Post-partum Psychiatric Disorders Flashcards
PostPartum blues
Postpartum (PP) blues: Low mood and mild depressive symptoms that are transient and self-limiting and are common in the perinatal period
They usually start 5 days after delivery and may last 1-2 weeks.
PostPartum depression
PP depression: depressive symptoms beginning within the 1st 12 months following childbirth and lasting for at least 2 weeks
PostPartum psychosis
PP psychosis: a psychiatric manifestation with abrupt onset after delivery that is characterized by psychotic symptoms
Risk factors
° Young age (< 25 years)
° Poor social support
° Difficulties with breastfeeding
° Cesarean sections, traumatic birth experience, or other perinatal complications
° Women with infants having health problems and/or with infants admitted to the NICU
° History of psychotic illnesses (especially anxiety and depression)
° Family history of psychiatric illnesses
° Previous episode of PP psychiatric disorder
° Stressful life events (during pregnancy and near delivery)
° Childcare stress (e.g., inconsolable crying infant)
° History of sexual abuse
° Financial difficulties
PostPartum blues typical symptoms
° The woman worrying that she will not make a good mother.
° Fears that her baby might die
° Anxious
° Agitation, restlessness, and tearful
° Insomnia
° Irritable
° Poor appetite
Feeling guilty and/or overwhelmed (especially about being a mother)
° Crying, sadness
° Rapid changes in mood and irritability
° Anxiety
° Poor concentration
° Eating too much or too little
° Insomnia or frequent awakenings at night
Management of postpartum blues
° Resolves spontaneously
° Provide reassurance.
° Encourage self-care.
Major risk for PostPartum depression
° Prior depression
° Hormonal changes during the puerperium
° Sleep deprivation
° Genetic susceptibility may contribute .
Risj factors for PostPartum depression
- History of depression
° Personal history of depression
° History of depression during pregnancy
° History of postpartum depression
° Family history of depression
- Recent stressful life events (unemployment of partner)
- Partner with depression
- History of mood changes associated with menstrual cycles or contraceptions use
- Daily stressors ( such as child care, lack of social support / financial especially from the partner, and family)
- Unintended pregnancy
- Baby blue
- Previous history or current poor obstetric outcomes ( miscarriage, preterm delivery, congenital malformation.)
Presentation for PostPartum depression
° Disinterest in self, in child, and in normal activities
° Feeling isolated, unwanted, or worthless
° Feeling a sense of shame or guilt about parenting skills
° ↑ Anger outbursts
° Suicidal ideation or frequent thoughts of death
° Tearfulness ° Insomnia or increased sleeping ° Extreme fatigue ° Appetite disturbance ° Headaches and back aches that do not resolve with Analgesics ° Extreme sadness
DSM-V criteria for major depressive disorder with peripartum onset:
A. Patients must meet at least 5 out of 9 symptoms for>2 weeks.
B. Depressed mood or anhedonia (reduced pleasure from previously enjoyable habits) must be among the patient’s symptoms.
C. Symptoms include:
° Depressed mood, almost everyday
° Anhedonia
° Appetite/weight changes (↓ or ↑)
° Sleep disturbances (↓ or ↑)
° Psychomotor agitation or retardation (patient is anxious and moves a lot, or barely moves)
° Loss of energy/fatigue
° Feeling worthless or excessively guilty
° Trouble concentrating
° Suicidal ideation and/or attempts
D. Symptoms cause a significant decline in function in social and occupational/school settings.
E. The patient does not have a history of:
° Other psychiatric disorders (especially bipolar disorder)
° Substance use
° Medical conditions such as hypothyroidism, nutritional deficiency, and cerebrovascular disease, which cause depressive mood
Limitations of the DSM-V criteria:
° Many symptoms, especially weight changes and sleep disturbances, are common and frequently unrelated to depression in the PP period.
° Restricts the diagnosis to symptoms beginning within 4 weeks of delivery → may lead to underdiagnosis
Laboratory studies for PP D:
° If patientsdohave a history of medical conditions known to cause depressive symptoms, tests should be ordered to assess status.
° Should be ordered if patients have other findings consistent with these conditions (e.g., new-onset constipation and goiter, which are suggestive of hypothyroidism)
- General Measures for PostPartum depression
° Mothers should be taught to recognize symptoms of depression, which they may mistake for the normal effects of new motherhood
E.g- fatigue, difficulty concentrating.
° Admission maybe necessary for severe postpartum depression
° Psychoeducational or support groups
*for mother with mid to moderate symptoms also those that don’t wish to take medication and want to breastfeed.
° Exercise therapy
° Massage therapy
2.General Measures for PostPartum depression
° Maintain an empathic and concerned attitude.
° Discuss uncertainty with a specialist at any point in the care pathway.
° Assess severity of the condition and suicide risk.
° Exclude and optimise treatment of underlying and/or comorbid medical conditions (e.g. hypothyroidism, anaemia, HIV/AIDS, TB, cancers, diabetes).
° Screen for and manage underlying or comorbid substance use, e.g. nicotine, alcohol, over the counter analgesics, benzodiazepines.
° Screen for bipolar disorder and comorbid psychiatric disorders – refer for specialist assessment.
° Explore and address psychosocial stressors:
- Stress management/coping skills – refer for counselling.
- Relationship and family issues – refer for counselling Refer to a social worker if abuse is evident.
° Provide self-help literature, where available, and refer to local support
Complications for PostPartum depression
° Risk of impaired maternal-child bonding → risk of behavioral problems and/or developmental delay in the infant
° ↑ Risk of developing major depressive disorder later in life
° Suicide (preventable with adequate treatment)
° Infanticide
° Father depression
PPD Medicine treatment First line
° It is important to ask for suicide risk in these patients
• Fluoxetine, oral, Initial dose: 20 mg
If there is no or partial response after 4–6 weeks, increase to 40 mg, if the is no change move to 2nd line
PPD Medicine treatment Second line
- Citalopram, oral, Initial dose: 20 mg
* Review the mother at 4 weeks and 6 weeks if she reports improvement. continue with the same dose
PPD Medicine treatment 3rd line
- If a sedating antidepressant is required
- Amitriptyline, oral, at bedtime.
- Initial dose: 25 mg per day.
- Increase by 25 mg per day at 3–5 day intervals.
- Maximum dose: 150 mg per day.
•If no response: discuss with a specialist (re-evaluate diagnosis, repeat general measures, prescribe alternative SSRI, psychotherapy, or ECT).
Postpartum psychosis
- Is the most severe form of postpartum psychiatric illness.
- It is a psychiatric emergency.
- At highest risk are women with personal history of bipolar disorder or previous episode of postpartum psychosis.
- In most women, symptoms develop within the first 2 weeks.
Symptoms of Postpartum psychosis
- Hallucinations
- Delusions– usually centering around the baby
- Illogical thoughts
- Attempts to kill the baby (infanticide)
- Insomnia
- Memory impairment
- Confusion
- Irritability
- Suicidal wishes or attempts to kill one-self
- Poor hygiene and mother will look dehydrated
- Fatigue
- Agitation/feeling of anxiety
- Disorientation
- May have a fever which may be associated with puerperal sepsis
- There may be breast engorgement from days of not breastfeeding
General Measures of Postpartum psychotic disorder
- Always admit a psychotic mother
- Ensure safety of the staff, patient and infant
- Sedate if necessary
- Ensure constant supervision of mother and baby to avoid harm to the baby but if baby is at severe risk keep it away from the mother.
- Counsel and give support to the spouse or relatives and involve them in care of mother and baby.
Aim of treatment in Postpartum psychotic disorder
Aim of treatment:
- Reduce depression
- Stabilize the mood
- Reduce psychosis
Breastfeeding & Psychotropic Medication
- Women who plan to breastfeed must be informed that all psychotropic medications, including antidepressants, are secreted into breast milk.
- Women treated with valproic acid & carbamazepine should avoid breastfeeding, because these agents have been associated with hepatotoxicity in the infant.
- Avoid breastfeeding in premature infants or in those with hepatic insufficiency who may have difficulty metabolizing medications present in breast milk
Medicine treatment for Postpartum psychotic disorder
- If there is fever look for signs of infection and watch out for delirium (refer to topic of Neurocognitive disorders).
- Haloperidol, oral, Initial dose: 0.5 mg daily, increasing to 5 mg daily.
OR
- Risperidone, oral, Initial dose: 2–3 mg daily.
- Give antibiotics in case of puerperal sepsis
