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.

Incidence:

Severe major postnatal depression affects about 3 to 5 % of women delivered.

It is more common in women who have undergone stressful childbirth and its aftermath. The stress on the mother includes the stress of feeding the baby, blood loss, painful breasts, lack of support from the spouse, insomnia and deficiency of mothering skills.

Clinical features of severe major postnatal depression:

Only a third of the patients present in the first three weeks following delivery.The remaining two-thirds present later(Usually between 10 and 12 weeks postpartum). The patients presenting in the first three weeks following delivery, present with the severe form of the illness.

The clinical features can be summarized as follows:

i)Classical features of severe depression such as early morning waking, mood which is worst in the morning and gradually improves as the day passes,(diurnal variation of mood) and impaired appetite.

ii)Impaired concentration

iii) Feelings of guilt and worthlessness.

iv)Patients are usually from low socio-economic status.

v) Anxiety and/or ruminative worry. Some may even suffer from panic attacks.

vi) Disturbed sleep is common.

vii) Inability to feel pleasure or enjoyment in life (Anhedonia).

In most African and Asian countries, the prevalence of postnatal depression is low. This low prevalence is probably due to support and care of the new born from the extended family.

Probable causes of severe postnatal depression:

i) Stress of delivery and disordered interpersonal relationship with partner/spouse.

ii)It could also be endogenous in nature -there is response to electroconvulsive therapy and antidepressent medication.

What is the risk of relapse of severe major postnatal depression?

For women who have postpartum illness only, the risk of relapse is about 1:2 to 1:3.

The risk of recurrence outside childbirth is low. Medication should be provided for at least six months. Some women may require longer duration of treatment.

Management of Severe Major Postnatal Depression

Antidepressants and hormones are useful in the management of depression.

Antidepressants should be the first line of treatment of depression. Hormonal treatment is useful if antidepressants are ineffective or are not tolerated.

Antidepressants:

Tricyclic antidepressants should be the treatment of choice. Tricyclic antidepressants are also relatively safer during breastfeeding. Some of the metabolites of these drugs have been detected in breast milk, but clinical neurotoxic features in breast fed infants of mothers who are taking tricyclics is very rare and therefore there is no justification for avoidance of the drugs when there is a clear indication for its use.

Examples of tricyclic antidepressants are: imipramine, amitriptyline, doxepin,dosulepin hydrochloride (dothiepin) and minaserin.

A suggested regime is dothiepin starting at 75mg nocte (at night ) and gradually increasing over a few days to 150mg nocte.

Improvement should be expected within 2 to 4 weeks and resolution of the illness takes 4 to 6 weeks. However antidepressants should be taken for six months after recovery, before reducing gradually.

References:

Pages 233 to 236,Psychiatric aspects of obstetrics and gynaecology. Chapter 11 ,Psychiatry and Medicine. Psychiatry, Oxford Core Texts.2nd Edition by Michael Gelder, Richard Mayou and John Geddes. 1999.

Pages 326 to 327. Severe Major Postnatal Depression. Chapter 21, Psychiatric Disorders in Pregnancy and the Puerperium. Obstetrics by Ten Teachers. 17th edition edited by Stuart Campbell and Christoph Lees.2003.

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

Maternity blues is an affective psychiatric disorder that does not usually develop into frank psychiatric disorders such as puerperal psychosis and major postnatal depression.

Clinical features and presentation:

It usually presents with sudden onset of low spirits any time from the first to the tenth day after childbirth. It can also present anytime in the first one year post-partum.Common symptoms of maternity blues include tearfulness, misery,anxiety,irritability, lability of moods, sleeplessness, headache, impaired memory and negative feelings towards the baby (rare and found only in serious cases).Other symptoms include lack of satisfaction with motherhood and sense of loneliness and isolation.It must be noted that clinical features of major depressive illness is absent.

Women affected usually have a background of frequent marital and social problems.

Maternity blues usually remits spontaneously, it is considered a minor depressive illness.The cause of maternity blues is not known. Hormonal changes in pregnancy and psychological difficulties (eg bad relationship with spouse) are thought to predispose to this condition.

Management of Maternity Blues:

This does not require any intervention apart from reassuring the patient and the next of kin.

Psychological treatment is as effective as antidepressents .

Psychological treatment includes six weekly sessions of specific counseling by a trained psychotherapist. Cognitive psychotherapy is also very effective.

Social support also goes a long way in alleviating the symptoms.

Patients and their relatives should be informed of possible future recurrences in subsequent pregnancies.

It is important to note that the benign nature of the disease should not give rise to a false sense of security. The patient must be observed carefully to rule out suicidal depression and infanticidal thoughts.

References:

Textbook of Obstetrics and Gynaecology for Medical Students by Akin Agboola et al. Volume 2 ,Obstetrics.1st Edition

Page 326 and 327 ,Mild postnatal depression (the blues),Chapter 21.Psychiatric Disorders in Pregnancy and the Puerperium. Obstetrics by Ten Teachers. Seventeenth edition .Edited by Stuart Campbell and Christoph Lees.

Factors contributing to psychiatric disorders in pregnancy include:

i) Hormonal changes in pregnancy.

ii) Changes in body image.

iii) Activation of unconscious psychological process specific to pregnancy.

iv) Mental stress due to maternal role.

Emotional Changes in the First Trimester of Pregnancy

In the first trimester , women exhibit emotional ambivalence. Ambivalence refers to mixed and contradictory feeling. One one hand there could be a sense of wellbeing, joyfulness and acceptance of the pregnancy, while on the other there could be anxiety, uncertainty and low spirit.

Most women also expect extra care and protection by people around them, in the immediate environment. Some imature women may exaggerate their need in the form of making unrealistic demands for support.

During the first trimester there could also be a fear of spontaneous abortion, which is common during the first trimester.

As expected a teenage unmarried expectant mother, without a reliable male partnet may have to face extra stress of parental rebuke and also neglect by her partner.

In some women, severe signs of morning sickness in pregnancy (Vomiting, salivation, lethargy and body weakness) will also add to her emotional difficulties.

Emotional Changes in the Second Trimester of Pregnancy

Fetal movements perceived by the mother (Quickening), provides psychological support for the mother during pregnancy. Fetal movements are perceived from the fifth month onwards. It also reassures the mother about her own reproductive ability.

During the second trimester ,the mother will also be concerned about human birth defects and genetic disorders such as sickle cell anaemia. Rhesus incompatibility will also be a great concern to the mother, especially if she is D-.

It is during the second trimester that the uterus enlarges enough to restrict the woman’s physical activities (including social and occupational activities).

Low income mothers , will be worried about the financial responsibilities of buying baby’s items. Hospitals should be encouraged to work with social welfare groups ,so that they can provide help and support for individuals who cannot afford medicine and items for the baby.

Emotional Changes in the Third Trimester of Pregnancy

The important psychological changes in the third trimester is the stress of the reality of pending motherhood and the large size of the uterus. There is also the fear and uncertainty of labour pains.

Even though there is a lot of psychological strain on pregnant women, fortunately only a few of them come down with frank mental disorders. Even women who do not come down with frank mental disorders should receive psychological support from the medical staff, relatives and friends.

Post-Partum Mental Disorders

Post-partum mental disorders can be categorized into three:

i) Maternity blues

ii)Puerperal psychosis.

iii) Other depressive disorders.

References:

Page 313 to 315, Chapter 36 .Psychiatric Aspects of Obstetrics Practice. Textbook of Obstetrics and Gynaecology for Medical Students -Volume 2. 1st edition by Akin Agboola et al.