ObstetricsTier 2Disease (DEADMAN)

Psychiatric complications, such as postpartum depression and psychosis

Description

Spectrum: "baby blues" (transient, self-limited, days 3-5 postpartum, up to 80% of women) -> postpartum depression (persistent, functionally impairing, onset within 12 months) -> postpartum psychosis (rare, acute-onset, typically within 2 weeks postpartum)

Postpartum depression: ~10-15% of women; postpartum psychosis: ~1-2 per 1,000 births - much rarer but a psychiatric emergency

Multifactorial - abrupt postpartum oestrogen/progesterone withdrawal, sleep deprivation, psychosocial stressors; prior psychiatric history is the strongest risk factor for both
Postpartum psychosis is strongly associated with bipolar disorder - a first episode may unmask previously unrecognised bipolar illness

Depression: screen with the Edinburgh Postnatal Depression Scale (EPDS) - score >=13 suggests likely depression; always screen for suicidal/infanticidal ideation
Psychosis: acute onset of mood lability, disorganised behaviour, delusions (often relating to the infant), hallucinations, confusion - rapid deterioration over hours to days

Depression: psychotherapy first-line for mild-moderate; SSRIs (sertraline preferred, well-studied in breastfeeding) for moderate-severe
Psychosis: a psychiatric emergency - admission (ideally a mother-baby unit), antipsychotics +/- mood stabiliser; safety assessment for mother and infant is paramount
Prior severe postpartum illness -> prophylactic planning for future pregnancies (early psychiatric involvement, consider prophylactic medication postpartum)

Postpartum psychosis - bipolar disorder, primiparity, family history
Postpartum depression - antenatal depression/anxiety, poor social support, intimate partner violence

Untreated postpartum depression can persist and impair mother-infant bonding and child development
Postpartum psychosis carries significant risk of suicide and, rarely, infanticide - urgent admission is not optional; most recover fully with treatment, but recurrence risk in future pregnancies is high (~50%)

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