A 28-year-old woman, gravida 1 para 1, comes to the office for a postpartum check-up 3 weeks following a cesarean delivery due to cephalopelvic disproportion. She is accompanied by her husband who expresses concern that his wife is crying frequently and having difficulty adjusting to being a new mother. He says, "She was so happy to get pregnant. Apart from the gestational diabetes and having to watch her diet, she was fine through much of the pregnancy. Now, she seems stressed and anxious and not as happy about the baby as I expected." The baby is doing well and had a normal check-up at the pediatrician. The patient describes mild discomfort at the incision site, tension headaches, poor appetite, and fatigue from frequent nighttime awakenings to breastfeed. She says, "I have no energy and feel guilty that I can't even enjoy the baby." The patient spends her time searching the internet for baby care advice but has difficulty remembering what she has read. She worries about the baby's health and fears "I'm a bad mother." Her medical problems include obesity and gastroesophageal reflux. The patient has no past psychiatric history. Family history is significant for alcohol abuse and type 2 diabetes in the patient's father and anxiety disorder in the mother. Physical examination is normal. Hemoglobin is 12.5 g/dL and TSH is 2.1 µU/mL. Her oral glucose tolerance test is within the normal range. Mental status examination reveals a depressed and anxious mood and a tearful affect. The patient has no thoughts of suicide or of harming the baby. Which of the following is the most likely diagnosis?

Question

A 28-year-old woman, gravida 1 para 1, comes to the office for a postpartum check-up 3 weeks following a cesarean delivery due to cephalopelvic disproportion.  She is accompanied by her husband who expresses concern that his wife is crying frequently and having difficulty adjusting to being a new mother.  He says, "She was so happy to get pregnant.  Apart from the gestational diabetes and having to watch her diet, she was fine through much of the pregnancy.  Now, she seems stressed and anxious and not as happy about the baby as I expected."  The baby is doing well and had a normal check-up at the pediatrician.  The patient describes mild discomfort at the incision site, tension headaches, poor appetite, and fatigue from frequent nighttime awakenings to breastfeed.  She says, "I have no energy and feel guilty that I can't even enjoy the baby."  The patient spends her time searching the internet for baby care advice but has difficulty remembering what she has read.  She worries about the baby's health and fears "I'm a bad mother."  Her medical problems include obesity and gastroesophageal reflux.  The patient has no past psychiatric history.  Family history is significant for alcohol abuse and type 2 diabetes in the patient's father and anxiety disorder in the mother.  Physical examination is normal.  Hemoglobin is 12.5 g/dL and TSH is 2.1 µU/mL.  Her oral glucose tolerance test is within the normal range.  Mental status examination reveals a depressed and anxious mood and a tearful affect.  The patient has no thoughts of suicide or of harming the baby.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: This patient's symptoms are concerning for major depressive disorder (depressed mood, anhedonia, sleep disturbance, poor appetite, impaired concentration, tearfulness, guilt). All patients should be screened for postpartum depression at the postpartum visit. Postpartum depression is diagnosed using the same diagnostic criteria used to diagnose a major depressive episode (>2 weeks of at least 5 of 9 symptoms that include depressed mood plus SIGECAPS: Sleep disturbance, loss of Interest, Guilt, low Energy, impaired Concentration, change in Appetite, Psychomotor retardation or agitation, and Suicidal thoughts). A screening instrument such as Edinburgh Postnatal Depression Scale can also be used to assess which women require a more thorough evaluation. Postpartum blues (Choice D) is a self-limited condition consisting of milder depressive symptoms with less impact on functioning. It typically peaks at 5 days postpartum and resolves within 2 weeks. By contrast, this patient's depressive symptoms have persisted beyond 2 weeks and appear to be worsening. (Choice A) Adjustment disorder is diagnosed only if symptoms do not meet criteria for another specific disorder such as major depressive disorder. (Choice B) Generalized anxiety disorder is characterized by persistent worry about multiple issues lasting at least 6 months. This patient's excessive anxiety is an associated symptom of her acute depression and revolves around the care of her infant. (Choice C) This diagnosis is given when the mood disturbance is directly caused by another medical condition (eg, hypothyroidism, anemia). This patient's laboratory results indicate that she is euthyroid, not anemic, and her gestational diabetes has resolved. Educational objective: All women should be screened for depression at the postpartum visit. Postpartum depression is diagnosed using the same diagnostic criteria for major depressive episodes that occur outside of the postpartum period. Postpartum blues is a milder form of depression with less impact on functioning and usually resolves within 2 weeks. References: The American College of Obstetricians and Gynecologists Committee Opinion no. 630. Screening for perinatal depression. (http://www.ncbi.nlm.nih.gov/pubmed/25932866) Identification and management of peripartum depression. (http://www.ncbi.nlm.nih.gov/pubmed/27175720) Postpartum psychiatric disorders: early diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/26330638)

A 28-Year-Old Woman, Gravida 1 Para 1, Comes to the Office