Yes

1. Case presentation on postpartum psychosis
Presenter Dr .Diba ( R1 )
Moderator : Dr . Daniel (Assistant professor of OBGYN )

2. Outline
• Objective
• The cases
• Comments
• Discussion
• References

3. Objective
• To discuss on the management of postpartum psychosis based on the case
as an entry.

4. CASE
• Name-G.Y
• Age- 34yrs
• Card No- 002365/10
• DOA-13/12/2014EC
• DOD-2/13/2014EC
HX
C/C-Come with referral paper
• This is GIIIPII (both alive ) mother whose LNMP was on 8/04/2014 EC
making GA 35+6
weeks. She regular ANC follow up at near by health center

5. • Currently present with referral paper from Boa Bedagalo HC with PE with
Severity feature
• She has history of headache , blurring of vision and epigastric pain

6. • Currently present with referral paper from Boa Bedagalo HC with PE with
Severity feature
• She has history of headache , blurring of vision and epigastric pain
P/E
• G/A – ASL
• V/S – BP- 140/90mmHg, PR- 84, RR -24, T -ATT.
• HEENT- Pink conjunctiva, non icteric sclera.
• LGS – No lymphadenopathy.
• R/S – Clear & resonant.
• CVS – S1 & S2 well heard, no murmur or gallop.

7. • Abdomen –36week sized gravida uterus
-longitudinal
-cephalic presentation
-FHB-132bpm
• GUS – no active vaginal bleeding
Ass-: MG + 3rd
tx px + PE with severity feature

8. Plan
CBC OBS U/S
-WBC=13.39 -Singleton IUPx
-Hct= 37.7% -FHB =+ve
- Hgb=17.4 -EFW-2100g
- PLT =179 -GA-33+4
wks.
-BG/Rh= B+ -
Placenta-fundal
- PICT– NR
-LFT ( AST=218.4 , ALT=90.02 )
-RFT ( Cr =0.75 )
- urine protein +2

9. management
• Admit to high risk
• Dexamethasone 6mg IM BID / 48hrs
• Mgso4 loading and maintenance as per protocol
• Hydralazine 5mg if BP >160/110mmhg
• Methyldopa 500mg PO TID
• Follow with PE follow up chart
• Consult senior

10. operation note (17/12/2014 )
• LUSTC/S was done for and indication of GIIMSAF @ LFSOL to effect 1.9 kg female
alive neonate with APGAR score of 6 , 7 and 7 at 1st
5th
and 10th
min respective
• IOF -health looking ovaries
- GIIMSAF
Postop order
• Put on MF(RL,DNS and NS) for 24 hrs.
• Ceftriaxone 1gm iv bid for 3days
• Metronidazole 500mg iv TID for 3days
• Diclofenac 75mg IM BID
• Keep NPO until BSA
• Keep catheter for 24hrs

11. Progress note (25/12/2014 )
• This is 20year old PIII mother on her 9th
post op day after LUSTC/S was done for an indication of
GIIMSAF @ LFSOL to effect 1.9 kg female alive neonate with APGAR score of 6 , 7 and 7 at 1st
5th
and
10th
min respectively .
• Currently she start to experience hallucination , talking to have harm , loss of interest and shouting .
• She had similar history on the previous pregnancy
• Complain surgical site pain
P/E
G/A-ASL
V/S BP-130/90, PR-84, RR-20 T-ATT
• HEENT- Pink conjuctiva, non icteric sclera.
• LGS – No lymphadenopathy.
• R/S – Clear & resonant.
• CVS – S1 & S2 well heard, no murmur or gallop

12. • Abdomen – flat which moves with a respiration
-horizontal lower abdomen clean surgical dressing
• GUS-no active vaginal bleeding
ASS-9th
postop day + MP + Postpartum psychosis
• Consult senior
• Consult psychiatric department
• Follow her condition strictly
• Psycho care

13. • DISCHARGE SUMMARY ( 2/13/2014 )
• This is a 34yrs old PIII mother on her 14th
day postpartum day after LUSTC/S was
done for an indication of LFSOL + GIIMSAF + Postpartum psychosis and she was
treated with resperidone 1gm po daily and FESO4 1tab po TID
• P/E
• G/A-well looking
• V/S-BP-120/70 PR- 86 RR-20 TEMP- 36.7
• HEENT- Pink conjunctiva, non icteric sclera.
• LGS – No lymphadenopathy.
• R/S – Clear & resonant.
• CVS – S1 & S2 well heard, no murmur or gallop

14. • ABD-clean transverse surgical scar ,no discharge , no tenderness
• GUS-No active vaginal bleeding
• MSK-No edema , no deformity
• CNS-COTTP
• Investigations
-Hgb- 9.7 and hct-27.1 , Plt-482 ,
-AST- 58 , ALT-46.6 , Cr- 0.57
-discharged on 2/13/2014 with iron 1tab po TID for 3months and resperidone 1gm po
daily
• Link to psychiatric department

15. • Strength
• psychiatric side consultation
• Early evaluation and senior
consultation
• Pitfall
• No psychiatric side evaluation
• No screening done during ANC Follow
up
• She didn’t start mood stabilizer and
prophylaxis
• No documentation whether it respond
to the started the antipsychotic or
not

16. Identified problems
• PE With Severity feature
• Postpartum psychosis
• Moderate anemia

17. Discussion time

18. Introduction
• DEFINITIONS
Psychosis is a disturbance in an individual's perception of reality.
Characterized by disturbance of thinking, perception, behavior, social integration
and occupation
• Postpartum psychosis
is the most severe puerperal mental disorder and typically occurs around the time of
delivery (within 2 -4 weeks).
 Postpartum emotional distress is fairly common after pregnancy and ranges from
mild blues, postpartum depression to psychosis.
Postpartum psychosis can pose a threat to the life of the mother or baby.
Our case
Start on 9th
postpartum day

19. • Prevalence
1 to 2 per 1000 births, and is far less common than postpartum blues and
postpartum depression.
It affects less than 1% of women.
• PATHOGENESIS
The etiology is not known, but can be genetic, immunologic, and hormonal factors,
as well as possibly sleep deprivation .
Familial susceptibility to triggering of psychosis following childbirth .
Rapid hormonal changes following childbirth may also play a role in triggering
postpartum psychosis . Our case
1, family history and psychosocial not documented

20. After birth, a rapid decline in estrogen and progesterone levels occurs and this is
thought to be caused by PP.
Estrogen plays a role in dopaminergic activity in the hypothalamus and it has been
suggested that there is a relationship between the emergence of affective psychosis
after birth and increased sensitivity of dopamine receptors .
 Estrogen receptor or glucocorticoid receptor gene polymorphisms have not been
associated with PP .
Postpartum psychosis has been associated with thyroiditis and preeclampsia in
studies on the relationship between PP and postnatal immunization .

21. Preeclampsia and postpartum psychosis
both disorders is strongly associated with first pregnancy, compared with
subsequent pregnancies
history of a prior episode is the strongest known risk factor for each disorder in
subsequent pregnancies
longer intervals between subsequent pregnancies, a relationship that has recently
been confirmed for first-onset postpartum psychiatric episode
 Together, the shared pattern of risk between pre-eclampsia and postpartum
psychiatric disorders may be evidence of a more fundamental relationship in their
underlying pathophysiology

23. • Associated mental disorders
Most often seen in patients who have been or will be diagnosed with bipolar
disorder
Can occur in women with a major depression with psychosis, schizophrenia, or
schizoaffective disorder.
Strongly and consistently associated with bipolar disorder .

24. • Risk factors
• The risk factors for postpartum psychosis include :
History of postpartum psychosis
Family history of postpartum psychosis
History of bipolar disorder, schizophrenia, or schizoaffective disorder
Family history of bipolar disorder
First pregnancy
Discontinuation of psychiatric medications for pregnancy
Our patient has previous
history of PP

25. • CLINICAL MANIFESTATIONS
Presents within two weeks of childbirth.
Hallucinations and delusions are usually present, often with thought
disorganization and/or bizarre behavior .
Mood disorder, such as manic or depressed mood (or both), severe insomnia, rapid
mood changes, anxiety, irritability, and psychomotor agitation .
Persistent severe insomnia (not related to caring for the newborn) is often
the first indication of an incipient postpartum psychosis.
Our patient has
1, hallucination
2,bizarre behavior

26. • Risk of suicide and infanticide
In the first year after childbirth, suicide increases 70-fold.
Suicide is the leading cause of maternal death up to one year after delivery.
2 out of 1000 have been found to commit suicide, usually by violent means .
Homicidal behavior is rare .
Third of women hospitalized expresses delusions about their infants
9 percent had thoughts of harming their infants.
4 percent commits infanticide .
Disorganization and confusion in the mother add to the potential risks for the infant,
who should not be left alone in the care of a mother with postpartum psychosis

27. Often use more irreversible and aggressive means (self incineration, jumping from
heights) compared with women complete suicide nonviolently (overdose).
 Critical analysis of safety of patient by inquiring about suicidal ideation
thoughts of dying, feelings of life not worth living, active plans to take her life, access
to weapons, and past suicide attempts.
Suicidal ideation must be taken seriously, and patients with recent or active suicidal
plans should be referred to an emergency setting.
Neonaticide is more difficult to prevent, as it involves denial of pregnancy.
Our case
No documentation suicidal
ideation , past suicidal attempts

28. • COURSE AND PROGNOSIS
Can be severe and prolonged.
May interfere with maternal-infant bonding, which is also disrupted by inpatient
hospitalization of the mother.
Women who sought help within 1 month of delivery had more favorable
outcomes and were less likely to suffer long-term disability than women with late-
onset PP, that is, after 1 month postpartum (13% and 33%, respectively).
Compared with women with new onset of non-PP, the patients with first episode PP
had higher levels of confusion and disorientation but required only half the time to
achieve treatment response.
Recurrence
Women experiencing first-episode have a high risk of recurrence (50% ).
Our case
There is recurrence in our patient
Our case
Less than 1month

29. • SCREENING
Women presenting for medical care during pregnancy or postpartum should be
screened for current mental health problems, a history of psychiatric treatment, and
a family history of mental illness.
Patients screening positive assessed for a history of mania or hypomania, psychotic
depression, or a psychotic disorder.
Patients with a family history of psychiatric disorders should be queried further
about a family history of hospitalization, suicide, mania, depression, or psychotic
disorder.
Patients with a personal or family history of one of these conditions should be
educated and monitored during the first weeks of the postpartum period.
More intensive monitoring and prophylactic treatment should be considered for
patients with a history of bipolar or schizoaffective disorder
Our case
not screened

30. Both the ACOG (2018b) and the United States Preventive Services Task Force now
recommend screening at least once during the perinatal period for depression and
anxiety (Siu, 2016).
All obstetrical care providers complete a full assessment of mood and emotional
well-being during the comprehensive postpartum visit (ACOG , 2018a)
At Parkland Hospital, mental illness screening is completed at the first prenatal visit
using a brief risk based query and again postpartum using a recognized screening
tool for postpartum depression

31. Diagnosis
A. Two (or more) of the following
1. Delusions -Fixed, false beliefs .
2. Hallucinations -– Sensory experiences without physical sensory stimulation including tactile,
visual, auditory, gustatory, and olfactory sensations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behaviour.
5. Negative symptoms (i.e., diminished emotional expression or avolition).
• Prognosis for recovery is excellent but about 50% of women will suffer a
relapse with subsequent deliveries. Our case
1, hallucination
2, Disorganized behavior

32. Delusions
Dead or deformed baby
Denial of birth or marriage, persecution
Hallucinations
Voice telling that to kill the baby
Feelings of
Not wanting to care for the baby
Wanting to do harm to the baby or to themselves
Close relation with childbirth
With in 4 weeks
Mean onset: 2-3 weeks after birth, (always within 8 weeks)

33. • The initial evaluation requires a history, physical examination, and laboratory
investigations to exclude an organic cause for acute psychosis .
• Important tests include a complete blood count (CBC), electrolytes, blood urea
nitrogen (BUN), creatinine, glucose, vitamin B12, folate, thyroid function tests, calcium,
urinalysis and urine culture in the patient with fever, and a urine drug screen.
• A careful neurological assessment is essential; this includes a head CT or MRI scan to
rule out the presence of a stroke related to ischemia (vascular occlusion) or hemorrhage
(uncontrolled hypertension, ruptured arteriovenous malformation, or aneurysm).
• The stroke patient is differentiated from the patient with PP by a history of hypertension
or preeclampsia, evidence of fluid/electrolyte imbalance, and complaints of severe
headache, unilateral weakness, sensory deficits, and even seizures with the neurological
event

34. DSM-IV
Mood disorder
Brief psychotic disorder
DSM-V
Postpartum mental disorders are not classified as a separate clinical diagnostic entity
in the DSM-5 and in the International Classification System of Mental and Behavioral
Disorders (ICD)
In DSM-5, postpartum psychosis is classified in the "short psychotic disorder" section
of the schizophrenia spectrum and other psychotic disorders.

39. • TREATMENT
Treated with a combination of antipsychotic and a mood stabilizer.
Benzodiazepines and antidepressants are used to treat insomnia or depression,
respectively, when present.
Pharmacotherapy is considered in the context of the mother's status regarding
breastfeeding.
Adjunctive psychotherapy ( psychoeducation, support, coordination of care, and
encouraging treatment adherence ) .
Our case
Mood stabilizer didn’t
start

40. • PSYCHOSIS AND AGITATION
Antipsychotic medications are first-line treatment for psychosis and agitation in
postpartum psychosis.
 Typically started while the patient’s diagnostic evaluation is underway.
Antipsychotic medication is generally used to treat psychosis regardless of its cause.
The exposure of infants to antipsychotics via human milk generally appears to be low
and clinically insignificant .

41. • Choice of antipsychotic
First-line treatment of patients with postpartum psychosis with one of the older,
second-generation antipsychotics (SGAs) rather than newer SGAs or first-generation
antipsychotics (FGAs).
SGAs are generally preferred over FGAs due to lower rates of extrapyramidal
symptoms and tardive dyskinesia .
Older SGAs, such as quetiapine, risperidone, and olanzapine, are preferred
over aripiprazole, ziprasidone, iloperidone, and asenapine because of longer clinical
experience and the safety data in pregnancy and lactation.
If a woman has a history of nonresponse to an older SGA, a new SGA can be used.
Our case
Start risperidone

42. • ANTIPSYCHOTIC RESISTANCE
Patients who do not respond to or tolerate antipsychotic medication or mood
stabilizers, trial of electroconvulsive therapy (ECT) .
Response to ECT is generally more rapid compared with response to medication
ECT useful if a rapid response is needed to prevent harm, e.g., the woman is at high
risk for suicide or infanticide, is catatonic or acutely agitated.
ECT has a relatively low rate of adverse effects in the general population, including
time-limited neurocognitive effects, rare cardiovascular or pulmonary compromise,
and risks associated with general anesthesia

43. There are no known effects of ECT on breast milk.
The American Psychiatric Association Task Force on ECT recommends that the
informed consent process include a discussion with the mother of potential risks to
the infant from breastfeeding during a course of ECT .
Anesthetic medications administered during ECT treatment generally pose little risk
to breastfeeding infants .
Exposure can be minimized by delaying breastfeeding for a few hours after ECT
therapy or by collecting and storing breast milk the day prior to ECT

44. • ADJUNCTIVE PSYCHOTHERAPY
Psychotherapy provide useful adjunctive treatment, focusing on psychoeducation,
support, coordination, and encouraging/monitoring adherence to medication.
Women who have experienced postpartum psychosis, but discontinue their mood-
stabilizing medication after hospital discharge are at increased risk for recurrence.
In patient care during the hospital stay with the patient's psychiatrist, obstetrician,
primary care physician, and pediatrician.
There are no clinical trials of the role of psychotherapy or other psychosocial
treatments in postpartum psychosis.

45. • SAFETY
The first priority of treatment for postpartum psychosis is to ensure safety.
A woman experiencing psychosis will generally not be able to care for herself or her
baby without significant family support; she should usually be hospitalized until
stable, though separation of mother and baby at this critical time is not optimal.
The mother should not be left alone with the infant.
Though uncommon, hospitals may make provisions for supervised daytime visits
with the infant.
Our case
admitted

46. • Breastfeeding
Women with mild to moderate illness may be able to breastfeed.
Patients who are more severely ill may be too disorganized or present too much of a
risk to the baby to breastfeed.
All psychotropic medications taken by the mother are transferred into breast milk
and are passed on to the nursing infant.
Breastfeeding women with postpartum psychosis should be monitored to ensure
adequate rest and sleep

47. • PREVENTION
Women with a history of bipolar disorder, a psychotic disorder, or a history of
postpartum psychosis can be identified though screening during prenatal care.
They should be educated about the increased risk of developing psychosis following
childbirth, instructed to contact their clinician for symptoms consistent with
psychosis, mania, and/or depression, and encouraged to make a plan for accessing
treatment quickly.
They should be monitored closely for the first few weeks postpartum for early
indications of psychosis or mood instability

48. Prophylaxis and mood stabilizer
Lithium
Start during peripartum or immediately after delivery
Weekly lithium levels may need to be measured.
 Common side effects are sedation, tremor, renal dysfunction, weight gain, nausea, vomiting, and diarrhea.
Toxic effects are associated with somnolence, confusion, severe tremors, renal dysfunction, and intractable
vomiting.
Women with vomiting are especially vulnerable to toxicity due to fluid loss.
Toxicity is managed with drug discontinuation, rehydration therapy, and monitoring of fluid and electrolyte balance
and renal function.
Diuretics and nonsteroidal antiinflammatory drugs (NSAIDs), which can impair renal clearance, should be avoided in
lithium-treated patients.
Developmental milestones are normal in infants exposed in utero to lithium
VALPROATE ( VALPROIC ACID )
CARBAMAZEPINE

49. • Impact of postpartum psychosis on child development ( American academy
of pediatrics )
Exhibit negative facial interaction
Discontinue breast feeding earlier in the postpartum
Exhibit behavioral problems ( sleep and eating difficulties , hyperactivity )
Delay in cognitive development
Emotional and social dysregulation
Early onset of depressive illness
Infanticide / neonaticide

50. • William 26th
edition
• Up-to-date 2018
• Gabe 7th
edition
• Textbook of Psychiatry
• Kendell, R. E., Chalmers, J. C. & Platz, C. Epidemiology of puerperal
psychoses. Br. J. Psychiatry 150, 662–673 (1987)
• Austin M. Puerperal affective psychosis: is there a case for lithium
prophylaxis? Br J Psychiatry. 1992;161:692–4

51. Thank you