Puerperal psychosis: identifying and caring for women at risk

SummaryPuerperal (postpartum) psychosis – the acute onset of a manic or psychotic episode shortly after childbirth – most commonly occurs in women with a bipolar disorder diathesis who have a vulnerability to a specific childbirth-related trigger. Women with bipolar disorder are at particularly high risk of puerperal psychosis, with a severe affective episode following between 25 and 50% of deliveries. Suicide is a leading cause of maternal death in the UK and it is clear that we must do more to identify and better manage women at high risk of illness related to childbirth. The clinical picture of puerperal psychosis can vary dramatically from hour to hour and can escalate quickly to a true psychiatric emergency. It is vital that clinical services identify women who are unwell and can respond quickly to the severity of illness, delivering treatment in the most appropriate setting for the mother and her baby.

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Postpartum Psychosis after Traumatic Cesarean Delivery

Healthcare ◽

10.3390/healthcare9050588 ◽

2021 ◽

Vol 9 (5) ◽

pp. 588

Author(s):

Evangelia Antoniou ◽

Eirini Orovou ◽

Kassiani Politou ◽

Alexandros Papatrechas ◽

Ermioni Palaska ◽

...

Keyword(s):

Bipolar Disorder ◽

Cesarean Delivery ◽

Health Care Professionals ◽

Psychotic Episode ◽

Postpartum Psychosis ◽

Childbirth Experience ◽

Emergency Cesarean ◽

History Of ◽

Psychiatric Complications

An emergency cesarean delivery can be a traumatic childbirth experience for a woman and a risk factor for postpartum psychosis, especially in a patient with a history of bipolar disorder. This article describes the case of a pregnant woman with an unknown history of bipolar disorder who developed an acute psychotic reaction during the procedure of an emergency caesarian section and switched to mania. The purpose of this case study is for perinatal health care professionals to identify suspicious symptoms and promptly refer to psychiatric services so as to ensure the mother’s and the newborn’s safety. This case study highlights the importance of assessing women with bipolar disorder or a previous psychotic episode for the risk of psychiatric complications in pregnancy and after childbirth. Midwifery education on perinatal mental health is crucial for the detection of suspicious symptoms and early referral to a specialist.

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Prophylactic Lithium in Puerperal Psychosis

The British Journal of Psychiatry ◽

10.1192/bjp.158.3.393 ◽

1991 ◽

Vol 158 (3) ◽

pp. 393-397 ◽

Cited By ~ 106

Author(s):

D. E. Stewart ◽

J. L. Klompenhouwer ◽

R. E. Kendell ◽

A. M. Van Hulst

Keyword(s):

Bipolar Disorder ◽

High Risk ◽

Lithium Carbonate ◽

Controlled Study ◽

Third Trimester ◽

Psychotic Illness ◽

Puerperal Psychosis ◽

The Third ◽

Larger Sample

At three centres, 21 women at high risk for puerperal psychosis were given prophylactic lithium carbonate late in the third trimester of pregnancy or immediately after delivery. Only two of the women had a recurrence of their psychotic illness while on prophylactic lithium. One woman given lithium during third trimester had an unexplained stillbirth. Although a larger sample in a carefully controlled study is still required, there now seems to be grounds for the use of prophylactic lithium immediately after delivery in women not breastfeeding who have previously suffered from either puerperal psychosis or bipolar disorder.

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Comorbid medical illness in bipolar disorder

The British Journal of Psychiatry ◽

10.1192/bjp.bp.114.152249 ◽

2014 ◽

Vol 205 (6) ◽

pp. 465-472 ◽

Cited By ~ 55

Author(s):

Liz Forty ◽

Anna Ulanova ◽

Lisa Jones ◽

Ian Jones ◽

Katherine Gordon-Smith ◽

...

Keyword(s):

Bipolar Disorder ◽

Suicide Attempts ◽

Mental Health Disorder ◽

Acute Onset ◽

Medical Illness ◽

Illness Burden ◽

Increased Risk ◽

History Of ◽

Dsm Iv ◽

The Uk

BackgroundIndividuals with a mental health disorder appear to be at increased risk of medical illness.AimsTo examine rates of medical illnesses in patients with bipolar disorder (n = 1720) and to examine the clinical course of the bipolar illness according to lifetime medical illness burden.MethodParticipants recruited within the UK were asked about the lifetime occurrence of 20 medical illnesses, interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and diagnosed according to DSM-IV criteria.ResultsWe found significantly increased rates of several medical illnesses in our bipolar sample. A high medical illness burden was associated with a history of anxiety disorder, rapid cycling mood episodes, suicide attempts and mood episodes with a typically acute onset.ConclusionsBipolar disorder is associated with high rates of medical illness. This comorbidity needs to be taken into account by services in order to improve outcomes for patients with bipolar disorder and also in research investigating the aetiology of affective disorder where shared biological pathways may play a role.Declarations of interestNone.

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Bipolar disorder and childbirth: the importance of recognising risk

The British Journal of Psychiatry ◽

10.1192/bjp.186.6.453 ◽

2005 ◽

Vol 186 (6) ◽

pp. 453-454 ◽

Cited By ~ 75

Author(s):

Ian Jones ◽

Nick Craddock

Keyword(s):

Bipolar Disorder ◽

Post Partum ◽

Bipolar Affective Disorder ◽

Significant Proportion ◽

Psychiatric Services ◽

Psychotic Episode ◽

Puerperal Psychosis ◽

Maternal Deaths ◽

North East ◽

Mother And Baby Unit

In October 2003 the report was published of an inquiry into the death of a psychiatric colleague that raised a number of important questions – not least regarding our management of women with bipolar disorder in pregnancy and the postpartum period (North East London Strategic Health Authority, 2003). Dr Daksha Emson took the life of herself and her 3-month-old daughter, Freya. This tragedy took place during a psychotic episode triggered by childbirth and was a consequence of her history of bipolar affective disorder. Sadly, the case of Dr Emson is far from unique. The Confidential Enquiries into Maternal Deaths (2001) found that suicide had become the leading cause of maternal mortality in the UK, accounting for 28% of maternal deaths (Oates, 2003a). The majority of the women who died by suicide suffered an abrupt onset of a severe psychotic illness within days of childbirth – a ‘puerperal psychosis', to use the traditional nosological label. For some women an episode of puerperal psychosis will be the first experience of severe mental illness, but a significant proportion of women will have had previous episodes. In the Confidential Enquiries into Maternal Deaths (2001), for example, 46% of the women who killed themselves (the majority by violent means) had previously been in contact with psychiatric services – and half of these had had a previous admission with a severe episode of illness following childbirth (Oates, 2003b). In many maternal suicides, therefore, the occurrence of an episode of severe post-partum psychiatric illness is an eminently predictable event. Although some women in the report were in contact with psychiatric services, none had received a detailed risk assessment, none had a formal management plan, and none was under close surveillance in the puerperium. It is also worth noting that none of the women in the cases of maternal suicide reported in the Confidential Enquiries was under the care of a mother and baby unit or perinatal psychiatric service (Oates, 2003a). The report on maternal deaths in 2000–2002 has now been published (Confidential Enquiries into Maternal Deaths, 2004) and, sadly, the findings are similar.

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Faculty Opinions recommendation of Effect of divalproex on brain morphometry, chemistry, and function in youth at high-risk for bipolar disorder: a pilot study.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1163697.625473 ◽

2009 ◽

Author(s):

Jean Frazier

Keyword(s):

Bipolar Disorder ◽

Pilot Study ◽

High Risk ◽

Brain Morphometry ◽

And Function

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Gambling problems in bipolar disorder in the UK: Prevalence and distribution

The British Journal of Psychiatry ◽

10.1192/bjp.bp.114.154286 ◽

2015 ◽

Vol 207 (4) ◽

pp. 328-333 ◽

Cited By ~ 19

Author(s):

Lisa Jones ◽

Alice Metcalf ◽

Katherine Gordon-Smith ◽

Liz Forty ◽

Amy Perry ◽

...

Keyword(s):

Bipolar Disorder ◽

Problem Gambling ◽

Severity Index ◽

Gambling Problems ◽

Rapid Cycling ◽

Probable Significance ◽

History Of ◽

Gambling Severity ◽

The Uk

BackgroundNorth American studies show bipolar disorder is associated with elevated rates of problem gambling; however, little is known about rates in the different presentations of bipolar illness.AimsTo determine the prevalence and distribution of problem gambling in people with bipolar disorder in the UK.MethodThe Problem Gambling Severity Index was used to measure gambling problems in 635 participants with bipolar disorder.ResultsModerate to severe gambling problems were four times higher in people with bipolar disorder than in the general population, and were associated with type 2 disorder (OR = 1.74, P = 0.036), history of suicidal ideation or attempt (OR = 3.44, P = 0.02) and rapid cycling (OR = 2.63, P = 0.008).ConclusionsApproximately 1 in 10 patients with bipolar disorder may be at moderate to severe risk of problem gambling, possibly associated with suicidal behaviour and a rapid cycling course. Elevated rates of gambling problems in type 2 disorder highlight the probable significance of modest but unstable mood disturbance in the development and maintenance of such problems.

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COVID-19 in a Cohort of Patients with Congenital Myasthenic Syndrome

Journal of Neuromuscular Diseases ◽

10.3233/jnd-210699 ◽

2021 ◽

pp. 1-3

Author(s):

Setareh Alabaf ◽

Karen O'Connell ◽

Sithara Ramdas ◽

David Beeson ◽

Jacqueline Palace

Keyword(s):

High Risk ◽

Neuromuscular Transmission ◽

Genetic Disorders ◽

Severe Disease ◽

Congenital Myasthenic Syndrome ◽

Referral Centre ◽

History Of ◽

Myasthenic Syndrome ◽

The Uk ◽

Rare Group

Congenital Myasthenic Syndrome (CMS) are a rare group of genetic disorders of neuromuscular transmission. Some subtypes of CMS can be associated with respiratory and bulbar weakness and these patients may therefore be at high risk of developing a severe disease from COVID-19. We screened 73 patients with genetically confirmed CMS who were attending the UK national referral centre for evidence of previous Severe Acute Respiratory Syndrome Corona Virus 2 infection and their clinical outcome. Of 73 patients, seven had history of confirmed COVID-19. None of the infected patients developed a severe disease, and there were no signals that CMS alone carries a high risk of severe disease from COVID-19.

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FRI0649-HPR HYDROXYCHLOROQUINE PRESCRIBING AND OPHTHALMOLOGY SCREENING WITHIN RHEUMATOLOGY DEPARTMENTS IN THE NORTH-WEST OF THE UNITED KINGDOM: A PROSPECTIVE REGIONAL AUDIT

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.1704 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 928.2-929

Author(s):

S. Juman ◽

T. David ◽

L. Gray ◽

R. Hamad ◽

S. Horton ◽

...

Keyword(s):

High Risk ◽

Risk Group ◽

Service Level ◽

High Risk Group ◽

North West ◽

The North ◽

The United Kingdom ◽

The Uk ◽

Treatment Dosage ◽

Sd Oct

Background:Hydroxychloroquine (HCQ) is widely used in the management of rheumatoid arthritis and connective tissue disease. The prevalence of retinopathy in patients taking long-term HCQ is approximately 7.5%, increasing to 20-50% after 20 years of therapy. Hydroxychloroquine prescribed at ≤5 mg/kg poses a toxicity risk of <1% up to five years and <2% up to ten years, but increases sharply to almost 20% after 20 years. Risk factors for retinopathy include doses >5mg/kg/day, concomitant tamoxifen or chloroquine use and renal impairment. The UK Royal College of Ophthalmologists (RCOphth) 2018 guidelines for HCQ screening recommend optimal treatment dosage and timing for both baseline and follow-up ophthalmology review for patients on HCQ, with the aim of preventing iatrogenic visual loss. This is similar to recommendations made by the American Academy of Ophthalmology (2016).Objectives:To determine adherence to the RCOphth guidelines for HCQ screening within the Rheumatology departments in the North-West of the UK.Methods:Data for patients established on HCQ and those initiated on HCQ therapy were collected over a 7 week period from 9 Rheumatology departments.Results:473 patients were included of which 56 (12%) were new starters and 417 (88%) were already established on HCQ. 79% of the patients were female, with median ages of 60.5 and 57 years for new and established patients respectively. The median (IQR) weight for new starters was 71 (27.9) kg and for established patients, 74 (24.7) kg.20% of new starters exceeded 5mg/kg daily HCQ dose. 16% were identified as high risk (9% had previously taken chloroquine, 5% had an eGFR <60ml/min/m2and 2% had retinal co-pathology). Of the high-risk group, 44% were taking <5mg/kg. In total, 36% of new starters were referred for a formal baseline Ophthalmology review.In the established patients, 74% were taking ≤5mg/kg/day HCQ dose and 16% were categorized as high risk (10% had an eGFR less than 60ml/min/m2, 3% had previous chloroquine or tamoxifen use and 2% had retinal co-pathology). In the high-risk group, 75% were not referred for spectral domain optical coherence tomography (SD-OCT). 41% of patients established on HCQ for <5 years, and 33% of patients on HCQ for >5 years were not referred for SD-OCT. Reasons for not referring included; awaiting 5 year review, previous screening already performed and optician review advised.Since the introduction of the RCOphth guidelines, 29% patients already established on HCQ had an alteration in the dosage of HCQ in accordance with the guidelines. In the high-risk group, 16% were not on the recommended HCQ dose.Conclusion:This audit demonstrates inconsistencies in adherence to the RCOphth guidelines for HCQ prescribing and ophthalmology screening within Rheumatology departments in the North-West of the UK for both new starters and established patients. Plans to improve this include wider dissemination of the guidelines to Rheumatology departments and strict service level agreements with ophthalmology teams to help optimize HCQ prescribing and screening for retinopathy.Acknowledgments:Drs. S Jones, E MacPhie, A Madan, L Coates & Prof L Teh. Co-1st author, T David.Disclosure of Interests:None declared

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1381. Rotavirus Gastroenteritis among older adults: discussion based on a systematic literature review

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.1563 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S700-S701

Author(s):

Cristina Carias ◽

Susanne Hartwig ◽

M Nabi Kanibir ◽

Ya-Ting Chen

Keyword(s):

Older Adults ◽

High Risk ◽

Acute Gastroenteritis ◽

Rate Ratio ◽

Rotavirus Gastroenteritis ◽

Incident Rate Ratio ◽

The Us ◽

Incident Rate ◽

The Uk ◽

Retrospective Database

Abstract Background While the burden of Rotavirus Gastroenteritis (RGE) is well recognized in young children, it is less so in older adults. However, older adults are also at high-risk of Acute Gastroenteritis (AGE) severe outcomes. In this review, we thus aimed to comprehensively assess RGE burden and vaccination impact in older individuals. Methods We performed a systematic literature review with PubMed and Scopus, from 2000 to 2019, using MESH and free-range terms. We included only studies that reported the incidence, and/or RV vaccination impact, in adults aged 60 and above and using regional specific data-sources. Results We analyzed 11 manuscripts for individuals aged 60 and above (Figure 1). Studies spanned Australia, Sweden, Netherlands, Canada (2), Germany (2), UK (2), and the US (2). Yearly inpatient RV incidence varied between 1.6 per 100,000 in Australia for those 65+ (retrospective database analyses, pre-vaccine); and 26 per 100,000 for those 85+ in Canada (modeling estimates for 2006-10, pre-vaccine). The incidence rate ratio for inpatient RGE between the post and pre-vaccine periods for those 65+ was 0.57 [95% CI: 0.10 – 3.15] in Canada, but 2.24 [95%CI: 1.78-2.83] in Australia, which may be due to increased testing for RV in the elderly post-vaccine. Reductions in the post-vaccination burden of RV and AGE among 60+ were reported in the UK (2 studies), and the US (2 studies) via retrospective database analyses In the UK, post-vaccine reductions in AGE health care-utilization were reported in the Emergency Department (21%), and outpatient centers (walk-in centers: 47%; general practice consultations: 36%). Retrospective database analyses documenting the incident rate ratio (IRR) of Rotavirus Gastroenteritis (RGE) and Acute Gastroenteritis (AGE) in older adults between the pre and post-vaccine period. Retrospective database analyses documenting the incident rate ratio (IRR) of Rotavirus Gastroenteritis (RGE) and Acute Gastroenteritis (AGE) in older adults between the pre and post-vaccine period. Conclusion While the burden of RGE mainly falls on young children, it also affects older adults. Retrospective database analyses reveal that, likely due to indirect vaccination benefits, increases in RV vaccination coverage have had an impact on lowering RGE, and AGE cases and healthcare utilization in older adults, a group at high-risk of severe outcomes for AGE. Disclosures Cristina Carias, PhD, Merck (Employee, Shareholder) Susanne Hartwig, n/a, MSD Vaccins (Employee) M.Nabi Kanibir, MD, Merck/MSD (Employee, Shareholder) Ya-Ting Chen, PhD, Merck & Co., Inc. (Employee, Shareholder)

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