Volume 8 Issue 9 September, 2018
Psychosis occurring during the first few weeks after delivery is not an uncommon condition. Postpartum psychosis (PP) is characterized by acute onset of mood swings, confused thinking, fearfulness and grossly disorganized behavior. Postpartum psychosis occurs in 1–2/1000 childbearing women within the first 2–4 weeks after delivery. Postpartum psychosis in mothers has significant impact on their health and infant’s safety.
The illness has its onset in the early postnatal period, usually the first month after childbirth. Clinically family members report of acute change in patient’s behavior i.e. becoming angry easily, not sleeping, reduced care towards the new born and reduced self-care. Later patients may display disruptive behaviors like becoming violent or fearful with delusions of persecution or completely stop talking, while displaying catatonic symptoms in the form of mutism, withdrawn behavior etc. Suicide is not an uncommon outcome in women with postpartum psychosis, more so if the presentation has associated depressive symptoms. Rarely infant related harm and violence may be seen in mothers who are disruptive and have delusions involving the new born child. Among patients who develop postpartum psychosis immediately after childbirth, around 80% have bipolar illness or schizoaffective disorder, while the rest have schizophrenia. A small but significant number of women who have postpartum psychosis are associated with organic causes like Cortico Venous Thrombosis (CVT), pregnancy induced eclampsia and infection. Several factors have been identified that significantly increase the risk of puerperal psychosis; of them past history of puerperal psychosis and family history of bipolarity are important predisposing factors. The presence of the above history increases the risk to up to 50% recurrence of puerperal psychosis.
Puerperal psychosis is an emergency and safety of both mother and infant is the first priority. Puerperal psychosis responds dramatically to antipsychotics and in some patients, there may be a need to use Electro Convulsive Therapy. Neuroimaging should be considered if patients present with symptoms of confusion, headache, seizure or any neurological deficits to rule out CVT. Mood stabilisers, mainly valproate and carbamazepine can be used to treat if the symptoms are predominantly bipolar in nature. Preventing relapse of mental illness during pregnancy and puerperium is important as more than 50% of women will have further episodes in postpartum in future if untreated. Breastfeeding can be continued while the patient is on psychotropic medications as the advantages outweigh the risks to the infant. Antipsychotic medications are secreted through breast milk, but it is less than 10% of that in maternal serum. It is important to watch for side effects in the infant, particularly in Low birth weight infants. Breastfeeding needs to be encouraged as it is known to improve mother infant bonding. Once the acute phase of symptoms remit, then mother should be helped to take care of the child and focus will be on improving mother infant bonding. Parents and couple should be educated for planning future pregnancy in view of higher risk of relapse in future childbirth.
Dr Girish Babu N
Associate Professor, Department of Psychiatry, SDMCMSH, Dharwad
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