Obstetric Mental Health

Question 1

How common is depression in and after pregnancy and does it present differently to normal?

Answer 1

10-15% of women will suffer with depression and or anxiety during pregnancy. This presents in a very similar way to Depression outside of pregnancy with the core symptoms being Low mood, lethargy and anhedonia. Important to ask about personal history of depression and postnatal depression as well as family history.

Question 2

How should severe antenatal depression be managed?

Answer 2

If severely depressed, or risk to mother or baby then urgent referral to mental health services. Specialist advise should be considered when changing or starting medication.

Question 3

How should newly diagnosed depression be managed during pregnancy?

Answer 3

Newly diagnosed depression – prioritise social support and psychological treatments
Anti-depressants – no safe drug to take so consult pharmacist. Tricyclics have lowest known risks and SSRI’s are relatively untested although fluoxetine is lowest risk but shouldn’t be used postnatally.
Sertraline most commonly used
Self-referral to Mum’s mind.

Question 4

How should anxiety be managed in the antenatal period?

Answer 4

For anxiety, CBT is preferred to anxiolytics. Benzodiazepine should be avoided.

Question 5

When is post partum depression screened for?

Answer 5

Postpartum depression is screened for at 4-6 weeks and 3-4 months post-delivery by health care workers who ask:

1. “In the past month have you been feeling down, depressed or hopeless?”
2. “In the past month have you lost any interest in doing things that make you happy?”
3. If yes to both then “is this something you would like help with?”

Question 6

How else can post natal depression be screened for?

Answer 6

The Edinburgh Postnatal Depression Scale may be used to screen for depression:
• 10-item questionnaire, with a maximum score of 30
• indicates how the mother has felt over the previous week
• score > 13 indicates a ‘depressive illness of varying severity’
• sensitivity and specificity > 90%
• includes a question about self-harm

Question 7

What are the 3 main mental health problems experienced by women post natally?

Answer 7

‘Baby-blues’
Postnatal depression
Puerperal psychosis

Question 8

Compare the incidence of baby blues, postnatal depression and puerperal psychosis

Answer 8

‘Baby-blues’
60-70% of women

Postnatal depression
Affects around 10% of women

Puerperal psychosis
Affects 0.2% of women. Higher in those with personal or family history of psychiatric disorders

Question 9

Compare when the baby blues, postnatal depression and puerperal psychosis most commonly occur

Answer 9

‘Baby-blues’
Seen 3-7 days following birth, lasts about a week and is more common in primips

Postnatal depression
Defined as up to 12 months post-partum but most cases start within a month and typically peaks at 3 months

Puerperal psychosis
Onset usually within the first 2-3 weeks following birth

Question 10

Compare the the signs and symptoms of baby blues, postnatal depression and puerperal psychosis

Answer 10

‘Baby-blues’
Mothers are characteristically anxious, tearful and irritable

Postnatal depression
Features are similar to depression seen in other circumstances.

Thoughts can focus around the baby and being a mother

Puerperal psychosis
Features include severe swings in mood and affective symptoms (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). Patients appear confused and distracted. Can occur rapidly or slowly.

Question 11

Compare the management of baby blues, postnatal depression and puerperal psychosis

Answer 11

‘Baby-blues’
Reassurance and support, the health visitor has a key role

Postnatal depression
As with the baby blues reassurance and support are important.

Mild to moderate – self-help and listening visits by health visitor

Moderate to severe – Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe.

Puerperal psychosis
Admission to hospital is usually required

Medication – 2nd gen antipsychotics, mood stabilizers, anti-depressants, ECT as well as long acting benzodiazepines.

Therapy – reassurance, self-help groups, CBT, family therapy and referral to local mental health services on discharge.

Question 12

What is the risk of recurrence of puerperal psychosis?

Answer 12

There is around a 20% risk of recurrence following future pregnancies

Question 13

Why is paroxetine recommended but fluoxetine best avoided in the post natal period?

Answer 13

Paroxetine is recommended by SIGN because of the low milk/plasma ratio. Fluoxetine is best avoided due to a long half-life

Question 14

What are the risk factors for postnatal depression?

Answer 14

• History of psychiatric illness or previous postnatal depression
• Unplanned pregnancy
• Lack of support
• Marital problems
• Social circumstances
• Sleep deprivation
• Hormonal changes