Case 68: Postpartum chest pain

 

Case 68: Postpartum chest pain

CASE 68: 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. When asked to describe the neck tightness she demonstrates that it

is all around the neck but especially anterior, and is related to the difficulty breathing. There

is no photophobia. The breathing difficulty occurs predominantly when the woman 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 episode the woman 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

delivery of a healthy female infant. There was some difficulty establishing breast-feeding and

bonding with the baby and she was finally discharged home on day 4 following delivery.

Since going home she has stopped breast-feeding but is finding it difficult to sleep even when

the baby is sleeping.

The woman 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

The woman appears thin and quiet, with little eye contact. When talking about the baby her

affect appears flat and she does not look at or touch the baby during the consultation. She is

apyrexial with blood pressure of 108/62 mmHg and heart rate 90/min. No signs of anaemia,

cyanosis or oedema are detected and chest and cardiac examinations are normal. The uterus

is just palpable in the lower abdomen.100 Cases in Obstetrics and Gynaecology

186

INVESTIGATIONS

Normal range for

pregnancy

Haemoglobin 10.8 g/dL 11–14 g/dL

Mean cell volume 78 fL 74.4–95.6 fL

White cell count 5.3×109/L 6–16×109/L

Platelets 237×109/L 150–400×109/L

Electrocardiogram (ECG): sinus rhythm, no abnormalities

Chest X-ray: normal heart and lung fields

Oxygen saturation: 100 per cent on air

Arterial blood gas

pO2 16 kPa 12–14 kPa

pCO2 3.8 kPa 5–6 kPa

Questions

• What is the likely diagnosis?

• What further questions would you wish to ask and what are the principles of

management?Case 68: Postpartum chest pain

187

ANSWER 68

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 postdelivery. 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.

• Postpartum 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.

• Postpartum depression:

• low mood

• crying

• anxiety over the baby’s health

• feelings of guilt toward 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 hallucinations are not

elicited because the doctor fails to take a thorough history.100 Cases in Obstetrics and Gynaecology

188

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 toward 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-pregnancyrelated episodes are common.

KEY POINTS

• Postpartum psychosis is generally diagnosed in the community after discharge

from hospital after delivery.

• Women with postpartum psychosis must be admitted to a mother and baby psychiatric unit, if need be under the Mental Health Act.