Postpartum Psychosis in Patient with COVID-19: Case Report

Introduction

Postpartum psychosis is an acute psychosis typically occurring in the two weeks following delivery. Signs and symptoms include disorganization, confusion, insomnia, irritability, hallucinations, and/or delusions with mania, agitation, depression, anxiety, or a mix of any of these qualities [1]. This varied clinical picture can make the disorder challenging to identify promptly. Due to the risks of infanticide and suicide, postpartum psychosis is a dangerous condition for mothers, infants, and potentially older children. Unfortunately, though it is rare, postpartum psychosis is an especially troubling disorder because it is challenging to predict and difficult to recognize in its early stages [1].

Research substantiates a link between severe COVID-19 infection and psychosis in non-pregnant patients, however, there has been much less investigation into the potential connection between COVID-19 infection and psychosis in the postpartum period [2]. One retrospective cohort study demonstrated an increase in the incidence of postpartum psychosis during the first year of the COVID-19 pandemic, and few case reports describe postpartum psychosis coinciding with COVID-19-related illness [3-7].

We present a patient with severe COVID-19 who rapidly developed psychotic symptoms in the postpartum period. We hope to add to the literature suggesting that critical illness with COVID-19 may be a precipitant of postpartum psychosis and promote increased vigilance for this devastating disorder during future waves of infection.

Case Presentation

Mrs. S was a gravida 2 para 1 in her mid-30s at 37 weeks gestation with no reported psychiatric history when she presented to the emergency department of our tertiary care center with shortness of breath, fatigue, cough, and pleuritic chest pain in the context of a previously confirmed SARS-CoV-2 infection. Her CT demonstrated multifocal pneumonia, and Mrs. S began treatment with dexamethasone, remdesivir, dextromethorphan, ceftriaxone, and doxycycline.

The patient was admitted to the medical intensive care unit (MICU) due to increasing oxygen requirements. Despite her worsening clinical status and extensive discussion with the Maternal Fetal Medicine specialists, Mrs. S declined continuous fetal monitoring and induction of labor. She adamantly refused to consent to a cesarean section, even in the circumstances necessary to save her or her child's life. Psychiatry was consulted to determine the patient's capacity to refuse this intervention. On evaluation, Mrs. S was fully oriented with organized thought but terminated the interview prematurely. During a subsequent evaluation, she refused to speak after answering a few basic questions. Therefore, her decision-making capacity was not determined at this time.

Over the next day, Mrs. S's respiratory status improved, and she had an uncomplicated spontaneous vaginal delivery. However, immediately postpartum, her behavior grew increasingly concerning. She refused all interventions for her baby, including phototherapy for jaundice, but could not articulate her reasoning or understanding of the consequences of refusing care. Upon reevaluation, the psychiatry team found Mrs. S, now unclothed and unkempt, more guarded and agitated than before. Upon interview, she was internally preoccupied with a complete inability to engage in a coherent conversation. During the interview, she insisted she was "feeding the baby," yet the infant was not latched. She mechanically repeated, "I don't know," when asked simple questions regarding the child's feeding and stooling. Psychiatry advised that she lacked the capacity to refuse medical interventions for herself and her child, and Mrs. S was started on risperidone 1mg twice daily for psychotic symptoms.

Later that day, Mrs. S refused to comply with oxygen treatment during an episode of worsening respiratory distress. She became hypoxic and began to make erratic statements expressing suicidal ideation and a desire to give up her baby. The obstetrics team called a rapid response. Despite haloperidol 5mg and lorazepam 2mg, Mrs. S continued to resist treatment. Due to persistent agitation, she then received midazolam 10mg and olanzapine 10mg before being intubated due to respiratory failure and upgraded to the medical ICU. In intensive care, the patient self-extubated and required physical restraints in addition to sedation with propofol and fentanyl. Psychiatry reevaluated and increased her antipsychotics to risperidone to 2mg twice daily and haloperidol to 5mg IV every six hours as needed. Mrs. S’s respiratory status further deteriorated over the following few days, and she required vasopressor support. At this point, the risperidone was discontinued due to several otherwise unexplained sinus pauses on ECG. Following a trial of prone positioning, Mrs. S’s respiratory status improved, and she was extubated after just over a week in intensive care.

After extubation, Mrs. S's psychosis improved remarkably. Her behavior was now appropriate, and she was without agitation or internal preoccupation. She described her mood as low but denied delusions, hallucinations, and suicidal/homicidal ideation. Mrs. S said she was looking forward to putting the previous events behind her so she could go home to see her baby. Psychiatry started valproate 250mg twice daily for mood stabilization. The patient was medically and psychiatrically cleared for discharge on oral antibiotics and valproate with close psychiatric follow-up.

Upon outpatient follow-up a week after discharge, the patient noted that the experience had been incredibly stressful, but she recognized that her treatment was necessary due to the nature of her symptoms. She and her husband noted that all her symptoms had resolved, and they desired discontinuation of the valproate. Her provider discussed halving the dose of the medication and reevaluating the taper during a one-week follow-up, but Mrs. S. failed to attend the scheduled visit and was unreachable by phone.

Discussion

Mrs. S’s psychosis made her a danger to herself and her child, which her providers quickly recognized and escalated psychiatric care appropriately. Multiple factors intersected to produce her psychotic symptoms in the context of recent birth and COVID-19 infection. Though no definitive differentiation was made between multiple differentials, here we consider the interplay of her postpartum status, severe COVID-19 infection, and steroid regimen may have contributed to her condition.

Postpartum psychosis is one of our leading diagnoses because Mrs. S’s symptoms were most readily apparent after giving birth. However, she did show signs of disorganized thought before delivery when she was incapable of providing informed refusal of cesarean section in the event of a life-threatening emergency. While Mrs. S. did not disclose a psychiatric history, which is often present in cases of postpartum psychosis, the condition can manifest in women without a history of bipolar disorder or depression [1]. Furthermore, the patient reported poor sleep throughout hospitalization, and sleep loss is known to contribute to the development or exacerbation of postpartum psychosis [8]. Given this evidence, it is possible that her psychosis was initiated by the physiological changes occurring during postpartum.

COVID-19 psychosis is another notable differential, as this patient’s psychosis rapidly resolved once her respiratory status improved, suggesting that her acute illness was a significant contributor. There is documented evidence of a relationship between acute respiratory illness and psychotic symptoms [9]. Data from the 1918 Spanish flu, 2003 SARS, 2009 H1N1, and 2012 MERS outbreaks demonstrate that more patients with these conditions are diagnosed with psychosis compared to the general population [10]. More specifically, research indicates that SARS-CoV-2 is neuroinvasive and that COVID-19 survivors found a higher-than-expected rate of psychotic disorders, greatest among those with more serious illness [11,12]. While there is growing evidence that severe COVID-19 infection can be a precipitant of psychosis, less is known about this relationship in the postpartum period [2].

To our knowledge, there is only one retrospective cohort study and fewer than 10 published cases concerning postpartum psychosis and recent or concurrent COVID-19 infection. The retrospective cohort study at a tertiary care center in the US identified a four-fold increase in the incidence rate of first-episode postpartum psychosis between the year preceding the COVID-19 pandemic and the first year of the outbreak [5]. Four of these cases were identified in the US, and another five were identified in India [3,4,6,7]. One report describes a 34-year-old postpartum woman who experienced a manic episode with psychotic features after treatment for severe COVID-19 [4]. She presented with paranoia, disorganized behavior, and perseveration, much like our patient. The other US case series identified three women with postpartum psychosis and COVID-19 infection closely preceding the onset of symptoms [3]. All three of these cases required inpatient hospitalization, and only one had a prior history of bipolar disorder [3]. One of the case series from India describes three otherwise healthy women who developed postpartum psychosis while also being diagnosed with COVID-19 [7]. Like our patient, these women recovered rapidly within a week after the onset of symptoms. A second case study from India identified two women who experienced COVID-19 infection during childbirth, and they suppose that this traumatic experience played a role in triggering their subsequent psychotic episodes [6].

The current body of evidence regarding COVID-19 infection and postpartum psychosis points to several factors that could explain this relationship. First, it is possible that the virus itself is triggering psychotic events in postpartum women, similar to how it triggers such mood disturbances in those who are not recently pregnant [2]. Evidence also demonstrates that immune system dysregulation, pro-inflammatory cytokines, and dysfunction of the hypothalamic-pituitary-adrenal axis, contribute to the development of postpartum psychosis [13,14]. Thus, severe COVID-19 illness may trigger psychosis in postpartum women who are predisposed to the condition. Several of the aforementioned case reports also highlight that the experience of suffering from a severe pandemic illness during childbirth, often accompanied by isolation and the separation of mother and child, could be a traumatic trigger psychosis in patients like ours [6,7]. It is also important to consider that Mrs. S’s behavioral changes may have stemmed from delirium, which can commonly present during critical illness due to hypoxia, exacerbation by hypoxia, sepsis, psychoactive medications, sensory deprivation, prolonged immobilization, and poor sleep hygiene [15]. Our patient was also treated with high-dose corticosteroids, which can lead to mood symptoms and steroid-induced psychosis [16].

Conclusions

Ultimately, a definitive differentiation between the leading differential diagnoses was not made in the case of Mrs. S. Our patient’s psychiatric symptoms rapidly deteriorated in the postpartum period yet rapidly improved following the resolution of her respiratory symptoms. We hypothesize that this patient’s rapid psychosis was secondary to severe COVID-19 infection combined with postpartum hormonal changes and an underlying susceptibility to the condition. The case provides insight into multifactorial causes of postpartum psychosis and the potential overlapping influence of severe COVID-19 infection with steroid treatment. Although a decisive link between these conditions has yet to be elucidated, and further investigation is necessary, increased vigilance may be warranted in this population. Due to the devastating potential consequences of postpartum psychosis, providers should remain highly suspicious of signs of psychosis, especially if there is severe concurrent COVID-19. Though cases are no longer at a critical level, we must be vigilant to the potential for future waves of COVID-19 and the emergence of other outbreaks of respiratory illnesses. In the inevitable case that another viral respiratory pandemic occurs, providers of postpartum women should be vigilant to the possibility that this context may provoke or exacerbate postpartum mood changes such as psychosis because these cases have the potential to be devastating.

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