Mental health in perinatal period RANZCOG guideline

Question 1

When is the perinatal period in the context of mental health?

Answer 1

From conception until 1 year post partum

Question 2

Risk factors for mental health problems in the perinatal period?

Answer 2

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

Question 3

Why is perinatal mental health important?

Answer 3

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

Question 4

What are the ‘baby blues’ and their incidence?

Answer 4

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

Question 5

What proportion of women experience antenatal anxiety or depression?

Answer 5

Up to 10%

Question 6

Incidence of postnatal depression?

Answer 6

Up to 16%

Fathers up to 10%

Question 7

Incidence of puerperal psychosis

Answer 7

1:1000

Question 8

Incidence of PTSD

Answer 8

2-3%

Question 9

Risks for women with bipolar

Answer 9

Risk of recurrence and higher risk of suicide

Question 10

Why is identification and treatment important?

Answer 10

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

Question 11

Diagnostic criteria for puerperal depression

Answer 11

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.

Question 12

Symptoms more specific for perinatal anxiety and depression

Answer 12

 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

Question 13

What screening tools for depression can be used?

Answer 13

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

Question 14

What to do depending on EDPS?

Answer 14

10-12- repeat in 2-4/52

>13- needs evaluation as could be facing a crisis

Question 15

How to diagnosis perinatal depression/anxiety?

Answer 15

Use accepted DSMIV/ICD10 criteria

Exclude physical cause e.g. check thyroid status etc

Question 16

Management options for PND?

Answer 16

• Psychological: CBT, interpersonal psychotherapy, psychodynamic therapy
• Medication: For moderate/severe depression

If severe- involve a psychiatrist

Question 17

Key questions to ask about obstetric history that increase risk of PND?

Answer 17

• 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?

Question 18

Issues to be aware of following birth that may increase likelihood of PND:

Answer 18

• 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?

Question 19

What are the risks associated with schizophrenia and pregnancy?

Answer 19

gestational diabetes,
low and high birth weight babies,
preterm delivery
increased risk of neonatal complications and hospitalisation

Question 20

What medications may be used to treat psychosis in pregnancy?

Answer 20

• 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

Question 21

Antenatal care plan for women with schizophrenia and monitoring for women on antipsychotics

Answer 21

• 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

Question 22

Preparation for labour for patients with acute psychosis or schizophrenia

Answer 22

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

Question 23

Treatment of postpartum psychosis

Answer 23

Lithium or ECT

Can’t breastfeed with lithium

Question 24

Risks of antidepressants in pregnancy

Answer 24

• 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.

Question 25

Risk of antidepressants?

Answer 25

Preterm birth 
Possible congenital defects 
Neonatal withdrawal 
Low birth weight 
Persistent pulmonary hypertension of the newborn

Question 26

Risks of lithium in pregnancy for the fetus?

Answer 26

Congenital cardiac abnormality, particularly Ebsteins anomaly

Data variable regarding other potential fetal abnormalities

Question 27

How should lithium in pregnancy be managed?

Answer 27

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