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Crisis Evaluation of The Perinatal Woman PPT. Ouellette MD
Crisis Evaluation of The Perinatal Woman PPT. Ouellette MD
Crisis Evaluation of The Perinatal Woman PPT. Ouellette MD
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Admissions/Month
50
40
30
20
Pregnancy
10
0
–2 Years – 1 Year Childbirth +1 Year +2 Years
Postpartum Psychosis
Postpartum Depression
Postpartum (10-15%)
Symptom
Severity
Postpartum Blues
(50-85%)
None
BABY BLUES
• Baby Blues usually develop 3-5 days after
delivery
• Hallmark is emotional reactivity
• Occur in 70-80 % of all new mothers
• Normal reactions to the hormonal changes
and stress of having a baby
• “Baby blues” persisting beyond 2 weeks or
showing signs of worsening raise questions
about PPD
PPD: EARLY RECOGNITION
12
RISK FACTORS
• Depression during pregnancy is the best predictor of post partum
depression
• Prenatal anxiety
• History of mood disorder, especially PPD and bipolar disorder
• Recently having stopped antidepressants or other psychotropics prior to
pregnancy
• Past history of trauma
• Pregnancy or neonatal loss or complications
• Difficult infant temperament
• Lack of social support or marital conflict
• Recent loss or stressful life events
• History of sexual abuse
• Low self esteem
• Breastfeeding difficulties
PRESENTATION OF PPD
• Usually develops slowly over the first three
months, often beginning within the first 4
weeks, though some women have a more
acute onset
• May affect ability to care for the baby
• Signs and symptoms are those of Major
Depression---depressed mood, irritability,
loss of interest and appetite, fatigue
insomnia.
• Often complain of being physically and
emotionally exhausted
PRESENTATION OF PPD
Some common features:
• Often express concerns about her ability to
care for her baby or anxiety about the baby’s
well being
• Anxiety symptoms are common including
frank panic disorder, hypochondriasis, and
most common, generalized anxiety disorder
• Women are often unable to sleep even when
given the opportunity
PRESENTATION OF PPD
• Frequently have intrusive, obsessional
ruminations
• Usually focused on the baby, often violent in
nature
• Egodystonic , VERY troubling to mothers
• NO problem with reality testing i.e. non-
psychotic.
• One study showed 50% of women with PPD
had these obsessional thoughts
VERY IMPORTANT TO DISTINGUISH
OBSESSIONAL THOUGHTS FROM PSYCHOSIS!
• NOT associated with psychotic symptoms
• Experienced as inside the head
• May be experienced dramatically as images in
the mind, e.g. as knives or bloody babies, etc
• Are often accompanied by protective or
avoidant behaviors, e.g. hiding all the knives,
refusing to bathe the baby, similar to the hand
washing used to neutralize the anxiety of fears
that accompany OCD
• DO NOT increase the risk of harm to the baby
• DO NOT necessitate separating mother and
baby
Questions to Ask:
“Woman who have just had babies commonly
report having a lot of anxiety including
repetitive scary thoughts …..”
– Have you been having any scary thoughts?
– Have you been experiencing any
frightening thoughts or images that you
just can’t get out of your head?
POST PARTUM PSYCHOSIS
• A PSYCHIATRIC EMERGENCY WHICH
REQUIRES IMMEDIATE INTERVENTION
• Typical onset is within 2 weeks after delivery,
first symptoms often within 48-72 hours
• Earliest signs are restlessness, irritability and
insomnia
• Often very labile in presentation
• Often looks “organic” with a lot of confusion
and disorientation
• Most often consistent with mania or a mixed
state
POST PARTUM PSYCHOSIS
• Includes agitation, paranoia, delusions,
disorganized thinking and impulsivity
• Thoughts of harming the baby are frequently
driven by delusions—Child must be saved from
harm, child is malevolent, dangerous, has special
powers, is Satan or God
• Auditory hallucinations instructing the mother to
harm herself or the child are common
• Rates of infanticide associated with untreated
postpartum psychosis have been estimated to be
as high as 4%.
Other Considerations
• The onset or worsening of OCD, PTSD and
panic disorder can also occur postpartum.
There can be considerable overlap with PPD.
• PTSD can develop in response to a traumatic
birth experience or pregnancy loss
• PTSD can emerge in pregnancy when past
physical or sexual trauma is reexpereinced
• Often are intermingled with symptoms of PPD
Postpartum Psychiatric Illness
Associated with Significant Mortality