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Postnatal depression diagnosis: passmed

Post-partum mental health problems range from the 'baby-blues' to puerperal psychosis.

The Edinburgh Postnatal Depression Scale may be used to screen for depression:
10-item questionnaire, with a maximum score of 30
indicates how the mother has felt over the previous week
score > 13 indicates a 'depressive illness of varying severity'
sensitivity and specificity > 90%
includes a question about self-harm


What is baby blues (passmed)

Seen in around 60-70% of women

Typically seen 3-7 days following birth and is more common in primips

Mothers are characteristically anxious, tearful and irritable


What is post natal depression (passmed)

Affects around 10% of women

Most cases start within a month and typically peaks at 3 months

Features are similar to depression seen in other circumstances

As with the baby blues reassurance and support are important

CBT may be beneficial. Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe** - whilst they are secreted in breast milk it is not thought to be harmful to the infant

*paroxetine is recommended by SIGN because of the low milk/plasma ratio
**fluoxetine is best avoided due to a long half-life


What is post partum psychosis (pass med)

Affects ~0.2% of women

Onset usually within the first 2-3 weeks following birth

Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)

Admission to hospital is usually required

~20% risk of recurrence following future pregnancies


What is the puerperium?

What to observe?

A period of maternal physical and psychological recuperation (starts immediately following expulsion of placenta and membranes and continues for 6 weeks).

1. Vital signs + general health: pulse, temp, RR, BP, circulation (haemoconcentration / diuresis increased).
2. Mood: over 50% experience ‘baby blues’ (typically first week) – support needs at home, life transition & lack of sleep.
3. Appetite / fluid intake: advise to eat normally, regular health snacks & iron rich foods, some require therapy for anaemia post pregnancy, poor appetite/overeating may indicate postnatal depression
4. Breasts
5. Uterine involution and ‘afterpains’: uterus returns to normal size/position, myometrium returns to normal thickness & decidua shed. Uterus ~1kg post birth 50-80g at end of 6th week. Afterpains = contractions during involution (often when breastfeeding due to release of oxytocin). Stronger pains experienced with multiparity.
6. Caesarean section wound healing: observe for signs of infection.
7. Lochia (vaginal fluid loss):
o Rubra: 1-3 days blood, tiny pieces amnion & chorion, vernix, lanugo
o Serosa: 4-10 days turning brownish/pink, blood, serous exudate, erythrocytes, leucocytes, mucus, micro-organisms, shreds of degenerating decidua
o Alba: white/yellowish can last up to 6 weeks – leucocytes, mucus, bacteria, epithelial cells
o Haemorrhage 2nd largest cause of death UK: may be concealed so consider if abnormal obs (agitation, anxiety, pain): primary >500ml first 24 hours, secondary up to 12 weeks after birth, risk factors: Tone, Tissue, Trauma, Thrombin  foul odour, increased loss or ongoing loss of small clots/abdo pain (may be sign of retained products / infection)
8. Perineal pain: bruising, stitches, pelvic floor exercises
9. Urine output: diuresis in first 24 hours, normal or reduced sensation and volume? Urge / stress / mixed incontinence  obstetric physiotherapy service. Risk factors for retention: prolonged labour, instrumental birth, complex perineal / labial tears, large baby, epidural / regional anaesthesia
10. Bowel function: passing flatus, constipation, haemorrhoids, psychological issues around first bowel motion post-birth can exacerbate constipation, dietary advice, urgency & soiling may indicate a serious problem e.g. anal sphincter injury. (3% incidence of severe obstetric anal sphincter injury) – risk factors nulliparity, instrumental birth, Asian ethnicity, macrosomic baby, prolonged labour, OP position, previous 3rd/4th degree tear (recurrence 5-7%).
11. Legs: observe for VTE & consider risk factors (largest direct cause maternal death: 26 women 2013-2015)

Sheehan’s Syndrome

Very rare in developed countries.

Severe bleeding during delivery causes damage to pituitary gland  hypopituitarism.
May have deficiencies in: ACTH, growth hormone, LH, FSH, prolactin & TSH
May be asymptomatic & most symptoms take months-years to develop. Most common: difficulty breastfeeding, amenorrhoea / oligomenorrhoea. Tiredness and weight changes also possible, or loss of pubic/underarm hair (gonadotrophin loss) or low blood pressure symptoms (ACTH).

Lymphocytic Hypophysitis (LH)

Lymphocytes enter pituitary gland  enlargement & impaired function. Most often in late pregnancy or postpartum period (but also pre-pubertal or post-menopausal women, or men). Symptoms: headache, visual field impairment & rarely diplopia.

Puerperal Fever

• Genital tract / uterine
• Breast infection
• Influenza
• Wound infection

Rates of death declined likely to due to increasing awareness of sepsis. Group A streptococcus: handwashing advice especially for mothers with young children at home. Encouraging all women to get flu vaccination when pregnant. Not always sepsis – can get low grade pyrexia with venous thromboembolism.

Perinatal mental Health
• Transition to motherhood
• Postnatal ‘blues’
• Postnatal depression
• Traumatic birth
• Puerperal psychosis
• Suicide

Screening important at booking/early pregnancy and early in postnatal period
Ask about:
Any past or present severe mental illness
Past or present treatment by specialist mental health service and/or inpatient care
First degree relative (mother, sister, daughter) severe perinatal mental illness
Also use Whooley questions:
Whooley Depression Screen. 1. During the past month, have you often been bothered by feeling down, depressed, or hopeless? 2. During the past month, have you often been bothered by little interest or pleasure in doing things?
Also consider GAD-2 scale: Over the last 2 weeks, how often have you been bothered by feeling nervous, anxious or on edge?
Over the last 2 weeks, how often have you been bothered by not being able to stop or control worrying?
Postnatal depression – 1:10 women.
Puerperal psychosis – 1-2 women in 1000 births. Key symptom insomnia. Hallucinations, severe thought disturbances.
Integrated care planning with perinatal mental health services in antenatal period.
Recommendation to read Bristol Serious Case Review and chapter 4 of MBRRACE report
Suicide is 3rd largest cause of direct maternal death in first 42 days after thromboembolism and haemorrhage. Overall up to one year it is the largest.
Traumatic birth – birth afterthoughts/counselling. Supportive birth planning for next time.

Baby: adaptation to extra-uterine life
• Pulmonary adaptation
• CV adaptation
• Thermal adaptation (importance of skin to skin contact)

Importance of avoiding hypothermia and hypoglycaemia. Hypoglycaemia reduces surfactant production  respiratory distress  increased work of breathing and exacerbation of hypoglycaemia. Keep newborns warm as need to adjust from being in body temperature environment to room temperature. Shut windows, turn off fans, keep baby skin to skin.


Pregnancy is a risk factor for developing VTE. Assess individual risk during pregnancy (at booking and any subsequent admission) & initiate appropriate prophylactic measures. Previous VTE history is automatically considered high risk and requires low molecular weight heparin throughout the antenatal period and also input from experts.

A woman at intermediate risk of developing VTE due to hospitalisation, surgery, co-morbidities or thrombophilia should be considered for antenatal prophylactic low molecular weight heparin. The assessment at booking should include risk factors:
• Age > 35
• BMI > 30
• Parity > 3
• Smoker
• Gross varicose veins
• Current pre-eclampsia
• Immobility
• Family history of unprovoked VTE
• Low risk thrombophilia
• Multiple pregnancy
• IVF pregnancy

4 or more risk factors  immediate low molecular weight heparin, continued until six weeks postnatal. If 3 risk factors  LMWH from 28 weeks and continued until six weeks postnatal. If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 months, as in other patients with provoked DVTs.

'In clinically suspected DVT or PE, treatment with low-molecular-weight heparin (LMWH) should be commenced immediately until the diagnosis is excluded by objective testing, unless treatment is strongly contraindicated.'

'Routine measurement of peak anti-Xa activity for patients on LMWH for treatment of acute VTE in pregnancy or postpartum is not recommended except in women at extremes of body weight (less than 50 kg and 90 kg or more) or with other complicating factors (e.g. renal impairment or recurrent VTE. Routine platelet count monitoring should not be carried out.'
- APTT is used for monitoring treatment with unfractionated heparin within this guidance.

Bacterial sepsis

Lactation Mastitis

Inflammatory condition of breast tissue +/- infection. Symptoms suggestive of infection may be seen in both types, but pyrexia symptoms more likely to persist >24 hours in infectious mastitis and may also produce considerable breast discomfort.

Clinical features
• Red, swollen, inflamed area of breast
• Breast hot to touch
• Fever >38
• Flu-like symptoms including chills, headache, muscle aches
• Painful lump caused by blocked duct

~3% of patients; mastitis may be complicated by a breast abscess. Common organisms responsible for mastitis & breast abscess:
• Staphylococcus aurea (most common)
• E. coli (or other gram negative bacteria)
• Bacteroides
• Streptococci (alpha, beta and non-haemolytic)

Majority divided into 4 groups:
• Neonatal infection
• Infections in lactating women
• Infections in non-lactating women
• Infections from localised skin infection

Lactational mastitis can be:
• Non-infectious (accumulated milk causes inflammatory response)
• Infectious (unresolved milk stasis leads to overcome of protection provided by immune factors in milk  bacterial overgrowth)
• Subclinical mastitis: indicators of an inflammatory response (e.g. interleukin-8) are present despite absence of clinical signs of mastitis.
o Commonly seen in Bangladesh, Tanzania, Malawi, South Africa
o Associated with inadequate milk removal and poor weight gain in infants
o HIV positive: higher rate of mother to child transmission of HIV since sub-clinical mastitis is associated with an increase HIV load in breast-milk

There is cellulitis of the interlobular connective tissue in the breast. Feeding may cause abration of skin around breast and on occasion cracking of the nipple. Permits entry of infective organisms and may result in circumareolar breast abscess or deep infection of the lactiferous ducts. Uncommonly, infections arise in the sebaceous glands (of Montgomery) of the areola (where they resemble skin boils). ~50% of all cases of mastitis seen in first 4 weeks after starting breast feeding although may occur at any stage during lactation or when the number of feeds (or milk expression) are reduced.

Post-natal depression