Puerperium, Puerperal Psychological - PowerPoint Presentation

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Puerperium,Puerperal Psychological Aspects

Dr. A.M.ABDULMALEK MB.BCH,DGO,JBOG,FICS,FRCOG.Senior consultant OB&GYN /Head of Dept. Specialty hospital , Amman

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PuerperiumIt is the time from the delivery of the placenta through the first 6weeks

after the delivery. By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery have resolved and the body has reverted to the nonpregnant state.2

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Normal Puerperium

UterusThe pregnant term uterus (not including baby, placenta, fluids) weighs approximately 1000 g. After 6 weeks, the uterus recedes to a weight of 50-100 g.Immediately postpartum, the uterine fundus is palpable at or near the level of the maternal umbilicus. Most of the reduction in size and weight occurs in the first 2 weeks,

return

to the true

pelvis.

Over

the next several weeks, the uterus slowly returns to its

nonpregnant state, although the overall uterine size remains larger than prior to gestation.

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The endometrial lining: rapidly regenerates. By the 16th day, the endometrium is restored throughout the uterus, except at the placental site.The placental

site: Immediately after delivery, the contractions of the arterial smooth muscle and compression of the vessels by contraction of the myometrium result in hemostasis. The size of the placental bed decreases by half, and the changes in the placental bed result in the quantity and quality of the lochia that is experienced.4

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Immediately after delivery, a large amount of red blood flows from the uterus until the contraction phase occurs. lochia rubra :

the volume of vaginal discharge rapidly decreases.lochia serosa: The red discharge progressively changes to brownish red, with a more watery consistency lochia alba: the discharge continues to decrease in amount and color and eventually changes to yellow.

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CervixRapidly revert to a nonpregnant state, but it never returns to the nulliparous state. End

of the first week, the external os closes ,a finger cannot be easily introduced.VaginaRegresses but it does not completely return to its prepregnant size. Resolution of the increased vascularity and edema occurs by 3 weeks,

it

is further delayed in breastfeeding mothers because of persistently decreased estrogen levels.

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PerineumThe swollen and engorged vulva rapidly resolves within 1-2 weeks.Most of the muscle tone is regained by 6 weeks.

The muscle tone may or may not return to normal, depending on the extent of injury to muscle, nerve, and connecting tissues.Abdominal wallThe abdominal wall remains soft and poorly toned for many weeks. The return to a prepregnant state depends on maternal exercise.

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OvariesThe resumption of normal function by the ovaries is highly variable and is greatly influenced by breastfeeding. The mother who does not breastfeed may ovulate as early as 27 days after delivery

.Most women have a menstrual period by 12 weeks; the mean time to first menses is 7-9 weeks.The delay in the return to normal ovarian function in the lactating mother is caused by the suppression of ovulation due to the elevation in prolactin.50 to 75 % of women who breastfeed return to periods within 36 weeks of delivery.

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BreastsLactogenesis, development of the ability to secrete milk, occurs as early as 16 weeks gestation under

effect of circulating progesterone from placenta After delivery of the placenta, there is a rapid decline in progesterone which triggers the onset of milk production and subsequent swelling, or engorgement, of breasts in the postpartum period.The colostrum is the liquid that is initially released by the breasts during the first 2-4 days after delivery. An

autocrine

process; the removal of milk from the breast stimulates more milk production.

Oxytocin

release after tactile stimulation of the nipple-areolar complex causes

myoepithelial

cells of the breasts to contract, which forces milk into the alveolar lumens and then into the ducts.

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Routine Postpartum CareThe immediate postpartum period

occurs in the hospital setting.Women remain 2 days after a vaginal delivery and 3-4 days after a cesarean delivery.Women are recovering from their delivery and are beginning to care for the newborn. The mother is monitored for blood loss, signs of infection, abnormal blood pressure, contraction of the uterus, and ability to void. There is also attention to Rh compatibility, maternal immunization statuses and breastfeeding.

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Vaginal deliveryswelling of the perineum and consequent pain. Routine care of this area includes ice applied to the perineum to reduce the swelling and to help with pain relief.

Pain medications are helpful both systemically as nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotics and as local anesthetic spray to the perineum.Hemorrhoids: Symptomatic relief is the best treatment during this immediate postpartum periodTampon use can be resumed when the patient is comfortable.

Cesarean delivery

post-op

pain at the abdominal incision.

can

be treated with heat or ice to the incision site, abdominal binder support, and use of systemic pain medication.

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Sexual intercourseWhen bright red bleeding ceases, the vagina and vulva are healed, and the woman is physically comfortable and emotionally ready.

Patient educationThe mother (and often the father) is taught routine care of the baby, including feeding, diapering, and bathing, as well as what can be expected from the baby in terms of sleep, urination, bowel movements, and eating.Providing education, support, and guidance to the breastfeeding mother is especially important during this time. The Baby-Friendly Hospital Initiation (BFHI) that aims to increase the numbers of infants who are exclusively breastfed worldwide. In women who choose not to breastfeed, Care

should be taken not to stimulate the breasts in any way in order to prevent milk production. Ice packs applied to the breasts and the use of a tight brassiere or a binder can also help to prevent breast engorgement.

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Discharge instructionsWho and where to call if she has problems or questions?Resuming her normal

activity.A vaginal delivery may resume all physical activity, as long as she experiences no limiting pain or discomfortA cesarean delivery must be more careful about resuming some of her activities in the postoperative period. She must avoid overuse of her abdomen until her incision is well healed in order to prevent an early surgical complications.A routine comprehensive postpartum evaluation. Unfortunately, there is a poor attendance rate

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Contraception options:Should be discussed before the mother leaves the hospital. Many options are available, as follows:

Natural methods can be used in highly motivated couples, Barrier methods: such as condoms, vaginal spermicides, diaphragms and cervical caps.

Hormonal

methods:

Combined

estrogen-progestin agents are taken daily by mouth or monthly by injection. Progestin-only agents are available for daily intake or by long-acting injections that are effective for 12 weeks

.

Intrauterine

devices:

can be placed immediately post partum (after delivery of the placenta) or after uterine involution occurs typically 4-6 weeks after delivery.

Permanent methods

of birth control (

ie

, tubal ligation, vasectomy) are options for those who are certain they do not desire more children.

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Abnormal PuerperiumHemorrhage Perineal Lacerations

Infections Endocrine Disorders Psychiatric Disorders15

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1-HemorrhagePostpartum

hemorrhage is defined as excessive blood loss during or after the third stage of labor. The average blood loss is 500 mL at vaginal delivery and 1000 mL at cesarean delivery. Objectively, postpartum hemorrhage is defined as a 10% change in hematocrit level between admission and the postpartum period or the need for transfusion after delivery secondary to blood loss. Early postpartum hemorrhage is described as that occurring within the first 24 hours after delivery. Late postpartum hemorrhage most frequently occurs 1-2 weeks after delivery but may occur up to 6 weeks postpartum.16

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EtiologyEarly : uterine atony, retained products of conception, uterine rupture, uterine inversion, placenta

accreta, lower genital tract lacerations, coagulopathy, and hematoma.late : retained products of conception, infection, subinvolution of placental site, and coagulopathy.Active management of the third stage of labor

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IncidenceVaginal delivery is associated with a 3.9% incidence of postpartum hemorrhage. Cesarean delivery is associated with a 6.4% . Delayed postpartum hemorrhage occurs in 1-2% of patients.

Morbidity and mortalityIn the United States, postpartum hemorrhage is responsible for 5% of maternal deaths. 18

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2- Perineal Lacerations Lacerations are a common sequelae of vaginal childbirth due to strain on the perineum and pelvic floor muscles,

53-79% of women sustaining some type of laceration during a vaginal delivery. Perineal lacerations are distinct from an episiotomy which is a purposeful surgical incision.An epidemiologic study in 2012 reported approximately 12% of vaginal births included an episiotomy.

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Perineal tears are classified into four categories :First degree lacerations

:injury to the skin and subcutaneous perineal tissue or vaginal epithelium only. Second degree lacerations : musculature of the

perineal

body, including the deep and superficial transverse

perineal

muscles, the

bulbocavernosus

muscle, and the pubococcygeus muscle. Obstetric

anal sphincter injuries (OASIS),

third

and fourth degree

perineal

lacerations

Third

degree lacerations

:

involve

the anal sphincter. T

hree subdivisions:

3A

tear.

less than 50% of the external anal sphincter is

torn.

3b

tear,

greater than 50% of the external anal sphincter is torn

.

3c

tear

includes complete rupture of the external anal sphincter as well as involvement of the internal anal sphincter

.

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Fourth degree laceration : is an injury involving the entire anal sphincter complex as well as the anal epithelium.

Approximately 4% of women have a clinically recognized OASIS immediately after time of vaginal delivery. Other tears after childbirth include periclitoral

,

periurethral

, and labial lacerations;

these should only be repaired to achieve hemostasis or to correct distorted anatomy. Additionally, lacerations to the

vulva, vagina, and cervix

also occur and should be repaired based on clinical assessment of bleeding or distorted anatomy.

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In individuals with a severe perineal laceration, the absolute risk of OASIS in a subsequent pregnancy is approximately 3%. Moreover,

67-90% of women with a previous OASIS have a subsequent vaginal delivery. Offer a cesarean delivery in those who sustained an OASIS in the following circumstances:women with anal incontinence after delivery.

women

who had further complications including wound infection or need for repeat laceration

repair.

women

who experienced psychological trauma due to significant laceration tear at time of delivery.

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3- InfectionsPrevention

Delivery by cesarean section is the single most important risk factor for postpartum maternal infection. In the absence of antimicrobial prophylaxis, women who have a cesarean delivery have a five to 20-fold greater chance of a postpartum infection compared to those who delivery vaginally. Individuals with a severe allergy to penicillin or cephalosporin a combination of clindamycin (900mg) with an aminoglycoside (ie gentamicin 5mg/kg IV) is recommended

.

The

prophylactic agent should be administered within

60 minutes prior to skin incision

to ensure adequate drug tissue levels; in emergent cases when this is not possible antibiotic administration should occur as soon as possible after the start of the cesarean delivery.

Compared

to

multidose

therapy, single-dose antibiotic administration is preferred because it just as effective with a reduction in costs, associated toxicity and risk of colonization with resistant organisms.

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A- Endometritis

EtiologyEndometritis is the primary cause of postpartum infection. The most common organisms are divided into 4 groups: aerobic gram-negative bacilli, anaerobic gram-negative bacilli, aerobic streptococci, and anaerobic gram-positive cocci. Specifically, Escherichia coli, Klebsiella pneumoniae, and Proteus species are the most frequently identified organisms.

Risk factors:

cesarean

delivery

,

young

age, low socioeconomic status,

prolonged

labor,

prolonged

rupture of membranes

,

multiple

vaginal examinations,

placement

of an intrauterine catheter,

preexisting

infection or colonization of the lower genital tract,

twin

delivery,

manual

removal of the placenta.

Even at

cesarean delivery

.

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IncidenceComplicates less than 3% of all vaginal deliveries.Cesarean delivery is the most important risk factor for development of postpartum

endometritis particularly when performed after the onset of labor and without antibiotic prophylaxis. The frequency in those who receive standard antibiotic prophylaxis prior a cesarean section delivery in the absence of labor is 1.7%. Increases to

11%

in patients have a cesarean delivery after the onset of

labor

Increases

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% in those who do not receive antibiotic prophylaxis after the onset of labor .

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Morbidity and mortality90% of women clinically improve after 48-72 hs. of IV antibiotics

Fewer than 2% of patients develop life-threatening complications such as septic shock, pelvic abscess, or septic pelvic thrombophlebitis. Symptomsfever, chills, lower abdominal pain, malodorous lochia, increased vaginal bleeding, anorexia, and malaise.Signs

fever

of 38°C or greater, tachycardia, and fundal tenderness. Some patients may develop

mucopurulent

vaginal

discharge

.

Differential

diagnosis

Urinary

tract

infection

Acute

pyelonephritis

Lower genital tract

infection

Wound

infection

Atelectasis

Pneumonia

Thrombophlebitis

Mastitis

Appendicitis

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WorkupCBC count with differential, urinalysis, urine culture,

blood cultures.Imaging: chest radiograph.TreatmentParenteral antibioticsBroad spectrum coverage with a combination of clindamycin and gentamicin is a commonly used and highly effective regimen for the treatment of

endometritis

with a cure rate of greater than 90%.

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B-Urinary Tract Infections

A urinary tract infection (UTI) is defined as a bacterial inflammation of the bladder or urethra. EtiologyRisk factors for postpartum UTI include cesarean delivery, forceps delivery, vacuum delivery, tocolysis, induction of labor, maternal renal disease, preeclampsia, eclampsia, epidural anesthesia, bladder catheterization, length of hospital stay, and previous UTI during pregnancy. The most common pathogen is E coli.

In

pregnancy, group B streptococci are a major pathogen.

Incidence

Postpartum

bacteruria

occurs in 3-34% of patients, resulting in a symptomatic infection in approximately 2% of these patients.

.

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SymptomsFrequency, urgency, dysuria, hematuria, suprapubic or lower abdominal pain, or no symptoms at all.

signsAfebrile. Suprapubic tenderness. Differential diagnosis

Acute

cystitis

Acute

pyelonephritis

Workup

Urinalysis, urine culture from either a clean-catch or catheterized specimen,

CBC

count.

Treatment

Treatment is started empirically in uncomplicated infection

Sensitivities

are available, use them to guide antimicrobial selection. Treatment is with a 3- or 7-day

regimen

.

Amoxicillin

is often still used, trimethoprim/

sulfamethoxazole

The

quinolones are very effective but

should

not be used in breastfeeding mothers.

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C-MastitisMastitis is defined as inflammation of the mammary gland.

EtiologyMilk stasis and cracked nipples, Mastitis is also associated with primiparity, Staphylococcus aureus.

Staphylococcus

epidermidis

, S

saprophyticus

, Streptococcus

viridans, and E coli.

Incidence

In the United States, the incidence of postpartum mastitis is 2.5-3

%.

Mastitis

typically develops during the first 3 months postpartum, with the highest incidence in the first few

weeks

Morbidity and mortality

abscess

, requiring parenteral antibiotics and surgical drainage.

Abscess development

complicates 5-11% of the cases of postpartum mastitis and should be suspected when antibiotic therapy fails

.

Symptoms

Fever, chills,

myalgias

, erythema, warmth, swelling, and breast

tenderness

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Signsarea of the breast that is warm, red, and tender. a tender, hard, possibly fluctuant mass with overlying erythema, a breast abscess should be considered

.Differential diagnosisMastitisBreast abscessCellulitisWorkup

Expressed

milk can be sent for analysis,

Treatment

moist

heat, massage, fluids, rest, proper positioning of the infant during nursing, nursing or manual expression of milk, and analgesics

.

When mastitis develops,

penicillinase

-resistant

penicillins

and

cephalosporins

, such as

dicloxacillin

or cephalexin, are the drugs of choice.

Resolution

usually occurs 48 hours after the onset of antimicrobial therapy. Lactation efforts should continue and the milk is still safe for newborn ingestion.

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D-Wound Infection

Infections of the perineum at the site of episiotomy or laceration, Infection of the abdominal incision after a cesarean birth.Wound infections are diagnosed on the basis of erythema, induration, warmth, tenderness, and purulent drainage from the incision site, with or without fever.

Etiology

Perineal infections:

rare

.

on

the third or fourth postpartum day. Known

risk factors include infected lochia, fecal contamination of the wound, and poor hygiene.

Abdominal wound infections

:

most

frequently the result of contamination with vaginal flora.

risk

factors

: diabetes

, hypertension, obesity, treatment with corticosteroids, immunosuppression, anemia, development of a hematoma,

chorioamnionitis

, prolonged labor, prolonged rupture of membranes, prolonged operating time, abdominal twin delivery, and excessive blood loss.

Incidence

The incidence of

perineal

infections is

0.35-10%.

Abdominal

wound infections is

3-15%

and can be decreased to approximately 2% with the use of prophylactic antibiotics.

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Morbidity and mortalityincreased length of hospital stay or hospital readmission. About 7% wound

dehiscence. More serious sequelae, such as necrotizing fasciitis, are rare, but patients with such conditions have a high mortality rate.Symptomspain, malodorous discharge, or vulvar edema.Abdominal wound infections develop around postoperative day 4 and are often preceded by

endometritis

. These patients present with persistent fever despite antibiotic treatment.

Signs

Perineal infections:

looks

erythematous and edematous and may be accompanied by purulent discharge.

Abdominal wound infections:

erythematous

, warm, tender, and indurated. Purulent drainage may or may not be obvious. A fluid collection may be appreciated near the wound, which, when entered, may release

serosanguineous

or purulent fluid.

Workup

Serial

CBC counts with differentials may be helpful,

CT

imaging of the abdomen may be indicated if an abscess is suspected after a cesarean delivery.

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TreatmentPerineal infections: symptomatic relief with NSAIDs, local anesthetic spray, and

sitz baths.Identified abscesses must be drained, Broad-spectrum antibiotics may be initiated.Abdominal wound infections: Antibiotics drainage and inspection of the fascia to ensure that it is intact.

Antibiotics may be used if the patient is afebrile.

Patients

do not require long-term antibiotics unless cellulitis has developed. Studies have shown that closed suction drainage or suturing of the subcutaneous fat decreases the incidence of wound infection when the subcutaneous tissue is greater than 2 cm in depth.

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E-Septic Pelvic Thrombophlebitis

Septic pelvic thrombophlebitis is defined as venous inflammation in the abdomen/pelvis with thrombus formation. It is associated with fevers and is unresponsive to antibiotic therapy.EtiologyBacterial infection of the endometrium seeds organisms into the venous circulation, which damages the vascular endothelium and in turn results in thrombus formation. The thrombus acts as a suitable medium for proliferation of anaerobic bacteria. Ovarian

veins are often involved because they drain the upper half of the uterus. When the ovarian veins are involved, the infection is most often unilateral, involving the right more frequently than the left.

Occasionally

, the thrombus has been noted to extend to the vena cava or to the left renal vein. Ovarian vein involvement usually manifests within a few days postpartum. Disease with later onset more commonly involves the

iliofemoral

vein.

Risk factors include low socioeconomic status, cesarean birth, prolonged rupture of membranes, and excessive blood loss.

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Incidence1 of every 2000-3000 pregnancies and is 10 times more common after cesarean birth (1 per 800) than after vaginal delivery (1 per 9000). Morbidity and mortality

Migration of small septic thrombi into the pulmonary circulation, resulting in effusions, infections, and abscesses. Only rarely is a thrombus large enough to cause death.SymptomsEndometritis.

Patients

with ovarian vein thrombosis may describe lower abdominal pain, with or without radiation to the flank, groin, or upper abdomen

.

N

ausea

, vomiting, and bloating, chills.

Signs

F

ever

greater than 38°C and resting tachycardia.

If

pulmonary involvement is significant, the patient may be

tachypneic

and

stridulous

.

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50-70% of patients with ovarian vein thrombosis have a tender, palpable, ropelike mass extending cephalad beyond the uterine cornu.

Differential diagnosisOvarian vein syndromePyelonephritisAppendicitisBroad ligament hematomaAdnexal

torsion

Pelvic

abscess

Enigmatic

fever

Drug feverViral syndrome

Collagen vascular

disease

Pelvic abscess

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Workupurinalysis, urine culture, and CBC count with differential.Imaging: CT scan and MRI are the studies of choice for the diagnosis of septic pelvic thrombophlebitis.

TreatmentAnticoagulation with intravenous heparin to an aPTT that is twice normal and continued antibiotic therapy. long-term anticoagulation is not required. Antibiotic therapy is most commonly with gentamicin and clindamycin. Other choices include a second- or third-generation cephalosporin,

imipenem

,

cilastin

, or ampicillin and

sulbactam

. All of these antibiotics have a cure rate of greater than 90%. Initially,

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4- Endocrine Disorders

Postpartum ThyroiditisPPT is a transient destructive lymphocytic thyroiditis occurring within the first year after delivery.EtiologyPPT develops 1-8 months postpartum and is an autoimmune disorder in which microsomal antibodies of the thyroid play a central role. PPT has 2 phases: thyrotoxicosis and hypothyroidism.Thyrotoxicosis occurs 1-4 months postpartum and is always self-limited. The condition is caused by the increase release of stored hormone as a result of disruption of the thyroid gland.

Hypothyroidism arises between the fourth and eighth month postpartum.

Risk

factors: a

positive

antithyroid

antibody test finding, history of PPT, and family or personal history of other thyroid or autoimmune disorders.

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Incidence4% of women develop transient thyrotoxicosis in the postpartum period. 66-90% return to a euthyroid

state; 33% progress to hypothyroid.Approximately 2-8% of women develop hypothyroidism in the postpartum period. Morbidity and mortalityHaving developed PPT, these women are at significant risk for recurrent disease after subsequent pregnancies.

History

thyrotoxicosis

may report fatigue, palpitations, heat intolerance, tremulousness, nervousness, and emotional

lability

.

Patients in the hypothyroid phase often complain of fatigue, dry skin, coarse hair, cold intolerance, depression, and memory and concentration impairment.

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Symptomstachycardia, mild exophthalmos, and a painless goiter.

Workupthyroid-stimulating hormone (TSH) test. If the TSH level is abnormal, check thyroid stimulating antibodies, free thyroxine index (FTI), and radioactive iodine uptake (RIU)TreatmentNo treatment is available to prevent PPT.

Thyrotoxicosis phase: No treatment is required for the thyrotoxicosis phase unless the patient's symptoms are severe. In this case, a beta-blocker is useful.

Hypothyroid phase: Since the hypothyroid phase of PPT is often transient, no treatment is required unless necessitated by the patient's symptoms. Treatment is with

thyroxine

(T4)

replacement

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Postpartum Graves DiseasePostpartum Graves disease is not common, 15% of postpartum thyrotoxicosis.Is an autoimmune disorder characterized by diffuse hyperplasia of the thyroid gland caused by the production of antibodies to the thyroid TSH receptor, resulting in increased thyroid hormone production and release.

Lymphocytic HypophysitisLymphocytic hypophysitis is a rare autoimmune disorder causing pituitary enlargement and hypopituitarism, leading to a decrease in TSH and to hypothyroidism.

Symptoms

include headache, visual field deficits, difficulty lactating, and amenorrhea.

Diagnosis

requires

histopathologic

examination. Most patients do not require

transsphenoidal

hypophysectomy

,

diagnosis

is based on history, physical, diagnostic imaging,

During

the acute phase of this disease, hormone replacement is often necessary.

Sheehan Syndrome

Sheehan syndrome is the result of ischemia, congestion, and infarction of the pituitary gland, resulting in

panhypopituitarism

caused by severe blood loss at the time of delivery

.

Patients

have trouble lactating and develop amenorrhea, as well as symptoms of cortisol and thyroid hormone

deficiency

Treatment

is with hormone replacement in order to maintain normal metabolism and response to stress.

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5- Psychiatric Disorders

Three psychiatric disorders may arise in the postpartum period: Bluespostpartum depression (PPD) postpartum

psychosis.

Postpartum blues

is a transient disorder

that

lasts hours to weeks and is characterized by bouts of crying and sadness

.

PPD

is a more prolonged affective disorder that lasts for weeks to

months . Anxiety

is a prominent feature of perinatal

mood

disorders while other “common” symptoms of depression such as changes in sleep, appetite, and libido may be normal in the setting of

pregnancy

Postpartum psychosis

occurs in the first postpartum year and refers to a group of severe and varied disorders that elicit psychotic symptoms.

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EtiologyThe specific etiology of these disorders is unknown. Psychologically, these disorders are thought to result from the stress of the peripartum period and the responsibilities of child

rearing.Other authorities ascribe the symptoms to the sudden decrease in the endorphins of labor and the sudden fall in estrogen and progesterone levels that occur after delivery. Low free serum tryptophan levels have been observed, which is consistent with findings in major depression in other settings. Postpartum

thyroid dysfunction

has also been correlated with postpartum psychiatric disorders.

Risk factors

undesired

pregnancy, feeling unloved by mate, age younger than 20 years, unmarried status, medical indigence, low self-esteem, dissatisfaction with extent of education, economic problems with housing or income, poor relationship with husband or boyfriend, being part of a family with 6 or more siblings, limited parental support (either as a child or as an adult), and past or present evidence of emotional problems.

Women

with a history of PPD and postpartum psychosis have a 50% chance of recurrence. Women with a previous history of depression unrelated to childbirth have a 30% chance of developing PPD.

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IncidenceApproximately 50-70% of women who have given birth develop symptoms of postpartum blues.PPD occurs in 1 of 7 women or approximately 10-15% of new mothers.

The incidence of postpartum or puerperal psychosis is 0.14-0.26%.Morbidity and mortalityPsychiatric disorders can have deleterious effects on the social, cognitive, and emotional development of the newborn. These ailments can also lead to marital difficulties.

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HistoryPostpartum blues :

is a mild, transient, self-limited disorder that usually develops when the patient returns home. It commonly arises during the first 2 weeks after delivery and is characterized by bouts of sadness, crying, anxiety, irritation, restlessness, mood lability, headache, confusion, forgetfulness, and insomnia.PPD: insomnia, lethargy, loss of libido, diminished appetite, pessimism, incapacity for familial love, feelings of inadequacy, ambivalence or negative feelings toward the infant, and an inability to cope. Consult a psychiatrist when PPD is associated with comorbid drug abuse, lack of interest in the infant, excessive concern for the infant's health, suicidal or homicidal ideations, hallucinations, psychotic behavior, overall impairment of function, or failure to respond to therapeutic trial.

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Postpartum psychosis: The signs and symptoms of postpartum psychosis typically do not differ from those of acute psychosis in other settings.Patients with postpartum psychosis usually present with schizophrenia or manic depression, which signals the emergence of preexisting mental illness induced by the physical and emotional stresses of pregnancy and delivery.

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TreatmentPostpartum blues

resolves by postpartum day 10;no pharmacotherapy is indicated. Providing support and education has been shown to have a positive effect.PPD lasts for 3-6 months, with 25% of patients still affected at 1 year.

Supportive care and reassurance from healthcare professionals and the patient's family is the first-line therapy

Research

on pharmacological treatment for PPD is limited because postpartum women are often excluded from large clinical trials.

The

standard treatment modalities for major depression have been applied to PPD

.

Electroconvulsive

therapy

as it

is one of the most effective treatments available for major depression. Treatment is recommended for 9-12 months beyond remission of symptoms, with tapering over the last 1-2 months.

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Postpartum psychosis: Treatment of postpartum psychosis should be supervised by a psychiatrist and should involve hospitalization as it is a medical emergency.

Specific therapy is controversial and should be targeted to the patient's specific symptoms. Patients with postpartum psychosis are thought to have a better prognosis than those with nonpuerperal psychosis. Postpartum psychosis generally lasts only 2-3 months.

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