Preeclamptic psychosis

Neurological manifestations of preeclampsia include holo-cranial headaches, hyperreflexia, visual field changes and blindness, and altered sensorium.[1] Psychiatric manifestations usually arise when eclampsia sets in and particularly affects primiparae. A gap may be noted between the seizures and the onset of psychotic symptoms, occasionally up to 4 days. Symptoms usually include features of mania, delirium, and retrograde amnesia.[2] Donkin Psychosis, first described by Arthur Donkin in 1863, is a specific form of pregnancy-associated psychosis and is also known as Eclampsia Psychosis Without Seizures.[3] Previous studies have shown that preeclampsia predisposes females to postpartum depression and postpartum psychosis.[4] We present a case of a patient who was brought to the emergency department with features of preeclampsia and psychosis.

A 36-year-old primigravida, with 36 weeks of gestation, was detected to have gestational diabetes mellitus and hypothyroidism during the first and second trimesters, respectively (adequate glycaemic control and thyroid status with medical nutrition therapy and oral thyroxine, respectively), with no past/family history of psychiatric illness, and was brought to the emergency department with elevated blood pressure since 18 days. Her blood pressure was 180/104 mmHg. No pedal edema was noted. A neurological examination did not reveal any abnormalities. She was diagnosed as a case of severe preeclampsia with impending eclampsia. In the ward, she was agitated, uncooperative, and intermittently crying, following which a psychiatric consult was requested. Mental state examination (MSE) revealed an ill-groomed lady, lying on the bed with her eyes closed, intermittently crying. She was uncooperative. The affect was depression. She had nihilistic delusions in which she believed that she, her parents, and all the patients in the hospital had died, and that only after she left her body would her parents and other patients become alive. No perceptual abnormalities were noted. She was oriented to time, place, and person. Attention was arousable and concentration was sustained. Relevant investigations were within normal limits, including CBC, liver/renal functions, serum electrolytes, blood glucose, and thyroid function tests. Urine was positive for proteinuria. She underwent emergency low-segment cesarean section under sub-arachnoid block and a healthy male child was born. However, she remained tearful and agitated, and nihilistic delusions persisted post-op. On the same day, she was administered an injection of haloperidol 5 mg intramuscularly. The next morning, her delusions were fragmenting and her interaction with family members improved. By afternoon, her delusions had completely fragmented. She was observed drug-free. Serial MSEs and ward observations did not reveal any overt psychopathology.

An earlier case report mentioning psychotic features during preeclampsia reported visual, tactile, and auditory hallucinations in a 21-year-old primiparous woman. The patient was not offered any antipsychotics, and there was spontaneous resolution of psychotic symptoms post-delivery.[5] In the present case, inj. Haloperidol was given to control psychotic symptoms and acute agitation. The current case, in addition to being a rare presentation, highlights the challenges in its diagnosis and treatment.

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The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.