First-onset postpartum psychosis

Mrs. B, a 28-year-old woman with no prior psychiatric history, delivered a healthy daughter after a first, normal pregnancy. During the first two days postpartum, she was breastfeeding her daughter with notably reduced sleep. By the third day postpartum, she became convinced that her husband wanted to kill their newborn. After her mother suggested that she discontinue breastfeeding, she became extremely violent, kicking her mother in the abdomen. Over the next 4 days, the family continued to struggle as Mrs. B became progressively more impulsive, irritable, and disorganized. One week postpartum, she was admitted to the Mother-Baby Unit of the Erasmus MC. During the admission interview, she exposed her breasts while shouting: “Look at these! My breasts are great! I want to breastfeed 24 hours non-stop!” She was diagnosed as manic with psychotic features (Young Mania Rating Scale 34). Physical examination and routine laboratory investigations were normal. She was treated with haloperidol and lorazepam. One week after admission, she remained actively manic with psychotic features, requiring the addition of lithium. On a combination of haloperidol, lithium, and lorazepam, her manic and psychotic symptoms went into remission over the next 3 weeks. She was discharged home from the hospital seven weeks after delivery, with close outpatient follow-up, lithium monotherapy, and mother-child interaction therapy. Three months postpartum, she was diagnosed with autoimmune thyroiditis and thyroxine replacement was started. Lithium therapy was discontinued after 9 months. During a followup of two years she did not experience major psychiatric symptoms.