De Novo Antepartum Psychosis with Somatic Delusions and Poor Response to Antipsychotics in a Primigravida with Gestational Diabetes and FGR: A Case Report

Abstract

Background: De novo antepartum psychosis—onset of psychotic symptoms during pregnancy without prior psychiatric history—is exceptionally rare and poorly characterized. Most reported cases occur in women with pre-existing psychiatric disorders or in the setting of obstetric emergencies.

Case Presentation: We report a 33-year-old primigravida at 35+4 weeks of gestation with no prior psychiatric illness who presented with acute psychosis characterized by irrelevant talking, somatic delusions of altered body form, and subjective decrease in fetal movement. She was diagnosed with gestational diabetes mellitus and fetal growth restriction during admission. Her psychosocial history included eight years of infertility in her first marriage to a mute husband, followed by remarriage and spontaneous conception. Initial treatment with haloperidol provided partial improvement; subsequent switch to olanzapine plus escitalopram showed poor response. Elective cesarean section was performed at 36+2 weeks, delivering a 2.0 kg male infant. Postpartum course was marked by severe worsening of psychosis, with hostility, nihilistic delusions, thought broadcasting, and refusal to acknowledge the baby. Electroconvulsive therapy was administered for three cycles, following which the patient responded well and was discharged after improvement with a plan for further follow-up.

Discussion: This case highlights key challenges in managing antepartum psychosis: presentation without prior psychiatric history, poor response to standard antipsychotic regimens, postpartum exacerbation despite delivery, and the potential role of psychosocial stressors such as long-standing infertility as unrecognised risk factors. The case underscores the importance of early interdisciplinary collaboration and the role of electroconvulsive therapy in treatment-resistant peripartum psychosis.

Conclusion: De novo antepartum psychosis should be considered in pregnant women presenting with acute psychotic symptoms, even without prior psychiatric illness. Treatment resistance may occur, and postpartum worsening is possible, emphasizing the need for close monitoring and escalation of therapy, including electroconvulsive therapy when indicated.