Management options

It is important that a full history is taken and neurological examination performed, since there are many causes of postpartum headache (Table 44.1). Neurological referral may be wise in difficult cases. PDPH is suggested by a history of dural puncture and typical symptoms, especially the postural element. However, it may follow apparently unremarkable epidural anaesthesia the incidence is unknown, although it may involve a number of factors including lack of recognition at the time of dural...

Labour and delivery

Regional analgesia and anaesthesia are not contraindicated for women with psychiatric disease. Women taking a MAOI can receive ephedrine or phenylephrine to correct hypotension caused by regional anaesthesia, but the anaesthetist should use smaller doses than usual and be aware that pressor responses may be exaggerated. Pethidine should be avoided, but fentanyl and morphine have both been used uneventfully. Use of patient-controlled intravenous analgesia is preferable to intramuscular analgesia...

Antidepressants

The most recent Report on Confidential Enquiries into Maternal Deaths Maternal and Child Health has highlighted the risk of postnatal depression and its potential to lead to postnatal psychosis and suicide. There are numerous case reports offering conflicting advice about the use of psychotropic drugs in lactating women. The tricyclic antidepressants amitriptyline, nortriptyline and desipramine are all excreted into breast milk, with the baby being exposed to approximately 1 of the maternal...