Organic prepartum and postpartum psychoses

There are many distinct forms of psychosis which start during pregnancy (prepartum) or after delivery (postpartum). In Europe and North America, only one – acute postpartum bipolar or polymorphic psychosis (postpartum psychosis)– is commonly seen. But, in times past, about one quarter of psychoses after childbirth were 'organic'.^[1] This means that a severe mental disturbance, usually in the form of delirium, develops as a complication of a somatic illness.^[2] The organic psychoses of childbearing will now be summarized, starting with two seen during pregnancy, followed by at least ten that begin after delivery. Those that occur during delivery itself will be described under a separate Wikipedia entry on the psychiatric disorders of childbirth.

Chorea psychosis

Sydenham's chorea has a number of psychiatric complications - character change, depression, Tourette's syndrome,^[3] hypnogogic hallucinations,^[4] defect states and acute psychosis.^[5] Chorea gravidarum is a severe variant, and most patients have one form or another of these mental changes. In the past, this form of chorea has been due to streptococcal infections, which are now usually controlled by antibiotics. But it still occurs as a result of systemic lupus or anti-phospholipid syndromes. Nevertheless chorea psychoses are very rare, with only about 50 prepartum cases reported in the literature. Occasionally they can break out after delivery, or after a termination of pregnancy.^[6]

Wernicke-Korsakoff psychosis

A severe mental disorder was described by Wernicke ^[7] and Korsakoff.^[8] Its most striking feature is loss of memory, which can be permanent. The cause is vitamin B₁ (thiamine) deficiency,usually found in severe alcoholics. It can also result from pernicious vomiting of pregnancy (hyperemesis gravidarum). Over 125 cases have been reported in the world literature and, although thiamine treatment has been available since 1936,^[9] these cases still occur in countries with advanced medical services, due to rehydration without vitamin supplements. A few patients have developed symptoms after the death of the foetus, miscarriage, termination of pregnancy or delivery.

Eclamptic psychosis

Eclampsia is the sudden eruption of convulsions in a pregnant woman, usually around the time of delivery. It is the late complication of pre-eclamptic toxaemia (that is, the triad of oedema, hypertension and albuminuria). In fatal cases, there are arterial lesions in many organs including the brain. Eclampsia is the commonest cause of unconscious delivery. Delirium occurs in about 5% of cases. About 240 detailed cases have been reported in the world literature.^[10] It particularly affects first time mothers. Seizures may begin before, during or after labour, but the onset of psychosis is almost always postpartum. Eclamptic delirium can occur without seizures.^[11] There is often an interval between seizures (or coma) and psychosis, a gap that has occasionally exceeded 4 days. The duration is classically short – one to two weeks, but a prolonged course (two months or more) has been observed. Recurrence after another pregnancy is unknown. After recovery amnesia, and sometimes retrograde memory loss may occur, as well as other permanent cerebral lesions such as dysphasia, hemiplegia or blindness.

Infective delirium

Postpartum infective delirium was described by Hippocrates ^[12]: 8/17 female cases in the 1st and 3rd books of epidemics suffered from postpartum or post-abortion sepsis, all complicated by delirium. In Europe and North America the foundation of the metropolitan maternity hospitals, together with instrumental deliveries and the practice of attending necropsies, led to epidemics of streptococcal puerperal fever, resulting in maternal mortality rates up to 10%. The peak was about 1870, after which antisepsis and asepsis gradually brought them under control. These severe infections were often complicated by delirium, but it was not until the nosological advances of Chaslin ^[13] and Bonhöffer ^[14] that they could be distinguished from other causes of postpartum psychosis. Infective delirium hardly ever starts during pregnancy, and usually begins in the first postpartum week. The onset of sepsis and delirium are closely related, and the course parallels the infection, although about 20% of patients recover from the infection, but develop chronic confusional states. Recurrences after another pregnancy are rare.

Cerebral venous thrombosis

Puerperal women are liable to thrombosis, especially thrombophlebitis of the leg and pelvic veins. Aseptic thrombi can also form in the dural venous sinuses and/or the cerebral veins draining into them. Most patients present with headache, vomiting, seizures and focal signs such as hemiplegia or dysphasia, but a minority of cases have a psychiatric presentation.^[15] The incidence is about 10/10,000 births in Europe and North America,^[16] but much higher in India, where large series have been collected.^[17]

Other vascular disorders

Arterial occlusion may be due to thrombi, amniotic fragments or air embolism. Postpartum cerebral angiopathy is a transitory arterial spasm of medium caliber cerebral arteries; it was first described in cocaine and amphetamine addicts, but can also complicate ergot and bromocriptine prescribed to inhibit lactation. Subarachnoid haemorrhage can occur after miscarriage or childbirth. Epidural anaesthesia can, if the dura is punctured, lead to leakage of CSF and subdural haematoma.^[18] All these can occasionally present with psychiatric symptoms.^[19]

Epilepsy

Women with a lifelong epileptic history are also liable to psychoses during labour in the puerperium. Women occasionally develop epilepsy for the first time in relation to their first pregnancy, and psychotic episodes have been described.^[20]

Ethanol withdrawal

Alcohol withdrawal states (delirium tremens) are recognized in addicts whose intake has been interrupted by trauma or surgery. This can occur after childbirth.

Hypopituitarism

Pituitary necrosis following postpartum haemorrhage (Sheehan’s syndrome) leads to failure and atrophy of the gonads, adrenal and thyroid. Chronic psychoses can supervene many years later, based on myxoedema, hypoglycaemia or Addisonian crisis. But these patients can also develop acute and recurrent psychoses, even as early as the puerperium.^[21]

Water intoxication

Hyponatraemia (which leads to delirium) can complicate oxytocin treatment, usually when given to induce an abortion.^[22]

Hyperammonaemia

Inborn errors of the Krebs-Henseleit urea cycle lead to hyperammonaemia. In carriers and heterozygotes, encephalopathy can develop in pregnancy or the puerperium. Cases have been described in carbamoyl phosphate synthetase 1, argino-succinate synthetase and ornithine carbamoyl transferase deficiency.^[23] This is the form of postpartum psychosis most recently described.^[24]

Incidental causes

All the above causes have a specific connection with childbearing. But diseases that have no such connection can fortuitously lead to postpartum psychosis, for example neurosyphilis, encephalitis, meningitis, thyroid disease or ischaemic heart disease.^[25]

The importance of these organic psychoses

With the great improvement in obstetric care, severe complications of pregnancy and childbirth have become rare. There is, however, a great contrast between Europe, North America, Australasia, Japan and some other countries with advanced medical care, and the rest of the world. The wealthiest nations produce only 10 million children each year, from a total of 135 million. They have a maternal mortality rate (MMR) of 6-20/100,000. Some poorer nations with high birth rates have an MMR more than 100 times as high,^[26] and, presumably, a corresponding prevalence of severe morbidity. For example, in Sub-Saharan Africa, twenty-one nations, with a combined birth rate of over 14 millions, have an MMR >1,000/100,000. Only a minority of deliveries in sub-Saharan Africa and South Asia are attended by skilled personnel (doctors, nurses or midwives).^[27] In Dar es Salaam, the majority of postpartum psychoses are organic.^[28] In Africa, India & South East Asia, and Latin America, these organic disorders may still be as important as they have been throughout human history.

References

1. ^ Brockington I F (2006) Eileithyia’s Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 323-325.
2. ^ Lishman W A (1997) Organic Psychiatry, 3rd edition. Oxford, Blackwell.
3. ^ Sandras C M S, Bourgignon H (1860) Traité Pratique des Maladies Nerveuses. Paris, Germer-Baillière, pages 397-411.
4. ^ Marcé L V (1860) L'État mental dans la chorée. Mémoirés de l’Académie de Médecine 24: 30-38.
5. ^ Breton A (1893) État mental dans la chorée. Thèse, Paris, no. 124.
6. ^ Brockington I F (2006) Eileithyia’s Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 1-23.
7. ^ Wernicke C (1881) Lehrbuch der Gehirnkrankheiten für Äezte und Studirende, volume 2. Kassel & Berlin, Fischer, pages 229-242.
8. ^ Korsakow S S (1887) Über eine besonderer Form psychischer Störung. Archiv für Psychiatrie21: 671-704.
9. ^ Brockington I F (2006) Eileithyia’s Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 23-49.
10. ^ Brockington I F (2006) Eileithyia’s Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 117-177.
11. ^ Donkin A S (1863) On the pathological relation between albuminuria and puerperal mania. Edinburgh Medical Journal 8: 994-1004.
12. ^ Hippocrates (5th century BC) Epidemics, volume 1, and Aphorisms, volume 4, in the edition translated by W H S Jones (1931). London, Heineman.
13. ^ Chaslin P (1895) Confusion Mentale Primitive, Stupidité, Démence aiguë, Stupeur Primitive. Paris, Harmattan.
14. ^ Bonhöffer K (1910) Die symptomatischen Psychosen im Gefolge von akuten Infektionen und inneren Erkrankungen. Leipzig and Wien, Deutlicke.
15. ^ Kalbag R M, Woolf A L (1967) Cerebral Venous Thrombosis, with Special Reference to Primary Aseptic Thrombosis. Oxford, Oxford University Press.
16. ^ Lanska D J, Kryscio R J (2000) Risk factors for peripartum and postpartum stroke and intracranial venous thrombosis. Stroke 31: 1274-1282.
17. ^ Srinavasan K (1988) Puerperal cerebral venous and arterial thrombosis. Seminars in Neurology 8:222-225.
18. ^ Jack T M (1982) Post-partum intracranial subdural haematoma. A possible complication of epidural analgesia. British Medical Journal 285: 972 only.
19. ^ Brockington I F (2006) Eileithyia’s Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 239-267.
20. ^ Brockington I F (2006) Eileithyia’s Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 271-275.
21. ^ Brockington I F (2006) Eileithyia’s Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 279-286.
22. ^ Brockington I F (2006) Eileithyia’s Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 287-288.
23. ^ Brockington I F (2006) Eileithyia’s Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 289-293.
24. ^ Yamada N, Fukui M, Ishii K, Shibata H, Okabe H, Ohomiya H, Matsunobu A, Nishizima M 1980) A case of adult form hypercitrullinemia with consciousness disturbance and marked hypertransaminasenemia after delivery. Nihon Shokakibyo Gakkae Zasshi 77: 1655-1660.
25. ^ Brockington I F (2006) Eileithyia’s Mischief: the Organic Psychoses of Pregnancy, Parturition and the Puerperium. Bredenbury, Eyry Press, pages 301-319.
26. ^ Hill K, AbouZahr C, Wardlaw T (2001) Estimates of maternal mortality for 1995. Bulletin of the World Health Organization 79: 182-192.
27. ^ AbouZahr C, Wardlaw T (2001) Maternal mortality at the end of the decade. Bulletin or the World Health Organization 79: 561-573.
28. ^ Ndosi N K, Mtawali M L, 2002) The nature of puerperal psychosis at Muhimbili National Hospital: its physical co-morbidity, associated main obstetric and social factors. African Journal of Reproductive Health 6: 41-49.