Perinatal psychiatry on the maternity ward: PPP, OCD, lithium, and disposition (MEQ)

(i) PPP vs OCD and dual risk. The index patient has early puerperal insomnia without fatigue, pressure of speech, delusions about the infant being switched, and an attempt to leave with the baby — this is postpartum psychosis (emergency syndrome, often bipolar-related), not blues.^[1][2] Dual risk: maternal absconding/self-harm and infant harm or unsafe care; continuous safety plan, supervised infant contact if needed, same-day senior psychiatry.^[1][3] The neighbouring woman describes ego-dystonic harm images with checking and preserved intent not to act — perinatal OCD, managed differently (anxiety/OCD pathway), not as PPP, though distress and care impact still need support.^[5]

(ii) Acute management. Concurrent medical exclusion given recent pre-eclampsia: BP, neurology, metabolic and infection work-up for organic confusion while starting psychiatric containment.^[1][3] Secure setting, 1:1 nursing, sleep restoration, antipsychotic and/or lithium pathway per severity and prior response, short-term benzodiazepine for severe insomnia if obstetric/neonatal teams agree, and early ECT consideration if life-threatening or refractory.^[3][1] Use local mental health law only if criteria met; statutes are jurisdiction-specific.^[2]

(iii) Lithium. Stopping lithium at conception after prior postpartum mania removed prophylaxis in a high-risk woman (Wesseloo/Bergink risk framing).^[7][8] Patorno NEJM 2017: lithium associated with increased cardiac malformations with small absolute risk increase — counsel with shared decision-making, not slogans.^[4] Going forward (and for future pregnancies): antenatal written plan, peri-delivery dose/level strategy with fluid shifts, neonatal monitoring, and obstetric-neonatal coordination.^[4][2]

(iv) Disposition. Prefer mother-baby unit when available for joint admission and intensive parenting support while treating maternal illness (Australian MBU models described by Galbally et al.).^[6] Alternatives: psychiatric unit with supervised infant access, or only home intensive perinatal follow-up if dual-risk allows. Document overnight contingency, medication, sleep plan, and early review — highest intensity early postpartum for prior PPP.^[6][7][1]