POSTPARTUM PSYCHOLOGICAL AND PSYCHIATRIC PROBLEMS

• Pregnancy and child birth are life changing events. Feeling tearful and ‘low’ is common. Postnatal psychological and psychiatric problems are divided into

1. Post-partum (Baby) blues
2. Postnatal depression
3. Postnatal psychosis

Risk factors include

• Previous history of postpartum depression or psychosis – recurrence risk up to 90%
• Personal or family history of mood disorder
• Depression during the current pregnancy
• Lack of social support network
• Relationship problems
• Recent negative life events such as a death in the family, financial difficulties, or loss of employment.

There is no association between obstetric factors and risk of post-partum depression

All women should be screened in the post-natal period

Antenatal screening should also be undertaken to identify women at increased risk

The Edinburgh Postnatal Depression Scale is a 10-item self-rated questionnaire used extensively for detection of postpartum depression.

A score of 12 or more or a positive answer on question 10 (presence of suicidal thoughts) requires more thorough evaluation.

Post-partum (baby) blues

• Occurs between days 3 – 10 post-partum.
• Common cause of feeling low in the immediate postpartum period.
• Women may feel tearful and irritable but do not require drug treatment.
• Close family support is essential.
• Further assessment required if symptoms persist for more than 2 weeks

Postnatal depression

• Affect about 1:10 mothers in UK.
• Usually occurs in the first 4-6 weeks postpartum and in some cases, lasts for several months.
• Delayed recognition & treatment places the mother and infant at risk and is associated with developmental and behavioural problems in the child. Mothers with postpartum depression are more likely to express negative attitudes about their infant and to view their infant as more demanding or difficult.
• Children of mothers with postnatal depression are more likely than children of non-depressed mothers to exhibit behavioural problems (sleep and eating difficulties, temper tantrums, hyperactivity), delays in cognitive development, emotional and social problems, and early onset of depressive illness.

Symptoms of postnatal depressions

• Low mood for prolonged periods of time (greater than 1 week),
• Feeling irritable most time
• Tearfulness
• Panic attacks
• Lack of concentration
• Lack of motivation or interest in herself or her baby
• Feeling guilty, lonely or unable to cope
• Difficulty sleeping
• Loss of libido
• Thoughts of harming herself or her baby

History

• Assess using tools like Edinburgh Postnatal Depression Scale. Symptoms vary from mild mood symptoms to severe neurovegetative symptoms and marked functional impairment
• Identify suicidal ideation and delusions / hallucinations which will indicate psychosis

Examination

• Aim is to exclude medical disorders such as anaemia and thyroid disease

Investigations

• FBC, thyroid function tests

Treatment options

• Nonpharmacologic treatment (like cognitive-behavioural) useful for women with mild-to-moderate symptoms.  Especially useful in breastfeeding mothers wishing to avoid medication
• Support groups may be helpful.
• Drug treatment reserved for moderate-to-severe depressive symptoms or failed response to non-pharmacological treatment.  
• Selective serotonin reuptake inhibitors (SSRIs) are first-line agents.  Side-effects include insomnia, jitteriness, nausea, appetite suppression, headache, and sexual dysfunction.
• Serotonin-noradrenaline reuptake inhibitors (SNRIs) are also effective
• It takes 2-4 weeks for symptoms to improve. Treatment should continue for 6 -12 in women with a first episode of depression while long-term therapy may be required for women with recurrent illness  
• Early treatment is associated with better prognosis
• Inpatient admission may be needed for women with severe symptoms
• Women with a history of recurrent depression or postpartum depression may benefit from prophylactic treatment with antidepressants immediately after delivery

Puerperal psychosis

• A more severe disorder affecting 1:1000 mothers and is a psychiatric emergency
• Symptoms include delusions, hallucinations, irritable behaviour and suicidal thoughts or thoughts of harming the baby
• Risk of infanticide up to 4% in untreated cases

History

• Identify hallucinations / delusions; suicidal thoughts and any threat to the infant
• Identify potential medical causes:
• Infections – chest, UTI, endometritis
• Drug use / drug abuse with withdrawal
• Alcohol use / withdrawal
• Symptoms of thyroid disease
• Headache / visual symptoms – raised intra-cranial pressure
• Identify risk factors – previous / family history of psychosis

Examination

• Pulse, temp, BP, SO2
• Chest, abdominal and lower limb examination (VTE) including any wounds / incisions for evidence of infection
• Mini-mental state examination

Investigations

• FBC, CRP, U&E, glucose, LFT +/- arterial blood gases
• Thyroid function tests
• Drug screen may be appropriate
• Further investigations dictated by clinical findings

Treatment

• Psychiatric emergency but organic causes must be excluded
• Manage as in-patient and it is usually possible to leave the woman with her baby with appropriate supervision
• Specialist mother & baby units and now very limited and the woman may need to be admitted to an obstetric or psychiatric ward
• Woman and her family will require substantial support and reassurance
• Anxyolytics and anti-psychotic agents are the mainstay of treatment
• Women with a history of psychosis or postpartum psychosis may benefit from prophylactic treatment with lithium, initiated either prior to or within 24 hours of delivery.