Postpartum Complications

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1. Puerperal Sepsis

• Pyrexia (fever) and tachycardia
• Foul-smelling lochia
• Pain and tenderness in the lower abdomen
• The most common organism is Streptococcus pyogenes (Group A beta-hemolytic streptococcus), which can cause endometritis and bacteremia. Staphylococci and anaerobes are also implicated.

• Blood cultures + wound swabs
• Broad-spectrum IV antibiotics (e.g., IV amoxicillin-clavulanate ± metronidazole; clindamycin + gentamicin)
• Sepsis bundle: IV fluids, monitoring lactate, organ support as needed
• Source control (e.g., evacuation of retained products if endometritis)

• Park's Textbook of Preventive and Social Medicine
• Jawetz Melnick & Adelberg's Medical Microbiology 28E

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2. Postpartum Hematoma

• Vulval hematoma - most common; below the pelvic floor
• Paravaginal hematoma - above the pelvic floor, extends into the broad ligament
• Broad ligament hematoma - serious; can be life-threatening

• Injury to blood vessels during delivery without a corresponding laceration of the overlying mucosa
• Episiotomy or perineal tear with poor hemostasis
• Instrumental delivery (forceps)
• Bleeding diatheses

• Severe vulval pain and pressure sensation
• Visible or palpable tense, fluctuant swelling
• Bluish discoloration of the perineum/vulva
• Tachycardia and hypotension if large

• Small hematoma (< 4 cm, stable): Conservative - ice packs, analgesia, observation
• Large/expanding hematoma: Surgical incision, evacuation of clot, suture of bleeding points, vaginal packing
• Blood transfusion if significant blood loss
• Antibiotics to prevent secondary infection

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3. Mastitis

• Staphylococcus aureus (40% of cases) - most common
• Escherichia coli
• Streptococcus species
• Community-acquired MRSA must be considered

• Severe pain, tenderness, swelling, redness of the breast (usually unilateral, one segment)
• Fever, chills, myalgias
• Flu-like systemic symptoms

• Mastitis: hypoechoic fluid surrounding subcutaneous fat lobules, no discrete fluid collection
• Abscess: discrete hypoechoic fluid collection with absent vascular signals

• Do NOT stop breastfeeding (or pumping) - continued emptying is therapeutic
• Frequent analgesia (NSAIDs/paracetamol)
• Antibiotics: antistaphylococcal penicillins (dicloxacillin/flucloxacillin) or 1st-generation cephalosporins
• Note: Sulfamethoxazole-trimethoprim is contraindicated in lactating mothers with infants < 2 months old
• If no improvement in 48 hours: assess for abscess with ultrasound
• Breast abscess: ultrasound-guided aspiration/drainage preferred; surgical drainage reserved as last resort (risk of milk fistula); IV vancomycin for septic inpatients

• Tintinalli's Emergency Medicine

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4. Urinary Tract Infection (UTI)

• Bladder overdistension and incomplete emptying postpartum
• Urinary catheterization during labor
• Perineal trauma and local contamination
• Epidural analgesia (reduces awareness of bladder fullness)
• Residual urine from uterine pressure

• Dysuria, frequency, urgency
• Suprapubic tenderness
• If ascending to kidneys (pyelonephritis): high fever, rigors, flank/loin pain, vomiting

• Urine culture and sensitivity (midstream clean-catch)
• Encourage high fluid intake
• Uncomplicated cystitis: 3-7 day course of antibiotics - nitrofurantoin (avoid if breastfeeding), trimethoprim, cefalexin (note: TMP-SMX avoided in first 6 weeks if breastfeeding)
• Pyelonephritis: IV cephalosporins or aminoglycosides, then oral step-down
• Remove/change urinary catheter early

• Park's Textbook of Preventive and Social Medicine

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5. Deep Vein Thrombosis (DVT) / Thrombophlebitis

• Leg becomes tender, pale, and swollen ("white leg" or phlegmasia alba dolens if severe)
• Calf tenderness, warmth, erythema
• Positive Homans' sign (limited diagnostic value)
• Frequently associated with varicose veins

• Wells score clinical probability assessment
• D-dimer (high sensitivity, low specificity postpartum)
• Compression duplex ultrasonography - first-line imaging
• CT pulmonary angiography if pulmonary embolism suspected

• Low Molecular Weight Heparin (LMWH) - treatment of choice; safe with breastfeeding
• Warfarin acceptable postpartum (safe in breastfeeding); target INR 2-3
• DOACs (rivaroxaban, apixaban) generally avoided while breastfeeding
• Graduated compression stockings
• Early mobilization - key prevention strategy
• Risk-stratify all postpartum women for VTE prophylaxis

• Early ambulation after delivery
• Hydration
• LMWH thromboprophylaxis in high-risk women (C-section, obesity, prior VTE, thrombophilia)

• Park's Textbook of Preventive and Social Medicine

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6. Psychological Complications

A. Postpartum Blues ("Baby Blues")

• Affects up to 65% of mothers
• Onset: days 3-5 after delivery
• Features: tearfulness, mood lability, anxiety, irritability
• Self-limiting; resolves within 2 weeks
• Management: reassurance, support, rest

B. Postpartum Depression (PPD)

• Affects 3-6% of women (some estimates up to 10-15% for major depression)
• DSM-5 specifier: "with peripartum onset" - onset during pregnancy or within 4 weeks of delivery (clinically, often recognized up to 12 months)
• Features: persistent low mood, anhedonia, sleep disturbance, guilt, poor bonding with infant, thoughts of self-harm
• 10% of mothers with blues progress to full major depression

• Psychotherapy (CBT, interpersonal therapy) - first-line for mild-moderate
• SSRIs (sertraline, paroxetine) - safe in breastfeeding; first-line pharmacotherapy
• Brexanolone (IV neuroactive steroid) - FDA-approved specifically for PPD
• Screen with Edinburgh Postnatal Depression Scale (EPDS)

C. Postpartum Psychosis (Puerperal Psychosis)

• Rare but psychiatric emergency - ~1-2 per 1000 deliveries
• Onset: 48-72 hours after delivery (can be delayed)
• Often follows a delivery complicated by hemorrhage or infection, but frequently occurs without any obstetric complication

• Alternating between noisy hyperactivity and mutism/inactivity
• Disorientation, thought disorder
• Baby may be rejected as not belonging to the mother
• Can present as:
  • ~40% predominantly affective
  • ~20% schizophreniform
  • Remainder: self-limited confusional psychoses (Boyd's series)
• Infanticide and suicidal ideation are the most dangerous aspects

• Eclampsia
• Sheehan's syndrome (pituitary infarction)
• Cerebral venous sinus thrombosis
• Ergot-induced psychosis
• Hypoxic-ischemic brain injury

• Urgent psychiatric admission (mother-baby unit if available)
• Mood stabilizers (lithium - caution with breastfeeding), antipsychotics
• ECT in severe refractory cases
• Risk: most closely related to past history of postpartum psychosis, bipolar disorder, or family history of bipolar disorder

• Adams & Victor's Principles of Neurology, 12th Ed
• Rosen's Emergency Medicine

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Summary Table

Postpartum Complications: Full Exam-Ready Notes

The puerperium = the period from delivery of the placenta to 6 weeks postpartum. Normal physiological changes (involution, lochia, hormonal shifts) create a backdrop against which complications must be recognized.

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1. PUERPERAL SEPSIS

Definition

Epidemiology

• Affects ~5% of vaginal deliveries and ~10% of cesarean sections
• Highest in low-resource settings with limited aseptic technique

Predisposing / Risk Factors

Causative Organisms

• Gram-positive cocci: Streptococcus pyogenes (Group A beta-hemolytic) - classically associated with virulent puerperal fever/septicemia; Staphylococcus aureus
• Gram-negative coliforms: E. coli, Klebsiella, Proteus
• Anaerobes: Bacteroides, Peptostreptococcus (important in polymicrobial endometritis)
• Less common: Chlamydia trachomatis, Mycoplasma spp.
• Note: Group A Strep can cause streptococcal toxic shock syndrome (STSS) - incubation as short as 14 hours after inoculation

Pathophysiology

• Most common form: Endometritis (infection of the uterine lining) - the uterine wound (placental site) provides a portal of entry
• Progression: Endometritis → Parametritis → Peritonitis → Septicemia → Septic shock
• Endometritis typically develops on day 2-3 postpartum
• Group A Strep uniquely causes a "wound" septicemia - organisms enter via the uterus after delivery and rapidly spread hematogenously

Clinical Features: History

• Fever (temperature >38°C on 2 separate occasions after 24 hours)
• Tachycardia - often early sign
• Foul-smelling, purulent lochia
• Lower abdominal/pelvic pain and tenderness
• Malaise, rigors

Clinical Features: Examination

Investigations

• FBC: raised WBC (leukocytosis) - note: mild leukocytosis is normal postpartum, so a WBC >20x10⁹/L should raise concern
• CRP, procalcitonin (markers of bacterial infection/sepsis)
• Blood cultures x2 (before antibiotics)
• High vaginal swab (HVS) and endocervical swab for MC&S
• Urine culture (concurrent UTI common)
• Pelvic ultrasound: look for retained products of conception (RPOC), parametric collection, abscess
• Lactate: if >2 mmol/L = sepsis; if >4 mmol/L = septic shock (use Sepsis-3 criteria)

Management

Immediate (Sepsis 6 Bundle - within 1 hour)

1. High-flow oxygen
2. Blood cultures (before antibiotics)
3. IV antibiotics (see below)
4. IV fluid resuscitation (30 mL/kg crystalloid if hypotensive)
5. Measure serum lactate
6. Urine output monitoring (catheterise)

Antibiotic Therapy

• Clindamycin 900 mg IV Q8H + Gentamicin 5 mg/kg IV Q24H
• This combination covers Gram-positive, Gram-negative, and anaerobic organisms
• Alternative: Co-amoxiclav (Amoxicillin-clavulanate) ± Metronidazole

Source Control

• Retained products of conception (RPOC): surgical evacuation (uterine curettage) under ultrasound guidance
• Pelvic abscess: drainage (surgical or CT/ultrasound-guided)
• Remove intrauterine devices if present

Supportive

• Most patients require inpatient admission
• If Group A Strep STSS suspected: add IV immunoglobulin (IVIG)

Complications if Untreated

• Septic pelvic thrombophlebitis
• Peritonitis
• Tubo-ovarian abscess
• Septic shock and multi-organ failure
• Asherman's syndrome (intrauterine adhesions)
• Infertility

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2. POSTPARTUM HEMATOMA

Definition

Classification by Site

                 PELVIC FLOOR
    ________________|________________
    |                               |
BELOW pelvic floor             ABOVE pelvic floor
Vulval hematoma            Paravaginal hematoma
(most common)              Broad ligament hematoma
                           (most dangerous - can be massive)

Causes / Risk Factors

• Injury to blood vessels not accompanied by overlying skin/mucosal laceration
• Episiotomy or perineal repair with inadequate hemostasis
• Instrumental delivery (forceps, ventouse) - distortion and tearing of vessels
• Prolonged second stage of labor
• Precipitate (fast) delivery
• Coagulopathy / bleeding disorders
• Varicose veins of the vulva

Pathophysiology

Clinical Features: History

• Severe, unrelenting perineal or pelvic pain - disproportionate to delivery trauma; the key symptom
• Feeling of intense pressure or "fullness" in the perineum/rectum
• Inability to void (urinary retention from hematoma compressing the urethra)
• Faintness, dizziness (if large - haemodynamic compromise)

Clinical Features: Examination

Investigations

• FBC: serial Hb to monitor blood loss
• Coagulation screen (PT, APTT, fibrinogen): exclude DIC or underlying coagulopathy
• Group & Save / Crossmatch: prepare for transfusion
• Pelvic ultrasound: identifies and sizes the hematoma
• CT scan: for broad ligament or retroperitoneal hematomas to define extent and guide management

Management

Conservative (small, stable hematoma < 3-4 cm)

• Ice packs to perineum (reduces swelling and provides analgesia)
• Regular analgesia (NSAIDs, paracetamol, opioids)
• Close observation: vital signs, Hb monitoring, serial size assessment
• Most small hematomas will reabsorb spontaneously over days-weeks

Surgical (large, expanding, or symptomatic)

1. Incision and drainage: single linear incision over point of maximum tension
2. Evacuation of clot
3. Identify and suture bleeding points (figure-of-8 sutures to ligate vessels)
4. Dead space obliteration: close in layers or pack with vaginal gauze
5. Drain: may be placed if cavity is large

Adjuncts

• Blood transfusion if Hb falls significantly
• Antibiotics: prophylactic to prevent secondary infection of the hematoma cavity
• Interventional radiology (IR): uterine artery embolisation (UAE) for persistent/recurrent broad ligament hematomas where surgery is difficult

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3. MASTITIS

Definition

Epidemiology

• Affects ~1/3 of breastfeeding women in the US
• Most common in the 2nd postpartum week (range: 1st week to several months)
• Progresses to breast abscess in ~3-10% of cases if untreated

Causative Organisms

Pathophysiology - "Milk Stasis + Retrograde Infection"

Milk stasis (poor latch, missed feeds, engorgement)
         ↓
Milk accumulates → creates inflammatory response
         ↓
Skin bacteria (S. aureus) enter via nipple crack/fissure
         ↓
Retrograde infection into lactiferous ducts and parenchyma
         ↓
MASTITIS → (if untreated) → ABSCESS

Clinical Features: History

• Unilateral breast pain, swelling, redness (typically one segment/quadrant)
• Fever, chills, flu-like myalgias and malaise
• Nipple discharge (may be purulent if abscess)
• Onset often sudden; classically in week 2

Clinical Features: Examination

Investigations

• Usually clinical diagnosis
• Breast milk culture: if recurrent, severe, or hospital-acquired infection (MRSA suspected)
• Ultrasound: key investigation if abscess suspected
  • Mastitis: hypoechoic fluid surrounding subcutaneous fat lobules, no discrete collection
  • Abscess: discrete hypoechoic fluid collection with absent vascular flow on Doppler

Differentials to Know

1. Engorgement - bilateral, no fever, presents earlier (day 3-5)
2. Plugged duct - tender lump, no systemic symptoms, no fever
3. Inflammatory breast carcinoma - rare but must exclude if fails to respond to antibiotics; refer for mammogram ± biopsy

Management

For Mastitis

• 1st line: Flucloxacillin 500 mg QDS orally (antistaphylococcal penicillin) OR dicloxacillin
• Alternative: Cefalexin (1st-generation cephalosporin) - if penicillin allergic
• If MRSA suspected: Trimethoprim-sulfamethoxazole (TMP-SMX) OR clindamycin (note: TMP-SMX contraindicated in neonates < 2 months old - cannot use if breastfeeding infant is < 2 months)
• Inpatient/septic: IV vancomycin

For Breast Abscess

1. Ultrasound-guided needle aspiration - first-line (can repeat if recollects)
2. Surgical incision and drainage (I&D) - reserved as last resort; risk of milk fistula formation
3. Continue antibiotics with anti-MRSA coverage (cephalosporins oral, or IV vancomycin if septic)
4. Continue breastfeeding unless antibiotic contraindicated for neonate
5. Recurrent infections in older women → excisional biopsy to exclude inflammatory carcinoma

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4. URINARY TRACT INFECTION (UTI)

Why Postpartum Women Are Vulnerable

Causative Organisms

• E. coli (~80%) - most common
• Klebsiella pneumoniae
• Staphylococcus saprophyticus (especially young women)
• Enterococcus faecalis
• Proteus mirabilis

Classification and Progression

Asymptomatic Bacteriuria
         ↓ (if untreated, ~30-40% progress)
Cystitis (lower UTI)
         ↓ (ascending infection via ureters)
Pyelonephritis (upper UTI) ← serious; causes ~10-15% of postpartum fever
         ↓ (if severe/untreated)
Urosepsis

Clinical Features

Cystitis

• Dysuria, frequency, urgency
• Suprapubic discomfort/tenderness
• Cloudy, offensive-smelling urine
• Low-grade fever (or no fever)
• Often afebrile with mild systemic symptoms

Pyelonephritis

• High fever (>38.5°C), rigors, sweats
• Loin/flank pain - unilateral or bilateral
• Costovertebral angle (CVA) tenderness on percussion
• Nausea, vomiting
• Systemic illness (may progress to sepsis)

Investigations

Management

Cystitis (uncomplicated)

• Oral antibiotics 5-7 days:
  • Nitrofurantoin (1st choice) - caution: avoid if GFR <45; avoid in early infancy (haemolytic risk)
  • Cefalexin 500 mg BD - safe in breastfeeding, commonly used postpartum
  • Trimethoprim - effective but avoid in first 6 weeks if breastfeeding (folate antagonist)
• Increased oral fluid intake
• Analgesia (phenazopyridine for dysuria if available)

Pyelonephritis

• Hospital admission required
• IV antibiotics:
  • IV ceftriaxone 1-2g OD (1st line)
  • IV gentamicin + ampicillin (alternative)
  • IV co-amoxiclav
• Step-down to oral when afebrile for 24-48 hours
• Total course: 14 days

Prevention

• Early removal of urinary catheter (within 12-24 hours postpartum)
• Bladder assessment post-delivery (check for retention - MUST void within 6 hours of delivery)
• Encourage early mobilization and regular voiding

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5. DEEP VEIN THROMBOSIS (DVT) / VENOUS THROMBOEMBOLISM (VTE)

Why This Matters

Virchow's Triad - All Three Are Active Postpartum

• VTE risk: 5-10x higher than in non-pregnant women
• Postpartum risk can actually be higher than antepartum
• Highest risk window: first 2-3 weeks postpartum; remains elevated to 6 weeks

Superficial Thrombophlebitis vs DVT

Clinical Features: History

• Unilateral leg swelling, warmth, pain (onset usually gradual)
• Calf ache worsened by walking
• Ask about: prior VTE, thrombophilia, family history, immobility, C-section, obesity

Clinical Features: Examination

• Swollen, erythematous, warm leg
• Calf >3 cm larger than opposite leg (measured 10 cm below tibial tuberosity)
• Pitting oedema
• Tenderness along the deep vein distribution (medial calf, popliteal fossa, femoral triangle)
• Homan's sign (calf pain on dorsiflexion): historically taught but poor sensitivity and specificity - do not rely on it
• If iliac/pelvic DVT: the whole limb may be swollen ("milk leg" / phlegmasia alba dolens) with a pale, cool limb

Clinical Decision Tool: Wells Score for DVT

Fuster and Hurst's The Heart, 15th Ed

Investigations

Management

Acute DVT Treatment

• Duration: minimum 3-6 months for provoked DVT (postpartum = transient provoking factor)
• Graduated compression stockings (Class II) for DVT

VTE Prophylaxis - Who Needs It?

Pulmonary Embolism (PE) - Red Flags

• Sudden onset dyspnoea, pleuritic chest pain, haemoptysis
• Tachycardia, hypoxia, hypotension (if massive PE)
• Immediate CTPA + therapeutic anticoagulation
• Thrombolysis if haemodynamically unstable (life-threatening)

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6. PSYCHOLOGICAL COMPLICATIONS

Overview - The Spectrum

POSTPARTUM BLUES ←――――――――――――――――――――→ POSTPARTUM PSYCHOSIS
(Mild, transient)        (PPD - moderate)        (Severe, emergency)
65% of mothers           3-6% of mothers          1-2 per 1,000
Days 3-5                 Weeks to months           48-72 hours
Self-limiting            Needs treatment           Psychiatric emergency

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A. POSTPARTUM BLUES ("Baby Blues")

Epidemiology

• Affects up to 65% of all mothers (most common)
• Onset: day 3-5 (coincides with hormonal shift: oestrogen/progesterone plummet after placenta delivery)
• Duration: < 2 weeks (self-limiting by definition)

Pathophysiology

• Serotonin dysregulation
• HPA axis reactivity
• Combined with sleep deprivation, pain, and psychological adjustment

Clinical Features

• Tearfulness, weeping without clear reason
• Mood lability (swinging between elation and sadness)
• Irritability and anxiety
• Mild fatigue and emotional fragility
• No impairment of infant care - key distinguishing point

Management

• Reassurance to patient and family (this is normal)
• Rest and sleep support
• Social support
• Monitor: if symptoms persist beyond 2 weeks → screen for PPD

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B. POSTPARTUM DEPRESSION (PPD)

Epidemiology

• 3-6% of women develop major depressive disorder (DSM-5 definition)
• Up to 10-15% if broader criteria used
• 10% of women with postpartum blues will progress to full PPD
• Often underdiagnosed

DSM-5 Classification

• Specifier: "With peripartum onset" - onset during pregnancy or within 4 weeks of delivery
• Clinically recognised up to 12 months postpartum in practice

Risk Factors (HIGH-YIELD)

Clinical Features: History

• Persistent low mood (> 2 weeks duration - unlike blues)
• Anhedonia (loss of pleasure in previously enjoyable activities)
• Insomnia (difficulty sleeping even when infant sleeps) or hypersomnia
• Fatigue and loss of energy
• Poor concentration, indecisiveness
• Feelings of worthlessness, guilt ("I'm a bad mother")
• Poor mother-infant bonding - reduced interaction, difficulty responding to infant cues
• Appetite changes (usually reduced)
• Thoughts of self-harm or suicide (must always ask)

Clinical Features: Examination

• Flat affect, tearfulness
• Poor self-care
• Slow speech and psychomotor retardation
• Assess: Are they caring adequately for the infant?

Screening Tool: Edinburgh Postnatal Depression Scale (EPDS)

• 10-item self-report questionnaire
• Score ≥10 = likely PPD (sensitivity ~80%, specificity ~90%)
• Question 10 asks directly about self-harm thoughts - this item alone requires immediate assessment if positive
• Should be administered at the 6-week postnatal check (and ideally at every health contact)

Investigations

• Thyroid function (TSH, free T4) - postpartum thyroiditis can mimic/cause depression
• FBC (anaemia), LFTs, renal function (rule out organic causes)
• Consider: drug and alcohol screen

Management: Stepped Care Approach

SSRIs in Breastfeeding

Brexanolone (Zulresso)

• Neuroactive steroid (synthetic allopregnanolone - a GABA-A positive modulator)
• FDA-approved specifically for PPD (2019)
• Mechanism: replaces the lost allopregnanolone signalling after placental delivery
• Given as a 60-hour IV infusion
• Rapid effect (within 24-48 hours) - faster than traditional antidepressants
• Note: Zuranolone is the oral version (FDA-approved 2023)

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C. POSTPARTUM PSYCHOSIS (Puerperal Psychosis)

Epidemiology

• 1-2 per 1,000 deliveries (rare but serious)
• Psychiatric emergency with risk of infanticide and suicide
• Often occurs in women with no prior psychiatric history - can be the first presentation of bipolar disorder

Onset

• Typically within 48-72 hours of delivery
• Can be triggered by a complicated delivery (haemorrhage, infection) or occur without any obstetric precipitant

Pathophysiology

• Abrupt fall in oestrogen and progesterone (sensitises dopamine receptors)
• Sleep deprivation amplifying vulnerability
• Strong genetic component (often first presentation of bipolar diathesis)

Clinical Features: History and Presentation

Breakdown of Presentation (Boyd's series):

• ~40% predominantly affective (manic or depressive episode with psychosis)
• ~20% schizophreniform (thought disorder, flat affect)
• Remainder: self-limited confusional psychoses

Differential Diagnosis (MUST EXCLUDE before diagnosing primary postpartum psychosis)

Management

Prognosis and Recurrence

• Most recover with treatment within 2-3 months
• High recurrence risk in subsequent pregnancies: up to 50% with prior episode
• Closely linked to bipolar disorder - many women will go on to be diagnosed with bipolar I
• All women with postpartum psychosis require preconception counselling before future pregnancies

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High-Yield Summary for Exams

Sources: Rosen's Emergency Medicine; Tintinalli's Emergency Medicine; Adams & Victor's Principles of Neurology 12th Ed; Park's Textbook of Preventive and Social Medicine; Fuster and Hurst's The Heart 15th Ed; Creasy & Resnik's Maternal-Fetal Medicine

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Differential Diagnosis: Postpartum Psychological Complications

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Key Differentiating Rules (Exam Mnemonics)

"Blues vs PPD vs Psychosis - ask 3 questions:"

1. When did it start? Blues = day 3-5; PPD = weeks later; Psychosis = 48-72 hrs
2. Is reality intact? Blues/PPD = YES; Psychosis = NO
3. Is the baby safe? Blues = yes; PPD = maybe (neglect risk); Psychosis = immediate danger

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Definitions: Postpartum Psychological Complications

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1. 🟡 Postpartum Blues ("Baby Blues" / "Maternity Blues")

A transient, self-limiting period of emotional lability occurring in the first days after delivery, characterised by tearfulness, mood swings, irritability, and mild anxiety, with no impairment of the mother's ability to care for her infant and no loss of contact with reality.

Key defining features:

• Onset: day 3-5 postpartum
• Duration: less than 2 weeks - if it persists beyond 2 weeks, it is no longer "blues" by definition
• Severity: mild - does not meet criteria for a depressive disorder
• Reality: fully intact
• Cause: directly tied to the abrupt drop in oestrogen and progesterone after placental delivery

"Usually this lasts for only a few days, being quelled by the return home, responsibility for the infant, and nursing." - Adams & Victor's Principles of Neurology, 12th Ed

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2. 🟠 Postpartum Depression (PPD)

A major depressive episode with onset during pregnancy or within 4 weeks of delivery (DSM-5 specifier: "with peripartum onset"), characterised by persistent low mood, anhedonia, impaired bonding with the infant, and significant functional impairment, lasting weeks to months if untreated.

DSM-5 Formal Definition:

"With peripartum onset" - applied when onset of a major depressive episode occurs during pregnancy or within 4 weeks following delivery

Core DSM-5 Criteria (must have ≥5 for ≥2 weeks, including at least one of the first two):

1. Depressed mood most of the day, nearly every day
2. Markedly diminished interest or pleasure (anhedonia)
3. Significant weight/appetite change
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive guilt
8. Poor concentration or indecisiveness
9. Recurrent thoughts of death or suicidal ideation

Clinically important note:

• While DSM-5 says "within 4 weeks," clinicians and the ICD-11 recognise onset up to 12 months postpartum as PPD
• Affects 3-6% of mothers by strict criteria; up to 15% by broader clinical definition

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3. 🔴 Postpartum Psychosis (Puerperal Psychosis)

A severe and acute psychiatric emergency arising within days of delivery, characterised by the abrupt onset of psychotic symptoms - including delusions, hallucinations, disorganised thinking, and gross disorientation - representing a complete break from reality, with significant risk of infanticide and suicide.

Formal Classification:

• Brief Psychotic Disorder with peripartum onset, OR
• Bipolar I Disorder, manic episode with peripartum onset and psychotic features (most common underlying diagnosis)
• Some cases: Schizophreniform disorder with peripartum onset

Defining characteristics:

• Onset: 48-72 hours after delivery (earliest of the three)
• Severity: severe - complete loss of reality testing
• Three core domains affected:
  1. Perception - hallucinations (typically auditory command)
  2. Thinking - delusions (often about the baby), thought disorder
  3. Consciousness - disorientation, confusion, fluctuating awareness

"The patient alternates between periods of noisy hyperactivity and of mutism and inactivity. She is disoriented and incapable of thinking clearly. The baby is sometimes rejected as not belonging to her." - Adams & Victor's Principles of Neurology, 12th Ed

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Side-by-Side: Definitions at a Glance

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The One-Line Rule for Each:

• Blues = Normal emotional reaction to hormonal crash - not a disorder
• PPD = Clinical depression that happens to start in the postpartum period - meets full MDD criteria
• Psychosis = Medical/psychiatric emergency - the mother has lost touch with reality and the baby is at risk