Differentials
Minor mood disorder (postnatal blues or 'baby blues')
SIGNS / SYMPTOMS
Minor mood disorder causing transient emotional lability during the first week after birth is common, and has a wide variety of symptoms typical of low and high mood.[8][9][10]
Care of the baby is not impaired, hopelessness and worthlessness are not prominent, and women do not feel suicidal.[90]
Self-limiting, but assess to ensure that the woman is not and does not become more severely depressed.
INVESTIGATIONS
Clinical diagnosis.
Postnatal (puerperal) psychosis
SIGNS / SYMPTOMS
Women with a history of bipolar disorder (1 in 4 deliveries) or a previous puerperal psychosis (1 in 2 deliveries) are at considerably higher risk.[136][137][138][139] However, postnatal psychosis may occur in women with no past psychiatric history.
Acute onset of a manic or depressive psychosis soon after birth. There is a very close relationship to childbirth, with >90% of women experiencing an onset in the first postnatal week and 73% of women experiencing an onset of symptoms by day 3.[10][140]
INVESTIGATIONS
Clinical diagnosis.
Obsessive compulsive disorder
SIGNS / SYMPTOMS
Presence of obsessions, compulsions or both. Obsessions are defined by recurrent or persistent thoughts, urges or images that are intrusive or unwanted. Compulsions are repetitive behaviours that the individual feels driven to do in response to an obsession.[1] Childbirth can trigger or exacerbate obsessive-compulsive disorder (OCD). OCD can occur after childbirth, alone or in combination with other psychiatric disorders such as major depressive disorder.[141]
INVESTIGATIONS
Clinical diagnosis.
Bipolar disorder
SIGNS / SYMPTOMS
Suspicious features include atypical features (mood reactivity, weight/appetite increase, hypersomnia, leaden paralysis, and interpersonal rejection sensitivity), racing thoughts, and psychotic symptoms.[1][15]
Postnatal depression is very common in women with bipolar disorder; screen for bipolar disorder in all patients presenting with suspected postnatal depression.[14]
A family history of bipolar disorder may be present.
The Mood Disorder Questionnaire (MDQ) is the most useful test available for screening for bipolar disorder in perinatal women.[15][126] It incorporates all pertinent information included in the other scales, with the addition of an assessment of irritability and impulsive behaviour. However, it has not been definitively validated.
INVESTIGATIONS
Clinical diagnosis. Suspicion of bipolar disorder (+/- a positive screening result) indicates a need for further clinical assessment.
Thyroid dysfunction
SIGNS / SYMPTOMS
Possible symptoms of hyperthyroidism (e.g., weight loss, sweating, nervousness, palpitations) or hypothyroidism (e.g., sluggishness, constipation, cold intolerance).
The time frame for postnatal (painless/lymphocytic) thyroiditis, which is characterised by transient hyper- and hypothyroid phases, may overlap with that for postnatal depression, although no causal relationship has been established between the two conditions.[135]
INVESTIGATIONS
Thyroid-stimulating hormone low (hyperthyroidism) or high (primary hypothyroidism).
Anaemia
SIGNS / SYMPTOMS
Symptoms and signs include pallor, fatigue, weakness, decreased exercise tolerance, and shortness of breath with exercise.
Clinical features specific to the underlying cause may also be identified.
INVESTIGATIONS
Hb <12 g/dL in women.
Organic brain dysfunction
SIGNS / SYMPTOMS
Patients have clinical symptoms or signs of the underlying cause. Brain dysfunction may be due to primary cerebral or systemic disease.[130]
INVESTIGATIONS
Brain CT or MRI may identify a structural neurological abnormality.
Target other investigations to the suspected underlying cause.
Exogenous toxic substances or hormones
SIGNS / SYMPTOMS
History of therapeutic use and/or misuse of known causative substances or hormones.
Other symptoms and signs specific to the substance or substances involved may be present.
INVESTIGATIONS
Urine drug screen may be positive in substance misuse and identifies the substance taken. However, drug screens are not definitive for drug misuse.
Postnatal symptoms unrelated to depression
SIGNS / SYMPTOMS
Symptoms such as sleep disturbance, weight change, and loss of energy commonly occur following childbirth without any associated depression.
Characteristic mood changes of depression are absent.
INVESTIGATIONS
Clinical diagnosis.
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