Mental Health problems in pregnancy or postpartum

Question 1

What is baby blues (+prevalence)

Answer 1

Feeling weepy, irritable, and muddled for the first week after birth
60-70% of women (600 in 1000)

Question 2

What are the clinical features of baby blues

Answer 2

Up to 10 days post partum
Presents around the second or third postnatal day and resolving by the fifth day

Tearfulness
Mild depression
Emotional lability (rapid, often exaggerated changes in mood, where strong emotions or feelings (uncontrollable laughing or crying, or heightened irritability or temper) occur)
Irritability
Muddled, impairment of concentration
Anxiety
Trouble sleeping (insomnia)
Fatigue

Question 3

What may be referred to perinatal services

Answer 3

Anxiety and trauma-related disorders that affects day to day functioning
Eating disorders
Affective illness
Emergency: psychotic symptoms
Suicidal thoughts of imminent risk of self-harm

Question 4

What is postnatal depression (+prevalence)

Answer 4

Postnatal absence of positive affect (loss of interest and enjoyment), low mood, and additional emotional, cognitive, physical, and behavioural symptoms
Mild-moderate: 125 in 1000 births
Severe: 30 in 1000

Question 5

What are the risk factors for postnatal depression

Answer 5

PMHx depression or anxiety
FMHx depression
Baby blues
Lack of social support
Poor partner relationship
Preterm birth, infant health problems, need for neonatal intensive care
Unplanned pregnancy
Unemployment

Question 6

What are the symptoms of postnatal depression

Answer 6

6 weeks post partum, peaks at 3 months

Low mood
Loss of interest or pleasure
Social withdrawal
Fatiguability
Suicidal ideation
Anxious preoccupation with the baby’s health
Feelings of guilt and inadequacy
Reduced affection for baby with possible impaired bonding
Obsessions phenomena (involving recurrent and intrusive thoughts of harming the baby)
Infanticidal thoughts

Question 7

What is puerperal psychosis (+ prevalence)

Answer 7

Affective psychosis linked to the postnatal period. It is a psychiatric and obstetric emergency, usually requiring hospital treatment
Affects 1-2 in 1000 (0/2%)
Recurrence after subsequ

Question 8

What is the prognosis for postnatal depression

Answer 8

Usually self-limiting within a few months
1/3 of women are still unwell a year after childbirth
Risk of subsequent relapse is high - around 1 in 4

Question 9

What is puerperal psychosis (+ prevalence)

Answer 9

Affective psychosis linked to the postnatal period. It is a psychiatric and obstetric emergency, usually requiring hospital treatment
Affects 1-2 in 1000 (0.2%)

Question 10

What are the risk factors of puerperal psychosis

Answer 10

BPAD or schizoaffective personality disorder (70%)
Previous puerperal psychosis
Complicated labour: puerperal infection, obstetric complications, caesarean section
PMHx mental health disorder
FHx mental health disorder
Primiparity
Lack of social support

Question 11

What are the symptoms of puerperal psychosis

Answer 11

2-3 weeks post-delivery with rapid deterioration

Begins with insomnia, restlessness and perplexity, mood swings (abnormal behaviour)
Later, psychotic symptoms emerge:
- Delirium
- Affective (psychotic depression or mania)
- Schizophreniform (like schizophrenia): Delusions and Hallucinations
Symptoms can fluctuate dramatically and rapidly
Distorted thoughts and behaviour may involve the baby, putting it at risk of harm.

Question 12

What are the differentials for mental health problems in pregnancy

Answer 12

Postpartum depression
Baby blues
Puerperal psychosis
Postpartum thyroiditis
Bipolar affective disorder
Obsessive compulsive disorder
PTSD

Question 13

What investigations should be done for mental health postpartum

Answer 13

Collateral history
Edinburgh postnatal depression scale (in last 7 days) or PHQ-9 (In the last 14 days)
GAD-2 scale for anxiety
Young mania rating scale

Bloods: FBC, U&Es, LFTs, TFTs, B12 and folate, vit D

Question 14

What is the management for baby blues

Answer 14

Reassurance
Support - ensure the health visitor is involved
Affects 3-8/10 women

Question 15

What is the management for mild-moderate postnatal depression

Answer 15

Seek advice from a specialist perinatal mental health team

Pyschosocial interventions
Facilitated self-help

Question 16

What is the management for mild postnatal depression with Hx of severe depression

Answer 16

Antidepressants (TCA, SSRI, or SNRI)
First line: sertraline

Question 17

What is the management for moderate-severe postnatal depression

Answer 17

First line: High-intensity psychological intervention e.g. CBT
Second line: antidepressants e.g. paroxetine, sertraline (SSRI), imipramine (TCA)

Severe/suicidal ideation/risk to baby → refer to mother and baby unit

Question 18

What are the considerations for antidepressant use post-partum

Answer 18

Antidepressants are secreted in breast milk, but thought to not be harmful to the infant. Must monitor the baby for adverse effects
SSRI: sedation, poor feeding, behavioural effects
TCA: drowsiness, poor feeding, behavioural changes

Question 19

Where can you go to for advice on medication in the post-partum period

Answer 19

Perinatal psychiatrists and specialist pharmacists
UK teratology information service (UKTIS)
UK drugs in Lactation advisory service (UKDILAS)

Question 20

What are the side effects of SSRI use in pregnancy

Answer 20

Persistent pulmonary hypertension
Transient neonatal withdrawal syndrome (CNS, motor, respiratory, and GI symptoms)
Neonatal adaptation syndrome
Cardiac malformations
Preterm delivery, LBW

Question 21

What are the side effects of SNRIs in pregnancy

Answer 21

PPersistent pulmonary hypertension
Irritability, tremor, muscle weakness, difficulty sucking, respiratory problems, low apgar score, hypoglycaemia, convulsions

Question 22

What are the side effects of TCAs in pregnancy

Answer 22

Cardiac malformations
Pre-eclampsia
Spontaneous abortion
Preterm delivery
Autism disorder
Neonatal withdrawal symptoms

Question 23

What is the management for puerperal psychosis

Answer 23

Admission to secondary mental health services (Mother and Baby unit) for immediate assessment (within 4 hours of referral)

1st Line: Atypical antipsychotics e.g. Olanzapine, aripiprazole, quetiapine

Question 24

What are the features of anxiety disorder in pregnancy

Answer 24

triggered or exacerbated
Often OCD:
- Obsessions usually focus on harming the baby:
—-“What if I have contaminated my baby” “I’m a paedophile “
—-“Images/urges of hurling the baby down the stairs”
- Risk is through the mother avoiding care to prevent harm from happening to the baby

Question 25

What is the management for anxiety in the postpartum period

Answer 25

First line: high-intensity psychological intervention e.g. CBT

Question 26

What is the management for PTSD in the postpartum period

Answer 26

First line: high-intensity psychological intervention e.g. Trauma‑focused CBT
- Eye movement desensitisation and reprocessing [EMDR]

Question 27

What is the prognosis for puerperal psychosis

Answer 27

25-50% risk of recurrence in following pregnancies

Question 28

What are the complications of postnatal depression

Answer 28

Self harm and suicide attempts
Infant complications:
- Failure to thrive
- Attachment disorder
- Developmental delay
- Depression

Question 29

What questions should you ask when assessing perinatal mental health

Answer 29

1. Attitude towards pregnancy, experience, any problems
2. Feelings of guilt or hopelessness
3. How she perceives her relationship with her baby
   - “Tell me about X”
   - “When X cries, how do you feel? If they don’t stop, how do you handle it?”
4. Depression screen
   - “have you often been bothered by feeling down, depressed, or hopeless?”
   - “have you often been bothered by having little interest or pleasure in doing things?”
5. Schizophrenia screen
   - “Some women worry that their baby is ill, abnormal, or bad. Is this something you worry about”
   - “Do you worry for X’s safety? How do you protect them?”
6. Risk assessment
   - “Is it every so stressful that you wish you hadn’t had X?”
   - “ thinking is really different from doing. Do you have any intention to actually harm X?”
7. PMHx: depression, postpartum mental health, BPAD
8. SHx: social networks, quality of relationships, living conditions, employment, DV and abuse, trauma or childhood maltreatment, alcohol and drug misuse, care of others