Prevalence of postpartum psychosis among patients attending tertiary care institute of Bhuj, Kutch - A cross-sectional study

 

 

Abstract              Background: Postpartum psychosis (PP) is a severe psychiatric disorder which typically manifests within days of childbirth in a small proportion of women. Diagnosis of psychosis in pregnant women can be challenging because some of the diagnostic symptoms of psychosis overlap with the symptoms of normal pregnancy. The aim of the present study is to study the age, parity, socio-demographic and obstetric and menstrual profile of patients suffering from post-partum psychosis. Material and Methods: The present study consisted of 75 patients diagnosed using DSM-5 criteria and was selected from the patients admitted in the tertiary care institute of Bhuj, Kutch with psychiatric manifestations in post partum period. Detailed socio-demographic variables were recorded. Menstrual and obstetric history was obtained regarding number of conception and number of deliveries, menstrual regularity and obstetric complications. Results: Majority of study subjects (64.5%) were in the age range of 18-25 years. Around eighty percentages of women were residing at rural area. As to parity the maximum number of subjects was primipara (64%), II parity were (22.6%) and multipara (13.5%). History of cesarean delivery was in 24% of subjects. On menstrual history parameter 36% patient revealed irregular menstruation and remaining 64% subjects had regular menstruation. Conclusion: Post partum psychosis is a medical emergency case and it requires effective drug therapy and close monitoring of the patient. Primiparity, younger age, and irregular menstruation appear to be a significant risk factor. The effective patient counseling and Continuous close monitoring of the patient by the clinical pharmacist can make the patient free from psychotic symptoms and bonding with child by the mother can be increased markedly

Key Words: Bhuj, Cesarean, Menstruation, Postpartum psychosis

 

INTRODUCTION

Postpartum, psychosis (PP) is a severe psychiatric disorder which typically manifests within days of childbirth in a small proportion of women (1-2 in every 1000 new mothers).^1,2 They are commonly divided into three categories: the ‘baby blues’, postnatal depression, and postpartum (or puerperal) psychosis. The main symptoms of PP include hallucinations and delusions, cognitive disorganisation and confusion, anxiety and sleep problems; rarely, affected mothers may attempt to injure themselves or their child, with maternal suicide and infanticide observed in some cases. The single largest risk factor for PP is a personal, or family, history of bipolar disorder or related psychotic disorder. Other risk factors that have been suggested as modulators of PP risk include: Primiparity, maternal age, stress levels in the puerperium, and maternal sleep problems; It occurs in about1 in every 1000 women (0.1%) who have a baby.^5,6 The exact causes of post partum psychosis are not clear, but one is more at risk if she has a family history of mental health illness, particularly as already have a diagnosis of bipolar disorder or schizophrenia. Psychological stresses also contribute to this high psychiatric morbidity. Women with a history of manic, depressive illness, has a much higher risk of psychiatric admission. Among patients who developed post partum psychosis immediately after child birth. Symptoms vary and can change quickly includes high mood and racing thoughts (mania), depression, severe confusion, losing inhibitions, paranoia, hallucinations and delusions. in contrast to postpartum depression, adverse early-life events do not appear to significantly enhance risk of developing PP in women with bipolar disorder. The condition is associated with obstetric complications, notably pre-eclampsia,⁷ a potentially-damaging increase in maternal blood pressure. During this period many susceptible women may experience diverse range of mental health problems including Depression anxiety and psychosis.^5,6 Of these postpartum psychosis is severe form of mental disorder with incidence rate is approximately 0.1%.4,5 Post-partum psychosis is a medical emergency condition with risk for suicide and infanticide. Early detection and treatment of mental disorders are essential for family functioning and parent child relationship and prevention of various short term and long term complications.^8.9,10 Diagnosis of psychosis in pregnant women can be challenging because some of the diagnostic symptoms of psychosis overlap with the symptoms of normal pregnancy (e.g., sleep or appetite change, fatigue, decreased libido).¹¹ Initial evaluation requires a thorough history, physical examination and laboratory investigations to exclude an organic cause for acute psychosis. Important tests include a complete blood count (CBC), electrolytes, blood urea nitrogen (BUN), creatinine, glucose, vitamin B₁₂, folate, thyroid function tests, calcium, urinalysis and urine culture in the patient with fever and a urine drug screen. A careful neurological assessment is essential which includes a head CT or MRI scan to rule out the presence of a stroke related to ischemia (vascular occlusions) or haemorrhage (uncontrolled hypertension, ruptured arteriovenous malformation, or aneurysm).¹² Faster recognition requires good knowledge of illness. Thus, the observations of present study will help in enhancing the pool of knowledge regarding various risk factors associated with post partum psychosis, which would guide in searching of various etiological factors associated with post partum psychosis.

 

MATERIAL AND METHODS

The present study consisted of 75 patients diagnosed using DSM-5 criteria and was selected from the patients admitted in the tertiary care institute of Bhuj, Kutch with psychiatric manifestations in post partum period.

This study will include all women whose children are less 1 year old and they are over 18 years old. Women with having systemic diseases and who do not want to participate in the study were excluded.

Detailed socio-demographic variables were recorded. Menstrual and obstetric history was obtained regarding number of conception and number of deliveries, menstrual regularity and obstetric complications.

Statistical analysis

The recorded data was compiled and entered in a spreadsheet computer program (Microsoft Excel 2007) and then exported to data editor page of SPSS version 15 (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics included computation of percentages, means and standard deviations. For all tests, confidence level and level of significance were set at 95% and 5% respectively.

 

RESULTS

Majority of the our study subjects (64.5%) were in the age range of 18-25 years. Around seventy one percentage of puerperal psychosis were belonging to low socio-economic status and remaining to middle and high socioeconomic status. Majority of subject of post partum psychosis were house wife (84.9%) followed by laborer class (15.2%). Around eighty percentage of women were residing at rural area. Most of subjects of post partum psychosis were illiterate (78.46%). Table 1 describes the obstetric and menstrual history of Women suffering from post partum psychosis. As to parity the maximum number of subjects was primipara (64%), II parity were (22.6%) and multipara (13.5%). History of prolonged labour and post-partum haemorrhage was found in 6.6% and 8% of subjects respectively. History of cesarean delivery was in 24% of subjects. On menstrual history parameter 36% patient revealed irregular menstruation and remaining 64% subjects had regular menstruation.

 

Table 1: Obstetric and menstrual profile of women with post-partum psychosis (n=75)

DISCUSSION

Postpartum depression (PPD) is a major maternal health problem in the first year after giving birth. Post partum psychosis is a rare psychotic disorder in female patient after child birth. It should be treated as medical emergency and immediate treatment should be started. The present study was devised to investigate various socio-demographic and obstetric and menstrual variables of patients with postpartum psychosis. The present study indicates that most of the patients with post partum psychosis are younger age group. The majority of our subjects were in the age range of 18-25 years. Further as high as 60% patients developed psychosis between 18-25 years of age as compared to only 6.67 % above 35 years of age. This finding is consistent with other researchers.^13-15Various biological and psychological factors could be responsible for an early age presentation of post partum psychosis. Yet possibility that younger age group is more vulnerable to develop acute psychosis could be another reason. The larger number of our subjects belonged to low class family (73%). Our finding is similar to past studies conducted by other investigators. Even one study found that living in a poor neighborhood socioeconomic environment might contribute to the development of postpartum psychosis.¹⁶ Higher occurrence of post-partum psychosis in low socio-economic status may be due to various clinical variable viz poverty, long standing maladjustment of patient, unstable family environment, poor communication, malnutrition etc and requires further investigation. Majority of patients were housewives (86.67%) or labourer (13.33%). We could not observe any specific predilection of psychosis towards any occupational group. The large number of subjects hailed from rural area (83.33%) as compared to urban area (16.67%). This finding was similar to other studies.^17,18 Majority of patients were primipara (60%). Present study reveals that post partum psychosis is more common in primipara and this finding also gets support from earlier studies.^19,20 In this study if there is any previous history of miscarriage, the odds that such a female gets post-partum psychosis is 4.613 times higher than a female without a miscarriage. This result was comparable to similar finding of the previous study by Playfair and Gower (1981) but no such association was noticed by Kumar and Robson (1984) ²¹

 

CONCLUSION

Post partum psychosis is a medical emergency case and it requires effective drug therapy and close monitoring of the patient. Primiparity, younger age, and irregular menstruation appear to be a significant risk factor. The effective patient counseling and Continuous close monitoring of the patient by the clinical pharmacist can make the patient free from psychotic symptoms and bonding with child by the mother can be increased markedly.

 

REFERENCES

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