Perinatal Mental Health
Perinatal mental health covers psychiatric conditions during pregnancy and the first year postpartum. Perinatal depression affects 10-15% of women; puerperal psychosis is a psychiatric emergency.
Key Facts
Perinatal depression affects ~10-15% of women; screening with Whooley questions at booking and postnatally Baby blues: Affects ~50-80% of women; onset days 3-5; resolves within 2 weeks — reassurance only Puerperal psychosis: Rare (~1 in 1,000 births); onset typically within 2 weeks of delivery — psychiatric EMERGENCY Puerperal psychosis features: Rapid onset, confusion, hallucinations, delusions, mania, lability — risk of infanticide NICE CG192: Specialist perinatal mental health team involvement for moderate-severe perinatal illness SSRIs in pregnancy: Sertraline is generally first-choice (most safety data); benefits usually outweigh risks Sodium valproate is absolutely CONTRAINDICATED in pregnancy (MHRA Pregnancy Prevention Programme) Lithium is teratogenic (Ebstein's anomaly risk ~1%) — specialist decision-making required; levels monitored frequently in pregnancy
Overview
Key Facts
Perinatal mental health conditions span from common (baby blues, perinatal depression) to rare but severe (puerperal psychosis). Maternal mental illness is a leading indirect cause of maternal death in the UK.
Epidemiology
Perinatal depression: ~10-15%. Perinatal anxiety: ~15-20%. Puerperal psychosis: ~1-2 per 1,000 births. Suicide is the leading cause of direct maternal death in the first year postpartum (MBRRACE-UK reports).
Aetiology
- Hormonal: Rapid oestrogen/progesterone withdrawal post-delivery; cortisol changes; thyroid dysfunction
- Psychosocial: Social isolation, relationship difficulties, unplanned pregnancy, previous psychiatric history
- Risk factors for puerperal psychosis: Previous puerperal psychosis (~50% recurrence), bipolar disorder (~25% risk), family history, primiparity
Pathophysiology
- Rapid hormonal changes post-delivery disrupt monoamine, GABA, and HPA axis function
- Puerperal psychosis may represent an extreme sensitivity to hormonal changes in genetically vulnerable women
- Sleep deprivation compounds biological vulnerability
- Immune system changes during and after pregnancy may contribute (neuroinflammation hypothesis)
Clinical Presentation
Baby Blues (Days 3-5)
- Tearfulness, emotional lability, irritability, anxiety
- Resolves within 2 weeks — reassurance and support
- If persists >2 weeks → consider postnatal depression
Perinatal Depression
- Low mood, anhedonia, fatigue, guilt (often about being a 'bad mother')
- Sleep disturbance beyond normal infant-related disruption
- Poor bonding with baby, anxiety about baby's health
- May present antenatally or postnatally (up to 12 months)
Puerperal Psychosis (Psychiatric Emergency)
- Onset typically within 2 weeks of delivery (often days 1-3)
- Rapidly fluctuating symptoms: Confusion, mania, depression, psychosis
- Hallucinations, delusions (often about the baby)
- Severe insomnia, agitation, bizarre behaviour
- Risk of suicide and infanticide — admit to Mother and Baby Unit (MBU)
Red Flags
- Thoughts of harming the baby — urgent specialist assessment
- Rapidly changing mental state in first 2 weeks postpartum — puerperal psychosis until proven otherwise
- Suicidal ideation — leading cause of maternal death
- Severe self-neglect or inability to care for baby
Differential Diagnosis
| Diagnosis | Key Features | Investigation |
|---|---|---|
| Baby blues | Onset day 3-5, resolves <2 weeks | Clinical assessment |
| Postnatal depression | Persistent >2 weeks, meets depression criteria | EPDS, PHQ-9 |
| Puerperal psychosis | Rapid onset, psychosis, confusion, within 2 weeks | MSE, urgent psychiatric assessment |
| Thyroid dysfunction | Fatigue, mood change, weight change | TFTs |
| Postpartum anxiety/OCD | Intrusive thoughts about baby's harm (ego-dystonic) | Clinical assessment |
| Postpartum PTSD | Following traumatic birth, re-experiencing, avoidance | PCL-5 |
Diagnosis / Investigation
Bedside
- Edinburgh Postnatal Depression Scale (EPDS): 10-item self-report; score ≥13 suggests depression; item 10 screens for self-harm
- Whooley questions: 2-item screening at booking and 4-6 weeks postpartum
- Risk assessment: Suicide risk, risk to baby, capacity to care for baby
- Bonding assessment: Mother-infant interaction observation
Bloods
- TFTs: Postpartum thyroiditis (occurs in ~5-10%, can mimic depression or psychosis)
- FBC, U&Es: Baseline
- Calcium: Hypocalcaemia
Special Tests
- EPDS: Validated screening tool
- GAD-7, PHQ-9: Comorbid anxiety and depression severity
Management
Non-pharmacological
- Baby blues: Reassurance, partner support, rest
- Mild depression: Guided self-help, facilitated self-help groups, exercise
- Moderate-severe depression: CBT (adapted for perinatal); IPT
- Puerperal psychosis: Admit to Mother and Baby Unit (MBU) — allows treatment while maintaining mother-baby bond
Pharmacological
Antenatal/postnatal depression:
- Sertraline 50-200mg OD — generally first-choice SSRI (most safety data in pregnancy and breastfeeding)
- Fluoxetine 20mg — alternative (but long half-life, slightly more data for neonatal effects)
- Discuss risks vs benefits — untreated depression also harms mother and baby
Puerperal psychosis:
- Antipsychotic (olanzapine 10-20mg) + mood stabiliser (lithium — if not breastfeeding)
- Benzodiazepine for acute agitation
- ECT: Highly effective for puerperal psychosis, especially with catatonia or treatment-resistant symptoms
Prescribing considerations in pregnancy:
- Avoid sodium valproate (teratogenic, MHRA PPP), paroxetine (cardiac malformations), benzodiazepines (floppy infant)
- Lithium: Specialist decision; associated with Ebstein's anomaly (~1% risk vs 0.05% baseline); if used, increase monitoring frequency
- SSRIs in third trimester: Small risk of neonatal adaptation syndrome (jitteriness, poor feeding — usually self-limiting)
Referral Criteria
- Suspected puerperal psychosis — EMERGENCY — crisis team or MBU
- Moderate-severe perinatal depression — specialist perinatal mental health team (NICE CG192)
- Women with pre-existing serious mental illness becoming pregnant — preconception counselling
- Thoughts of harming baby — immediate specialist assessment
Prognosis
- Baby blues: Self-limiting within 2 weeks
- Perinatal depression: Good response to treatment; ~50% recover within 6 months with treatment
- Puerperal psychosis: ~75% recover fully; ~50% risk of non-puerperal recurrence; ~25-50% recurrence in subsequent pregnancies
- Untreated perinatal depression: Adverse effects on infant attachment, cognitive development, and behaviour
- Suicide is the leading cause of maternal death in the first year (MBRRACE-UK)
- Long-term: Women with puerperal psychosis should be counselled about recurrence risk in future pregnancies
Other Relevant Information
EPDS Scoring
| Score | Interpretation |
|---|---|
| <10 | Low risk |
| 10-12 | Possible depression — further assessment |
| ≥13 | Probable depression — full assessment |
| Item 10 (self-harm) positive | Immediate risk assessment |
Prescribing in Pregnancy and Breastfeeding
| Drug | Pregnancy | Breastfeeding |
|---|---|---|
| Sertraline | Generally safe (first-choice) | Safe (low breast milk levels) |
| Fluoxetine | Generally safe | Caution (longer half-life) |
| Paroxetine | Avoid (cardiac defects) | Relatively safe |
| Lithium | Teratogenic (Ebstein's ~1%) | Avoid (excreted in breast milk) |
| Sodium valproate | CONTRAINDICATED | Relatively safe |
| Olanzapine | Specialist use | Monitor infant for sedation |