Puerperal Psychosis

Clinical Description

• A disorder affecting the mother, which can develop within 6 weeks of childbirth
• It can be particularly florid with vivid hallucinations, delusions, marked agitation and aggression
• Care must be taken, as there can be significant risk to both mother and baby

Signs and Symptoms

• Confusion
• Insomnia
• Anxiety
• Agitation
• Possible aggression
• Mood changes
• • Hallucinations (in any modality) and delusions (particularly paranoid persecutory)

Investigations

• The puerperium is a time of increased risk of many physical conditions such as sepsis, post- partum hemorrhage, metabolic imbalance, eclampsia etc.
• These conditions can present with delirium and so care must be taken to exclude underlying physical causes
• Full physical examination including vital signs
• FBC U&E LFT
• Blood/ urine glucose
• MRDT
• PITC

Treatment

• The aim of treatment is to reduce/ alleviate symptoms to allow a return to usual functioning and to promote good bonding between mother and baby
• Medication treatment duration is for at least 1 year
• First assess the risk of the mother to herself and her baby (some may have thoughts of harming their baby due to the psychotic symptoms) and the risk of aggressive behaviour
• If present follow Violence and Aggression Treatment Guideline. Ensure that the baby is in the care of a guardian and that all mother baby interactions are supervised until more stable
• Care should be taken in breastfeeding mothers as medication can be found in the breastmilk. Use low doses and increase slowly. Monitor the baby for evidence of sedation

Primary treatment

Give Risperidone 1mg 24 hourly. The medication should preferably be taken after breast feeding or after breast milk has been expressed to minimize amount ingested by baby.

Increase by 1mg weekly/two weekly depending on side effects and response to a maximum of 6mg once daily.

• If Olanzapine is available, use as primary treatment. Take baseline fasting blood sugar, weight and triglycerides before start. Prescribe 5mg once daily, increase to maximum of 10mg once daily. Monitor weight, random blood sugar, triglycerides monthly while on use.
• If Risperidone or Olanzapine not available, Chlorpromazine 100-200mg or Haloperidol 2.5-5mg may be used.
• Avoid use of diazepam. If necessary, use promethazine 25-50 mg or lorazepam 1-2 mg if agitated

Red Flags

For referral

• If symptoms persist or worsen, despite adequate doses of anti-psychotic for 6- 8 weeks
• If there is evidence that the baby is failing to thrive (dehydration, weight loss, inadequate care etc.)

For admission

• Marked agitation / aggression should be managed as an inpatient following the Violence and Aggression treatment guidelines
• Evidence that the patient is a risk to themselves (self-harm/ neglect/ vulnerable to exploitation) or risk to the infant, other children or others (agitation/ aggression)
• Screen for suicidal ideas and harmful thoughts toward infant at each follow-up as risk of suicide and infanticide remains high in first year after recovery.
• Ask about any drug or alcohol use and give appropriate advice.
• Once symptoms are improving advise the patient to return to their usual daily activities, including work if employed

Treatment duration

• If first episode: Medication is continued for 1 year from complete resolution of

Signs and Symptoms

• If previous episodes of psychotic illness (e.g., schizophrenia/ Bipolar affective disorder) continue medication for 2-5 years from complete resolution of symptoms
• When considering stopping medication, discuss carefully with the patient and guardian and start to reduce slowly over 4-8 weeks
• Advise about symptoms that would indicate relapse (difficulty sleeping, auditory hallucination, suspicious thoughts) and inform to return to the clinic promptly
• Continue to monitor until medication free for 2-3 months before discharging
• Advise them to return to the clinic for review if have any concerns in the future or when pregnant again (high risk of recurrence in future pregnancies)