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Continuing Education Activity
Continuing Education Activity
Around one in seven women can develop postpartum depression (PPD). While women
experiencing baby blues tend to recover quickly, PPD tends to last longer and severely affects
women's ability to return to normal function. PPD affects the mother and her relationship with
the infant. Maternal brain response and behavior are compromised in PPD. According to Beck in
2006, as many as half of PPD in new mothers go undiagnosed because of conflict in privacy and
not wanting to disclose to close family members. There is also a stigma around new mothers in
that disclosure may lead to abandonment and fear of lack of support. This activity reviews the
evaluation, treatment, and complications of postpartum depression and underscores the
importance of an interprofessional team approach to its management.
Objectives:
Describe common symptoms of postpartum depression.
Articulate the reasons that women may not seek care for postpartum depression.
Review management strategies for postpartum depression.
Plan a discussion amongst interprofessional, interprofessional team members regarding
the detection, evaluation, and management of postpartum depression so that this
condition is detected quickly and appropriate management can be implemented
immediately, enhancing patient outcomes.
Access free multiple choice questions on this topic.
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Introduction
Childbirth is a difficult and exhausting process. A female goes through a lot of hormonal,
physical, emotional, and psychological changes throughout pregnancy. Tremendous changes
occur in the mother's familial and interpersonal world. After childbirth, a mother can experience
varied emotions ranging from joy and pleasure to sadness and crying bouts. These feelings of
sadness and tearfulness are called "baby blues," and they tend to decrease over the first 2 weeks
after delivery.
Around one in seven women can develop postpartum depression (PPD). While women
experiencing baby blues tend to recover quickly, PPD tends to be longer and severely affects
women's ability to return to normal function. PPD affects the mother and her relationship with
the infant. Maternal brain response and behavior are compromised in PPD. According to Beck in
2006, as many as half of PPD in new mothers go undiagnosed because of conflict in privacy and
not wanting to disclose to close family members. There is also a stigma around new mothers in
that disclosure may lead to abandonment and fear of lack of support. [1]
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Etiology
PPD can occur in females having depression and anxiety in any trimester of pregnancy.
Risk Factors
Psychological: History of depression and anxiety, premenstrual syndrome (PMS), Negative
attitude towards the baby, the reluctance of baby gender, history of sexual abuse are perpetual
factors for developing postpartum depression.
Obstetric risk factors: Risky pregnancy which includes emergency cesarean section and
hospitalizations during pregnancy. Meconium passage, umbilical cord prolapse, preterm or low
birth infant, and low hemoglobin are associated with PPD.
Social factors: Lack of social support can cause postpartum depression. Domestic violence in the
form of spouse sexual and physical and verbal abuse can also be a causative factor in the
development of the disease. Smoking during pregnancy is a risk factor for developing PPD.
Lifestyle: Eating habits, sleep cycle, physical activities, and exercise may affect postpartum
depression. Vitamin B6 has known to be involved in postpartum depression via its conversion to
tryptophan and later on serotonin, which, in turn, affects mood. The sleep cycle is among the
factors influencing the risk of depression. It is evident that decreased sleep is associated with
postpartum depression. Physical activity and exercise decrease depressive symptoms. Exercise
decreases low self-esteem caused by depression. Exercise increases endogenous endorphins and
opioids which brings positive effects on mental health. This also improves self-confidence and
increases problem-solving capacity and helps in focusing on their surrounding environment. [2]
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Epidemiology
Postpartum depression most commonly occurs within 6 weeks after childbirth. PPD occurs in
about 6.5% to 20% of women. It occurs more commonly in adolescent females, mothers who
deliver premature infants, and women living in urban areas. African American and Hispanic
mothers reported onset of symptoms within 2 weeks of delivery, unlike white mothers, who
reported onset of symptoms later as one study reports.
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Pathophysiology
The pathogenesis of postpartum depression is currently unknown. It has been suggested that
genetics, hormonal and psychological, and social life stressors play a role in the development of
PPD.[3][4][5]
The role of reproductive hormones in depressive behavior suggests neuroendocrine
pathophysiology for PPD. There is ample data to advocate that changes in the reproductive
hormones stimulate the dysregulation of these hormones in sensitive women. The
pathophysiology of PPD can be caused by alterations of multiple biological and endocrine
systems, for example, the immunological system, the hypothalamic-pituitary-adrenal axis (HPA),
and lactogenic hormones. The Hypothalamic-pituitary-adrenal axis (HPA) is known to be
involved in the disease process of post-partum depression. HPA axis causes the release of
cortisol in trauma and stress, and if the HPA axis function is not normal, then the response
decreases the release of catecholamines leading to the poor stress response. HPA-releasing
hormones increase during pregnancy and remain elevated up to 12 weeks after childbirth.
The rapid changes in reproductive hormones like estradiol and progesterone following delivery
can be the potential stressor in susceptible women, and these changes can lead to the onset of
depressive symptoms. Oxytocin and prolactin also play an important role in the pathogenesis of
PPD. These hormones regulate the milk let-down reflex as well as the synthesis of breast milk. It
is often observed that failure to lactate and the onset of PPD occur at the same time. Low
levels of oxytocin are particularly observed in PPD and unwanted early weaning. During the
third trimester, lower levels of oxytocin are associated with increased depressive symptoms
during pregnancy and following delivery. [6]
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Evaluation
During the evaluation, it is important to include drug and alcohol history, smoking habits, and all
prescription and over-the-counter-drug medications. Screening for PPD can be done 2 to 6
months after childbirth. There are several screening tools available, and one of the most
frequently used is the Edinburgh Postnatal Depression Scale (EPDS). It is a 10-item
questionnaire filled out by patients and takes a few minutes to complete. An EPDS cutoff score
equal to or greater than 13 is required to determine if patients are at risk for developing PPD.
This screening test provides the basis for additional clinical tests. The objectives of the clinical
evaluation are to constitute the diagnosis, assess suicidal and homicidal risks, in this case usually
infanticide, and to rule out other psychiatric illnesses. [7]
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Treatment / Management
First-line treatment for peripartum depression is psychotherapy and antidepressant medications.
Psychosocial and psychological psychotherapy is the first-line treatment option for women with
mild to moderate peripartum depression especially if mothers are hesitant about starting on
medications and are going to nurse the newborn. A combination of therapy and antidepressant
drugs is recommended for women with moderate to severe depression. Selective serotonin
reuptake inhibitors (SSRI) are the first choice. Consider switching to serotonin-norepinephrine
reuptake inhibitors (SNRIs) or mirtazapine if SSRI is ineffective. Once an effective dose
reached, continue treatment for 6 to 12 months to prevent relapse of symptoms.
Pharmacologic recommendations for women who are lactating should include discussing the
benefits of breastfeeding, the risks of antidepressant use during lactation, and the risks of
untreated illness. Repetitive transcranial magnetic stimulation (TMS) is a treatment that may
provide an alternative option for women who breastfeed and are concerned about their babies
being exposed to medication. There is the most data for the use of sertraline for the prevention
and treatment of postpartum depression. The risk of breastfeeding while taking a serotonin
reuptake inhibitor is relatively low and women can be encouraged to breastfeed while on
antidepressants. After 12 weeks CBT mono-therapy was found to be remarkable to both
sertraline mono-therapy and combination therapy. The CBT mono-therapy group found the most
accelerated initial gains after treatment startup. An important factor in the duration of postpartum
depression is delayed treatment.
Transcranial Magnetic Stimulation (TMS) is a procedure that is non-invasive and uses magnetic
waves to stimulate and activate nerve cells. These cells are underactive in people with major
depression. It is usually done five times a week for 4 to 6 weeks to be effective. It is done in
patients who are not responding to anti-depressants and psychotherapy. Generally, TMS is safe
and well-tolerated, but there can be some side effects which include headaches, lightheadedness,
scalp discomfort, and facial muscle twitching. Some serious side effects are rare including
seizures, hearing loss if ear protection is not adequate, and mania in people with bipolar
disorder. [8]
Patients with severe postpartum depression may not respond to psychotherapy and
pharmacotherapy. For patients refractory to four consecutive medication trials, ECT is
recommended. ECT is particularly useful in patients with psychotic depression, with intent or
plans on committing suicide or infanticide, and refusal to eat, leading to malnutrition and
dehydration. [9][10] Several observational studies have suggested ECT as a safer option for
lactating mothers as there are fewer adverse effects on both the mother and the infant. [11][12]
Patients with severe postpartum depression that decline or don't respond to ECT; for these
patients, intravenous Brexanolone is recommended. Brexanolone received FDA approval in
March 2019, and it is the first drug to be specifically approved for postpartum depression.
Brexanolone is an aqueous formulation of allopregnanolone, a progesterone metabolite.
Brexanolone is only recommended if patients do not improve on antidepressants or ECT due to
its restricted availability and limited clinical experience. In the United States, Brexanolone is
only available at certified healthcare facilities, and patients are required to enroll in the Risk
Evaluation and Mitigation Strategy Program. Through this program, patients are continuously
monitored by a clinician during their IV infusion for increased sedative effects, sudden loss of
consciousness, and hypoxia. Brexanolone is administered intravenously as a continuous 60hr
infusion, which lasts approximately 2.5 days. Multiple clinical trials demonstrate Brexanolone is
usually well-tolerated in women with moderate to severe postpartum depression and can provide
a rapid beneficial response. [13][14] More clinical trials are needed to further access the long-
term safety and efficacy of Brexanolone in the treatment of postpartum depression.
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Differential Diagnosis
Baby Blues
Most commonly occurs around 2 to 5 days after delivery and resolves around 10 to 14 days.
Women experience crying bouts, sadness, anxiety, irritability, sleep disturbance, appetite
changes, confusion, and fatigue. It does not affect daily functioning or the ability to take care of
the baby.
Hyperthyroidism or Hypothyroidism
These conditions can also lead to mood disorders. They can be assessed by testing TSH and free
T4 levels.
Postpartum Psychosis
Postpartum psychosis is a psychiatric emergency with a potential suicide and infanticidal risk. A
female can experience hallucinations, lack of sleep for several nights, agitation, unusual
behavior, and delusions. It is an acute onset of manic or depressive psychosis within the first few
days or weeks after delivery.
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Prognosis
Postpartum depression has repercussions beyond physical harm to the child. Data reveal that the
condition also affects mother-infant bonding. Often the child is treated inappropriately with a
very negative attitude. This can have a significant impact on the growth and development of the
child. Children born to mothers with postpartum depression have been found to exhibit marked
changes in behavior, altered cognitive development, and early onset of depressive illness. More
important, these children are often obese and have dysfunction in social interactions.
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Complications
Postpartum depression affects the mother, father, and infant.
Mother: It can lead to chronic depressive disorder if not treated on time. Even if treated, PPD can
be a risk for future episodes of major depression.
Father: This can be a precipitating factor for depression in the father as this will be a stressful
event for the entire family.
Infant: Children of mothers who have untreated depression can develop behavioral and
emotional problems. More commonly seen are delays in language development. They can also
suffer from sleeping problems, eating difficulties, excessive crying, and attention-
deficit/hyperactivity disorder (ADHD).
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