Puerperal Psychosis (Postpartum Psychosis)
Summary
Puerperal (postpartum) psychosis is a severe psychiatric emergency occurring within days to weeks of childbirth, affecting approximately 1-2 per 1000 deliveries. It represents the most severe form of perinatal mental illness and presents with sudden onset of psychotic symptoms — mania, delusions (often about the baby), hallucinations, and confusion. The condition is a psychiatric emergency due to the significant risks of suicide and infanticide. Women with bipolar disorder have up to 50% risk of puerperal psychosis. Immediate admission to a Mother and Baby Unit (MBU) is the gold standard to keep mother and baby together while ensuring safety. Treatment includes antipsychotics, mood stabilisers (lithium), and sometimes ECT.
Key Facts
- Incidence: 1-2 per 1000 deliveries
- Onset: Days 3-14 postpartum (usually very sudden)
- Features: Mania, Psychosis, Delusions about baby, Rapidly fluctuating
- Risk Factors: Bipolar disorder (50% risk!), Previous puerperal psychosis, Family history
- Emergency: High risk of suicide and infanticide
- Admission: Mother and Baby Unit (MBU)
Clinical Pearls
"Bipolar = 50% Risk": Women with bipolar disorder have a 1 in 2 chance of puerperal psychosis. Pre-delivery planning is essential.
"Very Sudden Onset": Unlike postnatal depression, puerperal psychosis develops within days, often dramatically.
"Keep Mother and Baby Together": Admission to a Mother and Baby Unit is the gold standard. Separation increases psychological harm.
"ECT Saves Lives": Electroconvulsive therapy is highly effective and may be life-saving in severe cases.
Incidence
- 1-2 per 1000 deliveries
Risk Factors
| Factor | Risk |
|---|---|
| Bipolar disorder | 50% risk |
| Previous puerperal psychosis | 50-80% recurrence |
| Family history of puerperal psychosis | |
| Primiparity | First pregnancy slightly higher risk |
| Sleep deprivation | Precipitant |
Timing
- 50% onset within first week
- Peak: Days 3-7 postpartum
Proposed Mechanisms
- Rapid hormonal shifts (Oestrogen, Progesterone drop)
- Sleep deprivation
- Immune dysregulation
- Genetic vulnerability (especially bipolar)
Relationship to Bipolar
- Puerperal psychosis is closely linked to bipolar disorder
- May be first presentation of bipolar
- Similar phenomenology (mania, mixed states)
Features
| Feature | Description |
|---|---|
| Mania | Elevated mood, Increased energy, Reduced sleep |
| Psychosis | Delusions (often about baby — "baby is evil/special"), Hallucinations |
| Confusion | Disorientation, Perplexity |
| Rapid fluctuation | Symptoms change quickly (hour to hour) |
| Agitation or stupor |
Red Flags
| Risk | Concern |
|---|---|
| Suicide | High risk — always assess |
| Infanticide | Rare but devastating — delusions may involve baby |
| Command hallucinations | To harm self or baby |
Mental State Examination
- Appearance: Dishevelled, Poor self-care
- Behaviour: Agitated, Restless, or Withdrawn
- Speech: Rapid, Pressured, or Slow
- Mood: Elated, Labile, or Depressed
- Thought: Delusions (often related to baby), Thought disorder
- Perception: Hallucinations (auditory, visual)
- Cognition: Disoriented, Confused
- Insight: Often poor
Risk Assessment
- Suicide risk: Always assess
- Risk to baby: Delusions about baby, Neglect, Infanticide
Exclude Organic Causes
| Test | Purpose |
|---|---|
| FBC, U&Es, LFTs | General screen |
| TFTs | Hypothyroidism/Hyperthyroidism |
| Calcium | Hypercalcaemia |
| Blood glucose | Hypoglycaemia |
| Infection screen | Urinalysis, CRP, Septic screen |
| Drug screen | Illicit substances |
| CT/MRI head | If neurological signs or first presentation |
Management Approach
┌──────────────────────────────────────────────────────────┐
│ PUERPERAL PSYCHOSIS MANAGEMENT │
├──────────────────────────────────────────────────────────┤
│ │
│ THIS IS A PSYCHIATRIC EMERGENCY │
│ │
│ ADMISSION: │
│ • Mother and Baby Unit (MBU) — IDEAL │
│ • Keep mother and baby together if safe │
│ • General psychiatric ward ONLY if MBU unavailable │
│ • Baby safety must be ensured │
│ │
│ PHARMACOLOGICAL: │
│ • Antipsychotics (Olanzapine, Risperidone, Haloperidol) │
│ • Mood stabilisers (Lithium — effective in puerperal │
│ psychosis; Discuss breastfeeding risks) │
│ • Benzodiazepines (short-term for agitation/sleep) │
│ • ECT — Highly effective; Consider early if severe │
│ │
│ SUPPORTIVE: │
│ • Close 1:1 nursing observation │
│ • Partner and family involvement │
│ • Breastfeeding support (balance with medication) │
│ │
│ POST-DISCHARGE: │
│ • Perinatal mental health team follow-up │
│ • Long-term mood stabiliser (if bipolar) │
│ • Future pregnancy planning (HIGH recurrence risk) │
│ │
└──────────────────────────────────────────────────────────┘
Immediate
- Suicide (Risk is HIGH)
- Infanticide (Rare but devastating)
- Severe self-neglect
- Damage to mother-infant bonding
Long-Term
- Recurrence in future pregnancies (50-80%)
- Chronic psychiatric illness (Bipolar disorder)
Short-Term
- Most recover fully within weeks to months with treatment
- ECT may accelerate recovery
Long-Term
- 50% develop bipolar disorder
- 50-80% recurrence in subsequent pregnancies
Future Pregnancies
- Pre-pregnancy planning ESSENTIAL
- Prophylactic lithium or antipsychotic advised
Key Guidelines
- NICE CG192: Antenatal and Postnatal Mental Health
- MBRRACE-UK: Maternal Mortality Reports
Key Evidence
ECT
- RCT evidence supports early use in severe cases
Lithium Prophylaxis
- Reduces recurrence in future pregnancies
What is Postpartum Psychosis?
Postpartum psychosis is a rare but serious mental illness that can happen in the first few days or weeks after having a baby. It causes symptoms like confusion, unusual beliefs (delusions), mood swings, and sometimes seeing or hearing things that aren't there.
Who is at Risk?
- Women with bipolar disorder (1 in 2 risk)
- Women who have had postpartum psychosis before
- Women with a family history of postpartum psychosis
Is It Dangerous?
Yes, it is a psychiatric emergency. There is a risk of harm to both the mother and the baby. That's why it's so important to get help immediately.
What is the Treatment?
- Admission to hospital — ideally a Mother and Baby Unit so mum and baby can stay together safely
- Medication — antipsychotics, mood stabilisers
- ECT — in severe cases, this can be very effective
- Support — from mental health professionals and family
Will I Recover?
Yes, most women make a full recovery. However, the condition can come back in future pregnancies, so planning ahead with your doctor is important.
Primary Guidelines
- NICE. Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance (CG192). 2014. nice.org.uk/guidance/cg192
Key Studies
- MBRRACE-UK. Saving Lives, Improving Mothers' Care. 2023.