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Postpartum Depression

Depression Post Natal


Presentation

Symptoms can be different for different patients and usually show up within one year of childbirth. Maternity blues include emotional liability, irritability, mood swings, sleeplessness, sudden urge to cry and anxiety. These resolve spontaneously requiring no medication. These symptoms occur in varying degrees in most of the new mothers.

Along with above symptoms, there is a general loss of interest in daily activities along with a feeling of hopelessness so that it can be classified as Postpartum depression. Here the severity is more and along with these symptoms new mothers get thoughts of harming their babies, total lack of interest in baby and other negative thoughts. There may be loss of appetite and weight. Feelings of low self-esteem and self-worth will be prominent. In some cases onset maybe rapid and progressive.

Psychosis may occur in women with previous history of manic disorders. There is complete loss of contact with reality [5]. Delusions, hallucinations along with thoughts of killing might be there. Disorientation and confusion is marked. False ideas of new born baby being evil or deformed may be there as a result a want to kill may arise. This is a medical emergency which requires prompt treatment.

Palpitations
  • Frequent crying Irritability Low self-esteem Feeling exhausted Inability to concentrate Withdrawing from family and friends Feeling hopeless Losing interest in activities Anxiety attacks Panic attacks Headaches and chest pains Hyperventilation Heart palpitations[suicide.org]
  • Heart racing or palpitations 'Have you ever felt like your heart skipped a beat,' Jamie asked. 'Anxiety can cause both a racing heart and palpitations. When you’re really amped up, it can affect your heart, making it race, skip, or irregular.' 3.[dailymail.co.uk]
  • […] impaired concentration or memory; despondency or despair; thoughts of suicide; no feelings for the baby, or over-concern for the baby's health; guilt; panic attacks; feeling "out of control" or like you are "going crazy"; headaches; chest pains; heart palpitations[web.archive.org]
Osteoporosis
  • One of the clinical pictures related to physical complaints is osteoporosis in late pregnancy and lactation (PLO); this is a rare disorder, and its pathophysiology remains unknown.[ncbi.nlm.nih.gov]
  • Peggy Rice, Upender Mehan, Celeste Hamilton and Sandra Kim, Screening, assessment, and treatment of osteoporosis for the nurse practitioner: Key questions and answers for clinical practice—A Canadian perspective, Journal of the American Association of[doi.org]
Acute Low Back Pain
  • The authors report here a case of PLO and depression in a 35-year-old primiparous patient with acute low back pain and postpartum depression 4 weeks after caesarean section. Diagnosis was made by DXA scan and magnetic resonance imaging.[ncbi.nlm.nih.gov]
Restless Legs Syndrome
  • Our study demonstrated no significant association between Restless Legs Syndrome (RLS) during pregnancy and postpartum insomnia.[ncbi.nlm.nih.gov]
Feeling of Worthlessness
  • […] of worthlessness, shame, guilt, or inadequacy Difficulty in thinking clearly, concentrating, or making decisions Severe anxiety or panic attacks Thoughts of harming yourself or your baby Thoughts of death or suicide It is thought that between 3 and 6[psychcentral.com]
  • […] of worthlessness, and suicidal ideation.[britannica.com]
  • Along with a sad or depressed mood, you may have some of the following symptoms: Agitation or irritability Changes in appetite Feelings of worthlessness or guilt Feeling like you are withdrawn or unconnected Lack of pleasure or interest in most or all[nlm.nih.gov]
  • […] following symptoms are commonly present: Sad mood Loss of interest or pleasure in things that you normally enjoy Fatigue or loss of energy Appetite increase or decrease Sleeping too much or insomnia Feeling restless or as though you are slowed down Feelings[adaa.org]
Suicidal Ideation
  • A prospective study of thoughts of self-harm and suicidal ideation during the postpartum period in women with mood disorders.[doi.org]
  • ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide Footnotes[psychcentral.com]
Low Self-Esteem
  • Women go through emotional insecurity and anxiety which can lead to depression and low self-esteem. Coping with a newborn baby is physically, emotionally and mentally taxing for a new mother.[symptoma.com]
  • self-esteem Trouble managing stress Unrealistic ideas about motherhood Lack of sleep If the pregnancy was unwanted A complicated pregnancy Having a newborn with physical or behavioral problems New fathers can have postpartum depression, too.[web.archive.org]
  • Symptoms of postpartum depression include: Intense sadness Strong mood swings Frequent crying Irritability Low self-esteem Feeling exhausted Inability to concentrate Withdrawing from family and friends Feeling hopeless Losing interest in activities Anxiety[suicide.org]
  • These symptoms include, but are not limited to: Persistent sadness, anxiousness or "empty" mood Severe mood swings Frustration, irritability, restlessness, anger Feelings of hopelessness or helplessness Guilt, shame, worthlessness Low self-esteem Numbness[en.wikipedia.org]
  • self-esteem, negative feelings about the pregnancy, lack of sleep, financial concerns, premature or special needs child, multiple pregnancy, traumatic birth, chronic stress factors, and neurotransmitter deficiencies.[massagetoday.com]
Indecisiveness
  • […] pleasure in things that you normally enjoy Fatigue or loss of energy Appetite increase or decrease Sleeping too much or insomnia Feeling restless or as though you are slowed down Feelings of worthlessness or excessive guilt Difficulty concentrating or indecisiveness[adaa.org]
  • Postnatal depression in dads can show itself in different ways Symptoms can include: fear, confusion, helplessness and uncertainty about the future withdrawal from family life, work and social situations indecisiveness frustration, irritability, cynicism[nct.org.uk]
  • […] too much) nearly every day Psychomotor agitation or retardation nearly every day Fatigue or loss of energy nearly every day Feelings of worthlessness or excessive or inappropriate guilt nearly every day Diminished ability to think or concentrate, or indecisiveness[psychcentral.com]
  • […] observation of a depressed mood made by others Loss of interest or pleasure in activities Weight loss or decreased appetite Changes in sleep patterns Feelings of restlessness Loss of energy Feelings of worthlessness or guilt Loss of concentration or increased indecisiveness[en.wikipedia.org]
Anhedonia
  • As with other forms of depression, it is characterized by sadness and/or loss of interest in activities that one used to enjoy and a decreased ability to feel pleasure (anhedonia) and may present with symptoms such as cognitive impairment, feelings of[fda.gov]
  • Symptoms of major depression may include depressed mood, tearfulness, anhedonia, insomnia, fatigue, appetite disturbance, suicidal thoughts, and recurrent thoughts of death. [46] In the postpartum period, depression is characterized as intense sadness[emedicine.com]
Sexual Dysfunction
  • CONCLUSION: Midpelvic compared with low pelvic aOVD was not associated with an increase in sexual dysfunction, nor with symptoms of PPD at 6 months.[ncbi.nlm.nih.gov]
  • Adverse effects of the TCAs include sedation, weight gain, dry mouth, constipation, and sexual dysfunction.[emedicine.com]
Dysmenorrhea
  • In logistic regression model, endometriosis (OR, 1.27; 95%CI: 1.15-1.41), dysmenorrhea (OR, 1.13; 95%CI: 1.06-1.21) and abnormal uterine bleeding (OR, 1.21; 95%CI: 1.15-1.29) were associated with postpartum depression.[ncbi.nlm.nih.gov]
Lethargy
  • Nearly 6 percent to 9 percent of women develop PPT and manifest symptoms that can readily be construed as depression: fatigue, hair loss, depression, impairment of concentration, inability to lose weight, lethargy, and dry skin.[massagetoday.com]
  • […] present in human milk, exercise caution when administering to nursing women Plasma levels in breastfed infants are undetectable, one case of seizure in 6-month old infant5-HT 2A Receptor Antagonists Nefazodone * CPremature birth, infants drowsiness and lethargy[web.archive.org]
  • […] present in human milk, exercise caution when administering to nursing womenPlasma levels in breastfed infants are undetectable, one case of seizure in 6-month old infant5-HT 2A Receptor AntagonistsNefazodone * CPremature birth, infants drowsiness and lethargy[ncbi.nlm.nih.gov]
  • Table 4 lists the ACOG and AAP risk categories of commonly prescribed antidepressants. 62 Regardless of risk level, parents and clinicians should be attentive to symptoms of antidepressant toxicity in the infant, such as lethargy, irritability unresponsive[aafp.org]
Apathy
  • […] baby at night, even when the baby is asleep and you’re feeling exhausted difficulty concentrating and making decisions low self-confidence poor appetite (not eating enough) feeling very agitated or, alternatively, you can’t be bothered with anything (apathy[tommys.org]
  • A. if you feel you are not enjoying things you usually do, if you sit in a gloomy state at home, apathy to your child and maybe even wanting to harm him and you ,overwhelming fatigue, insomnia,loss of appetite. all this can lead to Postpartum depression[medical-dictionary.thefreedictionary.com]

Workup

Diagnosis cannot be reached by a single test. Diagnosis is done by a thorough medical, family and mental history. Complete assessment of patient’s background is done. Laboratory tests may be done to detect any hormonal imbalance [6].

Postpartum psychosis should be differentiated from maternity blues as the former affects daily functioning and can prove to be dangerous for both the mother and the baby.

Treatment

Treatment is an integration of physical, psychological, social and medical therapies. Hospitalisation should be done for potentially sucidal, severely depressed patients and in mania [7].

Medications along with psychotherapy prove useful and are the only treatment in most cases. Antidepressants such as selective serotonin reuptake inhibitors are given which are known to have lesser side effects. Hormone replacement therapy is given along with the above medications.

Counselling for both mother and partner go a long way in the treatment. Opportunities to express should be given to patients thus enabling to resolve minor episodes of depression. Reassurance along with family and social support helps the new mother to adjust to the changes in her life [8].

Prognosis

Patients with Postpartum depression have higher chances of getting some form of depression again at some point in their life. Relapse of this condition is very common. Children born to women with postpartum depression have a tendency to behavioural problems and difficult relationships.

Etiology

Numerous factors play a role in the etiology, but it varies from individual to individual. Social and psychological factors are known to play an important role, but there is no specific cause.
The most common theories postulated are:

  • Hormonal changes: Sudden drop in hormones post-delivery along with fluctuations in thyroid hormones that occur to every woman. These fluctuations result in changes in the body metabolism, which are thought to stimulate this condition [3].
  • Physical changes: Various physical changes along with significant physical trauma occur during pregnancy and childbirth. Women go through emotional insecurity and anxiety which can lead to depression and low self-esteem.

Coping with a newborn baby is physically, emotionally and mentally taxing for a new mother. Thus, interplay of above factors is supposed to be responsible for postpartum depression. There are a number of risk factors, women with previous history of depression, perinatal depression, premenstrual syndrome, birth related physiological or psychological trauma and poor family or marital relations.

Epidemiology

Although perinatal depression occurs, postpartum depression is more common. All over the globe, approximately 9-15% of women will experience postpartum depression. [4]

One in eight women will experience some form of depression post childbirth. Maternity blues occurs in 65 -90% of childbearing women. Severe types occur once in every 500-1000 births.

Postpartum depression is higher among poorer sections, teen pregnancies and women with poor family support. Depression occurs in fathers in about 1-25% cases. [2]

Sex distribution
Age distribution

Pathophysiology

Extreme physiological changes occur in a woman during pregnancy and childbirth. The exact pathogenesis is not known but hormonal irregularities along with abnormalities in hypothalamic-pituitary-adrenal (HPA) axis have been implicated.

Oestrogen and progesterone are steroid hormones derived from common fatty acids. Along with their reproductive function, they also display potent neuroregulatory effects, especially on mood and cognition. Irregularities in HPA axis also contribute to this condition.

Hormones have a striking effect on the HPA axis causing mood changes. The HPA under normal circumstances responds to stress and trauma by releasing cortisol along with negative feedback mechanisms, but in cases with severe depression the HPA axis reacts abnormally. Thus, the resulting inability to respond to periods of stress and trauma forms one of the most important biological finding in postpartum depression.

Prevention

Early diagnosis along with intervention helps prevent PPD. Patients with high risk factors should be educated about this medical condition. Counselling and support groups can also help.Homevisits along with family support [9] help reduce anxiety in new mothers.

Proper exercise along with diet should be given to women. Screening of high risk patient should be done. Family support and social support help in overcoming the depression [10].

Summary

Postpartum depression is a subtype of clinical depression which occurs to women after childbirth. The main trigger factor for this condition is childbirth. The onset of postpartum depression is within 4 weeks after delivery [1]. The severity of symptoms and duration determines the type of depression.

More than 80% cases are slow and gradual, starting within two weeks of delivery. This condition can happen even after a miscarriage or stillbirth.

Postpartum depression can affect normal functioning and have serious adverse effects on both the mother and the family. The symptoms range from mild to severe psychosis. Usually, every new mother will experience a certain level of anxiety, irritability, and sensitivity and mood changes post-delivery. These all resolve within 2-3 weeks, without any specific treatment. A more severe type of depression occurs late, often many weeks after childbirth, which is usually characterized by sadness, fatigue and depression. Recovery is within few months [2].

Patient Information

Postpartum depression is a common type of depression which occurs after childbirth. Depression can happen anytime during pregnancy but post childbirth is more common. About 15% women are affected, with this condition being more common in poorer people and broken families.

For a new mother, maternity blues are perfectly normal and usually settle down within a few days. This does not affect daily functioning of the mother. Hormonal changes are the supposed cause but the exact cause still remains unknown.

Normally, after having a baby, a woman will go through severe emotional turmoil along with mood swings, anxiety, sleeping disorders and concentration problems. There is no need to worry as they settle on their own without any treatment.

In case the severity as well as the duration of symptoms is greater, immediate attention needs to be given. Here symptoms can occur anytime from childbirth till one year of postpartum. Along with severe baby blue symptoms, patient may have negative thoughts towards the baby. Suicidal thoughts may prevail. The ability and desire to care for infant may be hampered.

Knowledge of risk factors is important for timely prevention. High risk factors include women with history of depression, depression during pregnancy, difficult pregnancies, poor family relations and various other factors.

The medical health provider will take a complete history of the patient, and after complete evaluation the treatment plan suiting the patient will be adopted. Anti-depressants are the medications of choice.

Counselling in the form of psychotherapy is very useful. Alternative modes of treatment like homeopathy or naturopathy might help. Family and social groups help the patients to come out of this condition. New mothers should take time out to relax, other than only tending to the baby. Good nutritious food along with exercise keeps the mother alert and fit.

There is no need for the patient to feel ashamed of the symptoms or guilty and it is best to consult a physician as soon as possible. Postpartum depression in does not indicate that the lady is a bad mother but it is a common condition.

If left untreated, it can interfere with normal functioning of mother. Thus, timely intervention will help the mother enjoy the bliss of motherhood.

References

Article

  1. Morof D, Barrett G, Peacock J, Victor CR, Manyonda I. Postnatal depression and sexual health after childbirth. Obstet Gynecol 102(6): 2003 Dec; 102(6):1318–25.
  2. Goodman JH. Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health. J Adv Nurs. 2004 Jan; 45 (1): 26–35.
  3. Hagen, Edward H (1999). The Functions of Postpartum Depression. Evolution and Human Behavior. 20 (5): 325–59.
  4. Segre, Lisa S.; O'Hara, Michael W.; Losch, Mary E. (2006). Race/ethnicity and perinatal depressed mood. .Journal of Reproductive and Infant Psychology. 24 (2): 99–106.
  5. Howell EA, Mora P, Leventhal H. Correlates of early postpartum depressive symptoms. Matern Child Health J. 2006 Mar; 10 (2): 149–57.
  6. Spinelli MG. Postpartum psychosis: detection of risk and management. Am J Psychiatry. 2009 Apr; 166 (4): 405–8.
  7. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987 June; 150 (6): 782–6.
  8. Beck CT. A meta-analysis of the relationship between postpartum depression and infant temperament. Nurs Res. 1996 Jul-Aug; 45 (4): 225–30.
  9. Kruckman, Laurence (1999). Rituals as Prevention: The Case of Postpartum Depression. In Heinze, Ruth-Inge. The Nature and Function of Rituals: Fire from Heaven. (pp. 213–28). Greenwood Publishing.
  10. Hoffman, Yonit; Drotar, Dennis. The impact of postpartum depressed mood on mother-infant interaction: Like mother like baby? Infant Mental Health Journal. 1991; 12: 65–80.

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Last updated: 2019-07-11 20:57