Authors: Ruth Agwaze, Grace Ro, Aspen Ainsworth, Bradley Van HeuKelum, Margaret Puelle

Title: Challenges Faced Treating Severe Postpartum Psychosis when Standard of Care is Contraindicated

Background: Thyroid dysfunction is a perinatal complication associated with mood disorders, particularly postpartum depression (Schmidt, 2022). However, there are few accounts of thyroid disorders leading to postpartum psychosis treated with antipsychotic and antithyroid agents (Fulton, 2024) We present a case of postpartum thyrotoxicosis and psychosis in which these medications were ineffective/contraindicated.

Case: A 36-year-old Black female G4P4004 with multiple sclerosis, migraines and anxiety presented to her primary care physician with persistent asymptomatic sinus tachycardia five months after a postpartum pulmonary embolism, despite treatment with propranolol. A few weeks later, she developed palpitations, weight loss, and tremors. Blood work showed free T4 > 4.4 ng/dL (reference range 0.9-1.7 ng/dL), antibodies to thyroglobulin and thyroid peroxidase, and undetectable TSH. She was diagnosed with Grave’s Disease and prescribed oral methimazole. Five months later, she presented to the hospital with diffuse abdominal pain and altered mental status. She had been self-treating with topical vitamin-infused oils instead of methimazole because she feared its side effects. For the next year, she had numerous hospitalizations due to paranoid and erratic behaviors, delusions of being married to a deceased rapper, and over 100-lb weight loss. In the hospital, she received IV methimazole which led to agranulocytosis. Higher antipsychotic and beta-blocker doses were ineffective. She had limited insight and made multiple attempts to leave against medical advice. Due to the need for consistent outpatient follow-up, social distancing, and concerns for future fertility, radioactive ablation was contraindicated. This left thyroidectomy as the only option, but she refused surgery when she was previously in a lucid state. Endocrinologists, psychiatrists, neurologists, and legal/ethical consultants concluded that treatment over objection was not acceptable because the patient was not in a life-threatening thyroid storm. Plasmapheresis was discussed, but this placed the patient at risk without guarantee that psychosis would resolve. One day, she spontaneously regained lucidity and consented to a thyroidectomy. She eventually returned to her baseline after weeks of levothyroxine treatment, and her tachycardia resolved.

Discussion: This case demonstrates the diagnostic and therapeutic challenges of treating psychosis in the setting of postpartum thyroiditis, as well as ethical implications of treatment in patients with limited capacity.

Conclusion/implications: This case provides further evidence that postpartum thyroid dysfunction can lead to postpartum psychosis. More research is necessary to understand the relationship between postpartum thyroiditis and psychosis, as well as guidelines for patients who may not respond to typical treatment regimens.

References: 1. Fulton, A., Mittal, N., & Deb, A. (2024). Postpartum Psychosis as a Consequence of Thyroiditis Versus Relapse: A Diagnostic Dilemma. Cureus, 16(1), e52357. https://doi.org/10.7759/cureus.52357 2. Schmidt, P. M. D. S., Longoni, A., Pinheiro, R. T., & Assis, A. M. (2022). Postpartum depression in maternal thyroidal changes. Thyroid research, 15(1), 6. https://doi.org/10.1186/s13044-022-00124-6