Menstrual Cycle, Pregnancy and Puerperium

Question 1

Premenstrual syndrome - when, epidemiology, symptoms, management

Answer 1

10 days prior to menstruation and remits 2 wks following
- higher in women >30, multiparous, significant psychosocial stress

Symptoms

• low mood, irritability, tiredness
• headache, bloating, breast tenderness

Management

• reassurance, healthy eating, stress-reduction, exercise
• abstain from alcohol/caffeine the wk before
• counselling for stress management, CBT
• pharm: contraception, SSRI, danazol

Question 2

Psychiatric medications in pregnancy and breastfeeding - antidepressants

Answer 2

TCA

• pregnancy: associated with neonatal hypoBG/jaundice - amitriptyline, nortriptyline, imipramine ok
• breast-feeding: avoid dose-in (infant resp depression), low dose amitriptyline appears safe

SSRI

• pregnancy: withdrawal symptoms in neonates, PAROXETINE C/I (foetal heart defects)
• breast-feeding: paroxetine and sertraline small amounts excreted in breast milk; fluoxetine and citalopram excreted in relatively larger (but still small amounts)

Overall: antidepressants

• pregnancy – amitriptyline, nortriptyline, imipramine, fluoxetine, sertraline
• breast feeding – paroxetine, sertraline

Question 3

Psychiatric medications in pregnancy and breastfeeding - antipsychotics

Answer 3

Pregnancy: self limiting EPS in neonates, OLANZAPINE INCREASE GESTATIONAL DM
–> FGAs favoured, SGAs NOT OLANZAPINE or CLOZAPINE

Breast-feeding: small amounts excreted, high dose has risk of lethargy in infant
–> Risperidone, Sulpride (although secreted into breast in larger amounts), Olanzapine?

Question 4

Psychiatric medications in pregnancy and breastfeeding - mood stabilisers

Answer 4

Pregnancy: TERATOGENICITY

• Valproate > Carbamazepine > Lithium > Lamotrigine
• avoid if possible, lamotrigine if really needed

Breast-feeding:

• Li – NEONATAL LI TOXICITY (40% secreted into milk)
• Valproate or Carbamazepine if rly necessary but risk of infant hepatotoxicity

Question 5

Psychiatric medications in pregnancy and breastfeeding - sedatives

Answer 5

Pregnancy:
- NO BZD IN FIRST TRIMESTER –> a/w floppy infant syndrome (hypotonia, breathing difficulty) and neonatal withdrawal syndrome

Breast-feeding:

• may cause lethargy in infant
• drugs with short half lives if necessary – LORAZEPAM for anxiety, ZOLPIDEM for sleep

Question 6

Postnatal blues - prevalence, onset, symptoms, cause, management

Answer 6

Up to 50% postpartum women
Within first 10 days of delivery, peak at day 3-5

Symptoms:
- episode of tearfulness, mild depression, emotional lability, anxiety, irritability

No link with events, demographics, obstetric events

SELF LIMITING, RESOLVE SPONTANEOUSLY

Question 7

Postnatal depression - prevalence, onset, cause, risk factors, symptoms, main differences with normal depression

Answer 7

10%
Within 3 months of delivery, lasting 2-6 months

Cause: PSYCHOSOCIAL factors strongly linked e.g. lack of close confiding relationship, young maternal age

Risk factors: Hx of depression, obstetrics complications, stressful events around pregnancy and childbirth

Symptoms:
- similar to normal MDD - low mood, anhedonia, anergia, suicidal ideation
AND
- ANXIOUS PREOCCUPATION WITH BABY’S HEALTH – feelings of guilt and inadequacy
- OBSESSION with recurrent and intrusive thoughts of HARMING BABY (need to ascertain if distressing to mother or whether there is potential risk)
- INFANTICIDAL THOUGHTS (need to check ambivalence, intention, cause e.g. any psychosis)

(Edinburgh postnatal depression scale)

Question 8

Postnatal depression - management, importance of rapid treatment and prognosis

Answer 8

Mx

• psychosocial: mother and baby groups, relationship counselling, problem solving
• midwives, health visitors (provide help with childcare)

If severe: antidepressants (except doxepin), ECT may be indicated
–> SIGNIFICANT RISK TO BABY’S COGNITIVE AND EMOTIONAL DEVELOPMENT IF MOTHER NOT TREATED RAPIDLY

Prognosis

• most respond to standard treatment
• 50% increased risk of developing similar illness in future childbirth
• 50% develop depressive illness unrelated to childbirth
• may have problems with child’s cognitive and emotional development

Question 9

Puerperal psychosis - prevalence, onset, risk factors, symptoms

Answer 9

1/500 births
Rapid onset between 4 days-3 wks post delivery

Risk factors: psychosocial factors less important
- primiparous, Hx or FHx of BAD or puerperal psychosis, delivery a/w C-section or perinatal death

Symptoms:

• initial - insomnia, restlessness, perplexity
• later - suspiciousness, marked psychotic symptoms (can fluctuate dramatically)
• often retain a degree of insight (may not disclose certain bizarre delusions or homicidal thoughts)

Question 10

Puerperal psychosis - management and prognosis

Answer 10

Management:

• risk assessment of infanticide and suicide e.g. thoughts of self-harm or harming baby, severe depressive delusions that baby should be dead, command hallucinations
• -> HOSPITALISATION necessary in severe cases
• pharm: antipsychotics, antidepressants, mood-stabilisers, BZD if severe disturbance –> stop breast-feeding if possible
• ECT effective in severe or treatment resistant cases –> RAPID EFFECT

Prognosis:

• most recover in 3 months (75% in 6 wks)
• 60% recurrence in future childbirths