Psychiatric role in managing postpartum depression after delirium in a patient with acute fatty liver of pregnancy and intrauterine fetal death
Abstract
Acute Fatty Liver of Pregnancy (AFLP) is a rare but life-threatening metabolic disorder that typically occurs in the third trimester and may lead to hepatic dysfunction, hepatic encephalopathy, and multisystem organ failure. While prompt delivery and intensive care can stabilize the patient physically, significant psychological complications may arise in the postpartum period. We report the case of a 22-year-old primigravida diagnosed with AFLP complicated by intrauterine fetal death (IUFD), hepatic encephalopathy, and delirium. The patient required 10 days of Intensive Care Unit (ICU) management before transitioning to the High Care Unit (HCU). Psychometric evaluation via the Confusion Assessment Method for the ICU (CAM-ICU) confirmed a mixed-type organic delirium, alongside a Positive and Negative Syndrome Scale–Excited Component (PANSS-EC) score of 19. After resolution of the acute organic delirium, the patient developed persistent grief, emotional lability, and severe postpartum depression, evidenced by an Edinburgh Postnatal Depression Scale (EPDS) score of 13. Her psychological distress was exacerbated by unique psychosocial stressors, particularly the concurrent healthy pregnancy of her identical twin sister, which triggered profound feelings of envy, inadequacy, and identity disruption. Management involved a tight multidisciplinary approach including Obstetrics & Gynecology, Internal Medicine, and Psychiatry. Psychiatric treatment focused on hepatic-safe pharmacotherapy using low-dose haloperidol (0.5 mg) during the acute delirium phase, followed by sertraline (25 mg) and structured Cognitive Behavioral Therapy (CBT) combined with grief counseling. At the one-month follow-up, her EPDS score improved to 10, demonstrating the crucial role of integrated medical and psychosocial care in mitigating complex bereavement and promoting neuro-psychiatric recovery following severe obstetric crises.
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References
Bakshi, R.K., et al., (2023). Oxidative stress and Liver disease in pregnancy—The role of Antioxidants. Journal of Hepatology and Clinical Research, 45(2), pp.112-125.
Burns, R.N., Vadlamudi, G., Ginsburg, J., (2024). The Fourth Trimester: Emergencies in the Postpartum Period. Emergency Medicine Clinics of North America, 42(1), pp.89–103.
Chow, R., Huang, E., Li, A., Li, S.Y. & Son, J.S., (2021). Appraisal of systematic reviews on interventions for postpartum depression: systematic review. BMC Pregnancy and Childbirth, 21(1), p.45.
Danaher, B.G., Seeley, J.R., Holt, C.J., Milgrom, J. & Gemmill, A.W., (2021). Internet and face-to-face cognitive behavioral therapy for postnatal depression: randomized controlled trial. Journal of Medical Internet Research, 23(12), p.e17185.
Huang, L., Zhao, Y., Qiang, C. & Fan, B., (2018). Is cognitive behavioral therapy a better choice for women with postnatal depression? A systematic review and meta-analysis. PLoS One, 13(10), p.e0205243.
Milgrom, J., Gemmill, A.W. & Ericksen, J., (2015). Treatment of postnatal depression with cognitive behavioural therapy, sertraline and combination therapy: a randomised controlled trial. Australian & New Zealand Journal of Psychiatry, 49(3), pp.236–245.
Naoum, E.E., Leffert, L.R., Chitilian, H.V. & Gray, K.J., (2019). Acute fatty liver of pregnancy: pathophysiology, anesthetic implications, and obstetrical management. Anesthesiology, 130(3), pp.446–461.
Radford-Smith, D.E., (2022). Metabolism in mood disorder across the gut-liver-brain axis. Translational Psychiatry, 12(1), p.184.
Sarkar, M., Brady, C.W., Fleckenstein, J. & Forde, K.A., (2021). Reproductive health and liver disease: practice guidance by the American Association for the Study of Liver Diseases. Hepatology, 73(1), pp.318–365.
Terrault, N.A., et al., (2022). Pregnancy-associated liver diseases. Gastroenterology, 163(1), pp.97–111.
Ushkalova, E.A. & Ushkalova, A.V., (2023). Comparative analysis of the use of selective serotonin reuptake inhibitors during pregnancy and the postpartum period. Safety of sertraline. Neurology, Neuropsychiatry, Psychosomatics, 15(5), pp.94-101.
Wang, H.Y., et al., (2016). Effect of caesarean section on maternal and foetal outcomes in acute fatty liver of pregnancy: a systematic review and meta-analysis. Scientific Reports, 6, p.28826.
Williamson, C., (2019). Liver and endocrine diseases in pregnancy. Oxford Textbook of Obstetrics and Gynaecology, Oxford University Press, pp.295-310.
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