Puerperal illnesses

&
Premenstrual Syndrome

Dr Alex Audu
Consultant Psychiatrist
 Puerperal mental disorders
Puerperium
The period of about six weeks after childbirth
during which the mother’s reproductive organs
return to their original non-pregnant condition

Puerperal/postpartum mental disorders

Disorders that commence within the six weeks
following childbirth
Risk factors
Puerperal mental disorders

Types

Maternity blues

Puerperal psychosis

Postpartum depression
 Maternity blues
Experienced by ½ to 2/3 of women after childbirth

Characterized by brief episodes of irritability, lability

of mood, and episodes of crying

Symptoms reach their peak 3–4 days postpartum

More frequent among primigravida

Not related to complications at delivery or to the use

of anaesthesia
 Maternity blues
Patients have
Patients often Although
often
speak of being frequently experienced
‘confused’, but tearful, patients
anxiety and
tests of may not be depressive
cognitive feeling depressed
symptoms in the
function are at the time but last trimester of
normal tense and
pregnancy
irritable
Also more likely to
give a history of
premenstrual
tension, fears of
labour, and poor
social adjustment
Maternity blues
Both the frequency of the emotional
changes and their timing suggest that
maternity blues may be related to
readjustment in hormones after delivery,
although this has not been established

No treatment is required because the

condition resolves spontaneously in a
few days
Postpartum psychosis (puerperal psychosis)
• In the 19th century, puerperal and lactational
psychoses were thought to be specific entities
distinct from other mental illnesses

• Later psychiatrists such as Bleuler and Kraepelin

regarded the puerperal psychoses as no different
from other psychoses, and neither ICD-10 nor
DSM-5 have a specific diagnostic category for
puerperal psychosis

• The term, nevertheless, continues to be used

widely by clinicians and patients
Postpartum psychosis: Epidemiology

More common
in primiparous
More common
women and in
Incidence: 1–2 in developing
those who have
per 1000 births than in
suffered
developed
previous major
countries
psychiatric
illness

bipolar disorder
has a 20% risk of
puerperal relapse
 Postpartum psychosis: Aetiology
• There is a genetic predisposition, which overlaps with
that of bipolar disorder, but apart from a possible
susceptibility locus on chromosome 16, no specific genes
or genetic pathways have been identified

• The early onset of puerperal psychoses has led to

speculation that they might be caused by the dramatic
hormonal changes that follow delivery

• Immunological factors have also been implicated

• The sleep deprivation associated with childbirth may play

a role
Postpartum psychosis: Clinical features
• Onset is often within 2–3 days of delivery, and
usually within the first 1–2 weeks
• A sudden onset and rapid deterioration is typical
• 3 types of clinical picture are observed: delirium,
mood disorder, and schizophreniform disorder
– Clinical features are similar to those of the
corresponding non-puerperal syndrome

• Insomnia and overactivity are often early features

• Perplexity and confusion are common
Postpartum psychosis: Management
• Assessment should be prompt and attention should
be to the potential risks to mother and baby
– As well as the usual psychiatric assessment it is essential
to ascertain the mother’s ideas concerning the baby

• Treatment usually requires inpatient care

• If available, admission is often best to a mother and

baby unit, where the child can remain with the
mother to minimize adverse effects on maternal
bonding
Postpartum psychosis: Management
Antipsychotics = mainstay of treatment

Antidepressants if depressive symptoms are prominent

Adjunctive benzodiazepines are helpful for insomnia and

sleep disturbance

Lithium if there is a clear bipolar component, though it is

advised that women taking lithium should not breastfeed

ECT if pharmacological treatment and psychological

support do not resolve symptomatology
Postpartum psychosis: Prognosis
Over 75% of women have a good outcome after
puerperal psychosis

Recovery usually occurs within a few months

High risk of relapse after the next delivery

Almost 70% of sufferers will have a non-puerperal

recurrence, usually of bipolar disorder
 Women with a history of puerperal psychosis should be
offered preconception care and regular psychiatric support
during and immediately after each pregnancy

 The benefits of
maintenance
medication
(antipsychotics and
mood stabilizers) often
outweigh the risks

 Sodium valproate
should be avoided, as
in all women of
childbearing age,
unless no other
treatment is effective
or tolerable
 Postnatal depression
More common than the puerperal psychoses

It is estimated that about a third of cases begin

during pregnancy

Tiredness, irritability, and anxiety are often more

prominent than depressive mood change

There are often phobic and obsessional symptoms

concerning fears about harming the baby
 Postnatal depression

• Most patients recover after 2–6 months, but

up to 30% still have some depressive
symptoms in the year following childbirth

• High risk (about 40%) of depressive relapse

subsequently, either postnatally or at other
times
 Postnatal depression: Aetiology
• Clinical observation suggests that postnatal
disorders are often precipitated in vulnerable
mothers by
– The psychological adjustment required after childbirth
– The loss of sleep
– The hard work involved in the care of the baby

• There is little evidence of a specific biological

basis different from depression in other situations
 Postnatal depression: Aetiology
• The main risk factors are a previous history of
depression (especially when accompanied by
obstetric complications) and indications of
social adversity

• Low levels of partner or other support,

relationship difficulties, and domestic violence

• Unintended pregnancy
 Postnatal depression: Management
• Many sufferers can be treated effectively with
counselling and help with solving practical
problems
• A small proportion need specific psychological
interventions or antidepressant medication
• A few with severe or complex problems require
referral to psychiatric services
• Exposure of the infant to drug via breast milk needs
to be considered but is generally low with SSRIs
such as sertraline
 Premenstrual Syndrome (PMS) and
Premenstrual Dysphoric Disorder (PMDD)
• PMS refers to a group of physical and behavioral
symptoms that occur in a cyclic pattern during
the second half of the menstrual cycle

• PMDD is the severe form of PMS

• PMS is not included in current classifications of

psychiatric disorder, but PMDD is included in
DSM-5 within the ‘Depressive disorders’ chapter
 PMS and PMDD

Diagnosis of PMDD requires a minimum of 5

symptoms, including mood symptoms, which
are clearly related to menstruation

The conditions should be distinguished from

the much more frequent occurrence of
similar symptoms that are not strictly
premenstrual in timing
 PMS and PMDD: Epidemiology
• Mild PMS is common, affecting up to 75% of women with
regular menstrual cycles

• PMDD affects 3–8% of women

• Estimates should be interpreted with caution

– Problem of definition: mild and brief symptoms are frequent
premenstrually, and it is difficult to decide when they should be
classified as PMS
– Information about symptoms is often collected retrospectively by
asking women to recall earlier menstrual periods, and this is an
unreliable way of establishing the time relationships
– The description of PMS symptoms is subjective and may be
influenced by knowledge that the enquiry is concerned specifically
with the PMS
 PMS and PMDD: Aetiology
• Uncertain

• Biological explanations have been based on

ovarian hormones (excess oestrogen, lack of
progesterone), pituitary hormones, and disturbed
fluid and electrolyte balance
– None of these theories has been proved

• Various unproven psychological explanations

have been based on possible associations of the
syndrome with neuroticism or with attitudes
towards menstruation
PMS
 PMS and PMDD: Symptoms
Fatigue, bloating, irritability, Difficulty concentrating
depression, and anxiety
(commonest symptoms) Fatigue, lethargy, or lack of energy
Sadness, hopelessness, or feelings Changes in appetite, which may
of worthlessness include binge eating or craving
certain foods
Tension, anxiety, or "edginess“
Excessive sleeping or difficulty
Variable moods with frequent sleeping
tearfulness
Feelings of being overwhelmed or
Persistent irritability, anger, and out of control
conflict with family, coworkers, or
friends Breast tenderness or swelling,
headaches, joint or muscle pain,
Decreased interest in usual weight gain
activities
 PMS Treatment
PMS has been treated with
progesterone, and also with oral
contraceptives, bromocriptine,
diuretics, and psychotropic drugs
• There is no convincing evidence that any of
these is effective, and treatment trials suggest
a high placebo response

Psychological support and

encouragement may be as
helpful as medication
PMDD Treatment

For PMDD, SSRIs and oral

contraceptives are considered
the treatment of choice, with
the latter primarily improving
the physical symptoms

Cognitive behaviour therapy

and lifestyle modifications
also have a role
 Resources
• Harrison P, Cowen P, Burns T, Fazel M. Shorter
Oxford Textbook of Psychiatry. 7th ed. Oxford
University Press; 2018.

• Casper RF. Patient education: Premenstrual

syndrome (PMS) and premenstrual dysphoric
disorder (PMDD) (Beyond the Basics).
https://www.uptodate.com/contents/premen
strual-syndrome-pms-and-premenstrual-
dysphoric-disorder-pmdd-beyond-the-basics