Perinatal

Question 1

Risk of major malformation in all pregnancies

Answer 1

2-3%

Question 2

When is risk of psychiatric episodes greatest in perinatal?

Answer 2

3 months postpartum

Question 3

Most common psychiatric illnesses in postpartum period?

Answer 3

Mood disorder - 80%

Question 4

Risk of depression during pregnancy

Answer 4

7-15% (7% outside of pregnancy)

Question 5

Relapse rate of depression during pregnancy if history of depression

Answer 5

50%

Question 6

Risk of postpartum depression

Answer 6

10%

Question 7

Risk factors for postpartum depression

Answer 7

Previous depression

Highest risk with bipolar

Question 8

Risk of postpartum psychosis

Answer 8

0.1-0.25% in general population
50% in bipolar
50-90% in those with history of postpartum psychosis

Question 9

Incidence of puerpural psychosis

Answer 9

1 in 1000 births

Question 10

Risk of relapse of bipolar in first month postpartum

Answer 10

8x increase, most relapses depressive

Question 11

Most vulnerable period for fetus of teratology from meds

Answer 11

Week 6-10

Question 12

What happens to medications during 3rd trimester?

Answer 12

Increase often needed as blood volume expands by 30%

Question 13

Treatment of SCZ in pregnancy

Answer 13

High risks associated with untreated SCZ, thus consensus to use antipsychotic at every stage of pregnancy.

Question 14

Common antipsychotics used in pregnancy

Answer 14

Olanzapine - most common
Haloperidol
Clozapine

Question 15

Treatment of depression in pregnancy

Answer 15

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

Question 16

Recommended antidepressants in pregnancy

Answer 16

Nortriptyline
Amitriptyline
Imipramine
Fluoxetine

Question 17

Treatment for pregnant women if treated on valproate or carbamazepine

Answer 17

Prophylactic folic acid 5mg OD from at least a month before conception
Prophylactic Vit K to mum and neonate after delivery

Question 18

Risk of SSRI in pregnancy

Answer 18

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

Question 19

Risk of Lithium use in pregnancy

Answer 19

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

Question 20

When is risk of malformation with lithium greatest?

Answer 20

2-6 weeks after conception

Question 21

Impact of lithium use on neonate

Answer 21

Hypotonia
Lethargy
Poor reflexes
Respiratory difficulties

Question 22

Risks of use of carbamazepine in pregancny

Answer 22

0.5-1% risk of spina bifida, craniofacial abnormalities, growth retardation, developmental delay

Question 23

Risk of birth defect on valproate

Answer 23

10% - any malformation
Dose-related
Mostly seen 17-30 days post conception
Increased risk in FHx of neural defects

Question 24

Impact of valproate use on neonate

Answer 24

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

Question 25

Risk of lamotrigine during pregnancy

Answer 25

3.2% frequency of malformations

Associated with cleft palate

Question 26

Impact of antipsychotic use on neonate

Answer 26

Floppy infants

Withdrawl - irritable, hyper and hypotone, underdeveloped reflexes

Question 27

Risk of congenital malformation with use of antipsychotic during pregnancy

Answer 27

2-2.4% if used in first trimester

Question 28

Which antipsychotics do not have serious effects on newborn

Answer 28

Clozapine - still birth and neonatal seizures have been reported, and gestational diabetes
Olanzapine - gestational diabetes
Risperidone
Quetiapine

Question 29

Use of benzos on pregnancy

Answer 29

0.6% risk of oral cleft and CNS and urinary tract malformation if used in first trimester
Neonatal toxicity (withdrawal), respiratory depression, hypotonia

Question 30

Lithium treatment programme in pregnant woman

Answer 30

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

Question 31

Things to take into consideration if mother taking psychotropic meds and breast feeding

Answer 31

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

Question 32

Factors to consider when deciding breast feeding while use of psychotropic in mother

Answer 32

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

Question 33

Recommended antidepressants in breast feeding

Answer 33

Sertraline
Paroxetine
SSRIs usually safe including fluoxetine and citalopram
TCAs - amitriptyline and imipramine

Question 34

Recommended antipsychotic in breast feeding

Answer 34

Olanzapine

Sulpride

Question 35

Recommended mood stabiliser in breast feeding

Answer 35

Avoid if possible

Valproate if essential

Question 36

Recommended sedatives in breast feeding

Answer 36

Lorazepam for anxiety

Zolpidem for sleep

Question 37

Can clozapine be used in breast feeding?

Answer 37

No, contraindicated due to higher conc of albumin in fetal blood

Question 38

Can lithium be used in breast feeding?

Answer 38

No, contraindicated

Question 39

Risk of neural tube defect on valproate

Answer 39

1.5%