Postpartum psychosis: Strategies to protect infant and mother from harm

Current Psychiatry. 2009 February;08(02):40-45

February 1, 2009|Current Psychiatry

Susan Hatters Friedman, MD;Phillip J. Resnick, MD;Miriam B. Rosenthal, MD

Counsel at-risk women before delivery, and be alert for rapid symptom onset

Table 2

Postpartum psychosis: Risk factors supported by evidence

Sleep deprivation in susceptible women
Hormonal shifts after birth (primarily the rapid drop in estrogen)
Psychosocial stressors such as marital problems, older age, single motherhood, lower socioeconomic status
Bipolar disorder or schizoaffective disorder
Past history of postpartum psychosis
Family history of postpartum psychosis
Previous psychiatric hospitalization, especially during the prenatal period for a bipolar or psychotic condition
Menstruation or cessation of lactation
Obstetric factors that can cause a small increase in relative risk: first pregnancy delivery complications preterm birth acute Caesarean section long duration of labor
Source: For bibliographic citations

Differential diagnosis

Clinical Point

Depression with rapid mood changes is a symptom that suggests postpartum psychosis rather than postpartum depression alone

The psychiatric differential diagnosis includes “baby blues”—mild, transient mood swings, sadness, irritability, anxiety, and insomnia that most new mothers experience in the first postpartum week. Schizophrenia’s delusional thinking and hallucinations have a more gradual onset, compared with those of postpartum psychosis.

Postpartum depression (PPD) occurs in approximately 10% to 15% of new mothers.¹⁴ Depressive symptoms occur within weeks to months after delivery and often coexist with anxious symptoms. Some women with severe depression may present with psychotic symptoms. A mother may experience insomnia, sometimes not being able to sleep when the baby is sleeping. She may lack interest in caring for her baby and experience difficulty bonding.

At times it can be difficult to distinguish PPD from PPP. When evaluating a mother who is referred for “postpartum depression,” consider PPP in the differential diagnosis. A woman with PPD or PPP may report depressed mood, but in PPP this symptom usually is related to rapid mood changes. Other clinical features that point toward PPP are abnormal hallucinations (such as olfactory or tactile), hypomanic or mixed mood symptoms, and confusion.

Box

Medical workup in differential diagnosis of postpartum psychosis

When evaluating a postpartum woman with psychotic symptoms, stay in contact with her obstetrician and the child’s pediatrician. Rule out delirium and organic causes of the mother’s symptoms, giving special consideration to metabolic, neurologic, cardiovascular, infectious, and substance- or medication-induced origins. The extensive differential diagnosis includes:

thyroiditis
tumor
CNS infection
head injury
embolism
eclampsia
substance withdrawal
medication-induced (such as corticosteroids)
electrolyte anomalies
anoxia
vitamin B₁₂ deficiency.¹¹

Suicidal thoughts or thoughts of harming the infant may be present in either PPD or PPP. Both elevate the risk of infanticide; one study found that 41 out of 100 depressed mothers acknowledged having thoughts of harming their infants.¹⁵

Psychosis vs OCD. Psychotic thinking and behaviors also must be differentiated from obsessive thoughts and compulsions.^10,16 Obsessive compulsive disorder (OCD) may be exacerbated or emerge for the first time during the perinatal period.¹⁷

In postpartum OCD, women may experience intrusive thoughts of accidental or purposeful harm to their baby. As opposed to women with PPP, mothers with OCD are not out of touch with reality and their thoughts are ego-dystonic.¹⁷ When these mothers have thoughts of their infants being harmed, they realize that these thoughts are not plans but fears and they try to avoid the thoughts.

Preventing PPP

Bipolar disorder is one of the most difficult disorders to treat during pregnancy because the serious risks of untreated illness must be balanced against the potential teratogenic risk of medications. Nevertheless, proactively managing bipolar disorder during pregnancy may reduce the risk of PPP.¹⁰

Closely monitor women with a history of bipolar disorder or PPP. During pregnancy, counsel them—and their partners—to:

anticipate that depressive or psychotic symptoms could develop within days after delivery¹⁸
seek treatment immediately if this occurs.

Some women will prefer to remain off medication during the first trimester—which is critical in organogenesis—and then restart medication later in pregnancy. This approach is not without risks, however (see Related Resources).

Clinical Point

Proactively managing bipolar disorder during pregnancy may reduce the risk of postpartum psychosis

Postpartum medication. Whether or not a woman with bipolar disorder takes medication during pregnancy, consider treatment with mood stabilizers or atypical antipsychotics in the postpartum to prevent PPP (Table 3). Evidence is limited, but a search of PubMed found 1 study in which prophylactic lithium was given late in the third trimester or immediately after delivery to 21 women with a history of bipolar disorder or PPP. Only 2 patients had a psychotic recurrence while on prophylactic lithium; 1 unexplained stillbirth occurred.¹⁹

A retrospective study examined the course of women with bipolar disorder, some of whom were given prophylactic mood stabilizers immediately in the postpartum. One of 14 who received antimanic agents relapsed within the first 3 months postpartum, compared with 8 of 13 who were not so treated.¹⁸

References

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