Definition:

The word puerperal psychosis should be dropped because of the wide range of presentation of the illness, coupled with the lack of well defined psychotic syndromes specific to the puerperium.

 

The international classification of diseases (ICD) recommends that psychiatric illnesses occuring soon after birth should be classified according to the predominant clinical feature of a particular functional psychosis. Therefore the diagnosis can range from schizophrenia to mania, depression and delirium.

Incidence of puerperal psychosis:

 

Puerperal psychosis occurs in about 1 in 500 births. Puerperal psychosis is more common among primiparous women (women who have not delivered before).

 

Puerperal psychosis is also more common in women with a family history of psychiatric disorder and those who have suffered previous serious major psychiatric disorder. However it must be noted that puerperal psychosis is not more common after complicated deliveries.

 

What are the different types of puerperal psychosis?

 

There are three types of puerperal psychosis:

 

i)Delirium

 

ii)Affective

 

iii)Schizophrenic.

 

The clinical feature of each type of puerperal psychosis is similar to the corresponding syndromes outside of the puerperium.

 

Delirium is now rare. It used to be common before the introduction of antibiotics in the treatment of puerperal sepsis.

 

Out of the three types of puerperal sepsis , the affective syndromes are the commonest followed by the schizophrenic.

 

Clinical features

One third of patients present with the manic form. The remaining two thirds present with depressive psychosis.

There is usually sudden onset after the 2nd day postpartum. Most of the patients present on the fifth day post partum.Unlike maternal blues, puerpural psychosis does not settle within 48 hours.

Patients may first present with fear, suspicion, agitation, insomnia,confusion and suspicion. The patient may also refuse food and drinks.After about 4 days the illness resembles affective psychosis. They may also present with delusional ideas about themselves and their babies. Some women may also present with first rank symptoms of schizophrenia such as hallucinations and delusions. The usual presentation is therefore schizo-affective psychosis

 

Management

 

The patient should be referred to a psychiatrist urgently, they may also require admission to a special mother and baby unit or a psychiatric unit. There are special psychiatric mother and baby units in some hospitals.

 

For moderate to severe depressive psychosis, ECT (Electroconvulsive therapy) is the treatment of choice. Due to its rapid effect ,ECT therapy also allows the mother to resume care of her baby quickly.

 

Tricyclic antidepressents (such as amitriptyline and imipramine) are also effective in the treatment of depressive clusters. However clinical improvement will take about 3 weeks. These drugs are also contraindicated in patients with heart disease

 

Patients presenting with frank schizophrenic psychosis should be sedated immediately with a neurolept medication. The medication will reduce agitation, fear,perplexity and distress. It will also help in reducing hallucinations and delusions,within a few days.

 

The neuroleptics commonly used in schizophrenic psychosis in the puerperium are chlorpromazine, haloperidol and trifluoperazine. Recommended doses ffor initial treatment are 50mg of chlorpromazine 3 times daily, haloperidol 5mg bd and trifluoperazine 5mg bd. The dose of chlorpromazine can be increased up to 150mg three or four times per day. In highly disturbed patients these drugs can be given as depot im injections. Syrups are also available and have a faster onset of action compared to tablets. Benzhexol (artane) or procyclidine can be used to control extrapyramidal reactions.

 

Lithium carbonate may be used in the treatment of acute mania, but breastfeeding should be stopped.

 

Prognosis

 

The prognosis is good. Most patients recover fully from puerperal psychosis.

 

A few patients with schizophrenic psychosis remain chronically ill.

 

The recurrence rate of puerperal depressive illness at a subsequent birth is between 1 in 2 and 1 in 3. The risk of recurrence is high if the patient has a baby within 2 years of recovery from her illness. Therefore patients should be advised to delay their next pregnancy until they have been well for at least two years.

 

Up to 50% of women with puerperal depressive illness will develop depressive illness unrelated to childbirth.

 

Patients with early onset puerperal psychosis respond well to treatment. However there is also a high relapse rate after recovery. Therefore it is important to continue medication for six months after recovery.

 

Patients may also relapse with other clinical psychiatric syndromes eg . a patient with manic psychosis can relapse with a depressive psychosis. If this occurs more than once , lithium carbonate will be useful to stabilize the mood for as long as six months to one year postpartum. For patients who have suffered from an episode of  manic-depressive illness (non-postpartum) , prophylaxis should be continued for two years following delivery.

 

It is also recommended that women who have had puerperal psychosis should be referred to a psychiatrist and monitored closely during subsequent delivery. Patients with a history of bipolar disorder may require lithium prophylaxis in the second and third trimesters (The first trimester should be avoided because of the high risk to the fetus). The prophylaxis should be stopped soon after delivery.

References:

Postpartum psychosis, Chapter 21.Psychiatric disorders in pregnancy and puerperium. Obstetrics by Ten Teachers. Edited by Stuart Campbell and Christoph Lees.17th Edition.

Textbook of Obstetrics and Gynaecology for Medical Students.Ist edition by Akin Agbola et al.Volume 2.

Psychiatric aspects of obstetrics and gynaecology,Chapter 11,Psychiatry and Medicine-Psychiatry-Oxford Core Texts. Second Edition. Michael Gelder, Richard Mayou and John Geddes.

 

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