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  #1  
Old 11-22-2012
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ObGyn Behavioral Changes 2 Days Postpartum

A 36-year-old woman, gravida 3, para 3, is 2 days status post cesarean section for dystocia when she begins wandering the hallways of the hospital at 2 AM. She is extremely confused and thinks that she is at the police station. She states that she cannot sleep, feels very anxious, and wants to hurt her baby. Her prenatal course was unremarkable. She has no medical problems and had never had surgery. She has been taking Tylenol with codeine postpartum for incisional pain. Which of the following is the most appropriate next step in the management?

(A) Fluoxetine
(B) Morphine
(C) Naloxone
(D) Psychiatric hospitalization
(E) Supervised visit to the nursery
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  #2  
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Default (D) Psychiatric hospitalization

(D) Psychiatric hospitalization
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D psychiatric hospitalization .. coz she wants to hurt her baby. and is delusional.
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This is Post parptum depression. So A. Fluoxetine. Wanting to hurt the baby is normal in PPD. She's not showing any signs of Psychosis warranting admission into a Psych Ward.

EDIT: Oh didn't read the part where she was confused and thinking she was at the police station. Could be D.
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(C) Naloxone

Guys, this is a clear cut case of drug induced delirium. Codeine is the culprit here. She is just delirious--thinks she is at the police station, wandering the hallways of the hospital at 2 AM.
Just don't fall for the "buzz" words/phrases. Postpartum depression/psychosis don't start so soon after delivery.
Look at the whole picture.
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I'm sure on this one....its D.......

i saw this question in kaplan q book...and got wrong in that test.....
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Quote:
Originally Posted by Novobiocin View Post
(C) Naloxone

Guys, this is a clear cut case of drug induced delirium. Codeine is the culprit here. She is just delirious--thinks she is at the police station, wandering the hallways of the hospital at 2 AM.
Just don't fall for the "buzz" words/phrases. Postpartum depression/psychosis don't start so soon after delivery.
Look at the whole picture.
2 days of Codeine in a CONTROLLED hospital setting ? I don't think that would be a likely DD.

And why can't PPD start immediately after delivery ? I have never come across that. I'm pretty sure it can pop up anytime within the 1st few weeks post delivery.
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Quote:
Originally Posted by Nik7733 View Post
2 days of Codeine in a CONTROLLED hospital setting ? I don't think that would be a likely DD.

And why can't PPD start immediately after delivery ? I have never come across that. I'm pretty sure it can pop up anytime within the 1st few weeks post delivery.
I never said that she overdosed on Codeine.
Delirium can happen with normal doses and especially common in a post-op patient in a hospital setting.
Delirium has this hallmark feature of "reversal of sleep wake cycle".
Hallucinations & Delusions are common.

Also, PPD does not start so suddenly (2 AM at night)
PPD does NOT cause confusion.

Quote:
Originally Posted by heartbeat View Post
A 36-year-old woman, gravida 3, para 3, is 2 days status post cesarean section for dystocia when she begins wandering the hallways of the hospital at 2 AM. She is extremely confused and thinks that she is at the police station. She states that she cannot sleep, feels very anxious, and wants to hurt her baby. Her prenatal course was unremarkable. She has no medical problems and had never had surgery. She has been taking Tylenol with codeine postpartum for incisional pain. Which of the following is the most appropriate next step in the management?
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Quote:
Originally Posted by Novobiocin View Post
I never said that she overdosed on Codeine.
Delirium can happen with normal doses and especially common in a post-op patient in a hospital setting.
Delirium has this hallmark feature of "reversal of sleep wake cycle".
Hallucinations & Delusions are common.

Also, PPD does not start so suddenly (2 AM at night)
PPD does NOT cause confusion.
My apologies, I meant PostPartum psychosis. That's her diagnosis (According to me). Which fits with her symptoms.

Codeine will definitely be part of the Differential don't get me wrong, I just believe with her other symptoms (wanting to hurt child, post partum) etc. Post partum Psychosis fits better.
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Quote:
Originally Posted by Nik7733 View Post
My apologies, I meant PostPartum psychosis. That's her diagnosis (According to me). Which fits with her symptoms.

Codeine will definitely be part of the Differential don't get me wrong, I just believe with her other symptoms (wanting to hurt child, post partum) etc. Post partum Psychosis fits better.
I agree that wanting to hurt her baby goes more in favor of PPP but extreme confusion is not a feature of PPP.
Also, there is no previous history of psychiatric disorder.
Quote:
Postpartum psychosis is the most severe form of postpartum psychiatric illness.[50] The condition is rare, occurring in approximately 1-2 per 1000 women after childbirth.[7] At highest risk are women with a personal history of bipolar disorder or a previous episode of postpartum psychosis.[51, 52]

Presentation

Postpartum psychosis has a dramatic onset, emerging as early as the first 48-72 hours after delivery. In most women, symptoms develop within the first 2 postpartum weeks.[50, 52] The condition resembles a rapidly evolving manic or mixed episode, with symptoms such as restlessness and insomnia, irritability, rapidly shifting depressed or elated mood, and disorganized behavior.[50, 52]
The mother may have delusional beliefs that relate to the infant (eg, the baby is defective or dying, the infant is Satan or God), or she may have auditory hallucinations that instruct her to harm herself or her infant.[3, 31, 38, 50, 52]
The risks for infanticide and suicide are high among women with untreated postpartum psychosis.[31, 38] Rates of infanticide in this population are as high as 4%.[38]

Management

Puerperal psychosis is a psychiatric emergency that typically requires inpatient treatment.[17, 49, 52] Most patients with postpartum psychosis have bipolar disorder. Acute treatment includes a mood stabilizer (eg, lithium, valproic acid, carbamazepine) in combination with antipsychotic medications and benzodiazepines.[17]
Electroconvulsive therapy (ECT) (often bilateral) is well tolerated and rapidly effective.[48]
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true that. i dont think codeine for 2 days can cause psychosis. it could add to her already existing post partum psychosis.
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Oh good question... I fell for the trap!

So what's the right answer and explanation? Also what question bank is this from so that I can see/review it again??
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Old 11-24-2012
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Lets make it very clear......
Delirium: means extreme confusion....
so this lady is having epidose of DELIRIUM, which is definitely a part of the symptomatology of PPS......beacuse PPS pts do have periods of Delirium OR Mania....
So i'm sure the most close Dx is: " PPS"
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  #14  
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The correct answer is D. This patient has postpartum psychosis. Postpartum psychosis typically occurs hours to days postpartum and is characterized by anxiety, agitation, insomnia, confusion, and ideation of hurting oneself, the baby, or others. Postpartum psychosis, especially when there are concerns regarding suicide or homicide, must be managed with psychiatric hospitalization for the patient.
Naloxone (choice C). Although this patient is taking codeine (an opioid), she has no evidence of opioid overdose. Thus, naloxone would not be recommended.
Fluoxetine (choice A) is an effective antidepressant. However, this patient has a full-blown postpartum psychosis including homicidal ideation. Management with fluoxetine would not be the most appropriate next step.
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