Obgyn · Year 3 · from Obgyn

Case 3: Postpartum Depression

Patient Demographics

• Age: 32 years
• Sex: Female
• Occupation: Software engineer (currently on maternity leave)

Chief Complaint

"I don't feel like myself. I can't stop crying and I don't feel connected to my baby."

History of Present Illness

The patient is 4 weeks postpartum following an uncomplicated vaginal delivery of a healthy infant. She reports persistent low mood, frequent crying episodes, difficulty sleeping even when the baby is asleep, decreased appetite, and overwhelming fatigue. She feels guilty that she is not "bonding" with her baby the way she expected and worries she is a "bad mother." She has intrusive thoughts about accidentally harming the baby (dropping, not waking up to feed) but denies any intention to harm herself or the baby. She has been isolating herself from friends and family.

Screening Scores

• Edinburgh Postnatal Depression Scale (EPDS): 18/30 (score >10 suggests possible depression; >13 indicates likely depression)

Distinguishing from "Baby Blues"

This patient's symptoms began at 2 weeks and have persisted, meeting criteria for postpartum depression rather than baby blues.

Risk Factors Present

• History of anxiety disorder
• Limited social support (spouse travels for work frequently)
• Sleep deprivation
• Difficulty with breastfeeding leading to guilt

Mental Status Examination

• Appearance: Disheveled, tearful
• Mood: "Sad and empty"
• Affect: Constricted, tearful
• Thought Content: Guilt about mothering, intrusive thoughts about accidental harm (ego-dystonic), no suicidal ideation, no thoughts of intentional harm to infant
• Cognition: Intact
• Insight/Judgment: Good - recognizes she needs help

Diagnosis

Postpartum Depression (Moderate Severity)

• Depressed mood persisting >2 weeks postpartum
• Anhedonia, guilt, sleep disturbance, appetite changes
• Functional impairment
• EPDS score 18

Safety Assessment

• No suicidal ideation
• No homicidal ideation
• Intrusive thoughts are ego-dystonic (distressing to her, not intended actions)
• No psychotic symptoms (hallucinations, delusions)
• NOT postpartum psychosis (would require emergent intervention)

Management Plan

Psychotherapy:

• Referral for cognitive behavioral therapy (CBT)
• Consider interpersonal therapy (IPT) - evidence-based for PPD
• Weekly sessions initially

Pharmacotherapy:

• Sertraline 50 mg daily (SSRI with good safety data in breastfeeding)
• Discuss that therapeutic effect takes 2-4 weeks
• Continue breastfeeding - minimal transfer to breastmilk

Support Measures:

• Encourage sleep when baby sleeps (partner/family to help with night feeds using expressed milk or formula supplementation)
• Connect with postpartum support groups
• Lactation consultant referral for breastfeeding difficulties
• Partner education about PPD

Safety Planning:

• 24-hour crisis line number provided
• Clear return precautions for worsening symptoms
• Family member (mother) to stay with patient this week

Follow-up:

• Phone check-in in 1 week
• Office visit in 2 weeks
• EPDS rescreening at follow-up

Clinical Course

• At 2-week follow-up: EPDS improved to 14
• At 6-week follow-up: EPDS 8, feeling "more like myself"
• Continued sertraline and therapy for at least 6-12 months

Teaching Points

• Screen ALL postpartum patients for depression at postpartum visits
• Postpartum depression affects 10-20% of new mothers
• SSRIs (sertraline, paroxetine) are compatible with breastfeeding
• Distinguish from postpartum psychosis (rare, psychiatric emergency)
• Untreated PPD affects maternal-infant bonding and child development

Clinical Image

Image Description: Sample Edinburgh Postnatal Depression Scale (EPDS) questionnaire showing the 10-item screening tool used to identify postpartum depression, with scoring guidelines.

Attribution: Public domain screening tool. Edinburgh Postnatal Depression Scale.

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