CHAIR PERSONS : PROF.DR.V.RAMANUJAM M.D. , D.P.M. ASST.PROF.DR.G.AMUTHA M.D. , D.C.H PRESENTOR: DR.GEETHA .A. I yr P.

INTRODUCTION
During the postpartum period 85% of women experience

some type of mood disturbance. For most the symptoms

are mild and short lived . However 10-15% of women develop more significant symptoms like anxiety and

depression. Postpartum psychiatric illness are typically

divided into 3 categories 1.Postpartum blues 2.Postpartum depression 3.Postpartum psychosis

PUERPERIUM
Otherwise defined as fourth trimester

Time from delivery until complete physiologic involution

and where major psychological adjustment occurs

IMMEDIATE-24 hrs EARLY-7days REMOTE-6weeks

ADJUSTMENT TO PREGNANCY
Every women responds in a variety of ways

psychologically to the stressors of pregnancy

Concern about fetal health, fear of child birth pain

and post partum childcare and life style changes

Because psychological stress often increases in

puerperium this is a time of increased mental illness

 The level of perceived stress is significantly higher

For whose fetus is at high risk for a congenital

malformation
For those who have medical and obstetrical

complications

HISTORY
Organic psychosis relating to childbirth recognised

and documented since the time of hippocrates

HISTORY
It has been thought for centuries that milk was delivered

from breasts to the other areas of body especially brain causing lacteal metastasis causing mental disorders and they offered prayers to god apollo as a part of healing

process

HISTORY
Later Bleuler noted postpartum schizophreniform

disorder was identical clinically with schizophrenia with no special clinical features
Kreplin in 1913 noted mania was more common

than schizophrenia and that too could only be

provoked if childbirth is already latent

HISTORY
The term puerperal psychosis was first described by

french physician Charles Lepois(1563-1633) which is due to excess (plethora) of dark humors
Louis Victor Marce define postnatal mental illness as a

morbid sympathie between postnatal mental state and bodily functions

DIAGNOSIS
A temporal relationship between onset of emotional or

mental symptoms and delivery is often the basis for diagnosing postpartum disorders

ICD10 CLASSIFICATION
F53-mental and behavioural disorders associated with

puerperium not elsewhere classified

The classification should be used only for mental disorders

associated with puerperium (commencing within 6 weeks of delivery)that do not meet the criteria for disorders

classified elsewhere in this book either because insufficient

information is available or because it is considered that special additional clinical features are present which make

classification elsewhere inappropriate

ICD10 CLASSIFICATION
F30-F39 indicate the specific type of mental

disorder(usually affective)

099.3 mental disease and diseases of the nervous system

complicating the puerperium

F53.0-mild mental and behavioural disorders associated

with the puerperium , not classified elsewhere includes Postnatal Depression nos.

Postpartum Depression nos.

ICD10 CLASSIFICATION
F53.1-severe mental and behavioural disorders

associated with the puerperium not elsewhere classified includes : puerperal psychosis nos.
F53.8-other mental and behavioural disorders

associated with puerperium,not elsewhere classified

F53.9-puerperal mental disorder, unspecified

DSM 1V CRITERIA FOR POSTPARTUM DISORDERS

The specific postpartum onset can be applied to

current major depressive, manic or mixed episode of major depressive disorder, bipolar I (or) bipolar II disorders (or) brief psychotic disorder if onset within 4 weeks after delivery of child

DSM 1V CRITERIA FOR POSTPARTUM DISORDERS

Postpartum psychosis can be put in the category of

psychotic disorder-not otherwise specified(nos.) If it does not meet the criteria for mood disorder with psychotic features, brief psychotic disorder, psychotic disorder due to general medical condition or substance

induced psychotic disorder

INWOOD CLASSIFICATION
Type i-Postpartum psychosis / Puerperal

brief

reactive psychosis
Type ii-Adjustment reaction with depressed mood
(Postpartum Blues/Maternal Blues)

Type iii-Postpartum major disorder

(Major Depression, Postpartum Neurosis (Or) Neurotic Reaction)

RECENT CLASSIFICATION -ACOG

1.

POSTPARTUM PSYCHOSIS

2. POSTPARTUM DEPRESSION 3. MOTHER INFANT RELATIONSHIP DISORDER 4. ANXIETY AND STREES RELATED DISORDER

EPIDEMIOLOGY
POST PARTUM BLUES - 2.9-50%
DEPRESSION

- 36%

SEVERE DEPRESSION - 10% ANXIETY HYSTERIA

- 7.5% - 2%

EPIDEMIOLOGY
Puerperal Psychosis 2/1000 Deliveries
Previous H/O Postpartum Psychosis

-Recurrence Is 70%
Previous H/O Postpartum Depression -Recurrence is 50% Relapse Rate For Bipolar Disorder - 30- 50%

ETIOLOGY
1. Physical, psychological and endocrinal changes occurring in ones body 2. Recognition of psyche in accordance with new mother role 3. Body image changes 4. Unconscious intraphysic conflicts relating to pregnancy ,childbirth and motherhood may be activated

ETIOLOGY

BIOLOGICAL

PSYCHOLOGICAL

SOCIAL AND INTERPERSONAL FACTORS

BIOLOGICAL FACTORS
GENETIC
1.Puerperal psychosis tends to run in families 2.Close relationship with bipolar disorder 1st degree relative

3.Variation in serotonin transporter gene influenced by estradiol 4.Linkage with chr. 16p 13 and 8g24 5.Presence of one allele was associated with 4 times risk of puerperal psychosis

ENDOCRINAL FACTORS
Progesterone,estrogen

levels

drop in

7-10

days

postpartum
Prolactin rises by 3rd day associated with affective

disturbance
Abnormal ( or) cortisol levels associated with

postpartum blues
PBI 40% lower in postnatal period, deficit in

thyroxine production result in depression

BIOCHEMICAL
Estrogen -D2 sensitivity rapid fall after delivery is

associated with acute symptoms

Se.Calcium is associated with puerperal psychosis Endorphins mood change Tryptophan, Serotonin,Normetanephrine-

postpartum Blues

BIOCHEMICAL
CAMP Postpartum Depression

Women predisposed to bipolar relapses in

puerperium had greater GH response in mid-luteal phase of menstrual cycle than control

SLEEP PATTERN
Just prior to delivery stage 4 NREM sleep and does

not return to normal until 2nd week postpartum increase ones susceptibility to emotional disturbances

PSYCHOLOGICAL FACTORS
Melges says that conflicts assuming the

mothering role are seen as leading to identity diffusion in these woman. Identity diffusion occur when the new mother is unable to assume the mothering role.
Early postpartum psychosis-schizoid personality Late postpartum psychosis-neurotic personality

SOCIAL AND INTERPERSONAL FACTORS

Low social class
Early sexual and marital problems Unmarried pregnancy Previous abortion Primiparous Living alone Caesarean section Being older Long interval between pregnancies

SOCIAL AND INTERPERSONAL FACTORS

Fertility Problems i.e. conceived after a long time
Marital Unsupportive husband Perinatal Death

POSTPARTUM BLUES
Prevalence 30- 75%

Time Of Onset - 3 to 5 days after delivery

Duration transient state of mental illness lasting for few

days to weeks usually 2 weeks

SYMPTOMS
Episodic Crying Spells Rapid Swings Between Positive And Negative Emotions Irritability Anxiety Insomnia Loss Of Appetite Heightened Sensitivity To Interact With Other

Persons And Infant

ASSOCIATION AND TREATMENT

No specific stressors or metabolic or endocrine abnormalities Awareness of motherhood responsibility

Treatment

Reassurance Psychological support by family members If symptoms persists for >2weeks evaluate for mood disorder

POSTPARTUM DEPRESSION
Incidence - 10-15% puerperal women
Time of onset within 3-6 months Duration - months to years if untreated

SYMPTOMS
Depressed Mood Tearfulness Anhedonia Loss Of Interest In Usual Activities Fatigue Loss Of Appetite Sleep Disturbances Feeling Of Gulit (Lack Of Love For Baby) Poor Concentration Suicidial Thought Thoughts Of Harming The Baby

EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS)

The Edinburgh Postnatal Depression scale (EPDS) is a

self-rating instrument that uncovers the presence of persistent low mood, anhedonia, guilt, anxiety and thoughts of self harm

EPDS

EPDS

PRECIPITATING FACTORS
Personal and family h/o depression
Family h/o mood disorders

Stressful life event

Social adjustment

Changes in HPO axis estrogen level

Risk of recurrence is 50%

TREATMENT
SSRI- SERTRALINE -1st line for breast feeding mothers

because of low risk.

25mg/day for 4 days and increased in small increments

until full remission

If the pt. has a response in 6-8 weeks the same dose

should be continued for 6 months after full remission

to prevent relapse

POSTPARTUM PSYCHOSIS
Rarest and most severe form
Incidence 1 in 1000

Includes Organic Mental Disorders Schizophreniform Disorder Bipolar Disorder

Time of onset: begins within 2 to 3 weeks and almost

always within 8 weeks of delivery

 Confusion

EARLY SYMPTOMS

Overactivity

Fatigue
Insomnia Distractibility

Thought disorders
Elation Liability of mood

Incontinence
Irrelevant speech Disorientation

LATE SYMPTOMS
Obsessive concern about babys health

Delusional idea that the baby is dead or defective

Paranoid ideas involving hospital staff or family

members doing harm to infant

Suicidal or infanticidal threats Auditory hallucinations commanding to kill the baby

INVESTIGATIONS
Thorough History Physical And Neurological Examination

CBC - Anaemia
Electrolytes - delirium,confusion BUN, creatinine Glucose Vit.B12,folate Thyroid Function Test Urine Culture If Present With Fever HEAD CT/MRI (To R/O Ischaemia Or

Haemorrhage)

DIFFERENTIAL DIAGNOSIS
ORGANIC PSYCHOSIS Cerebral venous thrombosis CAT Hemiparesis Seizures Dysphasia Headache Drowsiness Confusion POST ECLAMPTIC PSYCHOSIS Hypertension

DIFFERENTIAL DIAGNOSIS
CEREBRAL ANOXIA Due to cerebral haemorrhage, seizures, ccf GENERAL MEDICAL CONDITIONS Hypothyroidism

Cushings syndrome Substance induced psychotic disorder Pentazocine, Anti HTs Bacterial toxemia Electrolyte imbalance

Cerebral malaria

MANAGEMENT PPP
Postpartum psychosis is an emergency needs inpatient

hospital management
Steps Perform the risk /benefit analysis

Educate the family and the patient about her illness Initiate pharmacotherapy and supportive psychotherapy Reasses repeatedly the pt.s function and safety status

Breast feeding
Risks and benefits must be considered by the pt.

And the physician

Breast milk exposure of drugs can be limited by

Use of lowest therapeutic dose Use of fewer drugs to achieve response

Daily dividing doses to avoid high peak serum concentration

ANTIPSYCHOTICS
Indicated for treatment of acute psychosis ,bipolar

mania and schizophrenia

Olanzepine Risperidone Quetiapine Ziprasidone

2.5- 20 mg/day 2-6 mg/day 25-700 mg/day 20-80 mg/day b.d

MOOD STABILISERS
Because of high incidence of mania in postpartum

period antipsychotics or mood stabilisers may be needed

Because of lithium toxicity in breastfed infants

valproic acid and CBZ are used

Valproic acid indicated for bipolar illness

Starting dose 500-750 mg/day

Therapeutic level- 50-125 mcg/ml

MOOD STABILISERS
CBZ for treatment of mania
Starting dose 400 -1600 mg/day Therapeutic level 4-12 mcg/ml Oxcarbazepine for treatment of bipolar mania Dose 600-1200 mg/day Lamotrigine for maintenance therapy for bipolar

depression

ECT
Who failed several drug trials
Pts. With intolerable drug side effects Who require quick symptom relief due to gross

impairment in self-care ,cognition, judgement, that threaten their safety and well being
Severe depression , depression complicated by

psychosis, suicidal thoughts

 Supportive Psychotherapy

PSYCHOTHERAPY
improving parenting skills - to address maternal infant bonding and infant development

Other Psychotherapy

Family focussed therapy

Cognitive behavioural therapy

Interpersonal therapy

PREDICTORS OF RECURRENCE
Personal or family H/O puerperal psychosis
Personal or family H/O bipolar disorder Previous H/O depression Cessation of anti-manic treatment

PROGNOSIS
Prognosis is favourable in PPP when symptoms

emerge within 1 month of delivery than late onset PPP

RISK ESTIMATION
Previous H/O major depression 24 % risk of PPP
H/O Bipolar disorder

- 35% risk of PPP

H/O both Bipolar & prior PPP - 50% risk of PPP Previous H/O PPD

- 60% risk of PPD

PROPHYLAXIS
Women with h/o bipolar disorder or puerperal

psychosis benefit from prophylactic treatment with lithium either before delivery (36 weeks GA) or not later than 48 hrs after delivery
Women with previous PPD prophylactic

anti-depressant SSRI administered immediately after delivery

POSTPARTUM BIPOLAR DISORDER

Women with H/O Bipolar disorder have 30-50%

relapse rate during postpartum period

Sleep disruption and life stressors increases the risk of

relapse
Women should be maintained on mood stabilisers

within 24hrs of delivery

POSTPARTUM ANXIETY DISORDERS

Puerperal panic and phobic avoidance of infant

occurring in primi and in nuclear family

Anxieties about infant health and survival

- fear of SIDS occur in mothers with long term infertility and miscarriages
Treatment

supportive therapy
Sedation at night Relaxation therapy

PUERPERAL OBSESSIONAL DISORDERS

Obsessional rituals ,thoughts, images or impulses of

child harm
Experiences

infanticidal images and obsessional content may be of child sexual abuse

Treatment Strengthen positive maternal feelings

Cognitive behavioural therapy

REACTIONS TO COMPLICATED LABOUR

PTSD after

prolonged painful labours women

experience nightmares and repetitive images similar to those occur after experiences of war and natural disaster

Man y avoid further pregnancy

QUERULANT REACTION
Pathological complaining about perceived

mismanagement during labour

May interfere with infant care Treatment

- psychotherapy based on child centered activity

HORMONAL INTERVENTION
Women with low estradiol & refractory to

anti-psychotics are tried with sublingual 17B estradiol 3-6 times daily until serum conc.- 400 pmol/lit
Symptoms measured by BPRS shows improvement by first

week

Risk of thromboembolic events and endometrial hyperplasia Progesterone for the treatment of puerperal mania Both these are uncertain and under trial

CONTRACEPTION
Depot norethisterone enantate given within 48hrs of

delivery associated with depressive symptoms (Dennis et al.2008)

Avoid long acting progestogens in women with mood

disorders

Barrier method is safe

TAKE HOME MESSAGE

PPP is a psychiatric emergency
Needs urgent management and inpatient

hospitalisation