Postnatal Mood Problems

Question 1

+ve feelings in puerperium

Answer 1

• Satisfaction
• Increased closeness to her partner
• Increased closeness to her own mother
• Gradual ‘falling in love’ with baby
• Feeling of protectiveness towards baby
• Changes in relationship with martial partner: now ‘mother and father’, not just ‘husband and wife’

Question 2

-ve feelings in puerperium

Answer 2

• dissatisfaction, disappointment or distress over delivery process
• anxiety about baby
• rejection or ambivalence about baby
• jealousy about baby being centre of attention
• fears of harming baby
• physical discomfort and anxiety about physical change during birth
• overwhelming responsibility
• resentment at loss of freedom
• reactivation of poor relationship with own mother, leading to anxiety about repetition through generations

Question 3

When do postnatal blues typically occur? How common is it?

Answer 3

• Postnatal blues typically occur between fourth and tenth days of puerperium
• It occurs in 50-70% of women and affects primiparous and multiparous women equally
• It is so common that it is regarded as normal
• Self-limiting condition
• Usually lasts 24-48 hours
• May resolve faster with protected sleep and rest

Question 4

What are proposed hormonal factors of postnatal blues?

Answer 4

Combination of psychosocial factors and hormonal factors

Hormonal factors:
- Studies show E + P were higher in women with postnatal blues, but level of cortisol was similar
- Prolactin was higher in women with postnatal blues and may correlate with anxiety and depression

Question 5

What are the psychosocial factors of postnatal blues?

Answer 5

• anxiety in pregnancy
• experiencing pregnancy as unpleasant
• fear of childbirth and pre-existing anxious or pessimistic personality

Question 6

Based on NICE guideline, when should a woman be assessed for PND?

Answer 6

Question 7

What is postnatal depression? When does it commonly occur?

Answer 7

Question 8

What is postpartum psychosis? How common is it? When does it usually present? What is there a risk of?

Answer 8

Question 9

What are pre-existing mental health problems which may occur / relapse after childbirth?

Answer 9

Question 10

What is the leading cause of maternal deaths overall? What are the common methods?

Answer 10

Question 11

History taking for postnatal mood problems

Answer 11

Depression screening questions (Whooely questions)
- During the past month, have you often been bothered by feeling down, depressed or hopeless?
- During the past month, have you often been bothered by having little interest or pleasure in doing things?
- Is this something with which you would like help?

Question 12

What screening methods is used for postnatal depression?

Answer 12

Edinburgh Postnatal Depression Scale
- Ten-item, self-rated questionnaire that has been used extensively for the detection of postpartum depression
- Most commonly used cut-off score of >12 has an overally PPV of 57% and NPV of 99%

Question 13

What are some red flags in history taking?
- “Signs of warning of impending dangers of disaster”
- Psychosis & suicide

Answer 13

• Recent or rapidly changing significant alterations in mental state
• Emergence of new Sx, which can include psychotic Sx (delusions, hallucinations) or severe anxiety in relation to her infant’s (and/or other children’s) welfare
• Psychotic Sx that involve the infant
• Thoughts of violents self-harm or suicide
• Acts of violent self-harm or suicide
• New/persistent/nonreassurable ideas and expression of these ideas, where the woman believes she is incompetent/inadeqate as a mother or feels estranged from her infant
• Pervasive guilt and hopelessness
• Deterioration in function as a consequence of symptoms, e.g. self-care, care of the infant, avoidance of the infant
• Not eating
• Severe insomnia
• Psychomotor retardation

Question 14

For suicidal assessment, what must we assess?

Answer 14

• Any suicidal thoughts “wanting to die”, “not wanting to wake up” or “wanting to end it all”
• For long periods or may just be fleeting
• Any action plan

Question 15

Counselling of women diagnosed with postnatal blues

Answer 15

• A lot of women have emotional changes
• Hormonal changes + environemntal changes + physical changes = easy to have PND or low mood
• There are PND nurses + psychiatrists
• See husband as well to inform him of the condition (ask for consent first for this)

Screening for PND should be performed prior to patients’ postnatal discharge

Question 16

What are the indications for referral to psychiatric services?

Answer 16

• Sx of psychosis, severe anxiety, severe depression
• Suicidality
• Self-neglect
• Harm to others
• Significant interference with daily functioning
• Hx of bipolar disorder or schizophrenia
• Previous serious postpartum mental illness (puerperal psychosis)
• Patients on complex pscyhotropic medication regimen

Question 17

Management of postnatal mood problems should include a multidisciplinary team, consisting of:

Answer 17

• Obstetricians
• Midwives
• Psychiatrists
• Psychiatric nurses
• Clinical psychologists
• Primary care

Question 18

How should patients with postnatal mood problems be managed?

Answer 18

• Education of the condition
• Medications - anti-depressants, anti-psychotics, mood stabilisers
• Counselling
• Psychotherapy
• Electroconvulsive therapy (ECT) may be considered for severe cases