Perinatal Mental Health

Question 1

Severe mental health disorder in women is associated with more:

Answer 1

• Unwanted pregnancies.
• Pregnancies from sexual assault (mental health disorder increases vulnerability).
• Terminations (and psychological consequence on patient).
• Sexual partners.

Question 2

What are the effects of severe maternal mental illness on the foetus and infant?

Answer 2

• Small for dates, preterm and low birth weight babies.
• Increased incidence of child neuroloical abnormalities, developmental delays, attachment difficulties, academic difficulties.
• Failure to thrive.

Question 3

Describe depression in pregnancy.

Answer 3

• ~10-15% of pregnant women suffer from anxiety and / or depression during pregnancy.
• They exhibit the same symptoms and signs as depression at other times, with added specific worries about:
  
  • Changes in their role (becoming a mother, stopping work)
  • Changes in their relationships
  • Whether they’ll be a good parent
  • Fear that there will be problems with the pregnancy or the baby
  • Fear of childbirth
  • Lack of support and being alone

Question 4

What are the treatments for depression in pregnancy?

Answer 4

• If possible, use non-pharmacological interventions (CBT).
• Pharmacological treatments:
  
  • A careful risk-benefit assessment
  • Avoid 1st trimester exposure when possible
  • Use the lower effective dose for the shortest tme
  • Avoid polypharmacy
• Which drugs?
  
  • SSRIs generally fine (sertaline popular), but best to avoid paroxetine.

Question 5

What are the pharmacokinetics of pregnancy?

Answer 5

• Delayed gastric emptying and longer intestinal transit times - Increased absorption.
• Reduced blood flow to legs in late pregnancy - Reduced absorption of IM drugs.
• Increased plasma volume - Dilution effect on psychotropics.
• Increased body fat - Serum lipids may compete for protein-binding sites and alter unbound drug concentrations.
• Increased metabolism - lower serum levels of psychotropics.
• Increased CP450 and CYP3A4, reduced CYP1A2 activity.
• Increased constipation and lower blood pressure can potentiate side effects.

Question 6

Describe the baby blues.

Answer 6

• ~50% incidence
• Minor mood disturbance occuring 3rd-10th day post-partum.
• Tearful, irritable and labbility of affect.
• No specific treatment required, spontaneous resolution in days.

Question 7

Describe postnatal depression.

Answer 7

• Onset within 1 month post partum.
• Tiredness, irritability and anxiety often more prominent than low mood.
• Exhaustion or depression?
  
  • Exhaustion - still positive, recognise temporary and will improve, still enjoy life.
  • Depression - negative, hopeless, worthless, pessimistic about the future, anhedonia which are still present even after rest.
• Risk to baby of neglect and harm.
• Treatment same as other depressive illness bearing in mind breastfeeding.

Question 8

What questionnaires can be used to identify postnatal depression?

Answer 8

• The Whooley Questions
• Edinburgh Postnatal Depression Scale
  
  • 10 item screening test for depression.
  • NOT diagnostic of depression or bipolar disorder.
  • Should ideally be administered by health care professionals trained to recognise those with ‘false negative’ scores due to psychosis or retarded depression (rather than completed online by patient).
  • Also validated for use in fathers.

Question 9

What is Puerperal Psychosis?

Answer 9

• Onset 7-14 days post partum.
• Rarely due to organic cause now (sepsis).
• Usually an affective or Schizophrenic-like psychosis, including delusions, hallucinations and lack of insight.
• Link between bipolar affective disorder and puerperal psychosis.
• Women with bipolar affective disorder have a high risk of recurrence related to childbirth, with approx 70% experiencing an episode in the immediate postpartum period.
• Potential risk to baby (mother may believe baby is evil / abnormal).
• Hospital admission to Mother and Baby Unit highly likely.
• Treat as other psychotic illness.

Question 10

What are the factors which affect drug concentration in breast milk?

Answer 10

• Maternal plasma level
• Drug half-life
• Lipid solubility - breast milk is fatty and concentrates lipophilic drugs including psychotropics.
• Protein binding - free drugs transfer into breast milk.
• Time since delivery - in early post partum there are larger gaps between alveolar cells in the breast, increasing the amount of drug that passes from maternal blood. After 4 days this reduces.
• Fat content of milk - lipophilic drugs will show increased transfer in hind milk rather than fore milk.

Question 11

What are the factors which affect infant plasma drug levels?

Answer 11

• Amount of drug ingested.
• Infant metabolism - neonates have a reduced capacity to metabolise drugs for at least the first 2 weeks, this could increase with a preterm or ill infant.
• Infant excretion - the neonatal kidney is less efficient than an adult and only reaches that level at 2-5 months.
• CNS exposure - the blood brain barrier of a neonate is immature.

Question 12

Describe PTSD in the context of labour and delivery.

Answer 12

• Anxiety disorder cause by very stressful, frightening or distressing events, which may be relived through intrusive, recurrent collections, flashbacks and nightmares.
• ~3% of pregnancies.
• May be related to pregnancy raising issues concerned with past traumas, especially childhood sexual abuse or childbirth.

Question 13

Which other perinatal mental health disorders should you be aware of?

Answer 13

Eating disorders, OCD and phobias can all worsen in pregnancy.