Postpartum Blues

This condition is also known as “baby blues”

Characteristics of PPD Insomnia Tearfulness Crying spells Irritability Anxiety Decreased concentration Mood Swings

Postpartum Blues

Onset of symptoms 2-3 day post delivery

Peak around the 5th after delivery Resolve within 2 weeks

Postpartum Depression

Onset of symptoms within first 12 month after delivery

Often regarded as normal symptoms for a new mother or a mother caring for a baby.

Same DSM criteria as for non-pregnancy related depression

Postpartum Psychosis

AKA Puerperal Psychosis Characteristics:

Depression Delusions Thoughts of self harm (suicide) Thoughts of harming the infant

(infanticide)

Postpartum Psychosis

Incidence: 1 to 2 per 1000 childbirths 50% to 60% of cases- first child 50% of cases- family history of mood

disorders

Postpartum Psychosis

Symptoms Onset within days of delivery but normally 2

to 3 weeks Severe insomnia

Rapid mood swings

Anxiety

Psychomotor restlessness

Delusions and hallucinations

Pharmacologic Therapy PPD No antidepressants are approved by

the FDA for use during pregnancy

All psychotropic drugs are transferred through the placenta and breast milk

Consider prior history

SSRIs and TCAs have low detection in breastfed infant serum

Concerns for Psychotropic Use Risk of pregnancy loss or miscarriage Risk of organ malformation or

teratogenesis Risk of neonatal toxicity or

withdrawal syndromes Risk of longterm neurobehavioral

sequelae

Neonatal Withdrawal – TCAs TCA withdrawal syndrome:

Jitteriness Irritability Seizures

Anticholinergic effect of TCAs include: Functional bowel obstruction urinary retention

Neonatal Withdrawal - SSRIs Transient symptoms of:

Irritability Excessive crying Increased muscle tone Feeding problems Sleep disruption Respiratory distress

Pharmacologic Therapy

Increase risk of suicide after initiation of medication

If significant anxiety or insomnia present, consider adding benzodiazepine

Close follow-up

Antidepressant Choice

TCAs Desipramine and Nortryptiline are

preferred Least anti-cholinergic affects Minimize postural hypotension

SSRIs Fluoxetine is the best studied

Additional Considerations Doses of both SSRIs and TCAs may

need to be increased in pregnancy secondary to: Increased plasma volume Increased hepatic metabolism Increased renal clearance

Other Therapies

Hormonal Therapy Increased risk of PPD if Depo-provera

given within 48 hrs of delivery Transdermal estradiol may improve

symptoms Treat severe anemia Treat poorly controlled

hypothyroidism

Other Therapies (cont)

ECT Few adverse effects to mom or infant

Good when rapid treatment is needed

For severe depression with psychotic symptoms or acute mania

Length of Treatment

Based on patient history and severity of symptoms

Continue 12 months after full remission

Continue meds through pregnancy to reduce risk of relapse

Treatment of Postpartum Psychosis Consider it a medical emergency Patient should be hospitalized until

stable Mother is unable to care for herself

or the infant during the psychosis phase

Treatment of PPP (cont)

Medications focused on controlling both psychosis and mood swings

Combination therapy often necessary

Most will not be able to continue breastfeeding

ECT may be highly effective

Prevention

Monitor for signs in high risk women

Educate women and family members before childbirth

Counseling and increase social support prior to delivery

Consider starting therapy during third trimester or immediately after delivery