Psychological

Question 1

Epidemiology and incidence of postpartum depression

Answer 1

-10% of women
=1/3-1/2 severe

Question 2

Symptoms and signs of postpartum depression

Answer 2

-Most cases start within a month and typically peaks at 3-4 months postnatally
-Features similar to depression seen in other circumstances
=Clouded thinking, difficulty making decisions or choices
=Lack of concentration/poor memory
=Avoidance—physical/psychological
=Fear of rejection by partner
=Worry about welfare of partner/baby
=Thoughts of harming the baby
=Suicidal ideation
=Broken sleep and early-morning awakening
=Feeling hopeless on waking
=Loss of appetite, and loss of weight
=Extreme tiredness, and lack of vitality

=Persistent low mood for up to 10 to 14 days
=Feelings of inadequacy, failure
=Exhaustion, emptiness, sadness, tearfulness
=Lack of love for the baby/distance from the baby/dislike of the baby
=Guilt, shame, worthlessness
=Confusion, anxiety, panic
=Irritability, anger
=Fear for/of the baby
=Fear of being alone or going out
=Feelings of being on the outside—distanced from those around her

=Lack of interest/pleasure in usual activities
=Sleep disturbances/appetite changes
=Decreased energy/motivation
=Social withdrawal
=Poor self-care/inability to cope with routine tasks

Question 3

Diagnosis and investigations of postpartum depression

Answer 3

-The Edinburgh Postnatal Depression Scale may be used to screen for depression:
=10-item questionnaire, with a maximum score of 30
=Indicates how the mother has felt over the previous week
=Score > 13 indicates a ‘depressive illness of varying severity’
=Sensitivity and specificity > 90%
=Includes a question about self-harm

Question 4

Management of postpartum depression

Answer 4

-As with the baby blues reassurance and support are important
-NICE CKS state ‘Most women with the baby blues will not require specific treatment other than reassurance’
-Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe** - whilst they are secreted in breast milk it is not thought to be harmful to the infant

Question 5

Describe baby blues

Answer 5

-Seen in a round 60-70% women
-Typically seen 3-7 days following birth, more common in primips
-Mothers are characteristically anxious, tearful, and irritable, transient emotional lability
-Rapidly resolve
-Reassurance and support, health visitor has key role

Question 6

Incidence of puerperal psychosis

Answer 6

Affects approximately 0.2% of women

Question 7

Symptoms and signs of puerperal psychosis

Answer 7

-Onset usually within the first 2-3 weeks following birth, often within first few days after birth
-Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)
=Perplexity, fear (even terror), restless agitation, insomnia
=Purposeless activity, uncharacteristic behaviours, disinhibition, irritation, fleeting anger, resistive behaviours
=Fear for her own or baby’s health and safety or identity
=Elation and grandiosity, suspiciousness, depression or ideas of horror.
=As the condition develops, there is generally a combination of mania, depression, and psychotic symptoms.

Question 8

Investigations and diagnosis of puerperal psychosis

Answer 8

-Risk factors:
=Similar illness with a previous child
=Women with known bipolar affective disorder or previous psychosis
=Family history of bipolar illness or postpartum psychosis.
-Postpartum psychosis most commonly occurs within the first 2 weeks of birth and may rapidly deteriorate

Question 9

Management of puerperal psychosis

Answer 9

-Admission to hospital is usually required, ideally in a Mother & Baby Unit
-Antipsychotic or mood-stabilising drugs initiated to reduce disturbance of the mother–infant relationship. Other medication, such as antidepressants, may also be indicated.
=The psychiatrist will ensure suitable drug therapy if breastfeeding.
-Community follow-up with the perinatal mental health team
-Once recovered, discussion with the woman about risk of future illness and ways of reducing risk following a future pregnancy
-There is around a 25-50% risk of recurrence following future pregnancies

Question 10

PTSD in postnatal care

Answer 10

A proportion of women (and birth partners) experience birth as ‘traumatic’ and may develop symptoms of post-traumatic stress disorder (PTSD). It is important to enable parents to be open about their feelings about the birth and identify when further support may be required.