Postpartum psychosis

Introduction to postpartum psychosis Postpartum psychosis is a severe mental and behavioral disorder associated with the puerperium. Its clinical features are insanity, acute hallucinations and delusions, polymorphic course of depression or madness, and symptom variability. Postpartum psychosis is most common within 7 days after delivery. It is mainly caused by women who have maternity, many children and low socioeconomic class at the beginning of the new year. Most of these cases are sudden onset and have dramatic psychotic symptoms. As early as the end of the 19th century, it was discovered that mental illness was a mental disorder during the puerperium period and has recently received much attention. Nott studied women who gave birth in Sonthampton, England, from 1966 to 1967, and found that patients who had psychological counseling due to special psychological problems increased significantly 16 weeks after delivery. This was confirmed by studies by Kendall et al. He found that women with postpartum psychosis were significantly more likely than prenatal and non-pregnant women. basic knowledge The proportion of illness: 0.002% - 0.004% Susceptible people: good for postpartum women Mode of infection: non-infectious complication:

Causes of postpartum psychosis

(1) Causes of the disease

The exact cause of postpartum psychosis is still unclear. Many studies have suggested that the related factors of the disease are related to the combined effects of physiological, psychological and social factors.

Biological factors

(1) The change of hormone level in postpartum is the biological basis of its occurrence. After delivery, the fetal placenta is delivered, the blood estrogen and progesterone levels decrease rapidly, and the non-pregnancy level can be reached within 1 week after delivery. This physiological characteristic is exactly the same. The peak period of PPD is consistent. Recently, some scholars have adopted a small dose of estrogen and progesterone to prevent and cure PPD, which will help to study its pathogenesis.

(2) Studies have shown that postpartum HCG levels are significantly decreased, prolactin levels rise rapidly, hypothalamic-pituitary-adrenal axis function changes, and hypothyroidism is associated with postpartum PPD.

(3) Another study found that serotonin, norepinephrine, dopamine levels are associated with postpartum depression, and this increase in neurological dysfunction is associated with postpartum mania, and that postpartum -endorphin declines rapidly Elevated 2-adrenergic receptors are also associated with postpartum depression.

(4) The factors of childbirth: prolonged labor, birth forceps, cesarean section, postpartum hemorrhage, infection, lactation deficiency or neonatal factors such as low birth weight, neonatal asphyxia, complications and mergers during pregnancy and childbirth The incidence of postpartum depression is also increasing.

2. Psychological factors study found that women have psychological changes during pregnancy and childbirth, emotional vulnerability, strong dependence and other changes, so all kinds of stimulation during pregnancy and childbirth may cause psychological abnormalities, in addition to the above factors, unplanned pregnancy, for childbirth Anxiety, fear, the health of the baby, the unwillingness of the baby's gender, and the anxiety of becoming a mother to care for the child can cause psychological stress.

3. Social factors Research at home and abroad shows that marriage breaks down or is tense, couples are separated, families are not harmonious, life is difficult, lack of care and help from husband and family and society, low level of education, and low perinatal health care services may be PPD. The cause of the disease.

(two) pathogenesis

According to the study, postpartum psychosis and family history of bipolar disorder, history of bipolar disorder, primipara, and poor husband support, explain the pathogenesis and genetics of postpartum psychosis, psychosocial factors, personality defects, physical factors and Postpartum accumulation of hormonal changes, some people believe that forced personality and immature personality women are prone to post-production psychosis, Wieck et al (1991) proposed an endocrine mechanism, found to some extent can be predicted by postpartum morphine thorn test, Postpartum dehydration morphine experiments showed that women with increased hormone secretion were most likely to develop post-production psychosis, but the experiment was not taken seriously by Meakin et al. (1995).

Postpartum psychosis prevention

1. General prevention of mental disorders

(1) Strengthening pre-marital health care: Through various forms of health education before marriage, young people who want to marry can understand sexual physiology, sexual psychology, sexual health; plan for pregnancy and correct choice of contraceptive methods; pregnancy care, neonatal care and affecting male and female marriage and childbirth Medical knowledge such as common diseases and genetic diseases, pre-marital health care has a positive effect on improving women's reproductive health self-care awareness and ability, and it has played a positive role in controlling married couples with scientific contraceptive methods and reducing unplanned pregnancy.

(2) Carrying out psychological health care during pregnancy and maternity: maternal mental health care has become an important part of perinatal care. Prenatal examination should include psychological guidance and counseling routinely; it should be told what maternity women may encounter during pregnancy and childbirth. The psychological barriers enable them and their families to raise their cognition and identify abnormalities early; if abnormalities are found, they should be reported to the physician early, seek help and cooperate well with the physician during treatment; pay attention to the understanding of the predisposing factors, Screening for pregnant women with various risk factors for psychological disorders to give special intervention, of course, must include family assistance including the patient's husband, it is not uncommon for people with mental disorders to conceal their diseases to the end of pregnancy, which is not unusual. The patient's nervousness is an important cause of recurrence. The patient's husband or relatives should be instructed by the doctor together with the patient to fully understand the condition to avoid unnecessary mental stress and are willing to say changes in body and mind. Postpartum, especially the care of the baby. Became the cause of the disease, so it is very important to reduce the burden on the patient through family assistance. Period of physiology, psychological knowledge and main health care content, introduce the advantages and disadvantages of normal childbirth and different methods of delivery, especially for vaginal midwifery surgery, so that maternal elimination of mysterious fear of childbirth, improve They understand the level of cognition and mental health of the natural biological processes of pregnancy and childbirth, treat them with optimism and actively cooperate with childbirth, strengthen the health care during birth, carry out Doula delivery accompanied by experienced midwives, and help pregnant women to eliminate psychological problems in time. Eliminate negative emotions, continue to give maternal physiological and psychological scientific support, make their body and mind in the best state, is conducive to safe childbirth, actively carry out puerperal health care, pay attention to postpartum mental and psychological care and scientific baby care guidance, so that they are good The mentality assumes the role of a mother and can prevent the occurrence of mental illness.

(3) Popularization and promotion of family-based Doula delivery: no special care, accompanied by concentrated hospital delivery, making pregnant women feel strange, lonely and nervous and disturbed. In recent years, more and more scholars have paid attention to the impact of the surrounding environment on women. In particular, the problem of obstetric intervention rate caused by psychological factors is raised. Jin Hui et al (1996) psychological analysis of pregnant women shows that 93% of pregnant women expect to be accompanied by relatives during childbirth. Many studies have shown that a clean and comfortable family-based maternity ward To make pregnant women hospitalized, accompanied by husband or family members during childbirth, can increase their psychological support and security, invisible power to strengthen maternal self-confidence and patience, companion to give maternal care, care, touch, comfort, maternal mood Stable, good use of uterine contractions, rest time, physical exertion reduction, in order to facilitate smooth delivery and postpartum recovery, family wards are in line with the psychological needs of pregnant women, while perinatal health workers should completely change the perspective of pure medical services, Further improve the quality of perinatal care services, improve service attitudes, and pay attention to their psychological state Pay attention to spiritual encouragement, comfort and care, establish a good doctor-patient relationship, choose the best treatment plan for mother and baby, and provide them with a good service environment, especially after delivery, and provide services equipped with specialized midwifery Doula to accompany childbirth. Eliminate the fear, anxiety and exhaustion of their mothers to reduce the incidence of complications and psychological abnormalities.

(4) Promoting breastfeeding: Most mothers in the early stage of calving spend in the hospital, early sucking in the obstetrics, maternal and child room, and responsible care all paved the first step for successful breastfeeding, but above maternal Emotions can have a negative effect on milk secretion, affecting milk secretion, which in turn affects the health of newborns, aggravates the psychological barriers of mothers and becomes a vicious circle. In breastfeeding, mutual care and encouragement between nursing mothers is also required. Practice has proved that the mother-infant room has a higher success rate than the family-based training room. The important reason is the mutual care and encouragement between mothers and mutual exchanges. The implementation of maternal-infant room and breastfeeding is a continuation of maternal-child interdependence. When breastfeeding infants Inter-communication, influence and role can promote mother-child interaction, foster early mother-child exchanges and avoid feelings of coldness. At present, we have established a baby-friendly hospital in China, and the promotion of breastfeeding has been very successful. Good results, continued protection, promotion and support for breastfeeding can help prevent postpartum depression.

(5) Improve perinatal health care services: With the development of new medical models, research on prevention and treatment of health and disease related to psychosocial factors in perinatal care must also be included in the agenda. Perinatal health workers should master maternal psychology. Knowledge, improve psychological counseling and psychological nursing skills, pay attention to the characteristics of maternal psychological activities, correctly recognize, recognize their feelings, exert language effects, use sincere words, soft tone, patiently listen to their complaints, give spiritual comfort and encouragement, Pay attention to early identification of predisposing factors, take effective health care measures, relieve their concerns and mental stress, train community maternal and child health care personnel, master the appropriate techniques for predicting maternal emotional state, and improve their ability to screen and manage high-risk groups of postpartum depression.

(6) Cooperate with psychiatrists: While instructing patients to adhere to psychiatric treatment, gynaecologists should keep in touch with psychiatrists as needed to grasp the patient's personality and condition and find early recurrence of the disease. Once relapsed, the patient should be moved to a suitable place (in his or her home or hospital, etc.), and the psychologist should be promptly treated for psychological and medical treatment and relieved of the burden of childcare.

2. Psychological intervention according to various maternal psychological factors or risk factors will help reduce the occurrence of PPD.

(1) Improve the childbirth environment, establish a family-based delivery room to replace the previous closed-type delivery room, improve the maternal understanding of the natural process of childbirth, carry out guided delivery, accompanied by husband or other relatives after labor, can reduce its complications And the occurrence of psychological abnormalities.

(2) Pay attention to the health care during puerperium, especially the maternal mental health care. For women who have long delivery time, dystocia or have adverse pregnancy outcomes, they should give priority psychological care, pay attention to protective medical care, avoid mental stimulation, implement maternal and child room, encourage guidance. Breastfeeding, and do a good job in the health care of newborns, reduce the physical and psychological burden of the mother, counsel the maternal family to do a good job in maternal and newborn health care during the puerperium, and have a history of depression or maternal depression. Pay enough attention, identify the identification in time, and properly handle it to prevent postpartum depression.

(3) The perinatal health care work should pay attention to active medical services, master the characteristics of maternal psychology and psychological counseling skills, improve service skills and quality, and pay attention to the psychological health care work of the maternal perinatal period.

Postpartum psychotic complications Complication

Depression: Psychiatric patients may experience depression and even pessimism during different periods of the disease. It is particularly important to note that a significant proportion of patients who succeed in suicide commit suicide during the recovery period of the disease. After the patient's symptoms of psychosis were eliminated, the patient's illness was burdened with heavy thoughts, and he could not correctly treat the practical problems of further studies, employment, marriage, etc., and felt that there was no way to go, so he chose to be suicidal. In this regard, family members must prevent problems before they occur, and should first discover the psychological distress of the patients and promptly guide them.

Extremely excited: the patient's mental symptoms are characterized by severe mental disorders, disorganized speech, and lack of purpose. These patients may also be self-injured or injured. Since the patient's excitement is persistent, the family has sufficient mental preparation and is generally easier to prevent. Family members should keep their dangerous tools such as knives, scissors, fire, gas, etc., but the most fundamental method is to use large doses of drugs with strong sedative effects to control the excitement of patients.

Symptoms of postpartum psychosis Common symptoms Mental disorders Pathological arson Anxiety puerperium Mania puberty Stage State puerperium Illusion Delusion state Depression Insomnia Thinking disorder Suspicion

Common symptoms are characterized by a strong concern for one's own children or excessive anxiety about the health of the baby. Of course, this is also the case in some normal mothers. Clinical experience shows that postpartum psychiatric patients who murder their children usually have abnormal concerns. Or the prodromal symptoms of behaviors that worry about the health of their children can be seen as an increase in the number of pediatric emergency cases, and they are extremely uncertain about the health of their children when they seek medical treatment, but they cannot detect any abnormalities in the examination of the baby, but The mother will continue to feel "the baby has some problems; the baby's breathing is not normal; the baby's face does not look right", this mother will continue to seek medical care, and feel more and more worried about the child's health, sometimes It will soon develop into paranoia, imagining that the baby is very ill and even dying. Many mothers will develop into paranoia. It is easy to miss these early symptoms during the development of this disease, especially when it is not for the baby. It is difficult to find out that the mother is sick when she is with the same doctor.

Whether the psychological reaction after childbirth represents a unique spiritual category is still controversial. The symptoms and signs of the whole body are the same as those of non-pregnancy psychosis, but the frequency of symptoms is different. Most postpartum psychotic patients are mad and depressed, and the prominent clinical manifestations are confused. And disorientation, and postpartum mental disorders have a better prognosis than non-postpartum psychosis, and the course of disease lasts for 2 to 3 months.

At present, the biggest problem of mental illness in puerperium is whether it should be distinguished from other mental illness as an independent disease. Many scholars believe that it should not be separated, although its situation is special, and there are significant psychodynamic conflicts and anxiety. The goals are usually around newborns, but the symptoms and signs of psychiatric psychosis are the same as those of non-puerperal psychiatry, but there are still a few scholars who believe that it is a disease different from other psychiatric diseases.

The classification of postpartum depression has not been unified internationally. At present, most scholars divide PPD into postpartum depression, also known as postpartum depression and postpartum psychosis.

1. Postpartum depression refers to a transient crying or depression in the 7 days after birth, the incidence rate is 3.5% to 33.0%, and the Beijing area is 11.4% to 17.9%. The difference in incidence is due to the cultural background of each country. Due to different social conditions and diagnostic criteria, the main clinical manifestations of postpartum depression are sadness, depression, crying, loneliness, anxiety, fear, irritability, self-blame, low ability to perform, unable to perform the duties of the mother, and life. Lack of confidence, etc., accompanied by physical symptoms such as dizziness, insomnia, loss of appetite, decreased libido.

2. Postpartum psychosis is a severe mental disorder and behavioral disorder related to the puerperium. The incidence rate is 0.1% to 0.2%. Most of the cases occur within 7 days after delivery. The clinical features of postpartum psychosis are mental disorders, acute hallucinations and delusions, severe depression and The morphological course and symptoms of arrogant crossover are complex and variability, and its biological characteristics are sleep disorders and dietary changes.

1. Factors of personality, social adversity, tension between mother-in-law and mother-in-law, deterioration of marital relations, and even breakdown of marriage, economic difficulties, and poor housing conditions.

2. The medical history should be asked in detail about the patient's age, pregnancy, parity, pregnancy history, mental family history, and physical and psychological stress on the pregnant woman. The occurrence of this disease is related to mental stimulation. Common psychological stress: pregnancy, complication of labor, complications, depression of childbirth, fear, stillbirth, infant deformity, infant gender is not as good as hope, and patients have physical illnesses and so on.

3. Clinical manifestations

(1) Incidence: Most puerperal psychiatric diseases occur in the first two weeks after delivery, but any degree of mental illness may occur within 6 weeks after delivery. Many prodromal symptoms occur on the third day after childbirth. Some scholars have found mild mentality. Disorders occur on days 3 to 4 after delivery, with moderate depression and anxiety between delivery and the sixth week after delivery, and mental illness can occur anywhere after delivery to six months.

(2) Types of mental illness during puerperium: The clinical symptoms are complex, and it is difficult to distinguish the type of disease. Many reports are not classified according to the disease unit, but according to the combination of disease symptoms, the performance of mental illness during puerperium usually includes emotional, schizophrenic and other organic factors. Changes, but with the advancement of obstetric diagnosis and treatment, organic problems have been rare. Large-scale studies have found that the most common forms of psychiatric illness include severe depression and schizophrenia, and depression accounts for the vast majority. However, some American studies have found that schizophrenia is the main type, while in the UK, the problem of emotionalization is the overwhelming majority. This may be related to different diagnostic criteria. The clinical symptoms of postpartum psychosis are complex. Several states:

1 Depression state: It is the most common type of postpartum psychosis. It occurs more than 7 days after birth. The incidence is closely related to psychological factors, mainly characterized by low mood, pessimistic disappointment, sadness, anxiety, anxiety, and reluctance to contact with the outside world. When the condition worsens, depression, self-esteem, self-blame, self-sin, showing the compulsive fear of the newborn or the disgust of the newborn, and even the idea of killing the baby,

2 status: The onset is mostly in the early postpartum period. In the early stage, there may be insomnia, irritability, emotional instability, loss of appetite, etc., and later develop into a worry about the newborn, irritability, suspicion, and then soon obvious mental exercise Excitement, confusion, accompanied by various hallucinations, hearing the baby crying and others talking about her, can not care about the newborn, but also the danger of killing the baby,

3 Manic state: 1 to 2 weeks postpartum onset, manifested as sleepless, excited multilingual, active, singing, high mood, good boast of yourself, staying up all night, energetic, memory enhanced, self-feeling, manic After the state is calm, it can develop into a state of depression, so it is also called a state of depression.

4 hallucinations delusion state: most acute or subacute onset after childbirth, emotional symptoms are obvious, delusional content is fluctuating and owing to the system, there is a relationship of illusions, delusions, yelling, behavioral solitude, wounding, etc., similar Schizophrenia-like status, domestic data show that most acute onsets, foreign literature reports, more intense and youthful,

5 Reactive psychosis: performance anxiety, nervousness, gibberish, lack of consciousness, disorientation, repeated illusions and hallucinations, etc.

6 Infectious psychosis: clinical symptoms have high fever, conscious or paralyzed state, unclear language, disorientation, behavioral disorder, and sometimes muttered to himself.

The early manifestations of post-partum depression are difficult to distinguish from mother depression, but if a suicidal tendency or attempt or delusion occurs, it can be diagnosed as postpartum psychosis.

4. Physical examination includes general examination, obstetric examination and laboratory examination to rule out mental disorders associated with serious physical and brain diseases.

5. Psychological test There is no special psychological scale for assisting diagnosis of postpartum psychosis at home and abroad, but you can refer to the following psychological scale:

(1) Minnesota multiphasic personality inventory (MMPI): This table has been revised and widely used in China.

(2) Symptom rating scale: There are currently 90 symptom self-rating scales (symptom checklist-90, SCL-90), self-rating depression scale (SDS), anxiety self-rating scale (self-rating anxiety scale, SAS), etc., to understand the emotional state of the patient.

(3) Event rating scale: The life event scale (LES) is a widely used scale. The perinatal stress scale (PSS) is actively explored at home and abroad. The scale.

Postpartum psychiatric examination

1. Includes systemic examinations, obstetric examinations, and laboratory tests to rule out mental disorders associated with serious physical and brain diseases.

2, psychological test At present, there is no special psychological scale for assisting diagnosis of postpartum psychosis at home and abroad, but you can refer to the following psychological scale:

(1) Minnesota multiphasic personality level MMPI: This table has been revised and widely used in China.

(2) Symptom rating scale: There are currently 90 symptom self-rating scales (symptomchecklist-90SCL-90), self-rating depression scale (SDS), self-rating anxiety scale (SAS). Etc. to understand the emotional state of the patient.

(3) Incident Rating Scale: The life event scale (LES) is a widely used scale perinatal stress scale (PSS) that is actively explored at home and abroad. According to the risk factors, medical history and clinical features of the onset time, and comprehensive analysis of the systemic and obstetric examination laboratory tests and auxiliary psychological tests, the diagnosis can be correctly diagnosed. There are mainly the following methods for measuring and standardizing maternal behavior:

1 Minnesota Multi-Phase Personality Questionnaire (MMPI), which includes marriage, family social and physical and mental aspects, is used to assess maternal personality aptitude and susceptibility to mental illness;

2 The Edinburgh Postnatal Depression Scale (EPDS) is particularly suitable for the detection of postpartum depression. It mainly assesses low mood, lack of anxiety and sleep disorders, and is simple and easy to have satisfactory sensitivity and specificity;

The 390 Symptom Checklist 90 (SCL-90) Depression and Anxiety Self-Assessment Scale (SDS, SAS) was used to measure maternal emotional status and extent; 4 Life Events Scale (LES) applied more perinatal stress The Rating Scale (PPS) is actively exploring the use of the two scales to measure the psychological stress caused by events related to negative life events and emergency response to pregnancy and childbirth. Multidimensional evaluation of the factors causing adverse causes of obstetric factors and social support influences.

Diagnosis of postpartum psychosis

Diagnostic criteria

According to the onset time, relevant risk factors, medical history and clinical features, and comprehensive analysis of systemic and obstetric examinations, laboratory examinations and auxiliary psychological tests, it is necessary to correctly diagnose, and the current methods for quantitative and standardized evaluation of maternal behavior are mainly There are the following:

1 Minnesota Multi-Phase Personality Questionnaire (MMPI), which covers marriage, family, social and physical and mental aspects, and is used to assess maternal personality aptitude and susceptibility to mental illness;

2 Edinburgh Postnatal Depression Scale (EPDS) is particularly suitable for the detection of postpartum depression, mainly to assess low mood, lack of pleasure, anxiety and sleep disorders, simple and easy, with satisfactory sensitivity and specificity;

390 Symptom Checklists (SCL-90), Self-rating Depression and Anxiety Scale (SDS), used to measure maternal emotional status and extent;

4 The Life Events Scale (LES) is widely used, and the Perinatal Stress Rating Scale (PPS) is actively explored and used at home and abroad. The two scales can be used to measure negative life events and emergency related events of pregnancy and childbirth. The magnitude of psychological stress, multidimensional evaluation of pathogenic causes, adverse obstetric factors and the impact of social support.

Differential diagnosis

The most important feature of puerperal psychosis is the emergence of pathological thinking. According to the time of onset, the characteristics of thinking, combined with the psychiatric scale can make a diagnosis, and distinguish it from other puerperal mental disorders. Once the diagnosis of puerperal psychosis is made, both patients and their families will It has a great impact, so the diagnosis should be extremely cautious and consulted by a psychiatrist if necessary.

Postpartum depression often occurs within 2 weeks after delivery, and the symptoms are obvious after 4 to 6 weeks of labor. The clinical manifestations are the same as those of postpartum depression syndrome, but the degree is more serious, even the tendency of suicide or infant injury, the total score of Edinburgh postpartum depression scale Additions of 13 points can be diagnosed as postpartum depression; the American Psychiatric Association (1994) can also be used to identify the diagnostic criteria for postpartum depression in the book Diagnostic and Statistical Manual of Mental Disorders.

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