Maternal mental health Flashcards
How common are perinatal mental health conditions?
Affects 1:10 women
15-20% anxiety depression
3-5% require specialist input through perinatal mental health team
How is perinatal mental health identified?
Pre-conception counselling if pre-existing condition - explain how illness will affect pregnancy, medication alterations
Booking appointment
Antenatal period - PHQ2 screening
Acute presentation - MSE
What conditions require pre-conception counselling?
Severe depression
Bipolar
Schizophrenia
What happens at the booking appointment and when is it?
10 weeks
Full medical history
Drug history and substance abuse
Family history - first degree relatives with schizophrenia/postnatal depression/bipolar
Domestic/sexual abuse
Bloods
BMI
When should someone be referred to perinatal mental health team?
Pre-existing psychiatric condition - severe depression, bipolar, schizophrenia
FHx of first degree relative with schizophrenia, postnatal depression, bipolar
What questionnaire is used to diagnose post-natal depression?
Edinburgh post-natal depression score
What are the effects of perinatal depression on the baby?
Pre-term delivery
Emotional disorders and depressive illness in child
Behavioural difficulties
What are the effects of perinatal anorexia nervosa on the baby?
Low birthweight
What are the effects of schizophrenia on the baby?
Low birthweight
Preterm delivery
Stillbirth
What are the effects of post-natal depression on the baby?
Emotional disorders in child
Increased risk of depression
What effect can maternal mental health have on the foetus?
Epigenetic impact
Genetic processes - neurobiological processes
What effect can poor perinatal mental health have on the mother?
More women die of psychiatric illness than pre-eclampsia and amniotic fluid embolism
Suicide leading cause of maternal death up to 1 year post-delivery
How common is depression in the perinatal period?
Affect 12%
What are the S&S of perinatal depression?
Difficulty bonding with child
Suicidal ideation
Self-neglect
Anhedonia
Tiredness
Difficulty concentration
How is perinatal depression diagnosed?
PHQ9
What is the risk of recurrence of perinatal depression?
1:2 to 1:3 risk of postnatal depression
Why should perinatal depression be treated?
Reduces risk of postnatal depression which affects bonding with baby
What is the management of perinatal depression?
SSRIs - safe in pregnancy
SNRIs - can take during pregnancy but limited data
TCAs- risk in overdose
What is important to ensure in babies born to mothers on SSRIs?
Risk of persistent pulmonary hypertension if used > 20 weeks - must deliver in hospital and baby monitored for 24 hours
Risk of neonatal adaptation syndrome - tapering dose if appropriate - crying, jittery
What is important to take into account with SSRI treatment and breast feeding?
Readily transfer into milk but in low doses
Sertraline lowest dose so mothers often on this
Fluoxetine highest levels
How common is anxiety in pregnant women?
13%
What are the symptoms of anxiety?
Chronic excessive worry (not situational)
Hyperarousal
What is the screening tool for anxiety?
GAD-2
What is the diagnosis of anxiety?
GAD-7
What are the common anxiety disorders in pregnancy?
Generalised anxiety disorders
PTSD - flashbacks (can be a result of previous pregnancy, due to previous sexual abuse and routine examinations during pregnancy/labour)
OCD
Tocophobia
What is tocophobia?
Morbid dread and fear of childbirth
What are the two different types of tocophobia?
Primary - never delivered before
Secondary
What are the symptoms of tocophobia?
Request an elective CS
Identify underlying cause
What is the management of mild/moderate anxiety during pregnancy?
GAD- active/psychoeducation, self help
OCD - CBT, exposure therapy, self help
PTSD - trauma focussed CBT, EMDR
What is the management of severe anxiety during pregnancy?
GAD - CBT/applied relaxation/medication/combined therapy
Panic disorders - CBT/anti-depressants/self help
OCD - antidepressants/combined therapies/ECT
PTSD - drug treatment
What medications can be used in anxiety in pregnancy?
Anti-depressants (SSRIs)
Benzodiazepines - for short term management
What are the dangers of benzodiazepines during pregnancy?
Associated with cleft palate, neonatal withdrawal syndrome, floppy baby syndrome
How do you deal with the risks of benzodiazepines during pregnancy?
Lowest dose possible for shortest time possible
Avoid in third trimester
What are the risks of psychotic illness in pregnancy?
Increased risk of puerperal psychosis
How are mothers with psychotic illnesses managed?
Perinatal mental health team
Preconception
Birth planning meeting (32/40)
Intrapartum and postnatal care
Elective mother and baby unit admission - not always required - to prevent deterioration of mother
MDT management
How common is bipolar?
1% of population
Mean age of onset 17 to 22
What is bipolar?
Characterised by episodes of low mood and mania
What are the risks of bipolar in pregnancy?
25-50% risk of puerperal psychosis - emergency
What are the psychological managements of bipolar?
Relapse prevention
CBT
Psychoeducation
What are the pharmacological managements for bipolar?
Antipsychotics
Mood stabilisers
Benzodiazepines
Can antipsychotics be used in pregnancy?
Yes
Can antipsychotics be used in pregnancy?
Yes - not teratogenic
Can antipsychotics be used in pregnancy?
Yes - not teratogenic but possible link with cardiac malformation (1-1.5%)
What about antipsychotics should be avoided during pregnancy and why?
Depots - changed pharmacokinetics in pregnancy
Which antipsychotics should be avoided during pregnancy/perinatal period and why?
Olanzapine - increased risk of weight gain and gestational diabetes
Risperidone - raised prolactin so difficulty conceiving
Which mood stabiliser should not be used in women of child bearing age?
Sodium valproate
What are the risks of lithium to the foetus?
Ebstein anomaly
What is Ebstein anomaly?
ASD
Abnormal tricuspid valve
Enlarged RA
Right ventricular outflow tract obstruction
Can lithium be given during pregnancy and if so, when should it be avoided and how?
Yes
Avoid in first trimester and when breastfeeding
Switch to antipsychotic if possible
Lithium assays weekly - can easily get out of therapeutic range during pregnancy
What are the red flag mood symptoms during pregnancy?
Suicidal ideation
Feelings of incompetence as a parent
Estrangement from child
Hallucinations
How common is schizophrenia?
1% population
What are the positive symptoms of schizophrenia?
Hallucinations
Delusions
Thought disorders
What are the negative symptoms of schizophrenia?
Lack of empathy/drive
Catatonia
What are the risks of schizophrenia in pregnancy?
Risk of relapse post-delivery and puerperal psychosis (emergency)
What is the psychological management of schizophrenia?
Relapse prevention
CBT
Psychoeducation
What is the pharmacological management of schizophrenia?
Antipsychotics
Mood stabilisers
Antidepressants (for schizo-affective)
Benzodiazepines
What are the two main overarching reasons that women may experience post-natal mood changes?
Biological and psychological
What biological causes can cause post-natal mood changes?
Genetics - 50% risk if first degree relative had post-natal depression
Hormone changes
What psychosocial changes can cause post-natal mood changes?
Stressors
Support
Relationships
Finances
Housing
Which is the most important question on the Edinburgh postnatal depression score?
No 10 - thoughts of self harm
Even if score low on everything else needs acting on
How common are baby blues?
50-85% women affected
When is baby blues most common?
Days 3 to 10
Peak symptoms day 5
What are the symptoms of baby blues?
Crying
Irritability
Anxiety
What is the management of baby blues?
Self-limiting so reassurance and support
Physiological
How common is puerperal psychosis?
1-2 in 1000 women
When is the onset of puerperal psychosis?
Early post natal
50% by day 7
75% by day 16
95% by day 90
Often out of hospital so rely on reports from families
What are the risk factors for puerperal psychosis?
Bipolar
Previous postnatal psychosis > 50% risk
FHx postnatal psychosis/bipolar
Schizophrenia
What are the signs of puerperal psychosis?
Vague - insomnia, tearfulness, agitation
Delusions (most about baby), hallucinations
Mania
Rapidly changing mental state
What is the management of puerperal psychosis?
Exclude physical illness eg stroke/space occupying lesion
Psychiatric emergency - refer to crisis team
May need diazepam
Admission to mother and baby unit/psychiatric ward under mental health act
What is the risks of puerperal psychosis?
2% suicide risk
Infanticide risk - one to one care
What is the treatment for puerperal psychosis?
Antipsychotics
Antidepressants
Mood stabilisers
ECT
Psychotherapy/relapse prevention
Contraception
What is the prognosis of puerperal psychosis?
50% risk recurrence
65% may develop bipolar
Name 3 forms of loss of a child
Intrauterine death/stillbirth
Miscarriage
Non-viable pregnancy so termination
Neonatal death
Removed child by social services
Ectopic pregnancies
What can partners mental health be like after birth?
Mirrors mothers experiences
Offer support so mother has full support
