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Management:
Initial evaluation should include a thorough history, physical examination, and routine laboratory tests.
- Postpartum blues: Patients with postpartum blues have mild and transient symptoms, which remit spontaneously. It therefore requires no specific treatment or a psychiatric consultation. Support and reassurance is the mainstay of treatment.
- Postpartum depression: The early initiation of treatment results in a better prognosis. Women with postpartum depression are treated on the same guidelines as nonpuerperal depressed patients. The management can be grouped as;
- Non-pharmacological: These are useful and frequently employed in the treatment of mild to moderate postpartum depression and in patients who are reluctant to take medication. Debriefing is being introduced for women after childbirth with the aim of improving psychological recovery. This gives these women an opportunity to discuss their experiences of delivery with an empathic listener. Debriefing has been recommended as a health promotion strategy for all women following childbirth, as even uncomplicated childbirth can be traumatic. Cognitive behavior therapy and interpersonal therapy, which is a time-limited and has its focus on interpersonal relationships, have been successfully adapted for the treatment of postpartum depressed patients and are reported to be as efficacious as an antidepressant.
- Pharmacological: The efficacy of antidepressant medications, such as in standard treatment doses has been well established. No data suggests the efficacy and safety of any one agent over the other in women who breastfeed. Benzodiazepines may be added if severe anxiety symptoms are present. Tricyclic antidepressants may be used if their sedative action is warranted. Women who breastfeed should be informed about the effects of the medications and their secretion of breast milk. Severe complications appear to be rare, but the long-term effects are as yet unknown. In-patient hospitalization may be necessary in patients with severe depression and/or suicidal ideation, as might be electro-convulsive therapy. Joint hospitalization of the mother and the infant has shown good results.
- Hormonal Therapy: There is a dramatic fall in the estrogen and progesterone levels cause rapid shifts in the reproductive hormonal environment of the postpartum period. This created a role for hormonal manipulation in the treatment of postpartum mood disturbance. Various studies have demonstrated the efficacy of progesterone alone, while others have shown the combination of estrogen and an antidepressant to be beneficial. However at this point it is unclear which patients would respond to hormonal therapy and its role is still not well defined.
References:
- Astbury J, Brown S, Lumley J, Small R. Birth events, birth experiences and social factors in depression after birth Aust J Public Health 1994; 18: 176-184.
- Brown S, Lumley J. Maternal health after childbirth: results of an Australian population based survey. Br J Obstet Gynaecol 1998; 105: 156-161.
- Cox JL, Holden JM, Sagovsky R. Detection of Postnatal depression: Development of the 10-item Edinburgh Postnatal Depression scale. Br J Psychiatry 150:782, 1987.
- Cox JL, Murray D, Chapman G: A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry 163: 27, 1993.
- Elliott SA. Relationship between obstetric outcome and psychological measures in pregnancy and the postnatal year. J Reprod Inf Psychol 1984; 2: 18-32.
- Fisher J, Stanley R, Burrows G. Psychological adjustment to caesarean delivery: a review of the evidence. J Psychosom Obstet Gynaecol 1990; 11: 91-106.
- Hillan EM. Short-term morbidity associated with caesarean delivery. Birth 1992; 19: 190-194.
- MacArthur C, Lewis M, Knox EG. Health after childbirth. Br J Obstet Gynaecol 1991; 98: 1193-1204.
- Ralph K, Alexander J. Borne under stress. Nursing Times 1994; 90: 28-30.
- Lavender T, Walkinshaw SA. Can midwives reduce postpartum psychological morbidity? A randomized trial. Birth 1998; 25: 215-221.
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