Atypical Postpartum Psychosis and Neuropsychiatric Manifestations Coexisting With Global Cortical Atrophy

The neuropsychiatric sequelae resulting from postpartum hemorrhage (PPH)-induced hypoxic-ischemic brain injury (HIBI) are sparsely documented, presenting a complex diagnostic and therapeutic challenge for clinicians. We report the case of a 47-year-old woman who experienced PPH 13 years before her current presentation. Her PPH resolved following a partial hysterectomy and multiple transfusions, resulting in a coma from which she awoke with vivid hallucinations and altered memory. These symptoms initially improved, although she never regained baseline function and continued to experience cognitive distortion and hallucinations. She now presents 13 years later with an acute exacerbation of her symptoms after missing a dose of her long-acting injectable antipsychotic and continues to experience entrenched delusions involving false children, family, and occupational identities. Computed tomography of her brain at this presentation revealed global cortical atrophy disproportionately severe for her age, suggesting an organic cause of her symptoms. Her insight was poor, and she was unable to recognize the sequelae of her condition. During admission, her mental status rapidly progressed from cooperative to agitated as the health care team communicated their findings, which she deemed to be falsification and lies. This case underscores a unique neuropsychiatric manifestation secondary to severe PPH and HIBI with subsequent postpartum psychosis (PPP). HIBI can trigger or exacerbate psychosis and cognitive distortions through mechanisms including neuroinflammation in the acute phase, or structural brain alterations and neurotransmitter imbalances in the chronic phase. These mechanisms likely contribute to her mood disturbances, auditory and visual hallucinations, and false memories. Similar HIBIs of varying etiologies have been linked to diffuse cortical atrophy, as observed in this patient. Moreover, PPP is notable for its rapid onset and intensity, yet few cases detail progression to chronic neuropsychiatric symptoms without full recovery. This case represents a rare, chronic neuropsychiatric presentation following PPH and subsequent HIBI, emphasizing the need for vigilance in managing emerging psychiatric conditions after obstetric hemorrhage. Further research into neuropsychiatric outcomes after complicated PPH and hypoxic events is warranted to improve diagnostic and therapeutic strategies.