

Postpartum psychiatric disorders

Gizachew Asnake
MD, Assistant professor of psychiatry

03/03/2023 1
 Outline


 Introduction
 Postpartum blue
 Postpartum depression
 Postpartum psychosis
 Psychotropic medications during pregnancy

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 Introduction 1


 The postpartum period is a time of increased vulnerability to
psychiatric illness in the life cycle of women.

 About 85% of women experience some kind of mood

symptoms

 10-15% experience more severe and disabling symptoms

 The risk for postpartum psychiatric illness is highest during

the first 3 months after delivery
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 Introduction 2


Postpartum psychiatric disorders include:
 Postpartum blues:
 incidence 50–85 %
 Postpartum depression:
 incidence 10–15 %
 Postpartum psychosis:
 incidence 0.1–0.2 %

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 Postpartum blue(baby blue)


 Common benign, transitory, and self-limited condition

 Occurrs during the first 10days postpartum.

 It peaks between days 3 and 5

 The condition occurs in upto 85% of primipara

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 
Symptoms include:-
 Rapidly fluctuating mood, tearfulness, irritability,
anxiety, somatic symptoms, and sleeplessness.
The central feature of postpartum blues is the
marked lability of mood with increased emotional
reactivity to stimuli
 crying or becoming irritable, profoundly joyful, or sad

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 
Risk factors
 History of depressive episodes
 Depression during pregnancy
 Premenstrual depression
 Family history of depression
 Mothers with severe postpartum blues have three
times greater likelihood of developing postpartum
depression

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 Etiology

Psychosocial factors 
 Demographic variables, current stressors, obstetric
complications, and social support
 Influence in the intensity of blue
Biological factors
 Abrupt withdrawal of the hormones estrogen and progesterone
 Mood symptoms may be related to the large drop in the ß-
endorphin causing an endogenous opioid withdrawal state
 Lower levels of free plasma tryptophan

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 Treatment

No specific treatment

Support and reassurance

If symptoms are severe or prolonged over 2

weeks, blues may indicate the onset of
postpartum depression.
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 Postpartum depression


 Beginning usually at 2–4 weeks postpartum.

 The prevalence of postpartum depression (PPD) is 10–15

%.

 DSM-5 diagnostic criteria for PPD include symptoms of

major depression lasting for more than 2 weeks with
peripartum onset

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 Risk factors 1


 Low socioeconomic status
 Financial stress
 Marital discord
 Inadequate social and spousal support (both emotional
and instrumental support)
 Child care stress
 Stressful life events during pregnancy or early postpartum.
 Immigrant women

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 Risk factors2


Very young or older age
History of premenstrual dysphoric disorder
Severe postpartum blues
Depressive and anxiety symptoms during pregnancy
Personal history of mood disorder
Bipolar disorder (risk of recurrence is 30–50 %)
Postpartum depression (recurrence -40 %)
Discontinuation of antidepressant medications during pregnancy
Family history of mood disorder

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 Clinical features I


 Insidious onset within the first 3 months after delivery

 Symptoms include
 depressed mood, irritability, tearfulness, emotional lability, sleep
disturbance, fatigue, loss of appetite, poor concentration, feelings
of inadequacy, guilt, lack of pleasure, lack of interest in the baby,
and ambivalent or negative feelings toward the infant.
 Suicidal ideation is common but suicide attempts are
relatively infrequent in women with nonpsychotic
depression
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 Clinical features 2


 Woman may experience intrusive obsessive ruminations
involving the child and anxiety symptoms

 In 30 % of women symptoms could persist for as long as 2

years with persistent psychosocial stress

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 Etiology

Biological factors

 Rapid decline in the levels of hormones
 Estrogen and progesterone levels drop 200-fold, reaching pre-
pregnancy levels by the fifth postpartum day
 Abnormal thyroid function
 In 7% of women
 Diminished thyroid function may affect postpartum mood
through its association with diminished central serotonin
activity

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 
Psychosocial factors
 Inadequate social support, marital discord, and stressful life
events during pregnancy
 Migration, individuation, and separation from the family of
origin
Cultural influences
 Different cultures follow different rites of passage to
parenthood, which may include
 ceremonies, rituals, seclusion, rest, solicitude, and return
to the home of origin
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 
Consequences of Untreated Postpartum
Depression
Untreated postpartum depression can result in a
 Disturbed mother–infant relationship
 Future psychiatric morbidity in the child (depression,
conduct disorder, lower IQ)
 Marital tension
 Vulnerability to future depression, and suicide/homicide

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 Course and Prognosis


 The duration of postpartum depression is variable.

 Symptoms resolve within 3 months

 Women with a history of recurrent major depressive disorder

(MDD) and with severe symptoms can have a more protracted
course

 Good prognosis
 with early diagnosis and treatment
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 
 There is a 40 % risk of recurrence with subsequent
childbirth

 Have an enduring influence on the child’s psychological

development
 cause emotional, behavioral, cognitive, and
interpersonal problems later in life.

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 Treatment of postpartum depression


Primary prevention
1. Screening for
 antenatal depression, history of postpartum
depression, family history of depression.
2.Screening for other risk factors
 social support, financial status, negative life events.
3.Screening for thyroid antibodies and thyroid function

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 Edinburgh Postnatal Depression Scale

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 
For women with history of recurrent major
depression or postpartum depression or
depression during pregnancy
 prophylactic antidepressant treatment has been found
to reduce the recurrence of postpartum major
depression

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 
Secondary prevention
 Early diagnosis and treatment

 Less than one third of women with PPD receive any type of
intervention.
 Mild to moderate postpartum depression
 Psychological interventions
 Interpersonal therapy
 Cognitive behavioral therapy
 Self-help networks
 Peer and partner support
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 
Moderate to severe depression
 Antidepressants
 SSRI
 Women with postpartum depression may take longer to
respond to treatment and may require more antidepressant
agents
 ECT
 Hormone therapy

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 Postpartum (puerperal)psychosis


 Postpartum psychosis is a psychotic disorder occurring
after childbirth.
 It is primarily a bipolar affective disorder or a variant of
it

 One to two per 1,000 postpartum women are affected.

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 Risk factors


 Primiparity
 70–80 % of index cases occur after first childbirth, 35 times
more common in primipara
 Personal and family history of bipolar disorder
 Women with history of
 postpartum psychosis
 schizophrenia
 Perinatal mortality and obstetrical complications

 lack of partner or social support

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 
Etiology
 Family history of affective illness
 Hormone withdrawal
 lead to dopamine receptor supersensitivity as estrogen
increases dopamine receptor binding
 Sleep deprivation

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 
Clinical presentation
Severe form of postpartum psychiatric illness
Often abrupt and dramatic onset within the first
48–72 h after delivery
Symptoms resemble those of a rapidly evolving
mania or mixed state

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 
Earliest symptoms

 Restlessness, agitation, irritability, and insomnia.

 The symptoms are characterized by a mixture of

delirium, psychosis with confusion and
perplexity, emotional lability, delusions, and
hallucinations.
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 Postpartum psychotic depression


 Depressed mood (worst in the morning)
 Tearfulness
 Significant psychomotor retardation
 Sleep disturbances with early morning awakenings
 Appetite disturbances
 Preoccupation with feelings of guilt and worthless
 Delusions of the infant being dead or defective
 Hallucinations commanding the mother to harm the
baby
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 
Postpartum mania
 The woman is excited, euphoric, grandiose, irritable,
hyperactive
 Requires little sleep
 May have grandiose delusions about her baby
 having special powers or that the child is either Satan
or God.

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 Differential diagnosis 
 Exacerbation of primary psychiatric disorder
 Toxic, metabolic
 Neurologic causes
 Tumors, head trauma, infection, cerebral embolism, seizures,
 Electrolyte disturbances
 Vitamin deficiencies
 Thyroiditis
 Substance-induced psychotic disorder

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 Prognosis 
 Rate of infanticide as high as 4 %.
 With adequate treatment 95 % women improve within 2–3
months and have a good functional outcome
 Increased risk of subsequent episodes
 75 % of patients unrelated to childbirth.
 Puerperal recurrence is as high as 30 %

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 
Treatment
 PPP -is psychiatric emergency
 Both psychosocial and pharmacologic interventions are
necessary
 Acute treatment with a mood stabilizer in addition to
antipsychotic medication is indicated.
 Treatment with a mood stabilizer should extend beyond
the resolution of active symptoms to reduce the risk of
relapse
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 
 Electroconvulsive therapy in severe cases
 In women with a history of postpartum psychosis or
bipolar disorder
 prophylactic treatment with lithium or other mood
stabilizers instituted
 prior to delivery (at 36 weeks gestation)
 or no later than the first 48 h postpartum

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 
Lactation and psychotropic medications

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 
 Most psychotropic medications pass into breast milk in
varying amount
 Factors that determine the amount of diffusion into breast
milk include:-
 Maternal dosing and frequency
 Drug’s protein binding
 Lipid solubility
 Degree of ionization, and molecular weight

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 
 Infants have ;
 Higher gastric PH
 Low serum protein
 Full-term neonatal cytochrome P-450 activity is
approximately one half of that found in adults
 Hepatic enzyme immaturity is even more pronounced in
premature infants
 The newborn kidney is functionally immature

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 Treatment Guidelines during Lactation


 Before starting psychotropic medications:
1. Explain the potential risks and benefits

2. Refer for a pediatric evaluation to assess the baby’s baseline

behavior-sleep, feeding, and alertness.

3. Collaborate with the pediatrician and provide education

regarding possible infant side effects and interaction with other
medications.

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 
 Choice of medication is affected by a number of factors,
including :-
 Diagnosis of psychiatric illness
 Past history of treatment response
 Side-effect profile of the medication
 Pharmacokinetic characteristics that minimize
accumulation of the medication in milk and infant serum.

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 
Factors that minimize infant exposure include
 Minimum effective dose
 Short acting agents
 Medications without active metabolites
 Timing the breast-feeding for when the drug levels in milk
are lowest

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 Specific drug use during lactation


Antidepressants

 SSRI comprise a relatively safe group of medications for

depression and anxiety during lactation
 Sertraline and paroxetine have a uniformly low or non-
detectable infant serum level
 Paroxetine has cardiac risk for future pregnancy

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 
 Fluoxetine has active metabolite

 Fluoxetine and citalopram should be avoided or used with

caution due to the higher infant plasma levels than for other
drugs
 Adverse effects
 Fluoxetine
 Excessive crying, irritability, decreased feeding and watery
stools
 Citalopram
 Hypotonia, colic, decreased feeding and sleep difficulties
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 
TCAs
 All TCAs are excreted into human breast milk in low
concentrations
 Useful in the treatment of postpartum depression when :
 SSRIs have failed
 Woman has shown a previous good response to these
medications.
Causes sedation and respiratory depression in infants

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 
Benzodiazepine
 Benzodiazepines should be used with caution in lactation
because of the risk of
 sedation, respiratory depression, and withdrawal
symptoms.

 Low doses of medications with no active metabolites like

clonazepam ??, oxazepam, temazepam, and lorazepam
are preferred.

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 
Mood stabilizers
Lithium
 Lithium is secreted into breast milk and levels achieved
are nearly half of maternal serum levels
 Adverse effects
 cyanosis, hypotonia, heart murmur, T-wave changes, restlessness,
muscle twitches, lethargy and hypothermia.
 In a breast-fed infant exposed to lithium, serum
concentrations should be monitored

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 
Anticonvulsants
Valproate
 Valproic acid is considered compatible with breast-
feeding because of consistent low levels in the breast milk.
 It is important to monitor maternal and infant serum drug
levels and liver function tests every 2 to 4 weeks

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 
Carbamazepine
 Considered compatible with breast-feeding because of
low level detected in breast milk.
 Infants exposed to carbamazepine should be monitored for
possible hepatic complications.
 Maternal and infant serum drug levels and liver function
tests should be monitored every 2–4 weeks

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 
Lamotrigine

 Lamotrigine is excreted in considerable quantities (60 %)

into human breast milk.
 Infant serum levels were approximately one-third of
maternal levels
 Infants exposed to lamotrigine should be observed closely
for side effects.
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 
Antipsychotics
 Among the typical antipsychotics haloperidol is excreted
in relatively high amounts in breast milk
 Chlorpromazine exposure has been associated with
drowsiness and lethargy
 Risperidone and olanzapine exposure found to be low to
undetectable serum levels.

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 Meta analysis (Klinger et al 2013)


 Olanzapine and quetiapine were categorized as acceptable
for breast-feeding.
 Chlorpromazine, haloperidol, and risperidone were
categorized as possible for breast-feeding under medical
supervision.
 Breast-feeding cannot be currently recommended for
the following medications:
 Aripiprazole, asenapine, clozapine, droperidol, fluphenazine,
iloperidone, lurasidone, paliperidone, perphenazine, pimozide,
trifluoperazine, thiothixene, and ziprasidone.

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 Summary1


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 Summary2


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 References


 Handbook of consultation-liaison psychiatry,2nd edition

 Clinical manuals of women’s mental health

 Kaplan and sadock’s comprehensive text book f

psychiatry,10th edition

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 
Thank you

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