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Puerperal psychosis: identifying and caring for women at risk

  • Ian Jones and Sue Smith

Summary

Puerperal (postpartum) psychosis – the acute onset of a manic or psychotic episode shortly after childbirth – most commonly occurs in women with a bipolar disorder diathesis who have a vulnerability to a specific childbirth-related trigger. Women with bipolar disorder are at particularly high risk of puerperal psychosis, with a severe affective episode following between 25 and 50% of deliveries. Suicide is a leading cause of maternal death in the UK and it is clear that we must do more to identify and better manage women at high risk of illness related to childbirth. The clinical picture of puerperal psychosis can vary dramatically from hour to hour and can escalate quickly to a true psychiatric emergency. It is vital that clinical services identify women who are unwell and can respond quickly to the severity of illness, delivering treatment in the most appropriate setting for the mother and her baby.

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Copyright

Corresponding author

Dr Ian Jones, Department of Psychological Medicine, School of Medicine, Cardiff University, Henry Wellcome Building for Biomedical Research, Academic Avenue, Heath Park, Cardiff CF14 4XN, UK. Email: jonesir1@cf.ac.uk

Footnotes

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Declaration of Interest

I.J. has received honoraria or consultancy fees from Lilly, GlaxoSmithKline, Lundbeck, Janssen and AstraZeneca and research funding from GlaxoSmithKline.

Footnotes

References

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Puerperal psychosis: identifying and caring for women at risk

  • Ian Jones and Sue Smith
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eLetters

Risks and case registers in perinatal psychiatry

Devender Singh Yadav, Staff Grade Psychiatrist
27 November 2009



Puerperal psychosis is a psychiatric emergency. Assessing and managing risks is paramount. I will summarize the risks as follows:A. Risk to the mother:Suicide is the leading cause of maternal mortality in the U.K, accounting for 28% of the deaths. Women who committed suicides in the post partum period used a violent method of suicide, namely hanging or jumping. This contrasts with the usual finding that women are more likely to die from an overdose of medication in the non post partum period. Also compared to the other causes of maternal death, the suicides were older and socially advantaged. This reflects the severity of the illness and also calls into question the so called 'protective effects of maternity' [1].B. Risk to the baby:Risk to the newborn arises from psychotropic medication, both during the gestation period and also post partum. The other important risk due to new onset psychosis or relapse of psychosis during the post partum period is neonaticide, infanticide and filicide. Mothers who committed neonaticide were mostly troubled by psychosis and social problems, whereas infanticide and filicide were commonly associated in the context of post partum depression [2].In the unfortunate event of causing death of the newborn, Infanticide Act 1922 and the revised Infanticide Act 1938 are used by the defendant of the patient and this reduces the charge from culpable homicide to manslaughter, if it can be proven in the court of law that the patient "at the time of the act or omission the balance of her mind was disturbed by reason of her not having fully recovered from the effect of giving birth to the child or by reason of the effect of lactation consequent upon the birth of the child.''[3].C. Risk due to psychotropic medication:The USA Food and Drug Administration (FDA) rates drugs in five categories A, B, C, D and X. Valproic acid is listed in category X [The definition says, proved risk in humans (no indication for use, even in life threatening situations)], Lithium is listed in category D [Human fetal risk seen (may be used in life threatening situation)], Haloperidol &Chlorpromazine is listed in category C. [4] The risks and benefits of treatment with psychotropic versus maternal psychiatric illness must be carefully evaluated on an individual basis. Recently in the USA, GSK, manufacturer of Paroxetine was ordered to pay $2.5 Million [5]. Case registers in pregnancy might be helpful [6].A recent survey revealed that less than half of the mental health trusts in England provide specialist perinatal psychiatric services [7].

Specialist services which specifically address the needs of perinatal women have been advocated by the Perinatal Specialist Interest Group, Royal College of Psychiatrists, 2003; NICE (Guidelines CG45, 2007) and SIGN (Guidelines 60, June 2002).

In the absence of such specialist services, case registers in perinatal psychiatry could be set up easily by existing psychiatric teams to help with research, planning and implementation of services.

Prospective registers exist in the UK, for example the Epilepsy and Pregnancy Register [8]. Such case registers have achieved prominence with the advent of electronic case records and the technological capacity to derive anonymous databases from them [9].

I have no conflict of interest.References1. Oates M. Suicide: the leading cause of maternal death.2003. British Journal of Psychiatry, 183; 279-281.2. Oakley C, Hynes F & Clark T. Mood Disorder andviolence: a new focus.2009. Advances in Psychiatric Treatment, 15(4):263-270.3. Infanticide Act 1938, Second Reading. House of Lords Hansard, 22 March 1938. (Accessed Wikipedia on 12/11/09).4. Kaplan and Sadock's Synopsis in Psychiatry. 10th edition; Chapter 30 (Psychiatry and ReproductiveMedicine): pages 865-7.5. Tanne JH. Glaxo Smith Kline told to pay $2.5 M after jury finds Paroxetine caused son's heart defects. BMJ 2009; 339: b4266.6. Yadav DS. Case registers in pregnancy? BMJ 2009; 339:b42861. Oluwatayo & Friedman. 7. A survey of specialist perinatal mental health services in England. Psychiatric Bulletin 2005; 29: 177-79. 8. Morrow J, Russell A, Guthrie E, et al. Malformation risks of anti- epileptic drugs in pregnancy: a prospective study from the UK Epilepsy and Pregnancy Register. J Neurol Neurosurg Psychiatry 2006; 77: 193-8. 9. Perera G, Soremekun M, Breen G, Stewart R. Case register: noble past, challenging present, exciting future. Br J Psychiatry 2009; 195: 191-3
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