postpartum psychosisi journal club april 2012

7/31/2019 Postpartum Psychosisi Journal Club April 2012

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Dr. Mahir JalloGMCHRC

POSTPARTUMPSYCHOSIS

IS MORE PREVALENT INWOMEN WITH

AUTOIMMUNE THYROID

DISEASE

ClinicalThyroidology

Jan 2012Vol 24 Issue

11

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Postpartum psychosis is a life-threatening psychiatric emergency.. that occurs in 0.1% ofpostpartum women.. often without significant premorbid symptoms.

Clinical symptoms:Fluctuations in moodDelusions

HallucinationsAgitationInsomniaCognitive impairment

Thoughts of suicide and infanticide (hospital admission)

Women with bipolar affective disorder are at high risk. Up to 50% of those with bipolardisorder relapse in the early postpartum period often with psychotic symptoms.

Most patients with a postpartum psychosis have no previous history of psychiatric disorder.

BACKGROUND

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Many studies have postulated an involvement of the immune and endocrinesystems in the onset of postpartum psychosis.. but the specific etiologic factorshave remained unknown.

The aim of this study was to examine the hypothesis that autoimmune thyroiddysfunction may be associated with the onset of post partum psychosis

BACKGROU

ND

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Between Aug 2005 and Nov 2008.. the authors examined all patientsreferred to the mother and baby inpatient unit of the department ofpsychiatry at the Erasmus Medical Centre for evidence of PP using theStructural Clinical Interview DSM-4 Structured Clinical Interview (SCID) .

Of the 123 patients examined.. 55 fulfilled the criteria for postpartumpsychosis.

Those with previous psychiatric history or multiparity were excluded fromthe study.

31 consecutive primiparous women with no previous psychiatric historywere selected for the study.

23 presented with manic psychosis.. 5 had a mixed episode.. and 3presented with psychotic depression.

METHODS

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Selection of the control group (n=117) was based on primiparity.. regardless ofmedical or psychiatric history .. they were followed during pregnancy and thefirst year after delivery to determine the incidence of postpartum thyroid functionand postpartum depression.

Blood samples were obtained from all participants at 4 weeks and 9 monthspostpartum.

Patients with postpartum psychosis had blood samples taken at various timesover the 9 month study period.. as clinically indicated.

Thyroperoxidase antibody levels.. Thyrotropin.. and free thyroxine levels weremeasured to assess clinical thyroid disease

METHODS

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No difference was found in the frequency of cesarean section.. rate ofprimigravidity.. birth weight of the child.. or incidence of preterm birth b/w casesand controls.

None of the patients or controls had a history of thyroid or autoimmune disease

At 4 wks postpartum.. 5% of the control group had autoimmune thyroid disease(AITD).. with no cases of clinical thyroid dysfunction.

In contrast.. 6 of 31 (19%) of the patients with post partum psychosis metcriteria for AITD on admission to the hospital.. before the start of antipsychoticor lithium pharmacotherapy OR 4.44 95 %CI 1.32 to 14.92

Half of them also demonstrated clinical thyroid dysfunction at the timeadmission to the hospital.

The 9 month prevalence of AITD was significantly higher in women withpostpartum psychosis.. 9 of 31(29%) versus 15 of 117 controls(13%) OR 2.7895% CI 1.08 to 7.17

RESULTS

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Patients with PP showed a significantly higher rate of progression fromsubclinical AITD to clinical thyroid dysfunction P = 0.017

Specifically, of the 9 patients with AITD at the 9 month follow-up .. 6(67%) hadovert thyroid dysfunction as compared with only 20% of the control group OR

8.0 95% CI 1.23 to 52.25

The 3 patients in whom AITD and clinical thyroid dysfunction developed duringRx with mood stabilizers were all taking lithium.

In contrast.. none of the 18 lithium- treated patients without AITD had clinicalthyroid dysfunction.

RESULTS

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Women with postpartum psychosis are at higher risk of AITD but also of clinicalthyroid failure.

These data implicate thyroid dysfunction as an important clinical outcome inpatients with postpartum psychosis.

AITD represents a potentially strong etiologic factor for the development ofpostpartum psychosis.

Screening for TPO antibodies is warranted in patients with postpartum psychosis.

CONCLUSIONS

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Postpartum AITD defined as the presence of thyroid peroxidase) TPO)antibodies in the first year after delivery .. is reported in 5-7% of thepopulation

Postpartum thyroid dysfunction is characterized by 3 well defined clinicalpatterns.. all of them self limited in the vast majority of cases:

1. An initial phase of hyperthyroidism in the first 3 months postpartumfollowed by a euthyroid phase.

2. An initial hyperthyroid phase.. followed b/w 3-6 months postpartum by ahypothyroid phase with spontaneous resolution.

3. An initial hypothyroid phase b/w 3-6mnths after delivery followed byeuthyroidism.

In less than 5% of patients .. hypothyroidism may be permanent.

ANALYSIS AND COMPLIMENTARY

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It is important to follow up patients because permanent hypothyroidism occurredin 30-50% by 5 yr after the initial episode.

A pattern similar to women in whom type 2 D.M. developed following thediagnosis of gestational D.M.

The link b/w PP and chronic thyroiditis has been reported in the past.. although noevidence for an increase of AITD in patients with a late onset (>4wk afterdelivery) presentation of PP was found in the only previous systematic study.

In the present study.. a careful evaluation of women ( primigravida with no

previous psychiatric history) in whom serious signs of psychosis.. requiringantipsychotic Rx.. developed early in the postpartum period.. showed not only asignificant presence of thyroid autoimmune disease but also thyroid dysfunctionwithin 9 months postpartum.


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Only 3 of 31 patients presented with psychotic depression.. the others with manicpsychosis.. requiring multiple drug therapy.. including lithium.

The authors emphasized that of the lithium-treated women, thyroid dysfunctiondeveloped only in those with positive TPO antibodies.

The other imp observation is the higher rate of development of thyroiddysfunction in women with psychosis.. as compared to controls with AITD.

No information is given about the course of thyroid dysfunction at 9 monthspostpartum.

It would be of interest to know how many women had a spontaneous return to theeuthyroid state as commonly occurs in women with postpartum thyroiddysfunction .


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This is the first observational study of primiparous women with AITD and noprevious psychiatric history.. showing a high prevalence of first-onset PP ascompared with the general population

Therefore it is reasonable to consider a previous postpartum psychosis event..

including depression.. as an indication for thyroid screening in futurepregnancies of such affected women.

Whether early identification and Rx of thyroid autoimmune disease wouldchange the course of the disease deserves further study.


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THANKYOU

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postpartum psychosisi journal club april 2012

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