Psychiatry - Postpartum Psychosis

Question 1

Postpartum Psychosis?

Answer 1

• A severe mental illness
• Develops acutely in the early postnatal period – usually within 1st month
• Psychotic features are present
• Close link with bipolar disorder
• Psychiatric emergency
• Management requires specialist care
• Need to take into account the needs of the family and new baby, as well as the risks of medication whilst breast-feeding

Question 2

Postpartum Psychosis?

Epidemiology?

Answer 2

• Occurs following 1-2 per 1,000 deliveries
• Higher risk of psychosis in the few weeks following childbirth than at any other time in their lives
• Incidence is significantly increased in women with a history of hospitalisation for psychiatric illness, especially where the past history was related to pregnancy
• FHx of PPP = six-fold increased risk
• Risk even higher if 1st-degree relative BPAD
• Suicide and psychiatric conditions are known to be significant leading causes of late maternal death in the UK

Question 3

Postpartum Psychosis?

Aetiology?

Answer 3

Women at high risk of postpartum psychosis include those with:

• A past history of postpartum psychosis
• A past history of bipolar disorder
• A family history of postpartum psychosis or bipolar disorder

It is thought that postpartum psychosis may be a manifestation of underlying bipolar disorder. Possible contributing factors include sleep deprivation, hormonal changes, stress and genetic influences

Question 4

Postpartum Psychosis?

Presentation?

Answer 4

• Presentation typically within the first postnatal month
• Symptom progression from mild anxiety to severe psychosis can be rapid
• All significant changes to mental state in the postnatal period should be closely monitored, and should trigger referral to specialist services
• Symptoms may be depressive in nature or manic
• There may be hallucinations which may be auditory, visual, olfactory or tactile.
• There may be odd beliefs about the baby

Question 5

Postpartum Psychosis?

Differential Diagnosis & Management?

Answer 5

Differentials: Consider other psychiatric and organic causes

Management:

• Psychiatric emergency - urgent assessment, referral, and usually admission, ideally to a specialist mother and baby unit
• Management primarily pharmacological (see psychosis management)
• Antipsychotic +/- mood stabiliser
• Lithium – do not breastfeed
• Clozapine – agranulocytosis – avoid if breastfeeding
• ECT
• Education and supportive therapy
• Child protection services alerted if required
• Discharge with close follow-up

Question 6

Postpartum Psychosis?

Prevention?

Answer 6

First contact during pregnancy and postnatal period ask about:

• Past or present mental illness
• History of treatment by a specialist mental health team
• History of severe perinatal mental illness in first-degree relatives

Women with a history of severe mental illness should be referred to a secondary care mental health service

Women with a personal or family history of severe mental illness or perinatal illness should be monitored closely in the postnatal period

Care plans

Question 7

Postpartum Psychosis?

Prognosis?

Answer 7

• Prognosis for complete recovery is good
• There is significant risk of recurrence (1 in 2)
• Women who have been diagnosed with postpartum psychosis should be monitored very closely and referred early if they become pregnant again