Mental health in perinatal period RANZCOG guideline Flashcards
When is the perinatal period in the context of mental health?
From conception until 1 year post partum
Risk factors for mental health problems in the perinatal period?
a history of mental health problems, lack of support, previous trauma including physical, emotional or sexual abuse, isolation (physical, mental, cultural), stressful life events, a history of drug or alcohol abuse
Why is perinatal mental health important?
Suicide one of the leading causes of death in Australia/NZ
Maternal mental health conditions can also have an adverse impact on the growth and development of the fetus/infant, and the wellbeing of other family members
What are the ‘baby blues’ and their incidence?
Up to 80% of women will have emotional lability for the first 3-5/7 after birth, this can last for up to 10 days
What proportion of women experience antenatal anxiety or depression?
Up to 10%
Incidence of postnatal depression?
Up to 16%
Fathers up to 10%
Incidence of puerperal psychosis
1:1000
Incidence of PTSD
2-3%
Risks for women with bipolar
Risk of recurrence and higher risk of suicide
Why is identification and treatment important?
Of women identified with antenatal or postnatal depression, 50-70% of those untreated remain
depressed 6 months later. 2
5% of women will develop a chronic illness and 25% of women will develop recurrent depression.
Perinatal anxiety and depression has adverse consequences for mothers, fathers and children especially in respect to the critical parent-infant attachment that potentially influences the
mental health of the next generation
Diagnostic criteria for puerperal depression
Depressed mood AND/ OR Anhedonia (no interest or pleasure or enjoyment) Significant change in weight or appetite Markedly increased or decreased sleep Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or guilt Reduced concentration Recurrent thoughts of death or suicide
In addition, these symptoms must be accompanied by significant impairment in capacity to engage and function in usual activities e.g. parenting, occupational, social and other roles.
Symptoms more specific for perinatal anxiety and depression
Inability to enjoy activities which were enjoyed prior to pregnancy or birth
Can’t concentrate, make decisions or get things done
Physical symptoms such as heart palpitations, constant headaches, sweaty hands
Feeling overwhelmed and constantly exhausted
Feel numb and remote from family and friends
Feel out of control, or ‘crazy’, even hyperactive
Can’t rest even when the baby is sleeping
Have thoughts of harming themselves or the baby (infanticide)
Have constant feelings of guilt, shame, or repetitive thoughts
Feel trapped or in a dark hole or tunnel with no escape
Experience feelings of anger, grief, loss, tearfulness
Changes in appetite
Persistent negative thoughts
Feeling very irritable or sensitive
What screening tools for depression can be used?
Screening should be part of routine antenatal care
Can use antenatal risk questionnaire and Edinburgh postnatal depression scale
Also screen every woman for family violence, drug and alcohol use
Ask about a womans emotional, mental health and well being at every antenatal/post natal visit
What to do depending on EDPS?
10-12- repeat in 2-4/52
>13- needs evaluation as could be facing a crisis
How to diagnosis perinatal depression/anxiety?
Use accepted DSMIV/ICD10 criteria
Exclude physical cause e.g. check thyroid status etc
Management options for PND?
- Psychological: CBT, interpersonal psychotherapy, psychodynamic therapy
- Medication: For moderate/severe depression
If severe- involve a psychiatrist
Key questions to ask about obstetric history that increase risk of PND?
- Was the pregnancy planned?
- Was there a history of infertility, assisted reproduction or donor conception and what are the ongoing implications?
- Was/is there an extreme fear of childbirth (tocophobia)?
- If there has been a previous pregnancy, is there a history of antenatal or postnatal mood, anxiety or psychotic disorder?
- Is there a history of previous loss? Does that affect attachment with this child?
Issues to be aware of following birth that may increase likelihood of PND:
- How did the woman experience her birth? Did she feel out of control or traumatised?
- Was a history of sexual abuse triggered during birth?
- Did she experience severe sleep disturbance following the birth?
- Was a difficult birth acknowledged and debriefed by health professionals?
- Were her expectations of birth met?
- Did she deliver prematurely? Was the baby in special care?
- In what way did the woman’s birth experience contribute to postnatal adjustment difficulties?
What are the risks associated with schizophrenia and pregnancy?
gestational diabetes,
low and high birth weight babies,
preterm delivery
increased risk of neonatal complications and hospitalisation
What medications may be used to treat psychosis in pregnancy?
- Typical antipsychotics e.g. haloperidol
- Atypical second generation antipsychotics, such as olanzapine, risperidone, quetiapine, aripiprazole and clozapine
Very little data on safety- study of fetal risks of pts on antipsychotics confounded by other issues therefore difficult to know true impact of AP
General principles of treatment- monotherapy preferable at lowest necessary dose
Clozapine carries risk of agranulocytosis, neutropaenia and myocarditis therefore requires close monitoring and is used when other medications have failed
Antenatal care plan for women with schizophrenia and monitoring for women on antipsychotics
- Regular monitoring of full blood examination, urea and electrolytes, liver function tests, magnesium, calcium, folate, iron and vitamin D, ECG
- Regular weight and blood pressure checks
- Early glucose tolerance test at 16 weeks, particularly if on antipsychotic agents such as olanzapine, clozapine or quetiapine
- Close monitoring of fetal growth
- Neonatal assessment, including for extrapyramidal side effects and withdrawal
- Avoidance of pharmacological agents for lactation suppression
- Antipsychotic medication
Preparation for labour for patients with acute psychosis or schizophrenia
Consider whether she has capacity to consent
Consider an advanced directive if she has capacity now but might not have capacity in the future
May be helpful to have mental health staff present for labour care
May need postnatal care plan and consideration of tansfer to a psychiatric morther baby unit as risk of becoming psychotic/deteriorating post natally and bother mother and baby may be at risk
Treatment of postpartum psychosis
Lithium or ECT
Can’t breastfeed with lithium
Risks of antidepressants in pregnancy
- Possible risk of congenital cardiac condition but unlikley to be true, data very small
- Small increase in PPH
- Small increase in persistant pulmonar hypertension of the newborn (incidence remains very low)
- Poor neonatal adaptation syndrome (PNAS): can be a risk when antidepressants are taken in late pregnancy. Infants may be jittery and suffer hypotonia, respiratory distress, hypoglycaemia and seizures.
Risk of antidepressants?
Preterm birth Possible congenital defects Neonatal withdrawal Low birth weight Persistent pulmonary hypertension of the newborn
Risks of lithium in pregnancy for the fetus?
Congenital cardiac abnormality, particularly Ebsteins anomaly
Data variable regarding other potential fetal abnormalities
How should lithium in pregnancy be managed?
Balance of risks of taking lithium against mental health effects
- Risk of congenital defects
- Balanced against maternal mental health- risk of relapse of bipolar in pregnancy and postnatally/PN psychosis
- If taking lithium recommend detailed cardiac anatomy scan
- Close monitoring of lithium levels in pregnancy due to increased renal clearance, dose likely to be increased
