Postpartum psychosis: Protecting mother and infant Postpartum psychosis: Protecting mother and infant Urgent identification and treatment are needed to prevent potentially fatal consequences Susan Hatters Friedman, MD new mother drowned her 6-month-old daughter in the bathtub. The Phillip J. Resnick Professor of Forensic Psychiatry The married woman, who had a history of schizoaffective dis- Professor of Reproductive Biology Associate Professor of Pediatrics A order, had been high functioning and worked in a managerial Case Western Reserve University role prior to giving birth. However, within a day of delivery, her mental Cleveland, Ohio state deteriorated. She quickly became convinced that her daughter had Chandni Prakash, MBBS, MD a genetic disorder such as achondroplasia. Physical examinations, genetic Lead Maternal Mental Health Psychiatrist Auckland District Health Board testing, and x-rays all failed to alleviate her concerns. Examination of her Auckland, New Zealand computer revealed thousands of searches for various medical conditions Sarah Nagle-Yang, MD and surgical treatments. After the baby’s death, the mother was admitted Assistant Professor of Psychiatry and to a psychiatric hospital. She eventually pled guilty to manslaughter.1 Reproductive Biology Case Western Reserve University Cleveland, Ohio Mothers with postpartum psychosis (PPP) typically present fulminantly within days to weeks of giving birth. Symptoms of PPP may include not Disclosures The authors report no financial relationships with any only psychosis, but also confusion and dysphoric mania. These symptoms companies whose products are mentioned in this article, or with often wax and wane, which can make it challenging to establish the diag- manufacturers of competing products nosis. In addition, many mothers hide their symptoms due to poor insight, delusions, or fear of loss of custody of their infant. In the vast majority of cases, psychiatric hospitalization is required to protect both mother and baby; untreated, there is an elevated risk of both maternal suicide and infanticide. This article discusses the presentation of PPP, its differential diagnosis, risk factors for developing PPP, suicide and infanticide risk assessment, treatment (including during breastfeeding), and prevention. The bipolar connection While multiple factors may increase the risk of PPP (Table 1,2 page 14), women with bipolar disorder have a particularly elevated risk. After experiencing incipient postpartum affective psychosis, a woman has a Current Psychiatry DAVE CUTLER DAVE Vol. 18, No. 4 13 Table 1 make the presentation of PPP a confusing Postpartum psychosis: and distressing experience for both the Risk factors new mother and the family, resulting in delays in seeking care. Personal or family history of postpartum Subtle prodromal symptoms may include psychosis insomnia, mood fluctuation, and irritability. Bipolar disorder or schizoaffective disorder As symptoms progress, PPP is notable for a Postpartum Hormonal shifts after birth (primarily rapid drop rapid onset and a delirium-like appearance in estrogen) psychosis that may include waxing and waning cog- Immune activation nitive symptoms such as disorientation and Sleep deprivation in susceptible women confusion.8 Grossly disorganized behaviors Primiparity and rapid mood fluctuations are typical. Source: Reference 2 Distinct from mood episodes outside the peripartum period, women with PPP often experience mood-incongruent delusions and obsessive thoughts, often focused on Clinical Point 50% to 80% chance of having another psy- their child.9 Women with PPP appear less New mothers with chiatric episode, usually within the bipolar likely to experience thought insertion or spectrum.2 Of all women with PPP, 70% withdrawal or auditory hallucinations that bipolar disorder to 90% have bipolar illness or schizoaf- give a running commentary.2 are more likely to fective disorder, while approximately experience psychiatric 12% have schizophrenia.3,4 Women with admission than bipolar disorder are more likely to experi- Differential diagnosis includes ence a postpartum psychiatric admission depression, OCD those with any other than mothers with any other psychiatric When evaluating a woman with possible psychiatric diagnosis diagnosis5 and have an increased risk of postpartum psychotic symptoms or delir- PPP by a factor of 100 over the general ium, it is important to include a thorough population.2 history, physical examination, and relevant For women with bipolar disorder, PPP laboratory and/or imaging investigations should be understood as a recurrence of to assess for organic causes or contributors the chronic disease. Recent evidence does (Table 22,6,10-12 and Table 3,2,6,10-12 page 15). A suggest, however, that a significant minor- detailed psychiatric history should establish ity of women progress to experience mood whether the patient is presenting with new- and psychotic symptoms only in the post- onset psychosis or has had previous mood partum period.6,7 It is hypothesized that this or psychotic episodes that may have gone subgroup of women has a biologic vulner- undetected. Important perinatal psychiatric ability to affective psychosis that is lim- differential diagnoses should include “baby ited to the postpartum period. Clinically, blues,” postpartum depression (PPD), and understanding a woman’s disease course obsessive-compulsive disorder (OCD). is important because it may guide decision- making about prophylactic medications PPP vs “baby blues.” “Baby blues” is not an during or after pregnancy. official DSM-5 diagnosis but rather a norma- tive postpartum experience that affects 50% to 80% of postpartum women. A woman A rapid, delirium-like presentation with the “baby blues” may feel weepy or Discuss this article at Postpartum psychosis is a rare disorder, have mild mood lability, irritability, or anxi- www.facebook.com/ with a prevalence of 1 to 2 cases per 1,000 ety; however, these symptoms do not sig- MDedgePsychiatry childbirths.3 While symptoms may begin nificantly impair function. Peak symptoms days to weeks postpartum, the typical typically occur between 2 to 5 days postpar- time of onset is between 3 to 10 days after tum and generally resolve within 2 weeks. birth, occurring after a woman has been Women who have the “baby blues” are at an discharged from the hospital and during increased risk for PPD and should be moni- Current Psychiatry 14 April 2019 a time of change and uncertainty. This can tored over time.13,14 PPP vs PPD. Postpartum depression Table 2 affects approximately 10% to 15% of new 15 Medical differential diagnosis for mothers. Women with PPD may experi- postpartum psychosis ence feelings of persistent and severe sad- MDedge.com/psychiatry ness, feelings of detachment, insomnia, Infection (ie, endometritis or CNS infection) and fatigue. Symptoms of PPD can inter- Primary hyperparathyroidism fere with a mother’s interest in caring for Thyroid disease her baby and present a barrier to maternal Substance intoxication or withdrawal 16,17 bonding. Peripartum blood loss and anemia As the awareness of PPD has increased Tumor (primary or metastatic) in recent years, screening for depressive Autoimmune disease (anti-NMDAR symptoms during and after pregnancy encephalitis) has increasingly become the standard of Inborn errors of metabolism (urea cycle 18 care. When evaluating a postpartum disorder) woman for PPD, it is important to con- Head injury sider PPP in the differential. Women with Embolism severe or persistent depressive symp- Clinical Point Eclampsia toms may also develop psychotic symp- Medication-induced (such as corticosteroids) Consider postpartum toms. Furthermore, suicidal thoughts or thoughts of harming the infant may be Electrolyte anomalies psychosis in the present in either PPD or PPP. One study Anoxia (Sheehan’s syndrome) differential when found that 41% of mothers with depres- Vitamin B12 deficiency evaluating a woman sion endorsed thoughts of harming their Anti-NMDAR: anti-N-methyl-D-aspartate receptor for postpartum infants.19 Source: References 2,6,10-12 depression PPP vs postpartum OCD. Postpartum Table 3 obsessive-compulsive symptoms com- monly occur comorbidly with PPD,9 and Laboratory testing and OCD often presents for the first time radiologic imaging in the postpartum period.20 Obsessive- Complete blood count compulsive disorder affects between 2% Urinalysis to 9% of new mothers.21,22 It is critical to Comprehensive metabolic profile properly differentiate PPP from postpar- Urine drug screen tum OCD. Clinical questions should be Thyroid-stimulating hormone, free T4, and posed with a non-judgmental stance. Just thyroid peroxidase antibodies as delusions in PPP are often focused If neurologic symptoms are present: on the infant, for women with OCD, cerebrospinal fluid analysis, limbic encephalitis and antibody screening, serum ammonia obsessive thoughts may center on wor- concentration, EEG, and MRI ries about the infant’s safety. Distressing T4: thyroxine obsessions about violence are common in Source: References 2,6,10-12 OCD.23 Mothers with OCD may experi- ence intrusive thinking about accidentally or purposefully harming their infant. For example, they may intrusively worry that thoughts and fears that they focus on and they will accidentally put the baby in the try to avoid, rather than plan. The psychia- microwave or oven, leave the baby in a trist must carefully differentiate between hot car, or throw the baby down the stairs. ego-syntonic and ego-dystonic thoughts.