Perinatal Flashcards
Risk of major malformation in all pregnancies
2-3%
When is risk of psychiatric episodes greatest in perinatal?
3 months postpartum
Most common psychiatric illnesses in postpartum period?
Mood disorder - 80%
Risk of depression during pregnancy
7-15% (7% outside of pregnancy)
Relapse rate of depression during pregnancy if history of depression
50%
Risk of postpartum depression
10%
Risk factors for postpartum depression
Previous depression
Highest risk with bipolar
Risk of postpartum psychosis
0.1-0.25% in general population
50% in bipolar
50-90% in those with history of postpartum psychosis
Incidence of puerpural psychosis
1 in 1000 births
Risk of relapse of bipolar in first month postpartum
8x increase, most relapses depressive
Most vulnerable period for fetus of teratology from meds
Week 6-10
What happens to medications during 3rd trimester?
Increase often needed as blood volume expands by 30%
Treatment of SCZ in pregnancy
High risks associated with untreated SCZ, thus consensus to use antipsychotic at every stage of pregnancy.
Common antipsychotics used in pregnancy
Olanzapine - most common
Haloperidol
Clozapine
Treatment of depression in pregnancy
Delay until 2nd or 3rd trimester if possible
Explore CBT
If high risk of relapse or mod-severe depression then antidepressant during and after pregnancy
Recommended antidepressants in pregnancy
Nortriptyline
Amitriptyline
Imipramine
Fluoxetine
Treatment for pregnant women if treated on valproate or carbamazepine
Prophylactic folic acid 5mg OD from at least a month before conception
Prophylactic Vit K to mum and neonate after delivery
Risk of SSRI in pregnancy
Neonatal withdrawal
No increase in risk of major malformation except Paroxetine - VSD and ASD
13.3% risk of spontaneous abortion
Decreased gestational age
Low birth weight
In late pregnancy risk of persistent pulmonary hypertension
Risk of Lithium use in pregnancy
1 in 10 chance of malformation in first trimester
3x risk of all types of malformations, 8x risk of cardiac malformations
Ebsteins anomaly - 10-20x higher than general population, absolute risk is 1 in 1000
When is risk of malformation with lithium greatest?
2-6 weeks after conception
Impact of lithium use on neonate
Hypotonia
Lethargy
Poor reflexes
Respiratory difficulties
Risks of use of carbamazepine in pregancny
0.5-1% risk of spina bifida, craniofacial abnormalities, growth retardation, developmental delay
Risk of birth defect on valproate
10% - any malformation
Dose-related
Mostly seen 17-30 days post conception
Increased risk in FHx of neural defects
Impact of valproate use on neonate
Growth retardation 1-2% neural tube defect risk 10x increase risk of spina bifida 4x risk of VSD and pulmonary stenosis Digital and limb defects Low IQ
Risk of lamotrigine during pregnancy
3.2% frequency of malformations
Associated with cleft palate
Impact of antipsychotic use on neonate
Floppy infants
Withdrawl - irritable, hyper and hypotone, underdeveloped reflexes
Risk of congenital malformation with use of antipsychotic during pregnancy
2-2.4% if used in first trimester
Which antipsychotics do not have serious effects on newborn
Clozapine - still birth and neonatal seizures have been reported, and gestational diabetes
Olanzapine - gestational diabetes
Risperidone
Quetiapine
Use of benzos on pregnancy
0.6% risk of oral cleft and CNS and urinary tract malformation if used in first trimester Neonatal toxicity (withdrawal), respiratory depression, hypotonia
Lithium treatment programme in pregnant woman
Serum levels checked every 4 weeks, aim for lower end of therapeutic range
Level 2 USS and echo of fetus at 6 and 18 weeks for ebsteins
Increased dose in 3rd trimester as total body water increases but this reduces abruptly post delivery
Things to take into consideration if mother taking psychotropic meds and breast feeding
In preterm immature infants, do not expose to meds as more sensitive and immature LFTs
Infants older than 10 weeks are at lower risk of adverse effects if no evidence of accumulation
Check infants cardiac, renal and hepatic function first
Monitor infants progress, milestones and adverse effects including drowsiness, reduced tone, rigidity, tremor
Factors to consider when deciding breast feeding while use of psychotropic in mother
Severity and frequency of SMI in mother
Benefits of breast feeding
Impact of untreated mental illness on mother and infant
Family support
Compliance with treatment
Patient and family ability to recognise early warning signs
Physical health and maturity of infant
Recommended antidepressants in breast feeding
Sertraline
Paroxetine
SSRIs usually safe including fluoxetine and citalopram
TCAs - amitriptyline and imipramine
Recommended antipsychotic in breast feeding
Olanzapine
Sulpride
Recommended mood stabiliser in breast feeding
Avoid if possible
Valproate if essential
Recommended sedatives in breast feeding
Lorazepam for anxiety
Zolpidem for sleep
Can clozapine be used in breast feeding?
No, contraindicated due to higher conc of albumin in fetal blood
Can lithium be used in breast feeding?
No, contraindicated
Risk of neural tube defect on valproate
1.5%
