Postpartum psychosis — emergency assessment and treatment (MEQ)

(i) Working diagnosis and differentials. Working diagnosis: first-onset postpartum psychosis with manic/psychotic features in the early puerperium and bipolar-spectrum diathesis suggested by first-degree family history. Discriminators: day-7 onset, severe insomnia, delusional rejection of the infant, behavioural disinhibition. Differentials: bipolar I mania with postpartum trigger; organic (infection/delirium — afebrile here but still screen thyroid, metabolic, substances); substance-induced psychosis; severe postnatal depression with psychosis; primary OCD unlikely given ego-syntonic delusional conviction rather than ego-dystonic intrusion.[1]

(ii) Dual risk and setting. Assess maternal suicide/impulsivity/absconding risk and infant safety (delusional rejection, inadequate care, potential harm). Continuous observation; no unsupervised infant contact until risk reassessed. Prefer mother-baby unit if available and infant safety manageable jointly; otherwise general adult admission with written infant-care plan. Capacity assessment and local Mental Health Act least-restrictive process if she lacks capacity and refuses care — do not invent section numbers. Safeguarding liaison per jurisdiction.[5][1][7]

(iii) Acute treatment. Medical work-up (FBC, U&E, LFT, glucose, TSH, urine drug screen). Restore sleep with time-limited lorazepam 1–2 mg orally (or IM per protocol) with monitoring. Antipsychotic for mania/psychosis, e.g. olanzapine 5–10 mg orally at night, titrate toward 10–20 mg/day as tolerated with metabolic monitoring. Initiate lithium after renal/thyroid baselines, individualised dosing (often around 450–900 mg/day depending on formulation/renal function) aiming for therapeutic levels (commonly discussed ~0.6–1.0 mmol/L) with toxicity education. Lactation: individualised; safety may favour temporary formula while heavily sedated or lithium-treated. ECT if life-threatening severity, catatonia, poor intake, or non-response — high efficacy base in severe affective illness after consent and obstetric-anaesthetic liaison.[2][6][7]

(iv) Prognosis and next pregnancy. High acute remission rates with structured algorithms. Longitudinal course may be postpartum-limited in a subset or evolve multi-episode bipolar illness — counsel both. Recurrence risk in subsequent pregnancies is very high without planning. Preconception counselling, sleep plan, early-warning signs, and postpartum lithium prophylaxis decisions (Bergink high-risk prevention framing) coordinated with obstetrics. Partner education and MBU access plan.[2][3][4][8]