Introduction

Postpartum psychosis is a term covering at least twenty severe mental disorders that start abruptly soon after childbirth. Of these, postpartum bipolar disorders are overwhelmingly the most common in high-income nations; it is a rare psychiatric emergency beginning suddenly in the first two weeks after childbirth. The term ‘psychosis’ implies manic symptoms, stupor or catatonia, perplexity, confusion, disorders of the will and self, delusions and/ or hallucinations. It excludes psychiatric disorders that lack these symptoms; depression, however severe, is not included unless there are psychotic features.

Postpartum bipolar disorder

Signs and symptoms

Every symptom known to psychiatry occurs in these mothers—every kind of delusion including the rare delusional parasitosis, delusional misidentification syndrome, Cotard delusion, erotomania and the changeling delusion, denial of pregnancy or birth, command hallucinations, disorders of the will and self, catalepsy and other symptoms of catatonia, self-mutilation and all the severe disturbances of mood. Besides, the literature also describes symptoms not recognized, such as rhyming speech, enhanced intellect, and enhanced perception.

As for collections of symptoms (syndromes), about 40% have puerperal mania, with increased vitality and sociability, reduced need for sleep, rapid thinking and pressured speech, euphoria and irritability, loss of inhibition, violence, recklessness, and grandiosity (including religious and expansive delusions); puerperal mania is particularly severe, with highly disorganized speech, extreme excitement, and eroticism.

Another 25% have an acute polymorphic (cycloid) syndrome. This is a changing clinical state, with transient delusions, fragments of other syndromes, extreme fear or ecstasy, perplexity, confusion, and motility disturbances. In the past, some experts regarded this as pathognomonic (specific) for puerperal psychosis, but this syndrome is found in other settings, not just in the reproductive process, and in men. The World Health Organization places these psychoses in the ICD-10 under the rubric of acute and transient psychotic disorders. Manic and cycloid syndromes are regarded as distinct but studied long-term among childbearing women, the bipolar and cycloid variants are intermingled in a bewildering variety of combinations, and, in this context, it seems best to regard them as members of the same ‘bipolar/cycloid’ group. Together, the manic and cycloid variants make up about two-thirds of childbearing psychoses.

Onset groups

The postpartum bipolar disease belongs to the bipolar spectrum, whose disorders exist in two contrasting forms – mania and depression. They are highly heritable, and sufferers (less than 1% of the population) have a lifelong tendency (diathesis) to develop psychotic episodes in certain circumstances. The ‘triggers’ include many pharmaceutical agents, surgical operations, steroids, seasonal changes, menstruation, and childbearing. Research into puerperal mania is, therefore, not the study of a ‘disease-in-its own right’, but an investigation into the childbearing triggers of bipolar disorder.

Psychoses triggered in the first two weeks after the birth - between the first postpartum day (or even during parturition) until about the 15th day—complicate 1/1,000 pregnancies. The impression is sometimes given that this is the only trigger associated with childbearing. But there is evidence of four other triggers—late postpartum, prepartum, post-abortion and weaning. Marcé, widely considered an authority on puerperal psychoses, claimed that we could divide them into early and late forms; the late form begins about six weeks after childbirth, associated with the return of the menses. Many cases support his view in the literature with onset 4-13 weeks after the birth, mothers with serial 4-13-week onsets, and some survey evidence. The evidence for a trigger acting in pregnancy is also based on many reported cases, and particularly on the frequency of mothers suffering two or more prepartum episodes. There is evidence, especially from surveys, of bipolar episodes triggered by abortion (miscarriage or termination). The evidence for a weaning trigger rests on thirty-two cases in the literature, of which fourteen were recurrent. The relative frequency of these five triggers is given by the number of cases in the literature—just over half early postpartum onset, 20% each late postpartum and prepartum onset, and the rest post-abortion and weaning onset.

The course of the illness

With modern treatment, we can expect a full recovery within 6-10 weeks. After recovery from the psychosis, some mothers suffer from depression, which can last for weeks or months. About one third suffer a relapse, with a return of psychotic symptoms a few weeks after recovery; these relapses are not because of a failure to comply with medication, because they were often described before we discovered pharmaceutical treatments. A minority has a series of periodic relapses related to the menstrual cycle. Complete recovery, with a resumption of normal life and a normal mother-infant relationship, is the rule.

Many of these mothers suffer from other bipolar episodes, on average about once every six years. Although suicide is almost unknown in an acute puerperal manic or cycloid episode, depressive episodes later in life carry an increased risk, and it is wise for mothers to maintain contact with psychiatric services in the long term.

In the event of further pregnancy, the recurrence rate is high - in the largest series, about three quarters suffered a recurrence, but not always in the early puerperium; the recurrence could occur during pregnancy, or later in the postpartum period. This suggests a link between early-onset and other onset groups.

Cause and diagnosis

About half of women who experience it have no risk factors; but women with a prior history of mental illness, like bipolar disorder, a history of prior episodes of postpartum psychosis, or family history are at a higher risk. It is not a formal diagnosis but is widely used to describe a condition that appears to occur in about 1 in 1000 pregnancies. It differs from postpartum depression and maternity blues.

Treatment

Diagnosis of postpartum psychosis always requires hospitalization, where treatment is antipsychotic medication, mood stabilizers, and, in cases of strong risk for suicide, electroconvulsive therapy.

There is a need for further research into the causes and prevention; the lack of a formal diagnostic category and the difficulty of conducting clinical trials in pregnancy hinder research.

Risk factors

Women with a history of bipolar disorder, schizophrenia, prior episode of postpartum psychosis, or a family history of postpartum psychosis are at elevated risk; about 25-50% of women in this group will have postpartum psychosis. Around 37% of women with bipolar disorder have a severe postpartum episode. Women with a prior episode of postpartum psychosis have about a 30% risk of having another episode in the next pregnancy. For a woman with no history of mental illness who has a close relative (a mother or sister) who had postpartum psychosis, the risk is about 3%. There may be a genetic component; while mutations in chromosome 16 and specific genes involved in serotoninergic, hormonal, and inflammatory pathways have been identified, studies had confirmed none as of 2014.

Family history of affective psychosis, prenatal depression, and autoimmune thyroid dysfunction also increases the risk of postpartum psychosis.

About half of women who experience postpartum psychosis had no risk factors. Many other potential factors like pregnancy and delivery complications, cesarean section, sex of the baby, length of pregnancy, changes in psychiatric medication, and psychosocial factors have been researched, and we have found no clear association; the only obvious risk factor identified as of 2014 was that postpartum psychosis happens more often to women giving birth for the first time than to women having a second or subsequent delivery, but the reason for that was not known. There may be a role for hormonal changes that occur following delivery, in combination with other factors; there may be a role changes in the immune system as well.

Diagnosis

Postpartum psychosis is a psychiatric emergency related to the care of women after they give birth. The first evaluation requires a complete history, physical examination, and laboratory investigations to disbar a biological cause for acute psychosis and a careful neurological assessment. It is different from postpartum depression and maternity blues.

In contrast, about half of women have the maternity blues after birth, which is characterized by symptoms of mild mood swings, anxiety, and irritability that start about 3 to 4 days after delivery and last about a week. It is different from postpartum depression, which is experienced in some form by 20% of all women after birth and is like major depressive disorder.

The condition is not recognized in the DSM-5 as a distinct disorder nor in the ICD-10, but it is widely used clinically.

Screening

For women taking psychiatric medication, the decision as to whether continue during pregnancy and whether to take them while breastfeeding is difficult in any case; there is no data to guide this decision concerning preventing postpartum psychosis. There is no data to guide a decision as to whether women at elevated risk for postpartum psychosis should take antipsychotic medicine to prevent it. For women at risk of postpartum psychosis, informing medical caregivers, and monitoring by a psychiatrist during pregnancy, in the perinatal period, and for a few weeks following delivery, is recommended.

For women with known bipolar disorder, taking medication during pregnancy halves the risk of a severe postpartum episode, as does start to take medication immediately after the birth.

Management

In most cases hospital admission is necessary. Antipsychotic drugs and mood-stabilizing drugs such as lithium are typically administered but is not clear if mood stabilizers can be titrated to a high enough level quickly enough to be effective. Electroconvulsive therapy may be considered, especially if there is an elevated risk of suicide. Family support may be provided via a social worker.

Treatments

In the treatment of postpartum psychosis, there are no official guidelines. Once tests are administered, and we have excluded all the proper medical causes from the diagnosis, then the proper treatment is given based on the symptoms. Before the mother is released from the hospital, the team that administered treatment must work with the mother and her family to form a discharge plan that will strengthen her support, along with a close follow-up, and prevent stressors that will risk the mother relapsing. Also, for future pregnancies, the mother's primary care provider is advised to collaborate with other specialists on her care team, giving her care in the thought of antimanic prophylaxis during pregnancy or after childbirth.

History

Hippocrates mentioned postpartum delirium: there are 8 cases of puerperal or post-abortion delirium among the seventeen women in his books of epidemics. Between the 16th and 18th centuries about fifty brief reports were published; among them is the observation that these psychoses could be recurrent, and that they occurred both in breast-feeding and non-lactating women. In 1797, Osiander, an obstetrician from Tübingen, reported two cases at length - masterly descriptions which are among the treasures of medical literature. In 1819, Esquirol surveyed cases admitted to the Salpêtrière and pioneered long-term studies. From that time, puerperal psychosis became widely known to the medical profession. In the next two hundred years over 2,500 theses, articles and books were published. Among the outstanding contributions were Delay’s unique investigation using serial curettage and Kendell’s record linkage study comparing 8 trimesters before and 8 trimesters after birth. In 2017 a monograph reviewed over 2,400 works, with over 4,000 cases of childbearing psychoses from the literature and a personal series of over 320 cases.

Research directions

The lack of a formal diagnosis in the DSM and ICD has hindered research. The causes of postpartum depression are unknown and are under investigation. There is a need to better understand whether taking medication for prevention during pregnancy or immediately following birth is useful.

Other non-organic postpartum psychoses

It is much less common to encounter other acute psychoses in the puerperium.

Psychogenic psychosis

This is the name given to a psychosis whose theme, onset, and course are all related to an extremely stressful event. The psychotic symptom is usually a delusion. Over fifty cases have been described, but usually in unusual circumstances, such as abortion or adoption or in fathers at the time of the birth of one of their children. We occasionally see them after normal childbirth.

Paranoid and schizophrenic psychoses

These are so uncommon in the puerperium that it seems reasonable to regard them as sporadic events, not puerperal complications.

Early postpartum stupor

Brief states of stupor have rarely been described in the first few hours or days after birth. They are like the delirium and stupor more commonly seen during labor.

Organic postpartum psychoses

There are at least a dozen organic (neuropsychiatric) psychoses that can present soon after childbirth. The clinical picture is usually delirium - a global disturbance of cognition, affecting consciousness, attention, comprehension, perception, and memory - but amnesic syndromes also occur. The most common is infective delirium, first mentioned by Hippocrates. Eclamptic psychoses used to be common, and psychosis can also complicate pre-eclamptic toxemia without seizures. Two psychoses that usually develop during pregnancy can start in the puerperium: Wernicke-Korsakoff psychosis is a complication of pernicious vomiting; the cause is vitamin B1 (thiamine) deficiency, which has been available as a treatment since 1936, so it should be extinct, but cases continue to be reported from all over the world – more than fifty in this century—including some from countries with advanced medical services; most are due to rehydration without vitamin supplements. Chorea psychosis is a complication of chorea gravidarum, related to infection by Streptococcus pyogenes, which at present responds to antibiotics; it has virtually disappeared but could return if the streptococcus escapes control. Various vascular disorders occasionally cause psychosis, especially cerebral venous thrombosis, which is common in India. Other puerperal organic psychoses are associated with epilepsy, withdrawal of alcohol or other sedatives, hypopituitarism, and water intoxication due to the antidiuretic action of oxytocin. The most recently described (in the last decade of the 20th century) were hyperammonemia because of inborn errors of the Krebs-Henseleit urea cycle and Anti-NMDA Receptor Encephalitis in women who often have ovarian teratomas.

The psychoses mentioned had a specific link with childbearing. There are also organic puerperal psychoses associated with medical disorders without this specific connection; in them, the association seems to be fortuitous. They include neurosyphilis, encephalitis (including von Economo’s), meningitis, cerebral tumors, and ischemic heart disease.