Case 7

Puerperal Psychosis

Name of the Hospital - Teaching Hospital, Karapitiya

Name of the Consultant - Dr. G.G.A. Jayawardena

Name - Mrs. J.T.K.

Address - Poddala

Age - 33 yrs.

Supervised by

Dr.G.G.A. Jayawardena
MBBS, MD (Psychiatry)
Consultant Psychiatrist
Teaching Hospital, Karapitiya

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Mrs. J.T.K. is a 33 year old lady from Poddala. She has been living with her
husband.

History was taken from the patient and her husband.

PRESENTING COMPLAINTS

Increasingly disturbed behavior

Neglecting the new born baby 2 days duration
Poor sleep

HISTORY OF PRESENTING COMPLAINTS

She was apparently well until the end of her first pregnancy. At a routine clinic
visit she was found to have high blood pressure at thirty six weeks of
gestation. She was then admitted to the obstetric ward on 9th June 2005. Next
morning an emergency caesarian section was done due to impending
eclampsia. She had given birth to a baby boy. She didnt develop any fits. She
was discharged from the hospital after one week stay.

Two weeks after the childbirth her behavior became changed. She started to
shout at her relatives and abuse them in obscene words. She became over
talkative. She was seen talking and smiling to her self. Gradually she
neglected her baby. She stopped feeding the baby. She didnt care when her
baby was crying. She didnt change his nappies or didnt cuddle him. She had
refused to accept the baby. When her sister tried to attend the baby she was
angry and she started to assault them and break house hold items. However
she didnt harm her self or the baby. She did not express any suicidal ideas or
homicidal ideas towards baby or any other person. Her sleep became disturbed
and she didnt take her meals properly.

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On the second day evening she was taken to a psychiatrist in private sector.
Although the relatives were advised to admit her, they were reluctant to do so.
With the given medication also there was no control in her behavior. She
didnt sleep that night too. She had been shouting that she is Ajasaththa and
there is no one else on earth greater than her. Since she was uncontrollable at
home relatives realized the need of admission and next morning she was
brought to the hospital.

FAMILY HISTORY
Her mother had committed suicide when she was 56 years. She had two
previous suicidal attempts. When she was living, she had been suspicious of
neighbours and quarrelsome with the children. She had been irritable, and
thoughtful some times. However she was never on treatment. It seems either
she was suffering from a chronic psychotic illness or depression with
psychotic features.

Her father is 62years and a healthy person. She has 5 other siblings in the
family. They all are in good health.

PERSONAL HISTORY
Details related to birth and development was not available. There was no
history of epilepsy or meningitis in early childhood. She studied up to
advanced level and got through in arts stream. She didnt do any employment
after schooling. She is married to a mason. They have a monthly income of
fifteen thousand rupees. They live in their own house. They didnt have any
marital problem.

PAST MEDICAL HISTORY

No significant medical illnesses in the past.

PAST PSYCHIATRIC HISTORY

There was no history of changed behavior or any psychiatric illnesses in the
past.

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FORENSIC HISTORY
Nil of note.

PREMORBID PERSONALITY
She was a sociable woman. She had many friends and was capable of
maintaining relationships. She was able to cope with day to day problems in
her life well. She had leisure activities like watching TV, meeting neighboring
friends. She is a Buddhist and she was religious too. She never used any
psychoactive substances in the past.

MENTAL STATE EXAMINATION

Appearance and behavior
She was an averagely built young woman. She was wearing a bed jacket and a
cloth. Her bed jacket was soaked with breast milk. Her hair was uncombed
showing some degree of self neglect. She was distractible and it was difficult
to build a rapport with her. She showed some degree of disinhibition, tried to
get up from the chair and leave the room many times.

Speech
Her speech was spontaneous. But she was over talkative. She showed pressure
of speech. She talked irrelevant things at times. But it was coherent.

Mood
Her mood was labile varying from irritability to sadness and elation
sometimes. She sometimes cried suddenly during the interview.

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Thought
There was no flight of ideas or loosening of association.

There were no suicidal or homicidal thoughts. She firmly believed that she
was Ajasaththa and possessed a great power. It was a grandiose delusion.

She also claimed that all family members were charming against her using the
evil power of her dead mother. This was a persecutory delusion. She also had a
delusional belief that the baby is not hers.

Perception
She did not have any perceptual abnormalities.

Cognition
She was well oriented in time, place and person. Her attention and
concentration were poor. She failed to do the serial sevens test. In checking
her short term memory also she couldnt recall 2 items in the given address. It
seemed it was due to lack of attention and concentration. Her long term
memory was intact.

Insight
She did not believe that she has any mental illness. She said she did not need
any medication. This shows her lack of insight into illness.

PHYSICAL EXAMINATION
General examination
She was afebrile, not pale, not icteric and mild ankle oedema was present.

CVS Pulse rate 88/min, regular

BP 140/90mmHg
Heart sounds were normal

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Respiratory System
Lungs were clear
No added sounds

Abdomen
It was not distended
Surgical scar was healed well
No tenderness on palpation
No palpable lumps

Vaginal examination - normal

No evidence of purulent discharges

Nervous System
No motor or sensory deficits
Cranial nerves were normal

INVESTIGATIONS
We did full blood count, Blood urea, serum electrolytes, Urine full report,
Liver function tests and ECG. They all were within normal limits.

SUMMARY
A 33 year old primi mother presented with disturbed behavior, restlessness,
over talkativeness, neglecting the new born baby for two days about two
weeks after the partus. In her family history her mother had been suffering
from a long standing untreated psychiatric illness and committed suicide
ultimately.

On examination she was disinhibited, distractible and showed pressure of

speech. Her mood was labile. She had grandiose and persecutory delusions.
There were no perceptual disturbances. She had poor attention and
concentration and poor short term memory. She lacked insight into her illness.

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DIFFERENTIAL DIAGNOSES

1. Severe mental and behavioral disorders associated with the

puerperium, not elsewhere classified. F53.1

2. Mania with psychotic symptoms F30.2

3. Adjustment disorder F43.2

1. Severe mental and behavioral disorders associated with the

puerperium, not elsewhere classified.

According to the history of this patient, the onset of her illness had been about
two weeks after the child birth, within six weeks of delivery. She showed poor
sleep, irritability, psychomotor agitation, lability of mood, paranoid and
grandiose delusions. With the two days history of changed behavior, the
clinical features and the duration cannot be classified elsewhere appropriately
according to ICD-10 diagnostic classification. Risk of puerperal psychosis is
higher in those who gives a family history of major psychiatric disorder and in
primi para. These two factors were present in this case.

2. Mania with Psychotic Symptoms

She was restless, agitated, over talkative irritable and disinhibited with
decreased need for sleep. She showed pressure of speech, lability of mood and
grandiose delusions. Her attention and concentration were poor. She lacked
insight in to her illness as well. All these features favour diagnosis of mania
with psychotic features.

However on admission it was only a two day history of changed behaviour. To

diagnose mania, symptoms must be present minimum one week duration.

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3. Adjustment Disorder

This diagnosis is considered when there are states of subjective distress and
emotional disturbance usually interfering with social functioning and
performance, and arising in the period of adaptation to a significant life
change or to the consequence of a stressful event.

The child birth could be a stressful life event. Adjustment disorders can
manifest in various ways with emotional and behavioral problems. But this
diagnosis could not be entertained as she had other prominent symptoms in
sufficient severity to justify other specific diagnosis.

MANAGEMENT
Acute Management
The admission to the psychiatry unit was justified by the facts that she had
been posing a threat to herself, to the baby and to others as well. She had a
delusional belief towards the baby that the baby is not hers. This would even
lead to harm the baby. She had to be prepared to resume the care of the baby
as soon as possible.

Ideally she should have been admitted to a special mother and baby care unit.
Since we did not have such facilities we admitted her to our psychiatric ward
and the baby was admitted in a pediatric ward of the same hospital.

The relatives were explained the reasons for admission as they were highly
worried about her behaviour. We reassured them specially the husband that her
condition could be treated effectively. The need for urgent intervention and
adherence to our treatment plan was emphasized.

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Pharmacotherapy
She had to be sedated with Haloperidol 10mg intramuscularly on admission as
she was very restless. She was given Cholorpromazine 50mg mane and 100mg
nocte as antipsychotic. To achieve sedation, diazepam was given orally when
necessary basis. Benzhexol 2mg mane was given to counteract side effects.

It was difficult to explain the rationale of drug therapy at the begining as she
lacked insight. Furthermore she was suspicious about the staff. We waited for
next three days to see any improvement with the given drugs. She showed
only a minimal improvement. Therefore we deiced to see another option.

Electro Convulsive Therapy

As she showed a slow response to pharmacotherapy and as she had to resume
the care of the baby quickly we decided to give ECT. Furthermore prolonged
hospitalization of the mother would badly affect on infant attachment and
development.

We saw a remarkable response with each dose of ECT. She was given four
doses of ECT within a period of eight days. Her delusions became reduced in
intensity and her sleep, appetite and the behavior were improved.

Psycho-education
Once she was getting better we were able to build a good therapeutic
relationship. She was passing through a stressful situation with the first child
birth. She was explained that mental illnesses in the puerperium are a common
experience. She was reassured that our treatment would bring her back to
normal completely so that she could resume the care of the baby very soon.
She was stressed on the importance of complying with treatment. She was
advised to resume breast feeding in combination with formula feeds during the
night to ensure adequate sleep for her. She was asked to adjust the breast
feeding timing so that she would feed the baby just before her drug doses in
the morning and night. This would minimize the excretion of drugs via breast
milk to the baby.

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Husband and relatives were explained about the care plan. The emphasis was
made on continuation of medication. They were informed about the need for
good family support and to be in the watch out for the early signs of relapse.
She was discharged with the plan of reviewing her at the clinic in two weeks
time.

Follow up
She came for a follow up in two weeks time and showed a marked
improvement in her symptoms. She did not show any side effects to the drugs.
The importance of adherence to our treatment plan was re emphasized to both
patient and the husband.

DISCUSSION
Puerperal psychosis is one of the most serious psychiatric conditions. It can
endanger the lives of both mother and baby in its extreme forms.

The estimated incidence, calculated from admission rates for psychosis in

women within 90 days of parturition, is about one in 500 live births (Kendell
et al 1987).

Puerperal psychosis usually has a rapid onset in the first one or two weeks
after childbirth but is virtually never reported within the first few days of
puerperium (Brockington et al 1982). This patient also typically had an acute
onset in two weeks of delivery.

Several studies (eg. Kendell 1985, Marks et al 1992) have explained the risk
factor for major mental disorder appears to be the most robust predictors,
although lack of social support and single parenthood has also been identified
in some studies. Women with a previous history of post partum psychosis are
at a significantly greater risk (1 in 3) of a psychotic episode following a
subsequent pregnancy (Cox 1992). The only obstetric risk factor associated
with the development of post partum psychosis is being primiparous. So this
patient had two risk factors being primi and having a strong family history of
major mental illness.

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Three clinical presentations of puerperal psychosis are described in the
literature: affective, schizophreniform, and acute organic psychosis. Affective
syndromes constitute about 80% of puerperal psychosis. Similarly this patient
had more affective symptoms. As many as half the affective cases present with
features of mania and many researchers consider puerperal psychosis as a
variant of bipolar disorder.

Worsening insomnia is a common prodromal symptom of puerperal psychosis.

Psychomotor agitation may also be an early manifestation. However most
notable feature is the lability of mood, behavior and psychotic symptoms.
Affective states may shift dramatically from elation to depression over a
period of hours, while psychotic symptoms may appear suddenly after a week
or more of apparent remission. Paranoid delusions about family, friends or
professionals and abnormal ideas about the baby, all of which had in this
patient, appear to be very intense, may change markedly in their content over
hours or days. Perplexity, bewilderment and disorientation are common across
all three clinical presentations. Although suicide and infanticide are rare,
suicidal and infanticidal ideation may be a significant problem (Bluglass
1978).

In treatment, admission to the hospital is normally required. For in-patient care

it is preferably managed in a special mother-baby care unit to minimize
adverse effects on maternal bonding. However it is very difficult to supervise
safe care and presence of baby may complicate treatment. In our country we
dont have specialized mother and baby care units and mothers are almost
always admitted to a psychiatry unit without the baby, except for few
occasions where the baby needs special treatment and is admitted to the
Paediatric ward of the same hospital.

The primary pharmaceutical need is for sedation and interventions similar to

those used for non-puerperal psychosis, although dose of antipsychotic
medication required is often lower. Neuroleptics will pass into breast milk and

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as with antidepressants little is known of their effect on the developing infant
and therefore should be used with caution.

Electroconvulsive therapy is often the best treatment for patients with

depression or manic disorders of marked or moderate severity, because it is
rapidly effective and enables the mother to resume the care of the baby
quickly. If definite improvement does not occur within a short period, ECT
should be considered, especially if the onset was acute. This is why this
patient was given ECT.

Education of the patient and family is a vital part of the treatment package.
Education will help to reduce stress in adult relationships, but further input is
required to reduce the risks to the new born baby. Working with the babys
father is important, though it is often difficult to achieve because of his
vulnerability and unwillingness. The partner is potentially the main supporter
and his family is often instrumental in the mothers demoralization.

Prenatal psychiatric care is perhaps one of the psychiatric fields in which

extensive community care is most likely to work. Even though there is no well
developed community psychiatry net work available in our country we can
educate and liaise with the MOHs and public health midwives in such
situations. Because, it merits the best service we can provide in a situation
where the life and the wellbeing of two individuals are at risk.

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REFERENCES

1. Eve C Johnstone, Freeman CPL, Zeally AK, Companion to

psychiatric studies. 6: 556-562.

2. Michael Gelder, Richard Mayou, Philip Cowen. Shorter

oxford text book of psychiatry. 4: 499-501.

3. The 1CD-10. Classification of mental and Behavioral

disorders. WHO - Geneva. 1992;

4. Dewi B, Pritchard, Brian Harris. Aspects of perinatal

psychiatric illness. British Journal of Psychiatry 1996;
(196): 555-562.

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