Background: Postpartum hemorrhage is the leading cause of severe maternal morbidity and death. A prompt management of uterine artery embolization (UAE) . HEMORAGIK POST PARTUM. I. Definisi. Perdarahan postpartum adalah perdarahan lebih dari cc yang terjadi setelah bayi lahir pervaginam atau lebih dari. Risk factors of post partum haemorrhage in Indonesia. Rabea Pangerti Jekti,1 Eva Suarthana2. 1 Centre for Biomedical and Applied Health Technology.

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The objective is to provide an overview of the clinical features, prognosis, differential diagnosis, evaluation, and treatment of postpartum psychosis. The authors searched Medline —PsycInfo —Toxnet, and PubMed databases using the key words postpartum psychosis, depression, bipolar disorder, schizophrenia, organic psychosis, pharmacotherapy, psychotherapy, and electroconvulsive hemooragik.

A clinical case is used to facilitate the discussion. The onset of puerperal psychosis occurs in the first 1—4 weeks after childbirth. The data suggest that postpartum psychosis is an overt presentation of bipolar disorder that is timed to coincide with tremendous hormonal shifts after delivery. The patient develops frank psychosis, cognitive impairment, and grossly disorganized behavior that represent a complete change from previous functioning. These perturbations, in combination with lapsed insight into her illness and symptoms, can lead to devastating consequences in which the safety and well-being of the affected mother and her powt are jeopardized.

The somatic therapies include antimanic agents, atypical antipsychotic medications, and ECT.

Estrogen prophylaxis remains purely investigational. The rapid and accurate diagnosis of postpartum psychosis is essential to expedite appropriate treatment and to allow for quick, full recovery, prevention of future episodes, and reduction of risk to the mother and her children and family.

She underwent an uncomplicated delivery, and her baby boy was parthm term and healthy. This was a planned pregnancy, and the family was excited about the birth. Within 2 days of delivery, she told her husband that she thought he was poisoning her food and that the baby was staring at her strangely. She thought she smelled horses and heard them galloping out-side her bedroom.

She could not fall asleep even when her mother came to the house to care for their newborn and allow the patient to rest. Her husband noticed that she would gaze out the windows in their apartment for hours without explanation. She had not bathed for 6 days. She required much help in simple tasks, such as diapering her baby.

She parthm guilt about being a terrible mother and felt she did not deserve to have her family. She told her husband that she heard voices hemoraigk her to go with her infant son to the subway and jump in front of the train; these hallucinations terrified her and became stronger after she returned home hemoragok the hospital.

The husband became very concerned and brought his wife to the emergency room. The intention of this paper is to inform physicians and health professionals about PP so they will be able to recognize the symptoms, medically evaluate and appropriately and expeditiously refer the patient for psychiatric intervention, and educate the patient and her family about this illness.

Brockington 15 described the classic picture of a mother with PP: These were often mood-incongruent delusions of reference, hemogagik, jealousy, and grandiosity, 4611 along with visual, tactile, or olfactory hallucinations that suggest an organic syndrome. The baseline risk for PP is 1: Sleep loss, such environmental stressors as marital discord, and the precipitous drop plst hormone levels that occurs shortly after childbirth are other factors linked to PP.

In the first year after childbirth, suicide risk increases fold, and suicide is the leading cause of maternal death up to partym year after delivery. Suicidal ideation must be taken seriously, and patients with recent or active suicidal plans should be referred to an emergency setting. Homicidal behavior rarely occurs in PP. Spinelli 49 investigated 16 cases of neonaticide and found the women suffered from dissociative symptoms. These patients denied their pregnancy and the pain of childbirth; they often experienced dissociative hallucinations, brief amnesia, and depersonalization.


The mothers may avoid all antenatal obstetrical visits, deliver at home without any medical attention, and abandon the newborn pst giving birth. Neonaticide is more difficult to prevent, as it involves denial of pregnancy. In summary, the defining characteristic of PP is an illness hemroagik occurs shortly after childbirth.

PP is marked by symptoms of mood lability, cognitive disorganization, delusional beliefs, and hallucinations that resemble a clinical picture of delirium but is most likely an overt presentation of uemoragik illness. Predictors of recurrence include a personal or family history of PP, bipolar disorder, and cessation of antimanic treatment. All patients should be asked about the presence of suicidal and yemoragik symptoms. The woman with known bipolar disorder and partumm personal or family history of PP is at substantial risk for PP.

She and her family should be informed of the symptoms to recognize, that is, mood swings, confusion, strange beliefs, and hallucinations, especially in the first 2—4 weeks postchildbirth, and to contact her physician if these symptoms arise.

Even before delivery, the at-risk patient is encouraged to consult with a psychiatrist powt help her consider treatment options or treatment prophylaxis at delivery to avoid illness.

The Hemlragik is a self-rating instrument that uncovers the presence of persistent low mood, anhedonia, guilt, anxiety, and thoughts of self-harm. When the patient reports confusion, threats to hemoragij herself or others, difficulty caring for her children, or poor self-care, the physician must consider these as red flags and arrange a psychiatric referral quickly. PP is considered an emergency that necessitates an urgent evaluation, psychiatric referral, and possible hospitalization. Important tests include a complete blood count CBCelectrolytes, blood urea nitrogen BUNcreatinine, glucose, vitamin B 12folate, thyroid function tests, calcium, urinalysis and urine culture in the patient with fever, and a urine drug screen.

Uterine artery embolization for primary postpartum hemorrhage

partun A careful neurological assessment is essential; this includes a head CT or MRI scan to rule out the presence of a stroke related to ischemia vascular occlusion or hemorrhage uncontrolled hypertension, ruptured arteriovenous malformation, or aneurysm. The primary psychiatric diagnosis to consider with the case of early-onset PP is bipolar disorder.

These patients require antimanic drug treatment. Choices include lithium, such henoragik drugs as valproate or carbamazepine, and atypical antipsychotic medication, such as olanzapine, quetiapine, ziprasidone and the newer agent, aripiprazole. Patients with PP are differentiated from those with unipolar major depression by the presence of cognitive disturbance, delusional beliefs, and disorganized behavior.

Hemoragjk, women with a past history of unipolar psychotic depression can relapse shortly after delivery with an episode of PP. OC symptoms and OCD are characterized by intrusive thoughts and compulsive, irresistible behaviors.

Intrusive thoughts often center on themes of contamination, causing harm to their children, offensive violent or sexual images, religious preoccupations, and urges for symmetry. Rather, they avoid objects or places that provoke anxiety and suffer discomfort from their unwanted cognitions.

This contrasts with patients with florid psychosis, who are unable to discern reality, poet compelled to act on their delusional beliefs, and cannot assess the consequences of their actions.

Most patients oost pharmacotherapy in combination with cognitive behavioral therapy. Patients with refractory partu, may require augmentation with an atypical antipsychotic drug. PP could be a presentation of a primary psychotic disorder, such as schizophrenia. Mothers with schizophrenia also may suffer cognitive impairment. These women could benefit greatly by referral to in-home services for additional support and enhancement of parenting skills.

The process of psychoeducation is essential.

After stabilizing the patient and starting acute pharmacotherapy for PP, a careful discharge plan must be developed before the patient leaves the hospital. Referral to intensive outpatient therapy or day programalong with closely spaced out-patient follow-up visits, is advisable for the first several weeks after discharge.

A Review of Postpartum Psychosis

Treatment plans work best when they are individualized for each patient and include interventions hemorayik provided good response in the past. Sleep loss is a major precipitant of mania and PP. Patients and their families should be advised to contact their physicians quickly when symptoms recur.


Supportive psychotherapy that begins parttum to hospital discharge may incorporate parenting hemooragik and early infant interventions to address maternal-infant bonding and infant development.

In-home services could optimize both mother and infant outcomes. Other psychotherapy options, such as family-focused therapy, cognitive behavioral therapy, or interpersonal psychotherapy IPTare effective adjunctive treatments for postpartum mood disorders. These advanced forms of psychotherapy are recommended once patients have regained an organized level of thinking.

Acute pharmacotherapy is essential to manage the psychotic and mood-related symptoms of PP. The medication options include atypical antipsychotic agents and mood stabilizer or antimanic agents, such as lithium or antiepileptic drugs AED. For better treatment adherence, side effects can be minimized with lower starting doses that are titrated slowly to the response dose. Likewise, mothers must be instructed to observe for behavioral changes indicative of infant toxicity, such as poor hydration, sedation, poor feeding, and weight gain, as well as signs of hepatic and hematological pkst.

Mothers should be instructed to contact their pediatricians immediately when they notice these symptoms. Lithium is an important treatment option for the prevention and treatment of PP and a standard treatment for bipolar disorder.

Uterine artery embolization for primary postpartum hemorrhage

Results from small open trials suggest that women with past PP have better outcomes when lithium treatment begins immediately postdelivery. Retrospective reports and small case series indicate a lower likelihood for early postpartum parhum when treatment is resumed in the third trimester.

To avoid the high relapse risk after delivery, bipolar patients should be encouraged to resume treatment immediately after childbirth. Physicians and health professionals are advised to assess the renal and thyroid functions of patients who require lithium treatment for symptoms of PP. Drug levels and renal tests should be rechecked after 5 days of paetum treatment.

The target level of lithium is 0. The window between therapeutic and toxic serum levels is narrow. Patients must be instructed to avoid thiazides, non-steroidal anti-inflammatory agents, and angiotensin-converting enzyme inhibitors that alter fluid balance and interfere with the renal excretion of lithium.

Physicians must watch carefully for symptoms of toxicity in women on lithium: Toxicity is confirmed by elevated drug levels. Lithium toxicity must be managed immediately by stopping the drug, fluid rehydration, and close monitoring of electrolyte gemoragik and renal function.

Although lithium is ;ost commonly prescribed for breastfeeding women, investigators have noted that the avoidance is based on minimal data from over two decades ago.

Because the lithium levels of breastfeeding infants reach one hemoragio to one half of the therapeutic blood concentration, the AAP advises strict caution in breastfeeding when taking lithium. It is advised to check levels within 1 week of initiating VPA.

Periodic monitoring of serum concentration, liver function, platelet count, glucose, and lipid profile is suggested with worsened side effects, any dose adjustment, and at least once yearly while maintained on a stable regimen. Valproate levels are affected by enzyme-inducing AEDs, such as carbamazepine. Patients must be observed closely to ensure therapeutic efficacy. Side effects include nausea, weight gain, tremor, ataxia, diarrhea, abdominal pain, alopecia, hepatitis, thrombocytopenia, and, rarely, pancreatitis.

Menstrual irregularity, anovulation, polycystic ovarian syndrome, and insulin resistance may be associated with VPA.

It is protein-bound and induces hepatic cytochrome P 3A4 enzyme activity to triple its own clearance rate and the metabolism of such drugs as oral contraceptives within 2—4 weeks of initiation. Serum levels, liver function tests, and a CBC are indicated two or three times per year in symptomatic patients and at least once yearly for patients on maintenance therapy.

Side effects may include hepatitis, leukopenia, thrombocytopenia, rash, sedation, and ataxia. Treatment with CBZ and clozapine together is contraindicated because bone marrow suppression has been reported with this combination. Transient hepatic toxicity and cholestatic hepatitis 9091 may occur in neonates exposed throughout pregnancy and breastfeeding.