Puerperal mental disorders
• Postpartum blues.
• Postpartum depression.
• Postpartum psychosis
Psychotropic medication in pregnancy
WHY IS IT IMPORTANT ?
Women are at the greatest risk of developing a
psychiatric disorder during childbearing age .
The psychiatric disorders with the highest prevalence
in women are depressive and anxiety disorders up t o
20 % .
Women with histories of these disorders are at risk
for relapse during pregnancy, particularly if they
have experienced two or more relapses of the
Ideally, women with a history of any recurrent
psychiatric disorder should obtain a pre pregnancy
consultation to discuss the safest treatment approach
as they try to conceive and during the pregnancy
(False pregnancy) is a
condition in which a
woman feels she is
really pregnant, but
she is not actually
• It is generally estimated that false
pregnancy is caused due to changes in the
endocrine system of the body, leading to
the secretion of hormones which translate
into physical changes similar to those
• The underlying cause is often: MENTAL.
There are various explanations:
- attribute the false pregnancy to emotional
- intense desire to become pregnant, or an
intense fear of becoming pregnant.
- internal conflicts and changes in the endocrine
SIGNS & SYMPTOMS:
SIGNS & SYMPTOMS:
l similar to the symptoms of true pregnancy and
are often hard to distinguish from it .
l natural signs of pregnancy :amenorrhoea, morning
sickness, tender breasts, and weight gain .
l The most common symptom is: Abdominal distension(60
*N.B: often resolve under general anesthesia and the woman's
abdomen returns to its normal size .
l The second most common physical sign of
pseudocyesis is menstrual irregularity
* Women are also reported to experience the
sensation of fetal movements known as
SIGNS & SYMPTOMS:
Other common signs and symptoms:
- breast changes or secretions.
-labor pains (One percent of women eventually
experience false labor.)
- and softening of the cervix .
**The hallmark sign of pseudocyesis that is common to all
cases is that the affected patient is convinced that she is
PUERPERAL MENTAL DISORDERS
PUERPERAL MENTAL DISORDERS
During the postpartum period, up to 85% of women suffer
from some type of mood disturbance. Most women,
symptoms are transient and relatively mild (ie, postpartum
10-15% of women experience a more disabling and
persistent form of mood disturbance (eg, postpartum
depression, postpartum psychosis).
More recent evidence suggests that postpartum psychiatric
illness is virtually indistinguishable from psychiatric
disorders that occur at other times during a woman's life.
Up to 85% of women experience postpartum affective
* Rapidly fluctuating mood * tearfulness
* Irritability * Poor concentration
* Depression and anxiety * Sleep disturbance
Symptoms peak on the fourth or fifth day after delivery
and last for several days.
Generally time-limited and self - limited with
spontaneously remit within the first 2 postpartum weeks.
Symptoms do not interfere with a mother's ability to
function and to care for her child.
POSTPARTUM DEPRESSION (PPD):
Postpartum depression occurs in 10 -20 % of women in the general
population with risk of recurrence 50 % .
postpartum depression develops insidiously over the first 3 postpartum
months, more acute onset.
Postpartum depression is more persistent and debilitating than
Suspect if the blues last beyond 2 weeks with :
* Depressed mood * Tearfulness
*Inability to enjoy pleasurable activities * Insomnia & Fatigue
* Appetite disturbance * Suicidal thoughts
*Recurrent thoughts of death.
Anxiety is prominent, including worries or obsessions about the infant's
health and well-being
Postpartum depression often interferes with the mother's ability to care
for herself or her child.
Postpartum psychosis is the most severe form of postpartum psychiatric
1-2 per 1000 women after childbirth.
Postpartum psychosis has a dramatic onset, emerging as early as the first
48-72 hours after delivery. In most women, symptoms develop within the
first 2 postpartum weeks.
The condition resembles a rapidly evolving manic episode with symptoms
* Hallucinations *Delusions .
* Restlessness and insomnia
* Rapidly shifting depressed or elated mood, and disorganized behavior.
Post partum psychosis is a psychiatric Emergency that typically requires
inpatient treatment .
Risks for infanticide and suicide are high among women with this disorder.
Levels of estrogen, progesterone, and cortisol fall dramatically
within 48 hours after delivery.
Inadequate social supports
marital discord or dissatisfaction, or recent negative life
events are more likely to experience postpartum depression.
_ prior history of depression or family history of a mood disorder
are at increased risk for postpartum depression.
Women with a prior history of postpartum depression or
psychosis have up to 90% risk of recurrence.
SCREENING FOR POSTPARTUM MOOD
Predicting who is at risk for postpartum depression is difficult.
Individuals at great risk often have some of this risk factors :
Prior history of postpartum depression.
Personal or family history of mood disorder
Depression during a current pregnancy.
Inadequate social supports.
Marital dissatisfaction or discord
Recent negative life events such as a death in the family, financial
difficulties, or loss of employment.
Screening of all mothers during the postpartum period is
The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self
-rated questionnaire used extensively for detection of
POSTPARTUM BLUES TREATMENT
Postpartum blues typically is mild in severity
and resolves spontaneously.
No specific treatment is required, other than
support and reassurance.
Further evaluation is necessary if symptoms
persist more than 2 weeks.
POSTPARTUM DEPRESSION TREATMENT
Exclude medical causes for mood disturbance (eg, thyroid
Milder forms may respond to supportive psychotherapy. More
severe may require pharmacological treatment.
Nonpharmacological treatment for women with mild-to-moderate
symptoms. These modalities may be especially useful for mothers
who are nursing and who wish to avoid taking medications.
Psychoeducational groups may be helpful. Individual or group
psychotherapy (cognitive-behavioral and interpersonal therapy)
Pharmacological strategies are indicated for moderate-to-severe
depressive symptoms or when a woman fails to respond to
PHARMACOLOGICAL TREATMENT CONT,
Selective serotonin reuptake inhibitors (SSRIs) :
are first-line agents and are effective in women with
postpartum depression. eg, fluoxetine and sertraline
Serotonin-norepinephrine reuptake inhibitors
(SNRIs) or Tricyclic antidepressants :
may be useful for women with sleep disturbance eg ,
Nortriptyline and venlafaxine.
Anxiolytic agents : such as lorazepam and
clonazepam may be useful as adjunctive treatment in
patients with anxiety and sleep disturbance.
Preliminary data suggest that estrogen, alone or in
combination with an antidepressant, may be beneficial;
however, antidepressants remain the first line of
SPECIAL CONCERN (PPD)
First episode of depression, 6-12 months of treatment is
recommended. For women with recurrent major depression,
long-term maintenance treatment with an antidepressant
Inadequate treatment increases the risk of morbidity in
both mother and infant.
Earlier initiation of treatment is associated with better
Inpatient hospitalization may be necessary for severe
Electroconvulsive therapy (ECT) is rapid, safe, and
effective with severe postpartum depression, especially
those with active suicidal idea.
PUERPERAL PSYCHOSIS TREATMENT
Puerperal psychosis is a psychiatric emergency requires
Most patients with puerperal psychosis suffer from bipolar
disorder. Acute treatment includes a mood stabilizer (eg,
lithium, valproic acid, carbamazepine) in combination with
antipsychotic medications and benzodiazepines.
ECT (often bilateral) is tolerated well and rapidly effective.
Risk of suicide is significant in this population.
Rates of infanticide associated with untreated puerperal
psychosis are as high as 4%.
Breastfeeding and psychotropic medications :
All psychotropic medications, including antidepressants, are
secreted into breast milk. Concentrations in breast milk vary
Tricyclic antidepressants during breastfeeding are encouraging.
Reports of toxicity in nursing infants are rare, although the long-
term effects of exposure to trace amounts of medication are not
Avoid breastfeeding in women treated with lithium because this
agent is secreted at high levels in breast milk and may cause
significant toxicity in the infant.
Avoid breastfeeding in premature infants or in those with hepatic
insufficiency who may have difficulty metabolizing medications
present in breast milk.
Impact of postpartum depression on child development :
Postpartum depression may negatively affect these mother-infant
Mothers with postpartum depression are more likely to express
negative attitudes about their infant and to view their infant as
more demanding or difficult.
Children of mothers with postpartum depression are more
likely than children of nondepressed mothers to exhibit
behavioral problems .
* sleep and eating difficulties * temper tantrums
* hyperactivity * delays in cognitive development
* emotional and social dysregulation
* early onset of depressive illness.