Maternal Medicine - Perinatal Mental Health (including TOG - Postpartum Psychosis)

Question 1

How many pregnant women are affected by psychiatric disease?

Answer 1

20%

Question 2

How many deaths between 6/52 and 1 year are due to psychiatric causes?

Answer 2

25%

Question 3

Rate of mild-moderate depression/anxiety?

Answer 3

100-150/1000 maternities

Question 4

Rate of severe depressive illness?

Answer 4

30/1000 maternities

Question 5

1. Rate of postpartum psychosis?
2. When is peak onset?
3. What is the chance of PP if first-degree relative had it?
4. What is the risk of recurrence?

Answer 5

1. 1/1000 deliveries
2. 50% day 1-3, 75% by day 16, 95% by day 90
3. 74%
4. 50%; 35-65% will develop bipolar disorder

Question 6

What are the Whooley screening questions?

Answer 6

1. During the past month, have you often been bothered by feeling down, depressed or hopeless?
2. During the past month, have you often been bothered by having little interest or pleasure in doing things?
3. Is this something with which you would like help?

Question 7

What are the other screening tools?

Answer 7

1. Edinburgh postnatal depression scale (cut off 12)
2. Patient Health Questionnaire (PHQ-9) 0-27
3. Generalised Anxiety Disorder scale (GAD-2 and GAD-7) cut off 5, 10, 15

Question 8

What are the indications for referral to perinatal mental health?

Answer 8

1. woman with current illness where there are symptoms of psychosis, severe anxiety, severe depression, suicidality, self-neglect, harm to others or significant interference with daily functioning. Such illnesses may include psychotic disorders, severe anxiety or depression, obsessive–compulsive disorder and eating disorders.
2. woman with a history of bipolar disorder or schizophrenia.
3. woman with previous serious postpartum mental illness (puerperal psychosis).
4. women on complex psychotropic medication regimens.

Question 9

What is the incidence of ‘baby blues’ and when does it present?

Answer 9

3-10 days (peaks day 5)

30-80% of women

Question 10

1. What is the prevalence of depression and how many have symptoms antenatally?
2. How many still have depression beyond the first year?
3. How many relapse?

Answer 10

1. 11% in pregnancy up to 13% in first 3/12; up to 1/2
2. Up to 30%
3. 40% risk of relapse

Question 11

1. How many women are affected by postnatal depression?
2. When does it present?
3. What is the recurrence rate?
4. What is the treatment for PND?

Answer 11

1. 10-15/100; 3% affected severely
   42% if major depression with family history (15% if no FHx)
2. Peak presentations: 2-4 and 10-14 weeks post-delivery
3. 1:2 - 1:3
4. Mild-Moderate: facilitated self-help
   Moderate-severe: high-intensity intervention +/- SSRI, SNRI, TCA
   Severe: +/- mood stabiliser, ECT

Question 12

1. How many women with bipolar disorder will develop postpartum psychosis?
2. What is the incidence of BPD and mean age?
3. What is the rate of relapse of schizoaffective disorder perinatally?

Answer 12

1. 20-30%
2. 1%; 17-22 years
3. 25-50%

Question 13

What is the risk of suicide in a woman with postpartum psychosis?

Answer 13

2/100

Question 14

1. What are the adverse effects of SSRIs?

2. Which SSRIs are best when breastfeeding?

Answer 14

1. Persistent pulmonary hypertension of the newborn
   Congenital malformations
   Poor neonatal adaptation syndrome - majority symptoms within 72 hours
2. Sertraline and paroxetine

Question 15

Which TCA should be avoided when breastfeeding?

Answer 15

Doxepin

Question 16

What are the adverse effects of antipsychotics?

Answer 16

Congenital malformations
Poor neonatal adaptation syndrome
Metabolic syndrome
GDM and weight gain
Hyperprolactinaemia
(Atypical antipsychotics fewer)

Question 17

What are the adverse effects of mood stabilisers:

1. Lithium
2. Sodium valproate

What is the absolute risk of autism spectrum disorder/childhood autism if mum taking valproate?

Answer 17

1. Ebstein’s anomaly (septal/posterior leaflets of tricuspid displaced)
   Poor neonatal adaptation syndrome
   Lithium toxicity

2. Lower IQ (7-11 points)
Poor motor functioning
Poor language skills
Impaired learning
Increased risk autism and autistic spectrum disorder

4.4/100 and 2.5/100 respecitvely

Question 18

How often should Lithium levels be measured in pregnancy and what is management for labour/breastfeeding?

Answer 18

Every 4 weeks and then weekly from 36/40
Withhold during labour and childbirth
12 hours postdelivery before being reinstated
Do not advise breastfeeding

Question 19

What is the incidence of schizophrenia and bipolar disorder in the general population?

Answer 19

1% and 4% respectively

Question 20

What is the risk of recurrence of postpartum psychosis in subsequent pregnancies?

Answer 20

> 50%

Question 21

What % of the women who commit suicide have a diagnosis of severe affective disorder?

Answer 21

60%

Question 22

What are the admission rates to psychiatric hospital in the postpartum?

Answer 22

1-2 per 1000 births

Question 23

What is the risk of women with bipolr disorder suffering a severe recurrence following delivery?

Answer 23

1 in 4

Question 24

How many women with a hx of bipolar disorder and a personal or family hx of postpartum psychosis will have a delivery affected by PP?

Answer 24

1 in 2

Question 25

What obstetric factors have been linked with postpartum psychosis?

Answer 25

Primiparity (the only consistent)
Pregnancy and delivery complications
C/S
Female baby
Shorter gestation period

Question 26

How much more likely to relapse is a woman with bipolar disorder who has stopped medication antenatally vs one who continues?

Answer 26

x2

Question 27

How often should lithium levels be monitored in pregnancy?

Answer 27

Every 4/52 until 36/40

Then weekly until delivery