Postpartum blues
Postpartum blues, also known as baby blues and maternity blues, is a very common but self-limited condition that begins shortly after childbirth and can present with a variety of symptoms such as mood swings, irritability, and tearfulness. Mothers may experience negative mood symptoms mixed with intense periods of joy. Up to 85% of new mothers are affected by postpartum blues, with symptoms starting within a few days after childbirth and lasting up to two weeks in duration. Treatment is supportive, including ensuring adequate sleep and emotional support. If symptoms are severe enough to affect daily functioning or last longer than two weeks, the individual should be evaluated for related postpartum psychiatric conditions, such as postpartum depression and postpartum anxiety. It is unclear whether the condition can be prevented, however education and reassurance are important to help alleviate patient distress.
Signs and symptoms
Symptoms of postpartum blues can vary significantly from one individual to another, and from one pregnancy to the next. Many symptoms of postpartum blues overlap both with normal symptoms experienced by new parents and with postpartum depression. Individuals with postpartum blues have symptoms that are milder and less disruptive to their daily functioning compared to those with postpartum depression. Symptoms of postpartum blues include, but are not limited to:- Tearfulness or crying "for no reason"
- Mood swings
- Irritability
- Anxiety
- Questioning one's ability to care for the baby
- Difficulty making choices
- Loss of appetite
- Fatigue
- Difficulty sleeping
- Difficulty concentrating
- Negative mood symptoms interspersed with positive symptoms
Onset
Duration
Postpartum blues may last a few days up to two weeks. If symptoms last more than two weeks, evaluation for postpartum depression is recommended by the American Psychiatric Association.Causes
The causes of postpartum blues have not been clearly established. Most hypotheses regarding the etiology of postpartum blues and postpartum depression center on the intersection of the significant biological and psychosocial changes that occur with childbirth.Psychosocial causes
Pregnancy and postpartum are significant life events that increase a woman's vulnerability for postpartum blues. Even with a planned pregnancy, it is normal to have feelings of doubt or regret, and it takes time to adjust to having a newborn. Feelings commonly reported by new parents and lifestyle changes that may contribute to developing early postpartum mood symptoms include:- Fatigue after labor and delivery
- Caring for a newborn that requires 24/7 attention
- Sleep deprivation
- Lack of support from family and friends
- Marital or relationship strain
- Changes in home and work routines
- Financial stress
- Unrealistic expectations of self
- Societal or cultural pressure to "bounce back" quickly after pregnancy and childbirth
- Overwhelmed and questioning ability to care for baby
- Anger, loss, or guilt, especially for parents of premature or sick infants
Risk factors
Factors most consistently shown to be predictive of postpartum blues are personal and family history of depression. This is of particular interest given of the bidirectional relationship between postpartum blues and postpartum depression: a history of postpartum depression appears to be a risk factor for developing postpartum blues, and postpartum blues confers a higher risk of developing subsequent postpartum depression.
Pathophysiology
Estrogen and progesterone
After delivery of the placenta, mothers experience an abrupt decline of gonadal hormones, namely estrogen and progesterone. Major hormonal changes in the early postpartum period may trigger mood symptoms similarly to how more minor hormonal shifts cause mood swings prior to menstrual periods.Studies have not detected a consistent association between hormone concentrations and development of postpartum mood disorders. Some investigators believe the discrepant results may be due to variations in sensitivity to hormonal shifts across different subgroups of women. Therefore, development of mood symptoms may be related to a woman's sensitivity, based on genetic predisposition and psychosocial stressors, to changes in hormones rather than absolute hormonal levels.Other
The association between postpartum blues and a variety of other biological factors, including cortisol and the HPA axis, tryptophan, prolactin, thyroid hormone, and others have been assessed over the years with inconclusive results. Prolactin contributes to providing the correct amount of energy to support the mother and the fetus/offspring during pregnancy and lactation, but it also has a homeostatic role.Emerging research has suggested a potential association between the gut microbiome and perinatal mood and anxiety disorders.
Although several studies have measured lower levels of allopregnanolone associated with postpartum depression, and identified lower allopregnanolone levels as a risk factor for postpartum depression, many others fail to demonstrate such a relationship. Those studies that do suggest a relationship demonstrate reductions in allopregnanolone levels in women with a risk of developing postpartum depression, a reduction in women experiencing postpartum blues, and a negative correlation with depression symptoms in postpartum women.
Diagnosis
Classification
The proper diagnostic classification of postpartum blues has not been clearly established. Postpartum blues has long been considered to be the mildest condition on the spectrum of postpartum psychiatric disorders, which includes postpartum depression and postpartum psychosis. However, there exists some discussion in the literature of the possibility that postpartum blues may be an independent condition.Criteria
There are no standardized criteria for the diagnosis of postpartum blues. Unlike postpartum depression, postpartum blues is not a diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders.Investigators have employed a variety of diagnostic tools in prospective and retrospective studies of postpartum blues, including repurposing screening tools, such as the Edinburgh Postnatal Depression Scale and Beck Depression Index, as well as developing blues-specific scales. Examples of blues-specific scales include the Maternity Blues Questionnaire and the Stein Scale.
Differential diagnosis
Although symptoms of postpartum blues present in a majority of mothers and the condition is self-limited, it is important to keep related psychiatric conditions in mind as they all have overlap in presentation and similar period of onset.;Postpartum anxiety: Symptoms of anxiety and irritability are often predominant in the presentation of postpartum blues. However, compared to postpartum anxiety, symptoms of postpartum blues are less severe, resolve on their own, and last fewer than two weeks.
;Postpartum depression: Postpartum depression and postpartum blues may be indistinguishable when symptoms first begin. However, symptoms of postpartum blues are less severe, resolve on their own, and last fewer than two weeks. Mothers who experience severe postpartum blues appear to be at increased risk of developing depression.
;Postpartum psychosis: Although both conditions can cause periods of high and low moods, the mood swings in postpartum psychosis are significantly more severe and may include mania, hallucinations, and delusions. Postpartum psychosis is a rare condition, affecting 1-2 per 1000 women. Postpartum psychosis is classified as a psychiatric emergency and requires hospital admission.
Additionally, a variety of medical co-morbidities can mimic or worsen psychiatric symptoms.
Prevention
Screening
There are no specific screening recommendations for postpartum blues. Nonetheless, a variety of professional organizations recommend routine screening for depression and/or assessment of emotional well-being during pregnancy and postpartum. Universal screening provides an opportunity to identify women with sub-clinical psychiatric conditions during this period and those at higher risk of developing more severe symptoms. Specific recommendations are listed below:- American College of Obstetrics and Gynecology : In 2018, ACOG recommended universal screening for depression and anxiety using a validated tool at least once during pregnancy or postpartum, in addition to a full assessment of mood and well-being at the postpartum visit. This is in addition to existing recommendations for annual depression screening in all women.
- American Academy of Pediatrics : In 2017, the AAP recommended universal screening of mothers for postpartum depression at the 1-, 2-, 4-, and 6-month well child visits.
- United States Preventative Services Task Force : In 2016, the USPSTF recommended depression screening in the general adult population, including pregnant and postpartum women. Their recommendations did not include guidelines for frequency of screening.
Primary prevention