This document discusses different postpartum mood disorders including postpartum blues, postpartum depression, and postpartum psychosis. Postpartum blues typically begins 2-3 days after delivery and resolves within 2 weeks, while postpartum depression symptoms may occur within the first year. Postpartum psychosis is a medical emergency characterized by depression, delusions, and thoughts of harming oneself or the infant. Treatment involves medication, counseling, and in severe cases, hospitalization and ECT.
2. Postpartum Blues
This condition is also known as “baby blues”
Characteristics of PPD
Insomnia
Tearfulness
Crying spells
Irritability
Anxiety
Decreased concentration
Mood Swings
3. Postpartum Blues
Onset of symptoms 2-3 day post delivery
Peak around the 5th after delivery
Resolve within 2 weeks
4. 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
5. Postpartum Psychosis
AKA Puerperal Psychosis
Characteristics:
Depression
Delusions
Thoughts of self harm (suicide)
Thoughts of harming the infant (infanticide)
6. Postpartum Psychosis
Incidence:
1 to 2 per 1000 childbirths
50% to 60% of cases- first child
50% of cases- family history of mood disorders
7. 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
8. 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
9. 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
12. Pharmacologic Therapy
Increase risk of suicide after initiation of
medication
If significant anxiety or insomnia present,
consider adding benzodiazepine
Close follow-up
13. Antidepressant Choice
TCAs
Desipramine and Nortryptiline are preferred
Least anti-cholinergic affects
Minimize postural hypotension
SSRIs
Fluoxetine is the best studied
14. 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
15. 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
16. 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
17. 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
18. 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
19. 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
20. 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
Notas del editor
Several studies have shown a non-statistically significant increase in the number of miscarriages in women taking SSRIs or SRNIs – it is not clear if this is secondary to the medications or the depression itself. Two meta-analyses of ssri and tca use during pregnancy failed to show an increase in fetal anomalies. However recently - Swedish Medical birth registry has shown a 1.5 to 2 fold increased risk for cardiovascular malformations (vsd and asd) associated with 1 st trimester exposure to paroxetine Risk of neonatal toxicity of withdrawal syndromes during the acute neonatal period One study showed women who took fluoxetine in the 3 rd trimester had significantly higher rates of preterm delivery and poor neonatal adaptation. In full term infants, the mean birth weight was significantly lower. Fluoxetine is most studied of SSRIs. Could be beneficial in that it has a long half life, so one does not need to taper the dose. Zoloft shows to have one of the lowest levels in breast milk Long term effects on cognitive development and behaviour are unknown.
Seizures have only been seen with clomipramine
Have been seen with both fluoxetine and paroxetine Not clear if SSRIs with longer half lives have same withdraw symptoms
Need to take into account risks of fetal exposure to medication, potential impact of untreated maternal depression during pregnancy on neonatal outcome and potential risks of neonatal syndromes associated with certain antidepressants.
One study showed there was no difference between nortryptiline and placebo
Small study with transdermal estradiol showed improvement in women with severe and persistent ppd
ECT typically requires 3-9 treatments to produce an effective response. Treatments are 3x/wk Rapid treatment needed = mother at risk for suicide or infanticide In past 50 years there has been only four cases of preterm labor and none of SROM associated with ECT
While a patient ’s length of therapy is often based on their history of prior depression, recurrence rate, and severity of previous symptoms, it is often recommended that women continue medications for at least one year following full remission of symptoms. If a patient becomes pregnant while on antidepressants you should continue meds through pregnancy to reduce the risk of relapse. JAMA study in feb 1, 2006- of 201 women with h/o depression, 43% experienced relapse of major depression during pregnancy. Those who maintained meds during pregnancy only had 26% relapse vs 68% in those who stopped meds. 50% relapsed in 1 st trimester and 90% by end of 2 nd trimester Both duration of depressive illness and h/o more recurrent depressive were associated with significant increase in risk of depressive relapse during pregnancy Maintenance of euthymic mood during pregnancy is essential in reducing long term morbidity and mortality
Combination therapy is often required, including mood stabilizers, antipsychotics, benzodiazopines, and antidepressants. Consideration should be given to discontinuing breastfeeding secondary to potential effects of medication combinations of the infant.
Risk of ppd is 25% in women with previous h/o depression and 50% if prior h/o ppd