Perinatal mental health

Question 1

Define ‘baby blues’:

Answer 1

• Mood lability
• Tearfulness
• Mild anxiety or depression
• Fatigue
• Insomnia

Onset typically day 3-4 postpartum, when milk comes in.
Resolves spontaneously by day 10-14 postpartum.
Has physiological causes as well as social stressors.

Question 2

Define ‘postnatal depression’

Answer 2

No absolute definition. “…any non-psychotic depressive illness occurring during the first postnatal year” (SIGN).

DSM IV criteria for depression:

• 5 or more symptoms for at least 2 weeks.
• Must have at least one of: depressed mood or anhedonia.
• Accompanied by significant impairment in capacity to engage and function in usual activities.

Symptoms include:

• Depressed mood
• Anhedonia
• Sleep increased/decreased
• Significant change in weight or appetite
• Psychomotor agitation or retardation
• Guilt or worthlessness
• Fatigue, loss of energy
• Reduced concentration
• Recurrent thoughts of death or suicide

Peak diagnosis at 2-4 and 10-14 weeks postpartum; anytime in 1st year.

Question 3

What is the presentation of ‘puerperal psychosis’?

Answer 3

Typical onset 2-4 weeks post-partum

depressed or elated mood
mood lability
disorganized behaviour
delusions
hallucinations

Question 4

What % of mothers are affected by the baby blues?

Answer 4

50-70%

Question 5

What % of mothers are affected by depression antenatally?

Answer 5

10%

Question 6

What % of mothers are affected by anxiety?

Answer 6

16%

Question 7

What % of mothers are affected by depression postnatally?

Answer 7

15%

Question 8

What % of fathers of affected by anxiety or depression?

Answer 8

10-16% (similar to mothers)

Question 9

How common is puerperal psychosis?

Answer 9

1-2 in 1000 women

Question 10

After one episode of puerperal psychosis, what is a woman’s % risk of a recurrent episode in future pregnancies?

Answer 10

>50%

Question 11

What % of women with bipolar affective disorder (BPAD) will also develop puerperal psychosis?

Answer 11

20%

Question 12

What % of women are affected by PTSD after childbirth?

Answer 12

2-3%

Question 13

List the risk factors for maternal mental health (MMH) issues:

Answer 13

• Hx of MMH issues: depression, anxiety, PTSD, BPAD, BPD, schizophrenia.
• Lack of supports
• Isolation: psychical, mental, cultural including migrants.
• Hx of abuse: physical, sexual, emotional
• Stressful life events including hx of negative obstetric or neonatal outcomes.
• Hx of drug or alcohol abuse
• Social stressors.

Question 14

What are the impacts of MMH issues on:

• Mother
• Infant

Answer 14

Maternal effects:
- Poor mother-infant attachment

Infant effects:

• Preterm birth
• Low BW
• Admission to SCBU
• Emotional and behavioural disorders in children

Question 15

How would you screen for perinatal depression?

Answer 15

• Enquire about woman’s emotional wellbeing at every visit.
• Complete postnatal screening 6-12 weeks after birth and repeat at least once in first year.
• Use Edinburgh Postnatal Depression Scale (EPDS) - a 10 question self-scored questionnaire
• A score >10 highlights a woman at high risk for PND
• Repeat EPDS in 2-4 weeks if scores between 10-12.
• Refer for further assessment if EPDS scores 13 or more.
• EPDS has been validated in fathers, with a lower cut off of 5-6

Question 16

How would you screen for perinatal anxiety?

Answer 16

• Use items 3,4,5 in EPDS or use general anxiety disorder 7 item scale.

Question 17

How would you assess a woman for risk of suicide?

Answer 17

• Suicidal thoughts, plan, lethality and means.
• Protective and risk factors
• Strength of supports
• History of past behaviour
• Mental state
• Substance use

Question 18

Outline your general approach to detecting MMH issues:

Answer 18

• Screen for depression
• Screen for anxiety
• Assess risk of suicide
• Assess for psychosocial risk factors: use antenatal risk questionnaire (ANRQ).
• Assess for drug and alcohol abuse and family violence
• Assess mother-infant interactions
• Assess risk of harm to infant.
• Use cultural workers e.g. Maori, PI, migrants

Question 19

Outline risk and protective factors you would look out for when assessing mother-infant interaction:

Answer 19

Psychosocial risk factors:

• History of abuse
• Family violence
• Previous pregnancy loss
• Unwanted/unplanned pregnancy
• Support levels
• Inability to touch baby on day of birth or unable to care for baby in first week of life

Infant factors:

• Achieving milestones
• Achieving normal growth centiles
• ? Difficulties sleeping or feeding

Infant behaviour:

• Gaze avoidance
• Flat affect, emotionally under responsive
• Interacts easily with strangers
• Lack of crying

Maternal factors:

• MMH conditions
• Suicidal ideation
• Negative symptoms
• Medication side effects
• Substance abuse
• Risk taking behaviour

Protective factors:

• Sensitive to baby
• Responds to baby’s cues
• Mother has close relationship with at least one other adult

Question 20

What are the general principles in use of pharmacological treatments for MMH issues?

Answer 20

• Women on psychotropic mediations should be counselled preconceptually to optimise mental health mamagement and review th safety profile of their medications
• Prescribing psychotropic medications should only be carried out by mental health specialists, ideally with experience in perinatal mental health.
• Discussions about medication must include a risk-benefit analysis for both the woman and the fetus/infant
• psychological interventions should be maximised to avoid unnecessary drug exposure.
• Psychotropic medication with the lowest risk profile for the woman, fetus and infant should be chosen
• Take into consideration the woman’s previous response to medication and personal preference
• The lowest effective dose should be used
• Polypharmacy should be avoided
• Some medications require dose adjustments owing to the physiological changes (such as increased plasma volume and increased renal excretion). This includes, for example, lithium

Stopping medication

When a woman with severe mental illness decides to stop psychotropic medication in pregnancy and the postnatal period, discuss with her the reasons for stopping and consider:

• restarting the medication
• switching to another medication
• psychological interventions
• increasing the level of monitoring and support
• ensuring she is aware of the risks of stopping medication to both herself and the fetus/infant.

Question 21

What psychosocial support and psychological approaches are recommended for all women with depression or anxiety?

Answer 21

• Psychoeducation
• Support groups
• Mild-moderate depression: CBT and IPT
• Mother-infant difficulties: relationship interventions

Question 22

What pharmacotherapy is recommended for moderate-severe depression and anxiety?

What are the risks associated with these?
What are these medications not associated with?

Answer 22

1st line: SSRI - best safety evidence for sertraline

Risks:
- 1st trimester use up to 20 weeks: increased risk of miscarriage. Note: not with fluoxetine, sertraline.

• neonatal adaptation syndrome
• Small increased risk of neonatal convulsions, persistent pulmonary HTN, RDS.
• Avoid paroxetine in pregnancy - risk of major congenital anomalies concluding cardiac anomalies

Not associated with:

• SGA
• Congenital malformations
• Neonatal mortality

Question 23

What is the role of benzodiazepines in the treatment of moderate-severe anxiety in pregnancy?

Answer 23

• Should only be used short-term while awaiting onset of action of SSRI or TCA.
• Avoid long-acting benzos near birth.
• Do not use for insomnia.

Fetal/Neonatal Risks:

• Cleft lip and palate
• Preterm birth
• Low birth weight
• Neonatal respiratory distress
• Neonatal toxicity (reduced tone, drowsiness, apnoeas and RDS) and withdrawal

Question 24

What should you use as a hypnotic/for insomnia in pregnancy?

Answer 24

Doxylamine (antihistamine).
Category A.

Question 25

What are the indications for electroconvulsive therapy (ECT) for MMH issues?

Answer 25

• Severe PND resistant to medication.
• Puerperal psychosis resistent to medication.
• If used during pregnancy, need MFM input and CTG monitoring.

Question 26

Outline your management of a woman with puerperal psychosis:

Answer 26

• Assess risk to mother and baby and where required use mental health act to section women at risk
• Ensure safety - arrange 1 to 1 care if deemed high risk for mother or baby
• Urgent senior psychiatric specialist assessment as psychiatric emergency
• Pharmacotherapy should be started immediately on diagnosis of puerperal psychosis
• Mood stabilising agent - lithium, carbamazepine, sodium valproate
• Antipsychotic agents - olanzepine, risperidone, quetiapine
• Address sleep deprivation; start hypnotic nocte (zopiclone, doxylamine). Safe for BFing.
• Admit to facility for ongoing close observation; ideally mother and baby unit
• Continue to promote mother and baby interaction where safe and appropriate, including breast feeding
• Stop breast feeding if on lithium (secreted in high levels in breast milk and can cause neonatal lithium toxicity)

When recovering:

• Psychoeducation
• Future pregnancy planning

Question 27

Describe your pharmacotherapy plan for a woman with puerperal psychosis:

Answer 27

• Use sedating antipsychotic e.g. quetiapine.
• Mood stabilising agent: lithium, sodium valproate or carbamazepine
• Aim: reduce agitation, distress and insomnia while allowing antipsychotic to take affect within 1-3 weeks.
• Reduce and stop after 6 months if improved and first episode.
• Will need long-term medication if has BPAD or schizophrenia.

Question 28

Describe what you would discuss in your psychoeducation for a woman with puerperal psychosis:

Answer 28

Reassure overall good prognosis (response within 2-3 weeks) and emphasis need for psychiatric monitoring and medication.

Educate on early signs of relapse:

• Insomnia independent of baby’s waking
• Racing thoughts
• Erratic mood shift
• Severe anxiety
• Distractibility
• Unfounded preoccupation with baby or family’s welfare

Advise high risk of relapse in subsequent pregnancy > 50%, and should have MMH input during and after next pregnancy

Question 29

Describe what you would discuss regarding future pregnancy planning for a woman with puerperal psychosis:

Answer 29

• Defer subsequent pregnancy until symptom free for at least 1 year.
• Inform risk of recurrent episode >50%; needs early management of insomnia and close monitoring postnally.
• Clear mental health plan in future pregnancies.

Question 30

Describe your approach to managing a woman with severe mental illness (schizophrenia , BPAD, BPD) in pregnancy:

Answer 30

• Need MDT input, clear communication between team, written plan and continuity of care across settings.
• Assessment and care should include baby.
• Preconceptual counselling and planned parenthoot: inform of risk of relapse especially if stopping medication; do so gradually under psychiatric supervision.

Antenatal care:

• Monitor for relapse
• Education on nutrition, stop smoking and illicit drugs and alcohol
• Monitor weight gain, screen for GDM.
• Consider Oranga Tamariki input early.

Postnatal care:

• Monitor carefully in first month for relapse.
• Consider admission to mother-baby unit.
• Parenting skills input.

Psychological input:
- Psychotherapy. CBT for secondary anxiety/depression, PTSD.

Antipsychotics:

• Use for psychotic symptoms in pregnancy.
• Not associated with congenital and cardiac malformations, adverse pregnancy or neonatal outcomes.
• Olanzapine generally safest: weight gain, GDM
• Flupenthixol, quetiapine: associated with increased risk of miscarriage; stop at least 3 months prior to conceiving.
• Do not use clozapine in pregnancy; if using while breastfeeding, weekly infant WCC for 6 months for agranulocytosis.

Mood stabilising agents:
Anticonvulsants:
- Significant teratogenicity/folate antagonists. Increased risk of major and cardiac malformations; risk of adverse cognitive effects/low IQ in offspring.
- Wean gradually over 2-4 weeks prior to trying to conceive.
- Start high dose folic acid daily until 2nd trimester.
- Lithium - Avoid in pregnancy and breast feeding - increased risk of cardiac defects

Question 31

What special considerations are there for lithium use in pregnancy?

Answer 31

Preconceptually:

• Generally avoid in pregnancy and those wishing to conceive due to increased risk of cardiac defects called ‘Ebsteins phenomenon’ (1% background risk; risk in lithium-use 2-2.5%)
• Gradually ween dose over 4 weeks prior to trying to conceive in well women
• Only consider lithium in women who are not responsive to antipsychotic medication
• Dosing/weaning should be managed by psychiatrist.
• Ensure women who stop lithium during/prior to pregnancy know that they have high risk of symptoms relapse during pregnancy, and particularly postpartum

Antenatally:

• Lithium has a narrow therapeutic window, and high risk of toxicity
• Serum levels may increase in nausea and vomtiing of early pregnancy, dehydration, illness
• Serum levels will fall with haemodilution in advancing pregnancy
• Monitor maternal drug levels 4 weekly, then weekly from 36 weeks

Intrapartum:

• Stop lithium at onset of labour (due to increased placental transfer in labour and risks for low APGARS and prolonged NICU admission
• Check levels 12 hourly in labour, ensure good maternal hydration and monitor for signs of lithium toxicity

Postpartum:

• Recommence pre-pregnancy dose immediately after birth.
• Breastfeeding not recommended with lithium use due to transmission in breast milk and risk of neonatal lithium toxicity
• Monitor for signs of puerperal psychosis or disease relapse - highest risk is postpartum in the presence of sleep deprivation

Question 32

Regarding cognitive behavioural therapy (CBT):

What is its indication?
What are the benefits?
What are the risks/disadvantages?

Answer 32

Indication:

• First line mild-moderate depression
• Adjunct for moderate-severe depression

Benefits:
- Effective for mild depression

Risks/disadvantages:
- Limited access

Question 33

Regarding interpersonal therapy (IPT):

What is its indication?
What are the benefits?
What are the risks/disadvantages?

Answer 33

Indication:

• First line mild-moderate depression
• Adjunct for moderate-severe depression

Benefits:
- Effective for mild depression

Risks/disadvantages:
- Limited access

Question 34

Regarding SSRIs:

What is its indication?
What are the risks/disadvantages?

Answer 34

Indication:

• First line for moderate-severe depression, or depression not responding to psychological interventions
• Anxiety
• Bullemia nervosa

Risks/disadvantages:

• Small increased risk of congenital malformations
• Paroxetine significant risk of cardiac malformations
• Increased risk of miscarriage in first 20 weeks (except sertraline, fluoxetine).
• Neonatal risks:
• significant risk of poor neonatal adaptation syndrome.
• Small increased risk of persistent pulmonary hypertension of the newborn

Question 35

Regarding benzodiazpines:

What is its indication?
What are the benefits?
What are the risks/disadvantages?

Answer 35

Indication:

• awaiting onset of action of SSRI/TCA for moderate-severe depression and anxiety
• Acute episodes of severe anxiety/agitation/panic attacks

Benefits:
- Not associated with congenital or cardiac malformations

Risks/disadvantages:

• Increased risk of respiratory suppression if used around time of birth.
• Poor neonatal adjustment syndrome.
• Neonatal abstinence syndrome if prolonged use

Question 36

What is ‘poor neonatal adaptation syndrome’?

What is its management?

Answer 36

Newborns who have been exposed to SSRIs / SNRIs in utero can get this, which generally presents as a combination of

• tachypnoea
• feeding difficulty
• jitteriness, tremors, shivering
• irritability
• temperature instability
• sleep problems
• hypoglycaemia
• rarely convulsions

Current evidence suggests that PNAS may not be a result of drug withdrawal (old theory) but rather, it may result from overstimulation of the serotonergic system during development when fetuses are exposed to high levels of serotonin in maternal blood. (Presentation similar to serotonin syndrome in adults)

This is usually mild and self-limiting. There is little evidence about how long to observe the neonate for after birth, but it is thought that the majority of symptoms will occur within 72 hours of delivery.

Question 37

For babies whose mums took SSRIs/SNRIs during pregnancy, what respiratory complication should be monitored for?

Answer 37

Persistent pulmonary hypertension

Failure of the normal relaxation in the fetal pulmonary vascular bed during the circulatory transition that occurs shortly after birth

Question 38

Which anti-depressant is particularly associated with fetal cardiac defects?

Answer 38

Paroxetine

Babies should have full clinical exam after birth and pulse-oximetry

Question 39

What are the physiological causes and risk factors for the baby blues?

Answer 39

• Significant fall in oestrogen and progesterone postpartum are thought to exacerbate insomnia and precipitate the blues
• Women with higher oestrogen, progesterone and prolactin levels seem to be most at risk (? because of greater fall?)
• Low serotonin levels
• Cortisol levels unaffected

Question 40

What are the signs of lithium toxicity?
When is this complication most likely to occur?

Answer 40

blurred vision, GI disturbances (increasing anorexia, nausea, vomiting and diarrhoea), muscle weakness, coarse tremor, lack of co-ordination, ataxia, dysarthria, drowsiness, sluggishness, confusion and convulsions.

Occurs:

• If overdosed
• In labour
• Acute illness
• Dehydration

Question 41

What antidepressants have the best evidence for safety in breast feeding?

Answer 41

Best evidence for safety in breastfeeding for sertraline and paroxetine - no evidence short term harm and minimal detection in neonatal serum

Question 42

What are the risks and benefits of tricyclic antidepressants?

Answer 42

• No evidence of congenital anomalies
• No evidence of increased miscarriage

BUT

• Concerns regrading drug safety in overdose
• small amounts passed in breast milk

Question 43

What are the risks of antipsychotic medications taken in pregnancy for the mother and baby?

Answer 43

Maternal

• Common side effects: sedation, weight gain and metabolic syndrome, including gestational diabetes and hyperprolactinaemia.
• Prolactin levels should be measured in women who are taking prolactin‑raising antipsychotic medication and planning a pregnancy, because raised prolactin levels reduce the chances of conception.
• Extrapyramidal side effects associated with antipsychotics include akathisia, dystonism, Parkinsonism and tremor.
• When assessing the risks and benefits of antipsychotic medication for a pregnant woman, risk factors for gestational diabetes and excessive weight gain should be taken into account.
• Olanzapine and clozapine have been associated with as much as 7% weight gain above baseline with elevated triglycerides and new onset of diabetes or insulin tolerance. Patients on these medications will require a glucose tolerance test at 28 weeks of gestation because there is an increased risk of gestational diabetes.
• Optimisation of modifiable risk factors is important in this group of women.

Fetal

• There are limited consistent data regarding the teratogenic effect of antipsychotic medication.
• Antipsychotic exposure may be associated with an increased risk of congenital malformations.
• Some studies have shown an increased rate of small for gestational age and increased rates of gestational diabetes, preterm delivery and caesarean section.
• Neonatal adaptation syndrome is commonly observed.