PSYCHIATRIC DISORDERS DURING PUERPERIUM

Classification
There is little consensus regarding the classification of postpartum psychosis. Modern
classification systems do not recognise PP as a separate nosological entity. In the
International Classification of Diseases (ICD‐10),4 the category ‘mental and behavioural
disorders associated with the puerperium, not elsewhere classified’ should only be used when
unavoidable and includes only mental disorders commencing within 6 weeks of delivery that
do not meet the criteria for other diagnoses. In the Diagnostic and Statistical Manual of
Mental Disorders, fourth edition (DSM‐IV)5 postpartum affective episodes are treated as
mood disorders with a postpartum trigger: patients must meet the criteria for a mood episode
and the criteria for the postnatal‐onset specifier. In DSM‐IV a postnatal onset is considered to
be within 4 weeks of delivery. Despite these issues, however, the term postpartum (puerperal)
psychosis has remained in common clinical use.

Epidemiology
Record‐linkage studies estimate the admission rates to psychiatric hospital in the postpartum
as about 1–2 per 1000 births in the general population.6 However, the true incidence rates for
severe postpartum affective disorder may be higher, as at least some women with PP are
likely to be treated at home – particularly if facilities for admission with the baby are not
available.3

There is consistent evidence of a specific relationship between PP and bipolar disorder (BD).
Women with BD have at least a 1 in 4 risk of suffering a severe recurrence following
delivery.7 Bipolar women with a personal or family history of PP are at particularly high risk
with greater than 1 in 2 deliveries affected by PP.8

Aetiology and pathophysiology

Most episodes of PP can be considered as affecting women with a bipolar disorder diathesis
acted on by a specific puerperal trigger.3 A number of factors have been suggested that
increase vulnerability to the puerperal triggering of episodes of BD.

Genetic factors
There is robust evidence that the vulnerability to the triggering of affective psychosis by
childbirth aggregates in families and may define a genetically relevant subtype of bipolar
disorder.
Evidence from family studies suggests that episodes of PP are a marker for a more familial
form of BD

and that a specific vulnerability to the puerperal triggering of BD is familial.

Evidence from a linkage study indicated the possible location of a susceptibility gene on
chromosome 16.

 Particular candidate genes, such as those involved in the

serotoninergic11, 12 hormonal13, 14 and inflammatory15 pathways, have also been
investigated. It is hoped that identifying the genetic factors that increase risk will lead to more
individualised risk assessment, earlier identification of women at risk, and improved
treatments for women who become ill.

Obstetric risk factors

An increased risk of PP has been reported with a number of obstetric factors including:
primiparity; pregnancy and delivery complications; delivery by caesarean section; having a
female baby; and a shorter gestation period. However, findings are consistent only for
primiparity.16 The bias that women with a severe postpartum episode may be less likely to
go on to have further children is unlikely to be the sole, or even the main,
explanation.16 Given that there is little evidence of an association between PP and
psychosocial factors, the possibility remains that the effect of primiparity is, at least in part,
due to biological differences between first and subsequent pregnancies. In this regard, the
overlap with other pregnancy related disorders that also occur more frequently in first
pregnancies, such as pre‐eclampsia, is of interest. Hormonal, immunological and other
biological differences between first and subsequent pregnancies are interesting targets for
further investigation into the aetiology of PP.16

Changes in medications
Women with BD often come off mood stabilisers, such as lithium, preconception or in early
pregnancy because of concerns over toxicity to the fetus. A survival analysis comparing
women with BD who stopped taking lithium because of pregnancy compared with age‐
matched non‐pregnant women who discontinued lithium for other reasons, reported similar
rates of recurrence during the first 40 weeks after lithium discontinuation for both groups.
However, among subjects who remained stable over the first 40 weeks after lithium
discontinuation, postpartum recurrences were 2.9 times more frequent than recurrences in
non‐pregnant women during weeks 41–64 (70% versus 24%).17 Thus, the increased risk of
recurrence following childbirth for women with BD does not appear to be merely a result of
stopping mood‐stabilising medication.

Hormonal factors
The lack of evidence implicating psychosocial factors and consideration of the abrupt onset
during a time of major physiological change suggest that biological, possibly hormonal,
factors are important. The role of several hormones (including estrogen, progesterone,
prolactin, follicular stimulating hormone and luteinising hormone) has been considered, but
the evidence pointing to hormones in the aetiology of PP remains predominantly
circumstantial.

Sleep deprivation
A plausible hypothesis is that the sleep deprivation of delivery and the immediate postpartum
period is responsible for puerperal triggering of illness.18 Sleep loss can effectively trigger
the onset of mania in people with BD and sleep loss is, of course, common for new mothers.

Prevention
Screening for risk factors
In addition to a history of BD or PP, other risk factors for PP include having a first‐degree
relative who has experienced PP and having a first degree relative with BD.7 For women who
themselves have a history of mood disorder, particularly on the bipolar spectrum, a family
history of severe postpartum episodes is very important and may indicate a risk in excess of
50%. For women who have not suffered episodes of psychiatric illness themselves, it is not
so clear that family history is relevant. While a risk of PP of 1–3% in such women represents
a considerable increase on the population rate of around 1–2 in 1000 deliveries, it is unclear
whether extensive efforts to identify women who are well but with a family history is a
worthwhile strategy. These women may benefit from the risks being discussed with them if it
is something they have identified as a concern, but it also is possible that it may cause
unnecessary worry in women who will not go on to develop illness.

Because of the relapsing and remitting nature of BD, women at high risk are often currently
well and not in contact with mental health services and may fail to recognise the serious risk
of their situation. Thus, all women should be screened for known important risk factors at
their antenatal booking visit.1 Protocols should be put in place to ensure that women at
potential risk receive a formal risk assessment and management plan.19, 20
Women with schizophrenia also have an increased risk of hospitalisation after childbirth.
However, the specificity of the childbirth trigger in schizophrenia is still
controversial.21 Women with schizophrenia have a four‐fold lower relative risk of admission
in the postpartum period compared with those with BD.22 In many cases, schizophrenia is a
severe chronic illness and women are commonly admitted for assessment of parenting or to
help them to cope with the newborn rather than for the acute onset of a new episode.21

Management of women at high risk

Women at high risk of PP need very careful care before conception, throughout pregnancy
and during the postpartum period. The high risk of illness in the weeks following delivery in
a woman with a history of BD must be recognised both by healthcare professionals and by
the woman herself.19, 20

Ethical issues
The management of women at risk raises ethical questions on the role of the patient and her
family in the decision‐making process. Ethical principles of patient‐centred care provide the
foundation for the doctor–patient relationship: autonomy, justice, beneficence and
nonmaleficence.23 The clinician should avoid paternalistic attitude, exploring and
considering the values and the expectations of the patient and leaving the final informed
decision to the woman. If the woman wishes, family members can be involved in the decision
making process. The NICE guidelines suggest to discuss the teratogenic risk explaining the
background risk of fetal malformations in the general population (around 2–4%) and to
describe the risk using natural frequencies rather than percentages (for example, 1 in 10
rather than 10%).19 A written plan covering pregnancy, delivery and the postnatal period
should also be developed and discussed with the woman and her family.19

Pre‐conception
The possibility of future pregnancy should be considered in all women with BD who are of
childbearing age. Ideally the pre‐conception counselling should be conducted by a perinatal
psychiatrist,20 however, depending on availability, other psychiatric teams or GPs can
provide the necessary information to woman. The risks of illness following childbirth should
be discussed with women and the importance of seeking help emphasised. Decisions about
continuing or stopping medications before, or during, pregnancy are difficult and should be
the result of a detailed and individualised risk analysis.19 Although there are significant
concerns about the teratogenic effects of the medications used to treat BD, the risks of
stopping medication must also be considered. Data suggest that women with BD who stopped
medication during pregnancy were more than twice as likely to experience a recurrence than
 those who remained on medication.24 Data on the teratogenicity of psychotropic agents are
often controversial and an exhaustive discussion is beyond the scope of this review.
Consistent evidence suggest that valproate should be avoided, because of the high risk of
malformations,25 and because of negative effects on neurodevelopment.26 On the contrary, a
recent meta‐analysis found no significant association between any major congenital
abnormality and lithium.27 However, due to the wide confidence limits, considerable
uncertainty about the risk of lithium remains.

During pregnancy and after childbirth

Perhaps the most important aspect of care is to maintain close contact and review during the
perinatal period. Women at high risk, even if they are well, should be referred in pregnancy
for psychiatric assessment and monitored regularly for at least 3 months following delivery.
The good practice guidelines developed by Royal College of Obstetricians and
Gynecologists20 suggest that the following scenarios are indications for referral to
specialised perinatal mental health services where available, otherwise general psychiatry
services:

 current severe psychiatric symptom

 a history of serious postpartum illness or bipolar disorder or schizophrenia

 on complex psychotropic medications schemes.

Moreover, the guidelines suggest that referral should be considered for those with moderate
symptoms developed in late pregnancy or early postpartum or mild symptoms and a family
history of bipolar disorder or puerperal psychosis (COG). Psychiatric services should have
priority care pathways for pregnant and postpartum women and care by multiple psychiatric
teams should be avoided.1 Ideally, women should be managed by
multiprofessional/multidisciplinary teams, with a named obstetrician (possibly with special
interest in perinatal mental health), midwives, perinatal psychiatrist, community psychiatric
nurse, health visitors and GP. All communication between maternity and mental health
services should include primary care. A written care plan should be developed in
collaboration with all relevant healthcare professionals and recorded in all versions of the
woman's notes.19, 20

It may also be important to address other avoidable factors that may increase risk – such as
decreasing general levels of stress and paying attention to sleep in late pregnancy and the
early postpartum weeks. Liaison with maternity services should involve discussion about how
to manage the labour to reduce the sleep deprivation that can occur if labour is prolonged. For
 women with a history of BD who have been off medication in pregnancy the introduction of
prophylactic medication in the immediate postpartum period should be considered. Some
evidence exists for the use of lithium in this context, but the few studies have been open and
retrospective and there are practical problems with reaching therapeutic levels quickly to
cover the period of risk. These issues have led some perinatal psychiatrists to use typical or
atypical antipsychotics as prophylaxis.3

Diagnosis of postpartum psychosis (PP)

History and examination
Although all women should be assessed antenatally for known risk factors, such as personal
or family history of BD and psychosis, it is important to bear in mind that 50% or more of
women who develop PP have no history that puts them in a high‐risk group.3

The distinctive clinical features include sudden onset and rapid deterioration. The vast
majority of episodes have their onset within 2 weeks of delivery, with over 50% of symptom
onsets occurring on days 1–3.28 The clinical picture often changes rapidly, with wide
fluctuations in the intensity of symptoms and severe swings of mood. Common symptoms
and signs include:

 A wide variety of psychotic phenomena such as delusions and hallucinations, the

content of which is often related to the new child.

 Affective (mood) symptoms, both elation and depression.

 Disturbance of consciousness marked by an apparent confusion, bewilderment or

perplexity.

Differential diagnosis
 Primary cerebral or systemic disease (such as eclampsia or infection) should be
excluded. The misattribution to psychiatric disorder has led to a number of deaths in new
mothers.1

 Exogenous toxic substances or hormones: History of therapeutic use and/or abuse of

known causative substances or hormones, other symptoms and signs specific to the substance
or substances involved should be investigated. Urine drug screen may be positive in
substance abuse and identifies the substance taken, although it is not definitive for drug
misuse.
 Other psychiatric disorders of the puerperium: Baby blues affects 30–80% of births
and causes transient emotional lability during the first postpartum week. The mother typically
presents mood swings ranging from elation to sadness, insomnia, tearfulness, crying spells,
irritability, anxiety, and decreased concentration. Care of the baby is not impaired,
hopelessness and worthlessness are not prominent, and women do not feel suicidal. It is self‐
limiting, but assessment should ensure that the woman is not and does not become more
severely depressed.

 Postnatal depression (for a review see Musters et al.29). The tendency for all
postpartum episodes to be labelled as postnatal depression can lead to suboptimal care and, in
some cases, have dramatic consequences on mothers and babies.

Any psychotic symptoms, particularly delusions or hallucinations, substantially increase risk

for both mother and child. The woman should be referred for a same day emergency
appointment so that a detailed risk assessment can be carried out.

Management of women with postpartum

psychosis (PP)
Hospital admission
PP is a psychiatric emergency. The clinical picture may mislead, quickly become extremely
severe and vary significantly from hour to hour. Admission is usually necessary, even for
women with the most supportive of families. The NICE guidelines19 recommend that women
within a year of childbirth should be offered admission to a specialist mother and baby unit,
however, the provision of services across the UK is patchy and for the majority of women
there is no option of admission with her baby.3

Pharmacological treatment
A range of psychotropic medication may need to be employed. The treatment used depends
on a number of factors, including the symptoms that the woman experiences, her level of
disturbance and her previous response to medication. For many women the severity of the
illness does not allow breastfeeding. If breastfeeding is being considered, factors in the baby
such as prematurity and systemic illness should be considered in addition to the particular
properties of the medication itself. Limited data suggest that the use of lithium during
breastfeeding is not as problematic as once thought30 but is usually avoided because of the
risk of toxicity in the baby.

Follow‐up
Prognosis
The short‐term prognosis for PP is generally good. However, women need to be counselled
about the risks they run of a further puerperal or non‐puerperal episode. This will include
discussing the need for longer‐term mood stabilising medication and other measures that can
reduce the risk of recurrence. Despite the high risk of recurrence following further deliveries,
many women make the decision to become pregnant again and it is our view that women with
PP, or indeed women with bipolar disorder more generally, should not be told that they
should not have children.3

Conclusion
Postpartum psychosis is a severe condition complicating childbirth following approximately
1 in 1000 deliveries. In 50% of cases there is no prior history of psychiatric disorder. In other
women, however, there are clear factors – a history of bipolar disorder or previous episode of
PP – that identify women who are at very high risk (50% or more). Women at high risk need
to be identified in pregnancy and referred to psychiatric services for further assessment. PP is
a true psychiatric emergency and it is vital that it is recognised early and treated aggressively.

In the first 3 months after delivery, the incidence of mental illness is high.
Overall incidence is about 15–20%.
Sleep deprivation, hormone elevation near the end of gestation and massive postpartum
withdrawal contribute to the risk.