22 April 2020 Postpartum, also known as puerperium, is a very demanding phase. Women suffer different changes - biological, psychological, social - simultaneously that leave them highly vulnerable to the worsening or onset of psychiatric disorders: In addition to hormonal changes, there are psychological and social changes associated with the transition to motherhood; There is a need for social reorganization and adaptation to the new role of being a mother; The is a sudden increase in responsibility due to becoming a reference for a helpless person, with sleep deprivation and social isolation; It is necessary to restructure sexuality, body image and female identity. Postpartum dysphoria, postpartum depression and postpartum psychosis have been classically associated to the puerperium. In addition to these, several anxiety disorders are also related with this period. What is postpartum dysphoria Postpartum dysphoria, also known as baby blues, is mildest form of psychiatric condition in the puerperium. It can be identified in 50%-85% of women. Symptoms Symptoms of postpartum dysphoria usually start in the first days after delivery, peak on the 4th or 5th day and disappear spontaneously within a maximum of 2 weeks. These symptoms include easy crying, affective lability, irritability and hostile behavior towards family members and other persons. Some women may experience feelings of strangeness and depersonalization and others may experience euphoria. Treatment Mothers with baby blues do not need medication. The correct approach is an emotional support, understanding and assistance in the care of the infant. If symptoms persist for more than 2 weeks, then the woman should be evaluated because it may be a postpartum depression. What is postpartum depression Postpartum depression is any depressive episode that occurs in the months following the baby birth, usually between 2 weeks to 3 months after delivery. The prevalence of postpartum depression varies between 10%-20% and is affected by: Cultural factors, Period when the disease occurs, Diagnostic tools used. Symptoms Symptoms of postpartum depression may include sadness, loss of pleasure and interest in activities, weight and / or appetite changes, sleep disorders, psychomotor agitation or slowing, feeling of fatigue, feeling of worthlessness or guilt, difficulty in concentrating or having decisions and even thoughts of death or suicide. The clinical picture of depression at this time of life, has some particularities like: High probability of comorbidity with anxious and obsessive-compulsive symptoms, Lower incidence of suicide, Longer therapeutic response, often requiring more than one medication. Treatment Pharmacological therapy is the first-line treatment for postpartum depression. There are some antidepressants medicines that are compatible with breastfeeding. For this reason, women should not avoid seeking psychiatric help for fear of having to stop breastfeeding. Psychotherapy is also indicated. Risk factor for post partum depression The main risk factors associated with postpartum depression are: Personal history of depression, Depressive or anxiety episode during pregnancy, Negative life events during pregnancy or the puerperium, Deficient social or financial support, Conflicting couple relationship. Other risk factors are family history of psychiatric illness, baby blues episode, certain personality characteristics and low self-esteem. Postpartum depression is also associated with obstetric complications, premature birth, cultural factors, history of conflicting relationship with the mother and unwanted pregnancy. Protective factors for postpartum depression Protective factors for postpartum depression are: High self-esteem, Good marital relationship, Adequate social support, Physical and psychological preparation for changes related to motherhood. Consequences of postpartum depression Women with postpartum depression are at an increased risk of experiencing depressive episodes in the future and especially new episodes of this disease. Postpartum depression can have significant impact on quality of life, family dynamics and mother-baby interaction. Depressed mothers can have an insecure and non-affectionate relation with their children and often stop breastfeeding earlier. Infants are very vulnerable to maternal depression, because they depend on the quality of care and the mother emotional response. The more severe and persistent the maternal postpartum depression, the greater the likelihood of a negative impact in the mother-baby relationship and of repercussions on the child development. What is postpartum psychosis Postpartum psychosis is the most serious psychiatric disorder that can occur in the puerperium. It has an overall prevalence of 0.1%-0.2%, being higher in women with bipolar disorder. Postpartum psychosis usually begins quickly and symptoms begin within the first few days to 2 weeks postpartum. Symptoms The initial symptoms of postpartum psychosis are euphoria, irritable mood, fast speech, agitation and insomnia. Later, delusional ideas, hallucinations, disorganized behavior, disorientation, mental confusion, perplexity and depersonalization arise. The post-partum psychotic condition is a risk situation for infanticide. This usually occurs when delusional ideas involve the infant, such as ideas that he has a malformation or is dying, that he has special powers or that he is a god or a demon or that it is preferable to kill the child because she is convinced that has no competence to take care of him. Negligent behaviors in baby care, as well as suicidal and/or infanticidal ideas, should always be investigated in postpartum psychosis. Treatment and prognosis Due to the severity of the postpartum psychosis, hospitalization is usually necessary for evaluation and treatment. In about 20% of women there is a complete remission of the disease without further recurrences. Risk factors for postpartum psychosis Among the risk factors for puerperal psychosis are: Primiparity (first child); Obstetric complications; Personal or family history of psychiatric illness, especially other psychotic disorders. Postpartum anxiety disorders Postpartum has also been identified as a period of precipitation or exacerbation of anxiety disorders, like: Generalized anxiety disorder; Social phobia; Obsessive-compulsive disorder; Panic disorder; Post-traumatic stress disorder. Generalized anxiety disorder Generalized anxiety disorder can be aggravated or triggered in the puerperium, and is characterized by the persistent presence of anxiety or excessive worries. The concerns involve several life events and activities and are accompanied by symptoms such as restlessness, tiredness, difficulty in concentrating, irritability, muscle tension and sleep disturbance. Social fobia Social phobia, as well as some non-pathological social anxiety disorders, may aggravate in the puerperium, which is understandable given potentially uncomfortable social relationships during this period. During this phase, women have to contact with several health professionals, multiple visits to the newborn, people present at home to help with infant care. These exposures may lead them to become more introverted and very afraid of criticism. Obsessive-compulsive disorder The puerperium is the main life event related to the triggering or exacerbation of obsessive-compulsive disorder. The content of postpartum obsessions and compulsions usually involves the baby. Obsessive thoughts of aggressive ideias against the newborn are frequent, such as fear of dropping him on the floor, impulse to pour boiling water on the baby, to throw him against the wall or through the window, recurrent images of the baby suffocated in the cradle, suffering an accident or bleeding. Obsessive thoughts are intrusive, not recognized as thoughts mothers would expect to have, cause anxiety and discomfort and the woman tries to resist them, ignore them or neutralize them. The occurrence of aggressive obsessive thoughts against the baby is not associated with infanticidal behavior. Panic disorder There no doubt that in the postpartum period there is an exacerbation of the symptoms of the pre-existing panic disorder, as well as the appearance of symptoms for the first time. Some women may experience a certain increase in symptoms early in pregnancy. Physiological changes associated with pregnancy may result in tachycardia, sweating or occasional dizziness, and the pregnant woman may interpret these symptoms in a catastrophic manner and have partial or complete panic attacks. Posttraumatic stress disorder Post-traumatic stress disorder has also been related with postpartum. In this phase, several traumatic events can be experienced, which can lead to feelings of fear, helplessness or horror. Among them are: Situations of intense and prolonged pain; Emergency obstetric procedures; Experience of having been humiliated by the medical team; Fear of his death or the death of the fetus or newborn; Perception of congenital anomaly in the baby, among others. Posttraumatic post-traumatic stress disorder can affect the mother decision to have other children in the future, in addition to interfering with breastfeeding and the development of the mother-baby bond. Summing up During postpartum, about 85% of women experience some type of mood disorder. In most women the symptoms are mild and for a short period, but 10% -15% develop more severe symptoms. Both women and those around them must be aware of this risk, as well as of the need for timely intervention, given the negative impact that any psychiatric illness can have on the mother-baby relationship and on the child development. The content published in the Health Guide is intended for the general public and is provided for informational and educational purposes only. It does not replace individual medical assessment, diagnosis, or personalized clinical advice from a qualified healthcare professional. The content is produced or reviewed by physicians and other healthcare professionals at Hospital da Luz and is based on the knowledge available at the time of publication or the most recent update, as indicated at the beginning of each item.
