Psychological and Interpersonal

Issues Pregnancy and Postpartum

Dr. Anuradha Ellepola

Consultant Psychiatrist
2/20/2024 1
Pregnancy
Psychiatric disorders commoner in 1st and
3rd Trimesters than in 2nd
1st: Anxiety and Depression. Esp with
unwanted pregnancies
3rd : Anxiety, doubts, fears

2/20/2024 2
 Minor affective and anxiety symptoms are
common in pregnancy
Serious Psychiatric disorders are less common in
wanted pregnancies

More in:
Past Psy Hx
Serious medical illness
Poor attenders at antenatal care
substances
2/20/2024 3
Pseudocyesis
Rare
Belief of pregnancy
Amenorrhoea, ab distension, anxious
A somatoform disorder
Commonly resolve after Dx
Commoner among young

2/20/2024 4
Couvade syndromme
Husband of a pregnant xx experiences
symptoms of pregnancy
Resolve

2/20/2024 5
Spontaneous abortions
High rates of depression
Grief

More when there's a previous abortion

Getting better with time

2/20/2024 6
Stillbirth
Grief
Depression
Worries about future pregnancy

Help to mourn
Name to child
Hold the baby
Funeral

2/20/2024 7
Post-partum
immediately after birth of a child and
extending for six weeks

2/20/2024 8
 Postpartum Psychological Issues
Postpartum Blues
Postpartum Depression
Postpartum Psychosis

2/20/2024 9
Postpartum Blues

Affects 40 to 85% of new mothers

Peaks between postpartum days 3 and 5
Resolves within 24 to 72 hours
Subsides without treatment by postpartum
day 14

2/20/2024 10
Postpartum Blues
Symptoms:
Sadness, anxiety, irritability
Uncontrollable tearfulness
Wide mood swings
Occasional negative thoughts
Primary Treatment:
Supportive care and reassurance about the condition

2/20/2024 11
More frequent among
Primigravidae
Premenstrual tension
Fears, myths about labour
Poor social adjustment
Anxiety, depression in 3rd T

2/20/2024 12
Clinical Depression
15 to 25% of the overall population

< 25% under the care of a mental health

specialist

Twice as common in women

Peak incidence during primary reproductive

years (25 to 45 yrs)

2/20/2024 13
 PRESENTATION OF PPD
Usually develops slowly over the first three
months, often beginning within the first 4
weeks, though some women have a more
acute onset
May affect ability to care for the baby
Signs and symptoms are those of Major
Depression---depressed mood, irritability, loss
of interest and appetite, fatigue insomnia.
Often complain of being physically and
emotionally exhausted

2/20/2024 14
Postpartum Depression
Affects 10 to 15% of new mothers

Affects 26 to 32% of all adolescent new

mothers

Symptoms are more intense and longer

lasting

2/20/2024 15
 Postpartum Depression
Screening
Two-question Screener (PHQ-2)

1. Over the past two weeks have you ever felt

down, depressed or hopeless?
2. Over the past two weeks have you felt little
interest or pleasure in doing things?

Considered positive if answered yes to either

question
A score above 20 on the EPDS or any indication of
suicidality or psychosis warrants consideration for
crisis intervention services.
2/20/2024 16
If not using screening tools, be
specific:
“Are you been unable to sleep even when your baby
is sleeping?” (“Or do worries and anxiety keep you
awake?”)
“Have you found yourself crying a lot?”
“Have you had any thoughts that have been
worrisome or frightening to you?”
“Have you had any thoughts of harming yourself or
your baby?”
The suicide rate is increased 70 fold with
postpartum depression necessitating assessment of
suicidality as part of every screening for postpartum
depression.
2/20/2024 17
Postpartum Depression
Symptoms: (DSM IV-R)
Must be present most of the day, nearly everyday
for more than 2 weeks postpartum

Anhedonia

Dysphoric mood

2/20/2024 18
 PRESENTATION OF PPD
Some common features:
Often express concerns about her ability to
care for her baby or anxiety about the baby’s
well being
Anxiety symptoms are common including
frank panic disorder, hypochondriasis, and
most common, generalized anxiety disorder
Women are often unable to sleep even when
given the opportunity

2/20/2024 19
Postpartum Depression
Difficulty concentrating or making
decisions
Psychomotor agitation or retardation
Fatigue
Changes in appetite and/or sleep patterns
Recurrent thoughts of death or suicide

2/20/2024 20
Postpartum Depression
Feelings of worthlessness or guilt
(especially focusing on failure at
motherhood)

Excessive anxiety

Frequently focusing on the child’s health

2/20/2024 21
Who is at risk?
Family History – especially a personal prior
episode of depression
Mother experiencing poor marital
relationship/abusive relationship
Lack of social support and/or child care stressors
Comorbidities of substance abuse, anxiety or
somatization disorders
PHx of Depression

2/20/2024 22
Postpartum Depression
Interventions:
Medication
For more severe or chronic symptoms
Prior episodes or family histories w/ good response to
meds
Less costly and less time consuming
Psycho-therapy
Chronic psychosocial problems
Incomplete response to meds
Concurrent personality problems
Combination of both

2/20/2024 23
 Impact of Untreated Postpartum
Maternal Depression on the Infant
• Poor weight gain
• Sleep problems
• Less breastfeeding-depressed mothers more likely
to discontinue breastfeeding
• Impaired maternal health and safety practices
• Increased risk of child abuse and neglect
• Attachment and bonding failure

2/20/2024 24
Disruption in the infant-caregiver interactions which
promote brain neurological “wiring”:
Future , hyperactivity, conduct disorders and school
behavior problems
Delays in language and social development
Increased risk of depression and anxiety disorders
Maternal depression is an “Adverse childhood experience”
ACE, often it is not the only adversity
MATERNAL POST PARTUM MOOD IS ONE OF THE
STRONGEST PREDICTORS OF NEUROCOGNITIVE
DEVELOPMENT IN CHILDREN MEASURED UP TO
AGE SIX
2/20/2024 25
 Need for Patient Education
The greatest barrier to treatment for PPD in women is
lack of knowledge
Lack of knowledge about PPD, treatment options,
and community resources is common in postpartum
women and their families, and frequently leads to
delay in seeking treatment
Delay in treatment for PPD results in a longer illness
Information about PPD should be provided to women
in the prenatal period, soon after delivery, and further
encounters with healthcare providers in the first
postpartum year.

2/20/2024 26
Postpartum Psychosis
1 per 500 women after childbirth

Presentation can be dramatic

Onset as early as 48 to 72 hours postpartum

Symptoms develop within the first 2 weeks

after delivery

2/20/2024 27
 POST PARTUM PSYCHOSIS
A PSYCHIATRIC EMERGENCY WHICH
REQUIRES IMMEDIATE INTERVENTION
Typical onset is within 2 weeks after delivery,
first symptoms often within 48-72 hours
Earliest signs are restlessness, irritability and
insomnia
Often very labile in presentation
Often looks “organic” with a lot of confusion
and disorientation
Most often consistent with mania or a mixed
state

2/20/2024 28
Postpartum Psychosis
Early Symptoms Progressive Symptoms
Restlessness Depressed or elated
mood
Irritability Disorganized behavior
Sleep disturbance Mood swings/
instability
Delusions
Hallucinations
Dilirium

2/20/2024 29
 POST PARTUM PSYCHOSIS
Includes agitation, paranoia, delusions,
disorganized thinking and impulsivity
Thoughts of harming the baby are frequently
driven by delusions—Child must be saved from
harm, child is malevolent, dangerous, has special
powers, is Satan or God
Auditory hallucinations instructing the mother to
harm herself or the child are common
Rates of infanticide associated with untreated
postpartum psychosis have been estimated to be as
high as 4% and suicide as high as 5%

2/20/2024 30
More in:
Primiparous
Past major psychiatric illness
FHx of Psych illness
Unmarried mothers
Developing countries

2/20/2024 31
Management
Treatment setting
Mother and baby unit
Observation
ECT
Psychotropics

2/20/2024 32
Other Considerations
The onset or worsening of OCD, PTSD and
panic disorder can also occur postpartum.
There can be considerable overlap with
PPD.
PTSD can develop in response to a
traumatic birth experience or pregnancy loss
PTSD can emerge in pregnancy when past
physical or sexual trauma is reexpereinced
Often are intermingled with symptoms of
PPD
2/20/2024 33
When might your healthcare provider make a referral
for postpartum psychological problems?

Thoughts of suicide or homicide

Presence of psychotic symptoms
Severely impaired functioning
Failure to respond to anti-depressant treatment
trial
Comorbid substance abuse
Clinician preference

2/20/2024 34
Suicide
Worldwide suicide rate around16 per 100,000

Pregnancy and post partum:

90% with Psychiatry illnesses
Depression, Psychosis, Alcohol dependence
5 to 9 per million post partum suicides (UK)
Around 2 per million pregnant mothers (UK)
More in primi/ stillbirth/unwanted/ unmarried/ teenagers
Low rates due to social role during pregnancy and
puerperium

2/20/2024 35
 Thank You

2/20/2024 36