Literature review


How to cite: Satti ALC, Sartório MC, Moura MSG, Miziara ID. Dilemmas faced by expert physicians in the face of puerperl psychosis related to infanicide. Persp Med Legal Pericias Med. 2022; 7: e221221

Submitted 01/28/2022
Accepted 03/31/2022

The authors inform no conflict of interest.


Ana Laura de Carvalho Satti (1)

Maria Carolina Sartório (1)

Matheus Santos Guimarães de Moura (1)

Ivan Dieb Miziara (2)

(1) Hospital das Clínicas da Universidade de São Paulo, Departamento de Medicina Legal, Bioética, Medicina do trabalho e Medicina física e reabilitação da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo – SP, Brasil. (autor)

(2) Hospital das Clínicas da Universidade de São Paulo, Departamento de Medicina Legal, Bioética, Medicina do trabalho e Medicina física e reabilitação da Faculdade de Medicina da Universidade de São Paulo (USP), São Paulo – SP, Brasil. (orientador)



Introduction: Puerperal psychosis is defined as a type of brief psychotic disorder occurring within three weeks after delivery, but predominantly within the first 48-72 hours, although rare (0.1 to 0.2%), it is a medical emergency and should be be treated as soon as possible. The presence of prodromal symptoms (irritability, sudden change in behavior, among others) that rapidly progress to a psychotic condition (delusions and hallucinations). In this context, infanticide is the apex for forensic interpretation. In 2021, The Lancet publishes an article questioning whether puerperal psychosis is a new disease. Neither the ICD nor the DSM bring this diagnosis as a distinct disease . Objective: To expose the main conflicts faced by medical experts in the face of the alleged crime of infanticide from the perspective of the Penal Code Conceptual framework: Establishing the nexus between puerperal psychosis and infanticide is a very difficult task and often depends on documents from the attending physician. Material and methods: Study carried out at the Department of Legal Medicine, Bioethics, Occupational Medicine and Physical and Rehabilitation Medicine of the Faculty of Medicine of the University of São Paulo. A narrative review of the literature was carried out, focusing on signs and symptoms suggestive or conclusive of puerperal psychosis in the face of the crime of infanticide. Articles in the Lilacs and PubMed databases were accessed, applying the descriptors “psychotic disorder”, “postpartum psychosis”, “expertise”; Textbooks were also included. No time limit was established for the search, but articles obtained in full were included. Results: Article 123 of the Penal Code, from 1940, determines that the crime of infanticide is “killing, under the influence of the puerperal state, one’s own child, during childbirth or shortly after: Penalty – detention, from two to six years. ”, at this point it is visible the difficulty to assertively define what it is right after, as well as to establish the mental criteria that made this crime an action in which the woman was not aware of the fact performed. Science still struggles to establish nosology and the temporal relationship between the onset of mental changes and childbirth and which biological changes are involved, these are the words of one of the greatest researchers on the subject, Patrick McGorry. The search for a genetic relationship between bipolar disorder and puerperal psychosis has been suggested. But, another issue to be discussed, not all puerperal psychoses are linked to infanticide. Another dilemma faced is the lack of habit in applying the terms infanticide and neonaticide with their individual designations. The first would be the death of a child in the first year of life by its mother and the second would be the death within the first 24 hours of life. The central question for the medical expert is to establish whether the neonaticide stems from a social issue in which the child is unwanted or whether it stems from a dissociative, depersonalization or hallucinatory disorder in which the mother does not have the capacity for understanding and self-determination. The medical literature rarely attributes neonaticide to mental illness. It is up to the medical expert to establish with technical rigor that at the time of the criminal act the woman was under a condition of illness that completely abolished her capacity. In this way, the medical expert must carry out the examination by complying with the technical rite and request medical documentation on the clinical and mental conditions of the expert at the time of the puerperium. The search for risk factors can help the doctor, but it is necessary to know that the profile of women varies according to the typology of the fact, that is, neonaticide and infanticide. Differential diagnoses between delusional misidentification syndrome which may be accompanied by hostility towards delusional erratic identification, Capgras syndrome in which the woman may believe that her child has been switched and that the child in front of her is an imposter. Due to the transience of psychotic symptoms, the psychiatric expertise that determines the imputability of the infanticidal mother is often performed in the absence of any clinical manifestation of psychosis. Conclusion: The psychiatric expertise of the woman who claims puerperal psychosis is challenging due to the elusiveness of the symptomatic picture and the late realization. It is based on an analysis of medical documentation – from the moment of childbirth and the puerperium – symptoms described by close family members, the epidemiology of the condition and its association with mood disorders.

Keywords: psycosis, puerperal psycosis, infanticide. 

Bibliographical references

  1. Sarmento R, Setúbal MSV. Abordagem psicológica em obstetrícia: aspectos emocionais da gravidez, parto e puerpério. Rev. Ciênc. Méd. Campinas. Jul/set 2003; 12 (3): 261-268.
  2. Kendell RE, Chalmers JC, Platz C. Epidemiology of puerperal psychoses. Br J Psychiatry. 1987 May;150:662-73. Erratum in: Br J Psychiatry 1987 Jul;151:135. PMID: 3651704.
  3. VanderKruik R, Barreix M, Chou D, Allen T, Say L, Cohen LS; Maternal Morbidity Working Group. The global prevalence of postpartum psychosis: a systematic review. BMC Psychiatry. 2017 Jul 28; 17 (1); 272.
  4. Manual diagnóstico e estatístico de transtornos mentais: DSM-5. Porto Alegre: Artmed, 2014.
  5. Sadock BJ, Sadock VA, Ruiz P. Compêndio de psiquiatria: ciência do comportamento e psiquiatria clínica. 11a edição. Porto Alegre: Artmed, 2018.
  6. Jones I, Craddock N. Bipolar disorder and childbirth: The importance of recognising risk. British Journal of Psychiatry. 2005; 186 (6), 453-454.
  7. Munk-Olsen T, Laursen TM, Mendelson T, Pedersen CB, Mors O, Mortensen PB. Risks and predictors of readmission for a mental disorder during the postpartum period. Arch Gen Psychiatry. 2009 Feb; 66 (2):189-95.
  8. Brasil. Presidência da República, Subchefia para Assuntos Jurídicos. Decreto-lei no 2.848, de 7 de dezembro de 1940. Código Penal. Brasília, DF; 1998.
  9. Friedman SH, Sorrentino R. Journal of the American Academy of Psychiatry and the Law Online. 2012, Sep. 40 (3); 326-332.
  10. Levitzky S, Cooper R. Infant Colic Syndrome—Maternal Fantasies of Aggression and Infanticide. Clinical Pediatrics. 2000;39(7):395-400.
  11. Brockington I. Suicide and filicide in postpartum psychosis. Arch Womens Ment Health. 2017 Feb; 20 (1):63-69.
  12. Friedman SH, Horwitz SM, Resnick PJ. Child Murder by Mothers: A Critical Analysis of the Current State of Knowledge and a Research Agenda. American Journal of Psychiatry 2005 Sep; 162 (9), 1578-1587.
  13. D’ Orban, PT. Women who kill their children. The British Journal of Psychiatry. 1979. 134(6), 560–571.
  14. Kendell, R, Chalmers, J, Platz, C. Epidemiology of Puerperal Psychoses. British Journal of Psychiatry, 1987, Jan. 150 (5), 662-673.
  15. Brockington I. Suicide and filicide in postpartum psychosis. Arch Womens Ment Health. 2017 Feb; 20 (1); 63-69.
  16. Cantilino A; Zambaldi CF; Sougey EB; Rennó Júnior J. Transtornos psiquiátricos no pós-parto. Rev. psiquiatr. clín. São Paulo); 2010, Out. 37 (6): 288-294, 2010
  17. Anis-Ur-Rehman, Clair, D, Platz, C. Puerperal Insanity in the 19th and 20th Centuries. British Journal of Psychiatry. 2018, Jan. 156(6), 861-865.
  18. Carpanini, Thays. Thiago Mendonça de Vasconcelos O ESTADO PUERPERAL COMO HIPÓTESE DE INIMPUTABILIDADE PENAL. Revista Científica Semana Acadêmica. Fortaleza, ano MMXXI, Nº. 000204, 26/01/2021.
  19. ______. Código Penal. Decreto – Lei 2.848, de 07 de dezembro de 1940.
  20. Ronchi J A (im)possibilidade de excludente de culpabilidade no estado puerperal no crime de infanticídio: um estudo acerca da (in)imputabilidade do agente causada pela doença mental nos casos comprovados de psicose. 2013. 66 f. Trabalho de Conclusão de Curso (Graduação em Direito) – Universidade do Extremo Sul Catarinense, Criciúma, 2013.
  21. Almada ACCA, Felippe AM. Infanticídio e estado de psicose puerperal: uma análise das jurisprudências. CADERNOS DE PSICOLOGIA, Juiz de Fora, v. 2, n. 4, p. 374- 393, jul./dez. 2020.
  22. Rangel, Camila Caires. Uma análise crítica acerca das controvérsias do estado puerperal no crime de infanticídio Conteudo Juridico, Brasilia-DF: 15 set 2021..
  23. Teles, Ney Moura. Direito Penal: parte especial: arts. 121 a 212, v. 2. São Paulo: Atlas, 2004.
  24. Rudá, Antonio Sólon. Limites temporais do estado puerperal nos crimes de infanticídio. Revista Jus Navigandi, ISSN 1518-4862, Teresina, ano 15, n. 2635, 18 set. 2010. Disponível em: Acesso em: 15 set. 2021.
  25. Silva, Andréa Araújo; Polanczyk, Adriana Silva; Millán, Tatiana. Psicose puerperal: uma revisão. Rev. cient. AMECS ; 9(2): 45-9, jul.-dez. 2000.
  26. Palomba, Guido Arturo. Tratado de psiquiatria forense civil e penal. São Paulo: Atheneu, 2003.
  27. Post-partum psychosis: birth of a new disorder? Editorial. The Lancet Psychiatric 2021. Disponível:
  28. Lewis G, Blake L, Seneviratne G. Delusional Misidentification Syndromes in Postpartum Psychosis: A Systematic Review. Psychopathology. 2022;16:1-10. DOI: 10.1159/000526129.