Having Postpartum Problems
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Q:  Having Postpartum Problems


Dear Dr. Phelps

My wife gave birth to our son on 30.01.09 and 7 days after that she lost touch with reality after not sleeping for 4 days straight . She was experiencing audio and visual hallucinations , did not want to sleep , talked of non existing things . We seeked doctor help the next day and he administered haloperidol , akineton and depakin chrono . After 3 weeks , the doctor started reducing the haloperidol and akineton and now 22.03.09 we are 5 days just on depakine . Unfortunately my wifes dad died 2 days ago and after hearing the news she is slowly falling into her old ( manic ) state again . There is no history of depressions in her family . She is breastfeeding atm but I fear that the doctor will put her back on haloperidol when we meet him . I am really worried and thought she will recover fast but its not that simple . My wife is 26 years old . Please what do you think about this situation , do you think breastfeeding is stressing her thus not helping recovery ?

Yours ,
Martin


Dear Martin --
first of all, congratulations on the birth of your son.  I'm sorry here that such a joyous occasion has been so complicated by the symptoms that your wife is experiencing.

Here are some thoughts on this situation, on the basis of the symptoms you describe:

1. First of all, what is going on here?  As you probably have learned, this situation sounds like a situation which is unfortunately common, thought to occur about one time in a hundred for people with a diagnosis of bipolar disorder: "postpartum psychosis".

Unfortunately, this can also occur in women who have never had bipolar symptoms before.  Going 4 days without sleep could produce such symptoms in quite a few people.  In addition, the substantial hormonal changes after birth are well recognized to sometimes lead to mood symptoms ("postpartum depression").  For now, it is important to put off conclusions about what the future may hold in terms of symptoms, and focus on getting the current symptoms well controlled, and your baby while taking care of.  In other words, you will likely remain unclear for months, perhaps even a few years, whether or not this episode means that your wife does indeed have "bipolar disorder" and requires ongoing treatment for that.  First of all, the challenge is to get symptoms well controlled now.  This question about the future should be deferred for months.

2. Are these the appropriate treatments?  Based only on a paragraph you have submitted, these do indeed sound very routine.  As you have probably learned, the “akineton” is just to counteract a side effect from haloperidol, so that really, she has been given to medications: an antipsychotic -- haloperidol; and a "mood stabilizer" – valproate (depakin, also known as Depakote in the United States).  The doctor tried to get that down to one medication quickly, which is also routine and appropriate.

3.  How sad, to lose her father in the middle of this.  Your note implies that the haloperidol was a bad experience the first time, because you are worried about her going back on it.  Most likely, if that was needed, it would again be for a short period of time.

An alternative might just be to focus on medications which could help her sleep, because loss of sleep, as you have seen, can lead to manic symptoms.  There are even some non-medication approaches to sleep that, at least in my clinic, we are exploring.  Here is a description of that line of thought: Light and Darkness in Bipolar Disorder Treatment.

4.  One particular aspect of breast-feeding that might be regarded as part of the problem is the potential for sleep deprivation, when your son needs to be fed at night.  In the United States, some women use a "breast pump" device to extract and store milk during the day, so that the father can be in charge of nighttime feedings using mother's milk. I'm not sure whether such devices are available in Bulgaria.

In the essay about light and darkness linked above, I believe I have mentioned the idea of avoiding light, particularly blue light, in the middle of the night for women who are waking up to breast-feed.  That is a relatively simple step, if you have not already taken it.

5. What about valproate (depakin) and breast-feeding?  The American Academy of Pediatrics regards valproate as compatible with breast-feeding.  A little bit of the medication gets into the milk, but in the few studies that have looked at how much of the medication is actually found in the baby's blood, there was very little.  There is only a single case report of a related medical event, in an infant.

I regret that, because of a letter-management error on my part, this reply is likely to be very late in reaching you.  I hope that by now, things are quite different, much improved.  Indeed, I hope that most of this story is now unnecessary.  Nevertheless, some of the information above may be of use to you.  As you have learned, there is a risk of some recurrence of something like this with a subsequent pregnancy.  Because of what you are learning here, you will be much better prepared if there is a "next time".  Good luck to you and your family.  Your wife is fortunate to have a husband who is so determined to understand what is going on.

Dr. Phelps

 

Published May, 2009
 

 

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