CLINICAL CASE
Unit Two: Obstetrics
Section B: Abnormal Obstetrics
Objective 29: Anxiety and Depression
“I’ve been having troubles at home and I came to get some help.”
Ms. Davis is a 22-year-old G3P2Ab1 African American who presents for e valuation of
depressed mood with suicidal and homicidal ideations. Ms. Davis reports that besides
being overwhelmed by having a newborn baby, her 2 ½-year-old daughter recently
experienced a severe illness. Since that time, she intermittently has thoughts about
hurting herself and her children. Her mother is award of her concerns and is currently
caring for the children.
During her visit, Ms. Davis describes feeling depressed, sleep deprived, guilty and
hopeless. She also states that she has had crying spells and a decreased appetite for
the last two months. She can go “a day or two” without being hungry or eating, and
she reports feeling like her children “would be better off without me or if they weren’t
here.” She has made no plans to act on these feelings, although she notes that these
feelings have increased in frequency over the past two months.
Ms. Davis states that sometimes when she hears the newborn cry, she thinks she hears
a voice in her head telling her to “just shake him until he stops crying.” When she has
these kinds of thoughts, she says, she calls her mother or husband or reads the Bible
until these thoughts and feelings subside. She worries, however, that one day she will
not be placated by these means alone.
Ms. Davis pregnancy was uncomplicated. She had a normal vaginal delivery at term.
She initially tried to breast feed, but stopped after 3 days due to “sore nipples.”
PMH
None
Family history
Father has HTN, mother has NIDDM, sister has depression (treated with fluoxetine).
Social history
Patient denies ETOH, tobacco or drugs. Patient lives with her husband of 5 years and
her 2 children. She is a stay-at-home mother.
Physical Exam
VS: T=35.1C; HR=57; RR=16; BP=127/65; Ht=5’6”; Wt=173 lbs.
General
Tearful African American female in no apparent distress.
HEENT
Normocephalic, atraumatic
Neck: Soft, supple, no masses, no thyromegaly
Skin
Tattoo on L upper arm; mild scarring on L shin. “M” tattoo on L medial malleolus
Breast
No masses, discharge, erythema, dimpling, or abnormal fixation to chest wall; no
lymphadenopathy. Lungs: Clear to auscultation with good air movement. CV: RRR
with no murmurs, rubs or gallops. The uterus is anteflexed, non-tender and normal
sized.
Abdomen
Soft, non-tender, +BS; no distention, no masses and no organomegaly.
GU
The external genitalia are normal in appearance for her age. The urethral meatus is
normal in appearance and location. The urethra is without mass or tenderness. The
bladder is normally located without mass or tenderness. The vagina is patent and
shows well estrogenized mucosa. The cervix is normal and consistent with a
multiparous female. The adnexa are unremarkable. Anal sphincter tone is normal.
Neurologic Exam
CN II-XII grossly intact; strength is 5/5 in all four extremities; light touch and
pinprick sensations intact. Finger-to-nose, rapid alternating movements and heel-toshin intact. Gait is steady with no evidence of festination or other aberrations.
Mental Status: Patient is well dressed, alert and cooperative during the interview. She
appears tired, but there is no evidence of psychomotor agitation or retardation. Mood
=depressed; affect=dysthymic. Ms. Davis is A&O x 3, and her memory is intact.
Thought processes are linear, clear and intact. Thought content reveals occasional
impulsiveness with regard to acting out towards her children. She has a recent history
of guilt, crying spells and hopelessness.
Teaching points: Postpartum depression
1.
Treat aggressively!
2.
Use drugs such as Sertraline and Amitriptyline, since they are safe in
lactating women. One study suggests that several commonly prescribed
and efficacious agents can be safely given to the breast feeding mother
suffering from postpartum depression (PPD). Quantifiable amounts of
the maternal medication are not found in the infant’s blood. Based on
this guideline, the authors recommend using the following drugs in
cases where the mother desires to continue breast feeding:
Amitriptyline, Nortriptyline, Desipramine, Clomipramine or Sertraline.
SSRIs preferred as tricyclic antidepressants have more side effects and
an overdose could be lethal.
3.
Fluoxetine (Prozac) is not a good drug for this disorder. Fluoxetine,
although a very useful and popular antidepressant, has been found to
permeate breast milk to levels approximately 20-25% of maternal
plasma. This has prompted the drug manufacturer to advise against the
use of this product in the breast feeding woman. In a case report, severe
colic, fussiness and crying were identified in a parturient taking
fluoxetine. It has also been associated with reduced growth that may be
of clinical importance in situations in which the infant weight gain is
already of concern. Shorter acting SSRIs, such as Paroxetine, preferred.
4.
Group treatment through a cognitive-behavioral program, plus
appropriate pharmacotherapy, will yield a better outcome than either
treatment alone.
Pharmacotherapy is a quick, efficient answer to the problem of PPD in
most cases – but it is not all of the answer. Group treatment through a
cognitive-behavioral program has been shown to be effective
treatment, as well. Other forms of psychotherapy have been studied
with fairly conclusive results and these forms of treatment augment the
antidepressant effects of these medications.
5.
Hormonal therapy is a newer option aimed at the potential causes of
PPD. Some investigators believe that mood disorders postpartum are
precipitated by changes in estrogen levels. The hypothalamic-pituitaryadrenal axis is greatly suppressed directly after childbirth, and some
researchers in the field of endocrinology believe that estrogen will
normalize CRH secretion and reactivate the H-P-A axis to mitigate
depressive symptoms in the postpartum woman.