risk should be evaluated by the psychiatric team and a multidisciplinary approach to their care should be taken involving the obstetrician, GP, midwives and social workersnot only antenatally but also posnatally fora minmum of six weeks.
Appropriate medications shold be prescribed as necessary.


Posted by Ron C.
RnRn

A.
Most important diagnosis to consider is puerperal psychosis. Nevertheless the patient must be reassured and feel she is taken seriously. Past personal & family history of psychiatric disease makes diagnosis more likely. Feelings of depression or suicidal thoughts will affect management. History taking from husband or family members may contribute valuable information and obstetric notes and hospital records must be scrutinized for previous psychiatric problems. Further history taking may reveal medical problems like thyroid disease or diabetes which can alter mental state. She must be asked for any symptoms or medication. Surgery related problems can also be a cause and she must be asked about fluid intake, output, dehydration and signs of infection such as fever, chills and dyspnea. Cerebral ischemia or bleed are rare, but must be suspected, especially if pregnancy was complicated by blood pressure problems.
Blood pressure, pulse rate & temperature are assessed. Skin is assessed to look for dehydration and fluid chart is noted. Chest auscultation may reveal pneumonia and wound is checked for infection. Full neurological examination is done and neck is assessed for thyroid swelling. Urine dipstick-testing for proteins, glucosuria or urinary tract infection. Bloods include full blood count and CRP to look for infection, renal function tests & electrolytes to identify imbalance, liver function tests as part of pre-eclampsia screen, thyroid function tests to rule out thyroid disease and random blood sugar to look for altered glucose metabolism. Chest X-ray or cerebral imaging only if physical examination would point to pneumonia or cerebral problems.
Any metabolic, electrolyte or fluid imbalance must be corrected and diabetes treated. If psychiatric disease seems likely, referral to psychiatrist is appropriate. Psychiatrist should assess mental state and whether there is danger for the mother harming herself or the baby. He may start her on neuroleptics or antidepressants. Cognitive therapy may contribute to treatment as well. Mother and child should ideally not be separated, but will require close monitoring in the ward as in psychosis rates of infanticide can be as high as 4%.

B.
Women with a positive personal or family history of psychosis or other psychiatric disease are at higher risk to develop this. To minimize risks they should ideally have pre-pregnancy counseling, assessing disease status, how long they have been stable and if so, what medication they are using. Some medication may affect the fetus or have terratogenic effects, but as a whole, a balance must be taken between this and risks of disease deterioration due to stopping or altering mediation. Often pre-pregnancy counseling is not possible, and these risk factors must be assessed on first intake. Another risk factor is presence of poor social background or instable social circumstances. This must be flagged up and to minimize risk of deteriorating existing disease or onset of new disease help must be arranged, which may involve social services. Overall in known disease a mental health-team approach is appropriate, which involves a psychiatrist, specialist midwife or nurse and obstetric consultant. GP must be involved, as he may know the woman well and may one of the first professionals to flag up any problems in antenatal or post-partum period. Delivery must be in hospital with post delivery at least for 6 weeks high rate for alertness of symptoms, as this is the most likely time for exacerbation or new onset of disease.
Posted by SUNDAY A.
Sunday\'s answers.

a) I would immediately call for help from senior midwives and consultant and i would approach the patient with someone else in the room with me. I would establish her mental state and reasons behing her thought that the staff are trying to harm her baby. I would ask about her sleep paterns, pain control, attitude and feeling to her baby and how this has changed since delivery. I would ask about previous mental illness and treatment and also get some history of similar episodes from her partner or relatives that may be present. I would consider urgent referral for psychiatry assessment and i would keep both mum and baby together in a separate room manned by a staff to keep an eye on her while waiting for review. I would consider referral to the regional baby and mother\'s unit if her condition did not improve and her GP, midwife, social service, Peadiatrician would be informed. First line antipsychotic such as haloperidol, chropromazine may be given if patient become agitated and violent while awaiting review.
b) A previous history of mental illness is a risk factor as well as family history of mental illness be it bipolar affective disorder, schizophrenia or depression. Stressful life evets such as consistent poor sleeping pattern ,bereavement, loss of job / earnings, dosmestic violence or unsupportive patner, can also contribute to the risk of developing post partum mental illness.
The above mentioned risk can be minimised by proper and effective antenatal screening for mental illness as advised by the CEMACH report and patient with significant risk referred for appropriate psychiatric input. Supportive structure should also be put in place for those who are not coping well with pregnancy such as regular counselling and psychotherapy. Antipsychotics should be started from day one after delivery for those with previous histroy of mental illness if indicated. Regular visit by the community psychiatric nurse and midwife should be encouraged ideally daily for the first 2 weeks postdelivery and regularly up to 6 weeks post delivery before subsequent follow up by the GP.
Posted by Asa A.
Dear Sir
according to NICE guideline
Issue date: February 2007 (reissued April 2007)
Antenatal and postnatal mental health

● Women who need inpatient care for a mental disorder within 12 months of childbirth should
be admitted to a specialist mother and baby unit unless there are specific reasons for not
doing so.


and this is the model answer you posted as an answer to the following question(essay # 124)

Justify your management of an 18 year old primigravida who has become acutely confused 48h after a normal vaginal delivery.

A good candidate should

? Recognise that this presentation poses a risk to the woman, her baby and medical staff (1)

? Know that confusional state could be a result of a pre-existing medical (SLE, hyperthyroidism, DM) or psychiatric disorder (psychosis), a new medical (puerperal thyroiditis, sepsis, VTE, electrolyte abnormality) or psychiatric (puerperal psychosis) disorder or the effects of drugs (prescribed or non-prescribed) and drug withdrawal including alcohol (2)

? Recognise the need to assess the woman promptly in an environment which reassures her (for instance, the presence of her partner or friend) but also protects medical staff from accusation of abuse / assault (chaperone) (1)

? Know that if there is immediate risk to the woman, her baby or staff / other patients, the duty psychiatrist should be contacted immediately and the woman may be detained under the Mental Health Act, preferably in a mother and baby unit (1) .

? Know that without detention under the Mental Health Act, the woman cannot be assessed / treated without her consent (1)

? Review obstetric notes (history of mental illness, past medical history) and take a history if possible. Identify physical symptoms ? headache, visual disturbance, SOB; and psychiatric symptoms - hallucinations / delusions (2)

? Enquire about use of unprescribed drugs and alcohol. Review drugs administered in hospital especially opiates (1)

? Perform physical examination with consent ? P, BP, Temp, chest, abdomen, calves and neuro exam; SO2 ? evidence of sepsis, VTE, neurological disorder (1)

? Investigations to exclude a medical cause ? FBC, U&E, glucose, CRP, LFT, TFT and if appropriate CXR (1)

? Treat any underlying / identified medical condition ? seek psychiatric opinion about use of anxiolytics (1)

? If no underlying medical disorder, puerperal psychosis is most likely diagnosis and psychiatric assessment should be requested (2)

? Woman may be managed on post-natal ward if the risk to herself and others is assessed to be minimal, otherwise she should be admitted to a dedicated mother and baby unit (1)

? Explain diagnosis and treatment to woman and partner (1)

? Inform GP and community psychiatric team on discharge (1)

Posted by Maayka ..
maayka

(a) The patient should be approached , together with the staff nurse in attendance , cautiously and empathically. The nurse would have been able to brief me of her antenatal care and history, particularly if she had a previous known medical condition, mental illness or family history of mental disorder. If she has just had her first baby then she is likely to be at risk of postpartum blues. It is important to differentiate between this and postpartum depression and psychosis. She would be asked about her concerns and if she may have felt sleep deprived and still experiencing pain post operatively , that she may be feeling anxious being in hospital and if so she is likely to have the transient postpartum blues. If she has pre- existing mental disorder, it is important to inquire if she was on medication or there was a change in dosage as it can precipitate an acute episode of mania in bipolar disorder or schizophrenia. It is important to ask subtly about suicidal intent as it may suggest psychosis.
As the event occurred acutely, it is important to rule out medical causes such as transient ischaemic attack (TIA), venous thromboembolism(VTE) and postpartum thyroiditis. This is by physical examination of her general well being. Ensure there is adequate oxygenation as anoxia can precipitate these symptoms. Her BP if elevated may suggest a TIA. The legs should be checked to rule out a possible deep vein thrombosis. Once coherent , to assess for depression, using the Edinburgh Postnatal Depression score .
Investigation will also include a U&Es to ensure there was no electrolyte imbalance as a cause. A thyroid function test should be sent off as it can present as depression postnatally.
Treatment will be dependent on the disorder diagnosed. Once a medical cause has been ruled out, a psychiatrist should be called for review. If postpartum blues, then supportive therapy with family support and use of cognitive behavioural or interpersonal therapy should be initiated. The patient should be seen regularly, even if discharged, by her GP and midwife with mental health service provider. Drugs are rarely needed as the condition is transient. If postpartum depression, the patient should have the same therapy but not separated from her baby if prolonged hospitalization is required. If no medication is required, an SSRI like fluoxetine may be used. Her caregivers need to offer constant support for a prolonged period, even when home and she should have regular visits by the mental health service provider and her midwife. Postpartum psychosis will require that she remains in hospital and initiation of antidepressant and antipsychotic, with constant supervision, under the guidance of a psychiatrist. She should be kept with her baby on the unit. Breastfeeding and bonding with her infant will always be encouraged, whatever the diagnosis.

(b) The risk is increased by the patient’s demographic status, that is being from a lower socioeconomic group, having marital or relationship discordance during the pregnancy. A past history of mental illness, especially if precipitated postpartum should be an alert to possible recurrence. Lack of social support, any other medical illnesses can be a burden on a patient.
These predictors can be detected by early booking and detailed history taken by the midwife to alert the obstetrician of the risk of mental illness in the pregnancy or occurrence in postnatal period. Determining if the patient with a known mental disorder has been compliant with medication or off medication, together with her general mental health will aid in deciding how closely supervised she should be following delivery.it is important to acquire the patient’s trust from booking and where possible, involve caregivers in her care.
For those mothers who have experienced a traumatic delivery or stillbirth or early neonatal death, they should be encouraged to speak with the health professionals as needed and caregivers support provided constantly.
All mothers seen at their postnatal visits should be asked about their general well being and mental state and asked if they feel they may want help, and if yes, they can be referred to the necessary service provider.
Posted by A H.
AH

I will peruse her antenatal notes to determine if risk factors for mental illness were identified and if any management plans were made. I will especially look for a personal or family history of mental illness, medications used, and time of last dose. I will also look for a history of illicit drug, alcohol and tobacco use as withdrawal may present in this manner.
I will exclude an organic cause for her symptoms.Past medical illnesses especially thyroid dsease will be sought. I will try to identify from the notes if there were difficulty during the caesarean section, especially major haemorrhage and the extent of fluid replacement and her urine output.
Trends in temperature, pulse blood pressure will be evaluated for signs of sepsis and hypotension. Blood investigations will include a full blood count looking for a low haemoglobin, elevated white cell count (sepsis) and low platelet count.Electrolyte imbalance will be excluded by doing serum urea and electrolytes. Thyroid function tests will also be done. Any abnormalities found will be corrected.
I will attempt to take a history and develop rapport and gain her trust. She will be referred to the psychiatrist or perinatal mental health team once an organic cause has been excluded.
She will be transferred to a mother and baby unit for continued monitoring and treatment.The lowest effective dose of drugs (antipsychotics) which are safe to use while breastfeeding, cognitive therapy and counselling will be used appropriately. Support for her spouse/ family and other children will be arranged.

b) The strogest predictor of post-partum mental illness is a personal history of mental illness. Nature and duration of mental illness, discontinuation of any drugs used are also risk factors. A family history of postnatal mental illness, low socio-economic support, not living with her partner or unmarried status are also risk factors. Drug abuse, life stressors during pregnancy and a high risk pregnancy will also put her at risk.

The risk can be minimised by taking a targeted histoy at the first antenatal and postnatal visit. She should be specifically asked if she suffers from any mental illness or she she experienced pospartum mental illness. A family history of postpartum mental illness will also be sought, as well as relevant social and drug history. At susequent visits she would be asked about feeling depressed, down or helpless, as well as a loss of intrest in doing normal activity. If she is receiving treatment for mental illness she will b ecounselled on he risks and benefits of using her medication. She will be advised of the risk of relapse if she stops. She will be switched to the lowest effective dose of the safest drug and she will be provided wih written information about symptom recurrence and drug safety. She will be given contact numbers so she can speak with a counsellor whenever she feels the need to do so.