Baby blues, Postnatal depression & Puerperal psychosis Flashcards
What can you find in maternal perinatal illness on examination of the baby?
- Flat occiput
- Paranoid mother
- Flat affect in baby
- Scared baby
NB: for a mother who is educated (e.g. who is a doctor) it may be easy to mask the symptoms
What is the referral criteria for perinatal mental health services?
- Anxiety and trauma-related disorders
- Eating disorders
- Affective illness
- Emergency: psychotic symptoms; failure to care for the baby, response to symptoms, evidence of suicidal thoughts or imminent risk of self-harm
What is the difference between bonding and attachment?
Attachment - from infant to caregiver; foundation of how relationships will be to others in later adulthood
Bonding - flows from the caregiver to the infant (develops rapidly - due to oxytocin and breastfeeding etc; but can take longer if that took longer for you or if you had a traumatic birth)
What is the importance of “good enough mothering” on future psychological wellbeing?
Good quality is determined by consistent availability of a sensitively responsive caregiver
Fosters secure attachment
What kind of questions can you ask in a perinatal formulation?
Look at previous history, pattern of symptoms, stressors
Loss of child, miscarriage, stillbirth, domestic abuse etc.
How common is postpartum psychosis? When is the onset?
2 in 1000 (50% are first episodes)
Onset within first 2 weeks
What are the clinical features of postnatal psychosis?
Early
- Rapid onset of
- Insomnia
- Restlessness
- Perplexity
Later
- Psychotic symptoms settling into one of three patterns…
- Delirium
- Affective (psychotic depression of mania)
- Schizophreniform (like schizophrenia)
Rapid progression and changing ‘kaleidoscopic’ picture i.e. some temporary symptom free intervals can occur. Exclude any delirium or substance misuse (intoxication or withdrawal).
What are the risk factors for postpartum psychosis?
Previous personal or FH of puerperal psychosis or BPAD
Puerperal infection
Obstetric complications
What are the differentials for postpartum psychosis?
- Delirium or substance misuse (intoxication or withdrawal)
- Postnatal depression (PND)
- Baby blues (peaks at day 5 and gone by day 10)
- Maternal OCD
What red flag questions can you ask if worried about perinatal psychosis?
Do you have new thoughts and feelings, which make you disturbed or anxious?
Are you experiencing thoughts of suicide or harming yourself in violent ways?
Are you feeling incompetent, not able to cope, or estranged from your baby? Are these feelings persistent?
Do you feel you are getting worse or at risk of it?
What is the management of postnatal psychosis?
- Admission to MBU - 1:1 or 2:1 nursing or PICU if risk is too high
- Medication - depending on presentation give antipsychotic, antidepressants, lithium or benzodiazepines (control agitation).
- ECT - in severe cases can be life-saving
What is the prognosis with puerperal psychosis?
Most recover within 6-12 weeks
Overall risk of recurrence is about a third
What are the important features to assess in the risk assessment in postnatal psychosis?
To self - suicide is the leading cause of maternal death in the UK
To others -
From others - x
What is infanticide? What is the importance of the infanticide act?
Legally differentiates infanticide from manslaughter/murder (1922, amended 1983)
Infanticide - wilful act or omission which causes death of a woman’s child being under age of 12 months
“at the time of the act or omission the balance of her mind was distrubed by reason of her not having fully recovered from the effect of giving birth to the child or by reason of the effect of lactation”
What are the features of baby blues? How soon after birth does it occur/peak?
- 50-80% of females will experience this after birth
- short-lived - up to 48 hours of…
- emotional lability
- irritability
- tearfulness
- occurs within first 10 days and peaks at days 4-5
What is the management of baby blues?
Explain and reassure
Although sometimes may progress to postnatal depression which will require treatment
What scale can be used by midwives/health visitors to screen for derpression in a new mother?
Edinburgh Postnatal Depression Scale
5min test
Maximum score is 30 but 10 suggests depression
What are the features of postnatal depression?
Ask about COGNITIVE rather than physical symptoms.
Similar to normal depression but particularly feelings of…
- fatigue (NB: this is normal with a baby therefore focus on cognitive symptoms in new mothers)
- irritability
- anxiety.
- Depressive cognitions often relate to the baby e.g. guilt or feeling like a failure as a mother
- Recurrent intrusive thoughts about harming the baby may occur or obsessions or serious plan
What are the risk factors for postnatal depression?
- Biological - higher oxytocin levels mid-pregnancy are associated with early PND
- Socioeconomic - unemployment
- Younger age
- Bad childhood - poor attachment with own parents, abuse
- Poor social support
- Previous pregnancy loss
- Personality factors
- Socially prescribed perfectionism
How common is postnatal depression?
1 in 10 mothers affected in the year after birth
When should you admit someone with postnatal depression?
Admit to MBU if:
- severe depression
- +/- suicidal ideation
- +/- infanticidal ideation
What is the prognosis with postnatal depression?
Most respond well to treatment within a month although some take longer and have difficulties for a year.
What is the general management of postanatal depression?
Depends on risk assessment if treated at home or admission required. If supported at home…
Liaise with GP - ASAP
Support at home - health visitor, mental health input, childcare arrangements if necessary
Medication - analgesia if pain from obstetric complications, antidepressants if necessary. NB: analyse whether risk of suicide and if so then give shorter prescriptions.
Follow up - this should be longer than usually provided postnatally and needs to be assertive i.e. ensuring reminder letters are sent out and community midwives involved.
What are the complications of postnatal depression for the baby?
Risk - infanticidal ideation
Attachment - affects baby’s attachment and may have long lasting effects on personality and development so early and effective treatment of PND is necessary.
What are the features of maternal OCD?
Obsession = recurrent unwelcome thoughts /images /ideas or doubts.
Compulsions = related behavioural or mental acts to suppress or neutralise the distress or prevent a feared outcome
Causes significant functional impairment
What are some examples of maternal OCD?
- Fear of contamination - perceives a high risk of infection or of being poisoned
- Thoughts or images of harming child
- Thoughts or images of others harming their child
- Thoughts of images of child being harmed by an accident
- Repeatedly checking baby’s breathing or waking a sleeping baby for reassurance
What screening questions can you use to assess maternal mental health?
- How do you feel when you look at your baby?
- Do you ever worry that there might be something wrong with them?
- It can be difficult to look after a baby, do you ever feel that you cannot cope?
- Are there times when they wont stop crying? How does that make you feel?
- How do you picture things in a month’s time?
- Do you ever wish you hadn’t had your baby?
- Do you have any worrying thoughts about your baby?
How many cardiac and birth defect occur without medication?
1 in 100 for cardiac defects
3 in 100 for birth defects
No medication is without risk
Which part of pregnancy is most important to be careful with prescribing?
First trimester
How does pregnancy affect pharmacokinetics/dynamics in pregnancy?
Blood volume increases between 30-50%
Baby pushes up diaphragm reducing residual volume and increasing respiratory rate
Increased progesterone (causing N&V and hypomobility of ureters)
Increased oxygen consumption
Why is antipsychotic prescribing more risky in females?
Slower drug absorption, metabolism and excretion in women all lead to higher plasma levels and risk of SE
Women reach higher dopamine receptor occupancy compared to men at similar serum levels , since oestrognes increase dopamine sensitivity
Women overmedicated by default as most studies in men
Risk of overmedicating increases when sex hormones are high (e.g. ovulation and gestation) , whereas higher doses may be require at low-hormonal periods (e.g. menstruation and menopause)
Are antidepressants safe in pregnancy?
No significant increased risk of congenital malformations or spontaneous abortion. SSRIs safe (sertraline 1st line). TCAs (amitriptyline, imipramine, nortriptyline) also safe but riskier in overdose (as cardiotoxic).
Clinical risk of discontinuing = relapse
Usually safer to continue during pregnancy than to stop and it is not recommended to stop antidepressants abruptly
What are some complications of antidepressant use during pregnancy to the fetus?
Neonatology following delivery of baby for:
- Neonatal withdrawal syndrome
- Persistent pulmonary hypertension of the newborn
- Cardiac malformation (Paroxetine SSRI)
Are antipsychotics safe during pregnancy? What is a major risk with antipsychotics in pregnancy?
No significant increased risk of congenital malformations or spontaneous abortion.
BUT risperidone has 26% risk of cardiac malformations if taken in first trimester
All concentrations will DECREASE by third trimester (biggest effects with Quetiapine and Aripiprazole, no change in Olanzapine) so monitor dosing to prevent relapse
Which antipsychotics are relatively safe during pregnancy?
Haloperidol, chlopromazine, olanzapine, quetiapine
NB: women have higher clozapine levels than men
Which mood stabiliser would you never prescribe to women of childbearing age? What alternatives can be used?
Sodium valproate - teratogenic and contraindicated in all girls/women with child-bearing potential according to NICE (dose dependent)
BAP recommends olanzapine and fluoxetine
Refer to perinatal psychiatrist + prebirth planning meeting
Are mood stabilisers safe during pregnancy?
Mood stabiliser use in early pregnancy may increase risk of malformations and affect neurodevelopment
Give 5mg folic acid (not usual 400mcg) from preconception until 12 weeks gestation to prevent this
What is the relative infant dose (RID) of most medications regarded as acceptable in breastfeeding?
RID of 1-5% (up to 10%) regarded as acceptable
Don’t make the patient choose between meds and breastfeeding. Almost all drugs pass through breastmilk.
Which psychiatric drugs can reduce lactation/milk supply?
Aripiprazole and promethazine can reduce milk
NB:Benzos can accumulate in the infant
How does risk of postnatal depression and postnatal psychosis change with number of pregnancies?
Risk of postnatal depression stays the same with each subsequent pregnancy
Risk of postnatal psychosis decreases with each subsequent pregnancy
Does pregnancy increase risk of mental illness?
No but period following birth does
