perinatal and postnatal mental health

Question 1

what is perinatal mental health

Answer 1

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

Question 2

types of disorder that are seen

Answer 2

Anxiety Disorder
Depression (including postnatal depression)
Puerperal psychosis
PTSD
Pre-existing illness

Question 3

impact of perinatal mental health

Answer 3

• emotional wellbeing of the woman and family
• bonding, attachment and care of baby
• relationship with partner, wider family and others

Question 4

patient factors that results in poor detection

Answer 4

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

Question 5

health professional factors that results in poor detection

Answer 5

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

Question 6

What qs are initially asked in perinatal mental health

Answer 6

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

Question 7

RFs for perinatal mental health

Answer 7

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

Question 8

red flags of perinatal mental health

Answer 8

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

Question 9

what are baby blues

Answer 9

Starts within 3 or 4 days, self limiting by around 14 days

Tearfulness, low mood, irritability, feeling anxious, over-reacting

Question 10

Mx for baby blues

Answer 10

No treatment required, aside from reassurance and support

Question 11

what is postnatal depression

Answer 11

• 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

Question 12

Tx for postnatal depression

Answer 12

Non Drug treatment as effective as antidepressants

Question 13

preventative strategies for postnatal depression

Answer 13

modified antenatal classes and postnatal peer support groups

Question 14

Mx of severe postnatal depression

Answer 14

referral to specialist perinatal mental health services essential

TCA, SSRI

Question 15

Sx of puerperal psychosis

Answer 15

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

Question 16

Mx of puerperal psychosis

Answer 16

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

Question 17

what simple lifestyle advice can be give for mild low mood and anxiety

Answer 17

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

Question 18

SEs of valporate

Answer 18

increase risk of neural tube defect by 1-2%, neurodevelopmental issues- contraindicated in women of childbearing age for psychiatric indications

Question 19

SEs carbamzepine

Answer 19

cleft lip 0.1%

Question 20

SEs of lithium

Answer 20

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)

Question 21

SEs of lamotrigine

Answer 21

increases risk of SJS

Question 22

SEs of olanzepine

Answer 22

fetal macrosomia, GDM

Question 23

SEs of SSRIs

Answer 23

pulmonary hypertension, Paroxetine in particular is associated with cardiac defects

Question 24

SEs of antimanic drugs

Answer 24

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.

Question 25

what is neonatal withdrawal

Answer 25

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

Question 26

What may be used to assess depression scale

Answer 26

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

Question 27

what are baby blues

Answer 27

Typically seen 3-7 days following birth and is more common in primips

Mothers are characteristically anxious, tearful and irritable

Question 28

Mx of baby blues

Answer 28

Reassurance and support, the health visitor has a key role

Question 29

what is postnatal depression

Answer 29

Most cases start within a month and typically peaks at 3 months

Features are similar to depression seen in other circumstances

Question 30

Mx of depression

Answer 30

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

Question 31

what is puerperal psychosis

Answer 31

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)

Question 32

Mx of puerperal psychosis

Answer 32

Admission to hospital is usually required

There is around a 25-50% risk of recurrence following future pregnancies

Question 33

why is fluoextine avoided in breastfeeding

Answer 33

as it has a long life

Question 34

risks due to postpartum psychosis

Answer 34

Fillicide and/or suicide

accidental death

risk to other household members

risk from others

in pregnancy - impact upon intrauterine environment

Question 35

maternal OCD

Answer 35

distressing thoughts about baby coming to harm

mother harming baby or touching baby inappropriately

risk of harm to others low

Question 36

PTSD in mum

Answer 36

related to this birth or previous birth, perceived trauma is important

Question 37

red flags of perinatal mental health

Answer 37

recent significant change

new thought of self harm

Question 38

Lithium effect in baby

Answer 38

cardiac malformations in the first trimester - Ebstein’s anomaly

Question 39

breastfeeding contraindicative meds

Answer 39

lithium and clozapine

Question 40

which SSRIs are safely used in pregnancy

Answer 40

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.

Question 41

which drug when taken during pregnancy, has been associated with cleft lip in babies?

Answer 41

benzodiazepines - first trimester