sporadic events, not puerperal complications. early postpartum stupor brief states of stupor have rarely been described in the first few hours or days after the birth.: 119–122 they are similar to parturient delirium and stupor, which are among the psychiatric disorders of childbirth. organic postpartum psychoses there are at least a dozen organic (neuropsychiatric) psychoses that can present in pregnancy or soon after childbirth.: 200–204 the clinical picture is usually delirium – a global disturbance of cognition, affecting consciousness, attention, comprehension, perception and memory – but amnesic syndromes and a mania-like state: 25 also occur. the two most recent were described in 1980 and 2010, and it is quite likely that others will be described. organic psychoses, especially those due to infection, may be more common in nations with high parturient morbidity. infective delirium the most common organic postpartum psychosis is infective delirium. this was mentioned by hippocrates: there are 8 cases of puerperal or post-abortion sepsis among the 17 women in the 1st and 3rd books of epidemics, all complicated by delirium. in europe and north america the foundation of the metropolitan maternity hospitals, together with instrumental deliveries and the practice of attending necropsies, led to epidemics of streptococcal puerperal fever, resulting in maternal mortality rates up to 10%. the peak was about 1870, after which antisepsis and asepsis gradually brought them under control. these severe infections were often complicated by delirium, but it was not until the nosological advances of chaslin and bonhöffer that they could be distinguished from other causes of postpartum psychosis. infective delirium hardly ever starts during pregnancy, and usually begins in the first postpartum week. the onset of sepsis and delirium are closely related, and the course parallels the infection, although about 20% of patients continue to have chronic confusional states after recovery from the infection. recurrences after another pregnancy are rare. their frequency began to decline at the end of the 19th century, and fell steeply after the discovery of the sulphonamides. puerperal sepsis is still common in bangladesh, nigeria and zambia. even in the united kingdom, cases are still occasionally seen.: 27 it would be a mistake to forget this cause of puerperal psychosis. eclamptic and donkin psychoses eclampsia is the sudden eruption of convulsions in a pregnant woman, usually around the time of delivery. it is the late complication of pre-eclamptic toxaemia (gestosis). although its frequency in nations with excellent obstetric services has fallen below 1/500 pregnancies, it is still common in many other countries. the primary pathology is in the placenta, which secretes an anti-angiogenic factor in response to ischaemia, leading to endothelial dysfunction. in fatal cases, there are arterial lesions in many organs including the brain. this is the second most frequent organic psychosis, and the second to be described. psychoses occur in about 5% of cases, and about 240 detailed cases have been reported.: 28–35 it particularly affects first time mothers. seizures may begin before, during or after labour, but the onset of psychosis is almost always postpartum. these mothers usually experience delirium but some have manic features. the duration is remarkably short, with a median duration of 8 days. this, together with the absence of a family history and of recurrences, contrasts with puerperal bipolar/cycloid psychoses. after recovery, amnesia and sometimes retrograde memory loss may occur, as well as other permanent cerebral lesions such as dysphasia, hemiplegia or blindness. a variant was described by donkin . he had been trained by simpson (one of those who first recognized the importance of albuminuria) in edinburgh, and recognized that some cases of eclamptic psychosis occurred without seizures; this explains the interval between seizures (or coma) and psychosis, a gap that has occasionally exceeded 4 days: seizures and psychosis are two different consequences of severe gestosis. donkin psychosis may not be rare: a british series included 13 possible cases;: 35 but clarifying its distinction from postpartum bipolar disorder requires prospective investigations in collaboration with obstetricians. wernicke-korsakoff psychosis this was described by wernicke and korsakoff. the pathology is damage to the core of the brain including the thalamus and mamillary bodies. its most striking clinical feature is loss of memory, which can be permanent. it is usually found in severe alcoholics, but can also result from pernicious vomiting of pregnancy (hyperemesis gravidarum), because the requirement for thiamine is much increased in pregnancy; nearly 200 cases have been reported.: 36–41 the cause is vitamin b1 (thiamine) deficiency. this has been available for treatment and prevention since 1936, so the occurrence of this syndrome in pregnancy should be extinct. but these cases continue to be reported – more than 50 in this century – from all over the world, including some from countries with advanced medical services; most are due to rehydration without vitamin supplements. a pregnant woman who presents in a dehydrated state due to pernicious vomiting urgently needs thiamine, as well as intravenous fluids. vascular disorders various vascular disorders occasionally cause psychosis, especially cerebral venous thrombosis. puerperal women are liable to thrombosis, especially thrombophlebitis of the leg and pelvic veins; aseptic thrombi can also form in the dural venous sinuses and the cerebral veins draining into them. most patients present with headache, vomiting, seizures and focal signs such as hemiplegia or dysphasia, but a minority of cases have a psychiatric presentation. the incidence is about 1 in 1,000 births in europe and north america, but much higher in india, where large series have been collected. psychosis is occasionally associated with other arterial or venous lesions: epidural anaesthesia can, if the dura is punctured, lead to leakage of cerebrospinal fluid and subdural haematoma. arterial occlusion may be due to thrombi, amniotic fragments or air embolism. postpartum cerebral angiopathy is a transitory arterial spasm of medium caliber cerebral arteries; it was first described in cocaine and amphetamine addicts, but can also complicate ergot and bromocriptine prescribed to inhibit lactation. subarachnoid haemorrhage can occur after miscarriage or childbirth. all these usually present with neurological symptoms, and occasionally with delirium. epilepsy women with a lifelong epileptic history are liable to psychoses during pregnancy, labour and the puerperium. women occasionally develop epilepsy for the first time in relation to their first pregnancy, and psychotic episodes have been described. there are over 30 cases in the literature.: 56–58 hypopituitarism pituitary necrosis following postpartum haemorrhage (sheehan's syndrome) leads to failure and atrophy of the gonads, adrenal and thyroid. chronic psychoses can supervene many years later, based on myxoedema, hypoglycaemia or addisonian crisis. but these patients can also develop acute and recurrent psychoses, even as early as the puerperium.: 59–62 water intoxication hyponatraemia (which leads to delirium) can complicate oxytocin treatment, usually when given to induce an abortion. by 1975, 29 cases had been reported, of which three were severe or fatal. urea cycle disorders inborn errors of the krebs-henseleit urea cycle lead to hyperammonaemia. in carriers and heterozygotes, encephalopathy can develop in pregnancy or the puerperium. cases have been described in carbamoyl phosphate synthetase 1, argino-succinate synthetase and ornithine carbamoyltransferase deficiency.: 63–65 anti-nmda receptor encephalitis the most recent form of organic childbearing psychosis to be described is encephalitis associated with antibodies to the nmda receptor; these women often have ovarian teratomas. a japanese review found ten reported during pregnancy and five after delivery. other organic psychoses with a specific link to childbearing sydenham's chorea, of which chorea gravidarum is a severe variant, has a number of psychiatric complications, which include psychosis. this usually develops during pregnancy, and occasionally after the birth or abortion. its symptoms include severe hypnagogic hallucinations (hypnagogia), possibly the result of the extreme sleep disorder. this form of chorea was caused by streptococcal infections, which at present respond to antibiotics; it still occurs as a result of systemic lupus or anti-phospholipid syndromes. only about 50 chorea psychoses have been reported, and only one this century; but it could return if the streptococcus escapes control. alcohol withdrawal states (delirium tremens) occur in addicts whose intake has been interrupted by trauma or surgery; this can happen after childbirth. postpartum confusional states have also been reported during withdrawal from opium and barbiturates. one would expect acquired immunodeficiency syndrome (hiv/aids) encephalitis to present in pregnancy or the puerperium, because it is a venereal disease that can progress rapidly; one case of aids encephalitis, presenting in the 28th week of gestation, has been reported from haiti, and there may be others in countries where aids is rife. anaemia is common in pregnancy and the puerperium, and folate deficiency has been linked to psychosis. incidental organic psychoses the psychoses, mentioned above, all had a recognized connection with childbearing. but medical disorders with no specific link have presented with psychotic symptoms in the puerperium; in them the association seems to be fortuitous.: 6–73 they include neurosyphilis, encephalitis including von economo's, meningitis, cerebral tumours, thyroid disease and ischaemic heart disease. society and culture support in the uk, a series of workshops called "unravelling eve" were held in 2011, where women who had experienced postpartum depression shared their stories. notable cases in history and fiction harriet sarah, lady mordaunt (1848–1906), formerly harriet moncreiffe, was the scottish wife of an english baronet and member of parliament, sir charles mordaunt. she was the defendant in a sensational divorce case in which the prince of wales (later king edward vii) was embroiled; after a controversial trial lasting seven days, the jury determined that lady mordaunt had "puerperal mania" and her husband's petition for divorce was dismissed, while lady mordaunt was committed to an asylum. andrea yates had depression and, four months after the birth of her fifth child, relapsed, with psychotic features. several weeks later she drowned all five children. under the law in texas, she was sentenced to life imprisonment, but, after a retrial, was committed to a mental hospital. guy de maupassant, in his novel mont-oriol (1887) described a brief postpartum psychotic episode. charlotte perkins gilman, in her short story the yellow wallpaper (1892) described severe depression with psychotic features starting after childbirth, perhaps similar to that experienced by the author herself. stacey slater, a fictional character in the long-running bbc soap-opera eastenders had postpartum psychosis in 2016, and was one of the show's biggest storylines that year. in the house, m.d. episode forever, house takes the case of a mother with postpartum psychosis. legal status postpartum psychosis, especially when there is a marked component of depression, has a small risk of filicide. in acute manic or cycloid cases, this risk is about 1%.: 240–246 most of these incidents have occurred before the mother came under treatment, and some have been accidental. several nations including canada, united kingdom, australia, and italy recognize postpartum mental illness as a mitigating factor in cases where mothers kill their children. in the united states, such a legal distinction was not made as of 2009, and an insanity defense is not available in all states. the united kingdom has had the infanticide act since 1922. books written about postpartum psychosis and postpartum bipolar disorder the following books have been published about these psychoses: ripping, dr (1877) die geistesstörungen der schwangeren, wöchnerinnen und säugenden. stuttgart, enke. knauer o (1897) über puerperale psychose für practische ärzte. berlin, karger. twomey t (2009) understanding postpartum psychosis: a temporary madness. westport, praeger. harwood d (2017) birth of a new brain - healing from postpartum bipolar disorder. brentwood, post hill press.