Category Archive Puerperium

ByPam Harper

Puerperal Mental Fragility

Beware the mental fragility of mothers in the puerperium

Dr Dermot J Ward

A recent tragedy reminded me of a moment in time.  I had exchanged a certain smile with a lady across a crowded room. It was recognition not romance. The occasion, about two years ago, was a social gathering, a reunion of my medical school year’s fraternity.  The lady in question, married to an old medical friend from my year, had been a patient. The tale goes back to the ‘70s. She had developed a puerperal psychosis of severe magnitude with marked restlessness, agitation psychotic delusions. She possessed a previous personality free of any mental health problems. But the intensity of her puerperal breakdown was a huge worry and concern to her husband and family. There was no time lost in her being treated with ECT and support medication. She was discharged around three weeks later to the care of her husband. There was no recurrence.

 

My generation of physicians, and especially those in psychological medicine, were acutely aware that postpartum patients exhibiting even mild psychiatric symptoms were at special risk of a dangerously rapid deterioration in morbidity, in a matter of days which could lead to suicide and or  filicide (killing of the newborn baby,fortunately rare),  This was unlike non-puerperal clinical depression, mania, schizophrenia where such deterioration might occur over weeks, even months. Another difference in this patient group was the not uncommon perhaps slight body temperature rise which might in turn signal sepsis requiring attention. A further given was an acceptance that if such puerperal psychoses were inadequately treated, return to full health could be seriously prolonged.

 

On December 5, 2014, national newsmedia carried the sad account of Ms Charlotte Bevan aged 30, 5 days postpartum, who had walked unnoticed out of Bristol Maternity Hospital without a coat or shoes. She disappeared, but seen on camera later, walking past, clutching baby Zaani Tiana Bevan Malbrouck who was wrapped only in a blanket. A few days later their two bodies were found in the Avon Gorge beneath the Bristol Suspension Bridge. A friend quoted, said the hospital new Ms Bevan had “mental health problems”. Her partner, Mr Malbrouck, declared she had suffered from “schizophrenia and depression” in the days following the birth and was sleep deprived. “CCTV footage from the hospital showed her walking through security gates and past at least 4 nurses without being stopped. The hospital immediately began a “thorough review” into how Ms Bevan was allowed to leave unchallenged. Sadly, the Bristol Suspension Bridge is all too well known locally for its suicide history.

 

BBCRadio4 also highlighted the tragedy and secured a spokesperson from the Royal College of Psychiatrists to discuss it. Probably the discussion was time-pressurised, certainly short, the main theme was how some  mothers were reluctant to take medication for fear of its harming the baby. Such observation can certainly be the case. Presumably there was no time to discuss other aspects such as those touched on in para 2 above. Perfection can prove an elusive goal.

 

On 24th of November 2006 news media headlined how a depressed mother who tried to murder her daughter by jumping off the Humber Bridge with her two-year-old in her arms was jailed for 18 months the previous day. The mother Ms Angela Schumann, was aged 28. The judge remarked she had been one of only 3 people out of 85 to have survived the fall. On medical examination she had been found to have written on her stomach, “cause of death ,Julio”. Fuller accounts of this lady are available on the internet. Her trial was held some months after the fall because of injuries. She was finally released from prison in 2007 after Appeal Court Judges reviewed her case and intervened. I have since wondered how on earth a strong psychiatric report for her first court hearing resulting in her being recommended for treatment at worst in a secure psychiatric unit could not be made. Worrying. Perhaps I had missed something.

 

There are some 20 mother and baby units scattered about  the UK. Interestingly I could find only charitable organsiation websites on a net search, granted not an exhaustive one. It is difficult to think of any human society in which mothers and their babies are not regarded as a supremely precious human life form deserving our highest regard, care and protection. Regrettably, it can appear current NHS  society is not honoring that responsibility in “the envy of the world” NHS slogan compared with some decades ago.

 

(Originally published in IRISH MEDICAL TIMES, March 5, 2015)