Perinatal mood and anxiety disorders — assessment and emergency pathway (MEQ)

(i) Working diagnosis and differentials. Working diagnosis: first-onset postpartum psychosis (manic/psychotic presentation in early puerperium) with bipolar spectrum diathesis suggested by family history. Discriminators: rapid early-postpartum onset, insomnia, delusions involving infant identity, behavioural disinhibition. Differentials: bipolar I mania with postpartum trigger; delirium/organic (fever absent here but still screen infection, metabolic, thyroid); substance-induced; severe postnatal depression with psychosis; primary OCD is unlikely given ego-syntonic delusional conviction rather than ego-dystonic intrusion.[1]

(ii) Risk and setting. Dual assessment: maternal suicide/impulsivity/absconding risk and infant safety (delusional rejection, inadequate care, potential harm). Continuous observation, do not leave mother alone with infant unsupervised. Prefer mother-baby unit admission if available and infant safety can be managed jointly; otherwise general adult psychiatry admission with explicit infant-care plan and partner/family supports. Capacity assessment and local Mental Health Act least-restrictive process if she lacks capacity and refuses care. Safeguarding liaison as required by jurisdiction without inventing section numbers.[4][1][6]

(iii) Acute management. Restore sleep; medical work-up (FBC, U&E, LFT, glucose, TSH, consider urine drug screen). Structured pharmacological pathway: short-term benzodiazepine for severe insomnia/agitation (e.g. lorazepam orally/IM per local protocol, time-limited); antipsychotic for psychosis/mania (e.g. olanzapine or quetiapine oral, dose per response and monitoring — metabolic, sedation); lithium initiation when affective postpartum psychosis pathway indicated, with renal/thyroid baseline, pregnancy already completed, levels and toxicity education, lactation risk-benefit discussion (may need formula or specialist advice). Monitor response daily. ECT if life-threatening severity, poor oral intake, catatonia, medication non-response or need for rapid definitive control — high efficacy evidence base in severe depression and legitimate in selected PPP. Breastfeeding decisions individualised; safety of mother and infant outranks feeding preference in acute psychosis.[2][5][6]

(iv) Prognosis and planning. High acute remission rates with structured care, but high recurrence risk in subsequent postpartum periods and substantial longitudinal bipolar risk after first-onset PPP. Counsel preconception planning, early warning signs, sleep protection, and prophylactic strategies for future pregnancies. Engage partner, document relapse-prevention plan before discharge.[3][1]