perinatal and postnatal mental health Flashcards
what is perinatal mental health
refers to a woman’s health during pregnancy and the first year after giving birth
pre-existing mental illness or illness that develops for the first time during the perinatal period
types of disorder that are seen
Anxiety Disorder Depression (including postnatal depression) Puerperal psychosis PTSD Pre-existing illness
impact of perinatal mental health
- emotional wellbeing of the woman and family
- bonding, attachment and care of baby
- relationship with partner, wider family and others
patient factors that results in poor detection
Stigma Putting on a brave face Fear of being considered a ‘bad’ mother Fear the baby might be taken away Not knowing what is normal Not knowing if treatment will help
health professional factors that results in poor detection
Not asking Time constraints Not recognising risk factors or red flags Normalising or dismissing symptoms Lack of training or confidence Lack of access to specialist services
What qs are initially asked in perinatal mental health
brief screen for depression (whooley and arrol)
1) feeling down, depressed or helpless
2) little interest or little pleasure in doing things
3) you feel like you need help with anything
ask about anxiety with 2 item generalised anxiety scale (GAD-2)
1) Have you been feeling nervous, anxious or on the edge
2) have u not been able to stop control worrying
EDP 14-15
RFs for perinatal mental health
Prior diagnosis of mental health illness esp if severe is a strong predictor factor
Family history (first degree relative) of severe perinatal health illness
History of childhood abuse and neglect Domestic violence. Interpersonal conflict Inadequate social support Substance misuse Migration status (refugees - language cultural barrier), language and cultural barriers
Unplanned or unwanted pregnancy
Pregnancy complications or traumatic birth
Fetal or neonatal loss
red flags of perinatal mental health
Bipolar Disorder
1: 5 suffer puerperal psychosis
1: 2 experience severe postnatal depression
Severe Depression
1:2 risk of postnatal relapse
Disclosure
Women who think they have a mental health problem and come forward, often do- take seriously
Recent change in mental health
Recent change in mental health & emergence of new symptoms
New and persistent expressions of incompetence as a parent or estrangement from infant
New thoughts or acts of violent self harm
what are baby blues
Starts within 3 or 4 days, self limiting by around 14 days
Tearfulness, low mood, irritability, feeling anxious, over-reacting
Mx for baby blues
No treatment required, aside from reassurance and support
what is postnatal depression
- Starts within one or two month of giving birth
- Usual depression symptoms - anhidonia, insomnia, low mood
- Depending on severity, may struggle to care for baby
- Difficulty bonding with baby
- Feeling inadequate as a mother
- Thoughts about harm coming to baby
Tx for postnatal depression
Non Drug treatment as effective as antidepressants
preventative strategies for postnatal depression
modified antenatal classes and postnatal peer support groups
Mx of severe postnatal depression
referral to specialist perinatal mental health services essential
TCA, SSRI
Sx of puerperal psychosis
feeling ‘high’, ‘manic’ or ‘on top of the world’. low mood and tearfulness anxiety or irritability rapid changes in mood severe confusion being restless and agitated racing thoughts behaviour that is out of character being more talkative, active and sociable than usual
being very withdrawn and not talking to people
finding it hard to sleep, or not wanting to sleep
losing your inhibitions, doing things you usually would not do
feeling paranoid, suspicious, fearful
feeling as if you’re in a dream world
delusions: odd thoughts or beliefs that are unlikely to be true. You may think your baby is possessed by the devil, or that people are out to get you
hallucinations: you see, hear, feel or smell things that aren’t really there
Mx of puerperal psychosis
Management within specialist multidisciplinary team on a mother baby unit
antipsychotics, mood stabilisers, antidepressants
ECT is used with severe depressive psychoses
CBT in recovery phase
Risk of recurrence is 50% higher if next pregnancy within 2 years of recovery
what simple lifestyle advice can be give for mild low mood and anxiety
sleep hygiene
- waking and going to bed at the same time every day
- avoid coffee after 5pm
- avpid screens after 8pm
- hot drinks, reading in soft light, meditation before sleep
manage hyperemesis
- small regular meals
- good hydration
- ginger-based tea/biscuits
- regular antiemetics, reassure safe in pregnancy
importance of regular gentle exercise
- engage in a class for social interaction
- a structured group physical activity programme
encouraginf self-reflection on a particular anxiety issue
signposting to services
- mindfulness meditation
- specialised support groups
- pregnant women yoga
- mother and baby yoga/ swimming classes
SEs of valporate
increase risk of neural tube defect by 1-2%, neurodevelopmental issues- contraindicated in women of childbearing age for psychiatric indications
SEs carbamzepine
cleft lip 0.1%
SEs of lithium
must be used with extreme caution, and the mother must be able to comply with strict monitoring conditions. Can cause fetal hypotonia, poor reflexes, arrythmia, Ebstein’s anomaly, neonatal goitre (thyroid)
SEs of lamotrigine
increases risk of SJS
SEs of olanzepine
fetal macrosomia, GDM
SEs of SSRIs
pulmonary hypertension, Paroxetine in particular is associated with cardiac defects
SEs of antimanic drugs
infants should be monitored for sedation, poor feeding, behavioural effects and developmental milestones. There is limited data on the neurodevelopment effects of long-term exposure to these agents during breastfeeding.
what is neonatal withdrawal
symptoms (poor adaptation, jitteriness, irritability, poor gaze control, poor feeding, rarely seizures) have been reported in infants exposed to SSRIs in later pregnancy ESP PAROXETINE
thru placental circulation
self-limiting and generally occur within 24 – 48 hours (longer for fluoxetine) and typically last 1 -2 days
What may be used to assess depression scale
edinburgh postnatal depression scale
- 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
what are baby blues
Typically seen 3-7 days following birth and is more common in primips
Mothers are characteristically anxious, tearful and irritable
Mx of baby blues
Reassurance and support, the health visitor has a key role
what is postnatal depression
Most cases start within a month and typically peaks at 3 months
Features are similar to depression seen in other circumstances
Mx of depression
As with the baby blues reassurance and support are important
Cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine* may be used if symptoms are severe** - whilst they are secreted in breast milk it is not thought to be harmful to the infant
what is puerperal psychosis
Onset usually within the first 2-3 weeks following birth
Features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations)
Mx of puerperal psychosis
Admission to hospital is usually required
There is around a 25-50% risk of recurrence following future pregnancies
why is fluoextine avoided in breastfeeding
as it has a long life
risks due to postpartum psychosis
Fillicide and/or suicide
accidental death
risk to other household members
risk from others
in pregnancy - impact upon intrauterine environment
maternal OCD
distressing thoughts about baby coming to harm
mother harming baby or touching baby inappropriately
risk of harm to others low
PTSD in mum
related to this birth or previous birth, perceived trauma is important
red flags of perinatal mental health
recent significant change
new thought of self harm
Lithium effect in baby
cardiac malformations in the first trimester - Ebstein’s anomaly
breastfeeding contraindicative meds
lithium and clozapine
which SSRIs are safely used in pregnancy
SSRIs fluoxetine, sertraline, citalopram and escitalopram, as overall risks to the baby are small, and may be due to confounders in studies. SSRIs may cause withdrawal syndromes in neonates and increase the risk of persistent pulmonary hypertension.
which drug when taken during pregnancy, has been associated with cleft lip in babies?
benzodiazepines - first trimester
