Postpartum depression or medical problem?
Watch for fatigue, weight change, other physical signs.
Ask the patient is she is HIV positive. Watch for weight loss, fever, anorexia, and recurrent infections.
Substance abuse. Intoxication, withdrawal, or long-term alcohol or drug use can contribute to depression. Women at high risk for substance abuse disorder might not adhere to psychiatric treatment and may be prone to sexually transmitted diseases. If possible, see the patient every 3 to 4 weeks during the postpartum period.
Pain—if not adequately controlled—can fuel depression. Ask the patient if she has chronic pain or suffered a severe injury.
Table 1
Possible tests if postpartum patient is constantly fatigued
| Laboratory test | Confirms or rules out | Order if patient also presents with: |
|---|---|---|
| Acetylcholine receptor antibodies | Myasthenia gravis | Double vision, droopy eyelids, muscle weakness |
| Alkaline phosphatase | Primary biliary cirrhosis | Jaundice, pruritus |
| Antimitochondrial antibody | Primary biliary cirrhosis | Jaundice, pruritus |
| Antinuclear antibody | Systemic lupus erythematosus | ‘Butterfly’ facial rash, joint pain, morning stiffness |
| CBC | Microcytic anemia, megaloblastic anemia | Pallor, low energy, peripheral neuropathy, shortness of breath |
| Electrolytes | Adrenal insufficiency, renal disease | Low blood pressure, seizures, skin pigmentation |
| Glucose (fasting or glucose tolerance) | Type 1 or 2 diabetes mellitus | Blurred vision, excessive thirst/hunger, headaches, frequent urination, unexplainable weight loss |
| HIV | HIV infection/AIDS | Anorexia, recurrent infections, weight loss |
| Liver function tests | Alcohol abuse, hepatitis, primary biliary cirrhosis | Asterixis (flapping tremor), easy bruising, jaundice, pruritus, spider telangiectasias |
| Lumbar puncture | Multiple sclerosis | Bladder dysfunction, gait ataxia, ocular signs, sensory loss, spasticity |
Possible tests if postpartum patient has lost or gained weight
| Laboratory test | Confirms or rules out | Order if patient also presents with: |
|---|---|---|
| Antithyroid antibody | Postpartum thyroiditis | Constipation, dry skin, hair loss, lethargy, memory loss |
| Glucose (fasting or glucose tolerance) | Type 1 or 2 diabetes mellitus | Blurred vision, excessive thirst/hunger, fatigue, frequent urination, headaches |
| HIV | HIV infection/AIDS | Anorexia, fatigue, recurrent infections |
| TSH±thyroid panel | Hypothyroidism | Constipation, dry skin, hair loss, lethargy |
| TSH±thyroid panel | Hyperthyroidism | Agitation, anxiety, heat intolerance, palpitations |
Possible tests if postpartum patient has other physical symptoms
| Laboratory test | Confirms or rules out | Order if patient presents with: |
|---|---|---|
| Blood urea nitrogen/creatinine | Renal disease, dehydration | Back pain, frequent urination or oliguria, low blood pressure |
| Brain MRI | Brain tumors, white matter disease | Focal deficits, headaches, seizures, vision problems, vomiting |
| C-reactive protein | Rheumatoid arthritis | Joint pain, morning stiffness |
| ECG | Cardiomyopathy | Extremity swelling, palpitations, shortness of breath at night and with exertion |
| Erythrocyte sedimentation rate | Rheumatoid arthritis, SLE | ‘Butterfly’ facial rash, joint pain |
| Folate | Folate deficiency | Ataxia, loss of vibration and position sense, peripheral neuropathy, weakness |
| Prolactin | Prolactinoma, hypopituitarism | Amenorrhea/galactorrhea, headache, visual field loss |
| Rapid plasma reagin | Syphilis | Ataxic wide-based gait, loss of position, deep pain and temperature sensation, palmar/plantar rash |
| Rheumatoid factor | Rheumatoid arthritis | Morning stiffness, symmetric joint pain |
| Urinalysis | Urinary infection, diabetes, renal disease | Burning or difficulty with voiding, dark-colored urine, frequent urination |
| Urine drug screen | Substance abuse disorder | Erratic behavior, irritability or aggression; violence, mental status changes |
| Vitamin B12 | Anemia, malnutrition, inflammatory bowel disease | Loss of position or vibratory sensation, mood and cognitive changes, tingling and numbness in hands and feet |
| SLE: Systemic lupus erythematosus | ||
Determining a medical cause
Laboratory and neuroimaging findings—obtained in concert with the patient’s primary care physician—will help confirm or rule out a medical problem (Table 4). Consult with a neurologist, endocrinologist or rheumatologist if indicated.
Table 4
Findings that signal a possible postpartum medical problem
| Laboratory finding | Could signal … |
|---|---|
| Low hemoglobin, hematocrit and mean cell volume (MCV) values | Microcytic anemia |
| MCV >100 mm3 | Megaloblastic anemia |
| Positive anticardiolipin or antinuclear antibody | Systemic lupus erythematosus |
| Blood urea nitrogen >20 mg/dL, creatinine >1.5 mg/dL | Acute or chronic renal failure |
| Low specific gravity on urinalysis | Diabetes insipidus or renal tubular abnormalities |
| Proteinuria with glycosuria | Diabetes mellitus |
| Proteinuria with protein or cellular casts | Systemic lupus erythematosus |
| Hyponatremia and hyperkalemia | Adrenocortical insufficiency |
| Hypo/hypernatremia | Seizures |
| Albumin | Malnutrition |
| SGOT/SGPT >35 u/L (each) | Alcohol abuse disorder, hepatitis, hepatic encephalopathy |
| Alkaline phosphatase >120 u/L, positive antimitochondrial antibody | Primary biliary cirrhosis |
| Erythrocyte sedimentation rate >20 mm/hr | Systemic lupus erythematosus, rheumatoid arthritis |
| Positive rheumatoid factor | Rheumatoid arthritis |
| Prolactin >24 ng/mL | Prolactinoma |
| TSH >5 µu/mL | Hypothyroidism |
| TSH | Hyperthyroidism |
| IgG >1.4 mg/dL, oligoclonal bands, myelin basic protein in CSF | Multiple sclerosis |
| White matter hyperintensities in brain MRI | Multiple sclerosis, CNS vasculitis, tumors |
| Source: Reference 5 | |
Case: will the tumor resolve?
Mrs. A’s endocrinologist prescribes bromocriptine to manage her hyperprolactinemia, but she refuses to start the dopamine agonist after the doctor explains that it might cause psychosis.
Working closely, the psychiatrist and endocrinologist postpone bromocriptine therapy to see if the prolactinoma will resolve without treatment. They order brain MRIs every 6 months to track the tumor.
Mrs. A starts weekly psychodynamic therapy, during which she explores her fear of failure as a mother. Within 2 months, she recognizes that she has set unrealistically high expectations for herself. Adopting a supportive approach, the therapist encourages her to go on dates with her husband and run errands or relax alone for 2 hours each weekend.
The psychiatrist discusses sleep hygiene and adds quetiapine, 25 mg at bedtime; reduces gabapentin over 3 months to 300 mg nightly; and titrates sertraline to 100 mg/d. The psychiatrist also weans Mrs. A off temazepam over 3 months, watching closely for withdrawal symptoms.
At the psychiatrist’s suggestion, Mrs. A. resumes exercising at a gym four to five times a week. Mrs. A reduces zolpidem use—taking it only as needed for insomnia—then tapers off gabapentin. Quetiapine is discontinued.
