Mental Health Flashcards
Mental Health and Mortality in pregnancy
1/4 maternal deaths
1/7 due to suicide
Prevalence of mental health issues in pregnancy
1 in 5 during or 12/12 postpartum
1-2 in 1000 postpartum psychosis
Pre-existing BAD/affective disorder/puerperal psychosis = 1 in 2 risk of postpartum problems
Postnatal Depression
12-13% of women
15-20% in the 12 month postpartum period
- 7x increased risk if untreated during pregnancy
- poor fetal outcomes
Assessment of Mental Health
PHQ-9
Edinburgh
Neonatal adaptation syndrome
due to SSRI
also increased risk PPH/ ASD
Breastfeeding and antidepressants
sedation, feeding changes, behavioural issues
best data= fluoxetine
Perinatal OCD
2 in 100 (pregnancy at 12/12 after)
higher risk if primip
1/3 pre-existing will worsen
eg escitalopram, citalopram, fluoxetine, paroxetine, sertraline
Antidepressants in Pregnancy
sertraline/paroxetine/venlafaxine= increased risk abortion/pulmonary hypertension/1 in 100 cardiac issues
especially first trimester
recommend hospital birth
Depo Antipsychotics
Haloperidol/Risperidone
may raise prolactin, reducing fertility
Sodium Valproate
c/i in pregnancy
ok in Breastfeeding
10% physical abnormalities
20-30% intellectual changes
give 5mg folate
carbamazepine
neural tube defects- 3% risk
prothrombin precursor competitive inhibitor
enzyme inducer
5mg folate
lamotrigine
ok
closely monitor levels
3.2% cleft palate
Lithium
fetal heart malformations (1st trimester, especially ebstein’s)
1 in 10 abnormalities
present in breastmilk (floppy baby)
reduce levels in labour (monitor throughout pregnancy)
perinatal toxicity- hypotonia, cyanosis, goitre, diabetes insipidus
Breastfeeding
all SSRIs but fluoxetine are present in breast milk
discourage:
clozapine
carbamazepine
lithium
Alcohol
chlodiazepoxide if ok
Opioids
Neonatal abstinence syndrome
-70-95%, even if on methadone
can take methadone/buprenorphine, may need to increase 3rd trimester
can pass into breastmilk
avoid detox in pregnancy (higher risk of relapse)
Cross placenta, increased fluctuation/withdrawal
increased risk PTB/FGR due to contractions
no associated malformations
Stimulants
Cocaines, amphetamines
vasoconstriction:
abruption
PPROM
Low birth weight
prematurity
should avoid breastfeeding
Anorexia
delay conception until well
preterm
low birth weight
anemia
IUGR
mortality
Drugs contributing to female sexual dysfunction
SSRIs/antipsychotics/anticonvulsants
B-blockers/thiazides
lithium
benzodiazepines
GnRH agonists/aromatase inhibitors
Spironolactone
opioids, cocaine, alcohol
Sexual neurotransmitters
Pro:
Noradrenaline
Dopamine
Oxytocin
Melanocortin
Serotonin
Anti:
Prolactin
GABA
Serotonin at some receptors
Genital Congestion
Reflex autonomic response
neurological/vascular disease can inhibit
reduced estrogen> reduced vascularity>reduced NO to clitoris and reduce vasoactive intestinal peptide to vagina
Diagnosis of female sexual dysfunction
3 of below for over 6/12, causing clinically significant distress
-absent/reduced interest
-absent/reduced fantasies
- absent/reduced initiation
-absent/reduced to others initiation
-absent/reduced pleasure
-absent/reduced response to cues
-absent/reduced sensation
in over 75% encounters
Female orgasmic disorder
delay / infrequency/ absence or orgasms
or reduced intensity or orgasm
Persistent Genital Arousal Disorder
persistent / recurrent
unwanted and distressing sensations of arousal
over 3 months
Treatment of psychosexual problems
Psychotherapy
-conflicts of early life/previous relationships
Sex therapy
-anxiety/distraction/reduced communication
Mindfulness/CBT
-catastrophising/dissociation
Reduced sensitivity/lubrication
-estrogens or DHEA
Vulvodynia
Discomfort, usually burning
in absence of relevent visible findings
classified by site
provoked- on touch
unprovoked- without touch
Treatment of vulvodynia
Local Anaesthetics
TCAS:
amitriptyline 10-25mg OD
Nortryptyline
Gabapentin 300mg OD>BD>TDS
Pregabalin
Surgical excision of vestibule
desensitisation of pelvic floor
Erectile Dysfunction- assessment
HbA1c
Lipid profile
morning testosterone
BMI/smoking
Erectile Dysfunction- management
PDE-5 inhibitor regardless of cause
take an hour before sex on empty stomach
lasts 4-5 hours
Erection Physiology
complex intracellular cascade/smooth muscle relaxation
-sinusoidal blood flow increases
-occlusion of venous outflow
NO released by presynatpic cavernosal nerve fibres and endothelial cells= smooth muscle relaxation
GTP->cGMP- intracellular Calcium efflux
PDE5 mechanism
converts cGMP to 5 GMP
normalises calcium levels
Premature Ejaculation
Always / nearly always
prior to or within 1 minute of penetration
from first sexual experience or significant reduction to <3minutes
inability to delay ejaculation
negative personal consequences
Treatment of Premature Ejaculation
more frequent sex / masturbation
condom use
squeeze and stop/go
Pharmacology:
SSRI daily (off-label)
mental health questionnaires
depression- phq 9
anxiety- gad 7
ptsd- pcl 5
Tricyclic antidepressants in pregnancy
eg amitryptilline
generally safe
neonatal withdrawal syndrome
-reduce 3-4/52 before delivery
-risk overdose/maternal tolerability
1st generation antipsychotic
olanzapine
no robust evidence but used for a while without adverse effects
2nd generation antipsychotic
increased risk LGA/hypoglycemia
clozapine- floppy baby/agranulocytosis
check prolactin/diabetes
Anti-anxiety medications
benzodiazepines risks>benefits
gabapentin > pregabalin
oestrogen and progesterone may increased concentrations of benzodiazepines and chlordiazepoxide
Neonatal Abstinence Syndrome presentation (Opioids)
55-95%
24-72hrs
respiratory distress
irritability
reduced feeding or GI changes
seizures/hypertonia
Transference
feelings not due to situation but repetitions of reactions to persons in early childhood
counter transference- therapist derived
Vaginismus
Involuntary spasm of pelvic floor (incl pubococcygeus)
painful/difficult penetration
Hyposexual desire disorder
lack of desire- clear distress, interpersonal difficulty
treatment
estrogen +/- testosterone
buproprion (increase NA/DA)
flibanserin (serotonin receptor modulator)
Sexual Arousal disorder
reduced/absent fantasies or desire
unable to attain or maintian response to arousal
rx:
vibrator/suction
lubricants
avoid PDE-5 in women
Persistent Genital Arousal Disorder
spontaneous arousal unresolved by orgasm
stressful
rx:
SSRI/SNRI
Valproate
topical anaesthetic
Anorgasmia- causes
T11-L2 injury
endocrine
dermatological
malignant
abuse
AEDs
Modafinil
ADHD/Narcolepsy drug
enzyme inducer
