Case records of the Massachusetts General Hospital. Case 24-2008. A 35-year-old woman with postpartum confusion, agitation, and delusions.


Dr. Alexia E. Koukopoulos (Psychiatry): A 35-year-old woman was admitted to the inpatient psychiatry service of this hospital 5 days after the birth of her first child because of confusion, agitation, and delusions. The patient had been well until approximately 2 years earlier, when insomnia, auditory hallucinations, and disorientation, followed by severe depression and suicidal ideation, developed. After two inpatient psychiatric admissions, a diagnosis of bipolar disorder was made. The patient’s symptoms were controlled with lithium, 900 mg at bedtime, and citalopram, 40 mg per day, for the next 9 months. One year before admission, she was seen in consultation by the perinatal psychiatry service, since she and her husband wished to start a family. Approximately 11 months before admission, she discontinued her medications against the advice of her psychiatrist and the perinatal psychiatry consultant, and 2 months later, she became pregnant. During her pregnancy, she had intermittent dysphoria, anxiety, insomnia, and blunting of affect. She was advised by her physicians to resume her medications, but she declined to do so; she also stated that, should she become psychotic, she would not want to be given medications that could harm her child or preclude breast-feeding after delivery. Five days before admission to the psychiatry service, at 41 weeks 4 days of gestation, spontaneous rupture of membranes occurred. Approximately 12 hours later, a healthy male infant was delivered by emergency cesarean section, which was performed because there had been prolonged fetal heart-rate decelerations during labor. The patient’s postoperative recovery was uncomplicated. She began breast-feeding, and for the first 3 postpartum days, she was alert and oriented and interacted appropriately with her baby. During the third night, insomnia developed. At 5:30 a.m. on the fourth day, she was disoriented. She did not recall having given birth and did not recognize her baby; she appeared frightened and thought the nurses were trying to hurt her. An emergency psychiatry consultation was obtained, and olanzapine (15 mg) was administered orally. Around-the-clock observation by a hospital staff member was initiated. During the next 24 hours, the patient remained agitated and confused, and she refused all medications. She spoke only in her native language, and tried to choke herself and bite others. She appeared to be having auditory hallucinations. Restraints were placed on her arms and legs. The patient’s husCase 24-2008: A 35-Year-Old Woman with Postpartum Confusion, Agitation, and Delusions

DOI: 10.1056/NEJMcpc0804290

Cite this paper

@article{Viguera2008CaseRO, title={Case records of the Massachusetts General Hospital. Case 24-2008. A 35-year-old woman with postpartum confusion, agitation, and delusions.}, author={Adele Casals Viguera and Anne D Emmerich and Lee S . Cohen}, journal={The New England journal of medicine}, year={2008}, volume={359 5}, pages={509-15} }