Case Study Reports: Postpartum Chest Pain

POSTPARTUM CHEST PAIN

History

A 32-year-old Sri Lankan woman presents complaining of chest pain, neck tightness and shortness of breath 3 weeks after delivery. The symptoms have come on gradually over the last 2 days and are now severe. She feels as if she cannot breathe and thinks she is going to die.

The pain is heavy and stabbing and is constant though worse when she lies down and tries to sleep. The pain is not pleuritic and she says it radiates up into her neck. She does not have a cough or haemoptysis.

The neck tightness is all over the neck but especially anteriorly, and is related to the difficulty breathing. There is no photophobia or fever.

The breathing difficulty occurs predominantly when she is trying to sleep or is sleeping – it has woken her several times during the night. She is now terrified of going to sleep and is actively stopping herself from doing so as she is certain that she will die if she does.

Prior to this she has always been fit and well with no previous medical history reported.

The pregnancy was uneventful and she was admitted in spontaneous labour at 40 weeks. Cervical dilatation was slow and contractions were therefore augmented with syntocinon. Once fully dilated she had pushed for 90 min and subsequently underwent ventouse deliv- ery of a healthy female infant.

She had some difficulty establishing breast-feeding and bonding with the baby and was finally discharged home on day four following delivery. Since going home she has stopped breast-feeding but is finding it difficult to sleep even when the baby is sleeping.

She has lived in the UK for 18 months but her husband has been here for 6 years. Currently her mother is also staying with them to help with the baby. Both the woman and her mother speak very little English and the husband is interpreting.

Examination

She is thin and quiet, with little eye contact. When talking about the baby she is non- responsive and she does not look at or touch the baby during the consultation. Her blood pressure is 108/62 mmHg and heart rate 90/min. She is apyrexial. There are no signs of anaemia, cyanosis or oedema. Chest and cardiac examination are normal and the uterus is just palpable in the lower abdomen.

Questions

·              What is the likely diagnosis?

·              What further questions would you wish to ask and what are the principles of management?

Answer:

The symptoms initially sound possibly cardiac or respiratory in origin. However, the story does not fit with any specific disease and the examination and investigations are all normal. The absolute fear of sleeping is an important piece of information as is the reported affect.

This woman is suffering from postnatal psychosis. This occurs in 1 in 500 women with onset in the first 6 weeks post delivery. The commonest symptoms are delusions (e.g. the thought that she is going to die) and hallucinations.

The condition should be distinguished from the two other main psychological/psychiatric postnatal conditions.

·              Post-partum blues:

·              tearfulness

·              fatigue

·              anxiety over their own or the baby’s health

·              feelings of inability to cope

This is very common (probably affecting approximately half of mothers) usually after the third postnatal day, and resolves spontaneously over a few days.

·              Post-partum depression:

·              low mood

·              crying

·              anxiety over the baby’s health

·              feelings of guilt towards the baby

·              panic attacks

·              excessive tiredness

·              poor appetite

This occurs in 10 per cent of women, any time up to 6 months following delivery. It should be treated seriously with suicide risk assessment and antidepressant medication as well as social and practical support.

Further questioning

A trained interpreter should be sought rather than the husband who is involved in this case and may find it difficult to translate or address sensitive issues.

The woman should be asked for any previous personal or family history of mental illness or psychiatric treatment. She should then be asked more probing questions. How is her mood and appetite? Does she feel depressed? Does she have fears of harming herself?

Her relationship and attitudes to the baby are important – how does she feel about the baby? Is she finding the baby easy? Does she feel that the baby is healthy? Does she have any negative thoughts toward the baby such that it is bad or evil? Does she feel she might harm the baby?

Suicide is now the commonest cause of indirect maternal death, and non-English-speaking immigrants are particularly at risk as well as those aged over 30 years, with previous psychotic history, poor social support or traumatic delivery. This woman has three such risk factors.

The diagnosis should always be considered when symptoms do not appear to be backed up by the examination or investigations. Sometimes delusional symptoms or hallucin- ations are not elicited because the doctor fails to take a thorough history.

Management

Disease progression can be acute and this woman needs immediate referral to a mother and baby psychiatric unit for assessment and treatment. Depending on her feelings of harm towards herself or others, this may need to be under the Mental Health Act. Antidepressants, antipsychotics and possibly sedation may be needed. The baby may be at risk from neglect or harm secondary to the psychosis, so close supervision and support is essential. Recovery is expected within 2 months but repeat pregnancy and non-pregnancy-related episodes are common.