Perinatal Mental Health

Question 1

What is perinatal psychiatry?

Answer 1

• Prevention, detection and management of mental illness co-occurring or newly emerging in pregnancy of the postnatal period.
• The assessment and facilitation of the mother-infant relationship and developmental nees of infants in the contet of maternal mental illness.

Question 2

Increased risk

Answer 2

• Increased rate of psychiatric admission following childbirth (i.e. x22 risk of psychosis in 4 weeks following delivery)
• Women with BPAD at particularly high risk (increased risk for first-episode BPAD 2-28 days after delivery)
• Highest cause of maternal mortality in 2000-2002 - still in top 6
• Almost a quarted of women who die between 6 weeks and 1 years after pregnancy died from mental health related causes

Question 3

Red flag presentations

Answer 3

• Recent significant change in mental state or emergency of new symptoms
• New thoughts or acts of violent self-harm
• New and persistent expressions of incompetency or estrangement from the infant

Question 4

What disorders are we talking about?

Answer 4

• Severe mental illness
  
  • Schiophrenia
  • BPAD
• Anxiety disorders
  
  • Panic disorder
  • GAD
  • OCD
  • PTSD
• Depression
• Eating disorders

Question 5

Tokophobia

Answer 5

• Pathological fear of childbirth
• Primary - dread that pre-dated pregnancy
• Secondary - after traumatic of distressing delivery
• Associated with anxiety, depression, PTSD and bonding disorders

Question 6

Presentation of some disorders

Answer 6

Question 7

Postnatal depression presentation and risk factors

Answer 7

• Smiliar symptoms whether antenatal, post-natal or non-pregnancy
• Increased risk in early postnatal period (first 5 weeks)
• Risk factors for antenatal include:
  
  • Maternal anxiety
  • Life stress
  • Prior depression
  • Lack of social support
  • Domestic violence
  • Unintended pregnancy
  • Relationship factors
• Risk factors for postnatal include:
  
  • Past history of mental health issue during pregnancy
  • Lack of social support
  • Poor partner relationship
  • Recent life events

Question 8

Postpartum psychosis presentation and risk factors

Answer 8

• A wide variety of psychotic phenomena such as delusions and hallucinations, the content of which is often related to the new child
• Affective (mood) symptoms: elation and depression
• Disturbance of consciousness marked by an apparent confusion, bewilderment or perplexity
• The clinical picture often changes rapidly, with wide fluctuations in the intensity of symptoms and severe swings of mood
• Strong evidence from clinical, outcome and genetic studies for a close relationship with bipolar disorder.
• Onset usually in first 2 weeks
• Dramatic presentation - 95% affective with lability of mood, confusion, delusions
• Recovery from the initial episode is excellent - recurrence rate in subsequent pregnancy >50%
• Risk factors include Hx of postpartum psychosis or BPAD, FHx of postpartum psychosis or PBAD and primigravida

Question 9

General recommendations

Answer 9

• Maintain close contact and review during the perinatal period
• Address avoidable factors that may increase risk
• Decrease general levels of stress
• Attention to sleep in late pregnancy and the early postpartum weeks.
• Should not be told that they should not have children

Question 10

Determinants of early brain development

Answer 10

• Shift from exclusively genetic to environmental infulences
• Social interaction determines brain development
• Postnatal depression affectrs this due to distrubed mother-infant interaction

Question 11

Screening tools

Answer 11

• History taking
• EPDS
• Whooley questions (NICE)
• Self-report measures

Question 12

Management of postnatal depression

Answer 12

• Majority require social support and non-directive counselling (primary care)
• Psychological therapies
• Antidepressant therapy
• Referral if severity significantly impairing functioning, ideas of self-harm or harm to baby, unresponsive to medication
• Interventions do not necessarily prevent effects on child

Question 13

Prescribing in pregnancy

Answer 13

* Risk vs benefit

• Start decision making pre-pregnancy
• Pregnancy planning (contraception); Risk of illness; Risk of drug effects
• Avoid first trimester if possible
• Lowest effective dose for shortest time necessary
• Choose drugs with best evidence base
• Avoid polypharmacy
• Make individual assessment of risks and benefits
• Always involve the patient (& partner if appropriate)
• Acknowledge uncertainty
• Antidepresants are most common and have increased risk of cardiac malformations, pulmonery HTN of the newborn and neonatal adaptation syndrome

NB - Fluoxetine first line choice in pregnancy and sertraline drug of choice in breast feeding

Question 14

Risks of relapse

Answer 14

Question 15

Risks associated with timing of medication in pregnancy

Answer 15

Question 16

Management of pueperal psychosis

Answer 16

• Usually require admission
• Supervision of mother and baby and assisting mother with childcare tasks
• Antidepressant + neuroleptic and/or lithium and/or ECT

Question 17

Schizophrenia in perinatal care

Answer 17

• Reduced fertility rates compared to general population
• More likely to have:
  
  • Unplanned/unwanted pregnancies
  • Cigarette and alcohol use in pregnancy
  • Pregnancy complications
  • Delivery complications
  • SIDS
  • Possible increased fetal and neonatal death
• Less likely to:
  
  • Receive contraceptive advice
  • Engage with antenatal care
  • Remain the primary carer of their child

Question 18

Valproate afftects on baby

Answer 18

• Organ dysgenesis
  
  • Increases risk of NTDs
  • Risk greatest in 17-30 days post conception
  • Also causes craniofacial and cardiac anomalies
• IUGR
• Neonatal toxicity
  
  • Hepatotoxicity, dysrhythmias, hypoglycaemia, coagulopathies, withdrawal
• Neurobehavioural toxicity
  
  • Hyperexcitability and neurological dysfunction at 6 years

Question 19

Valproate affects on mother

Answer 19

• Increased risk of PCOS
• Also induces metabolism of OCP so need to increase dose

Question 20

Lithium in pregnancy

Answer 20

• Known teratogen
• Cardiac malformations (Ebstein’s anomaly) - greatest risk in 1st trimester
• Heart is formed early so stopping when pregnancy confirmed is too late
• Ebstein’s anomaly is:
  
  • Downward displacement of the tricuspid valve with TR
  • Right heart enlargement
  • ASD
  • Dysrhythmias (especially AF)
• Also known to cause:
  
  • IUG - increased weight
  • Neonatal toxicity
  • Neurobehavioural toxicity
• Management
  
  • Early detailed USS and ECHO
  • Increased frequency of lithium checks
  • Increased dose as pregnancy progresses due to change in fluid compartments and drug clearance
  • If not on lithium during pregnancy must restart immediately after delivery in high risk and be closely monitored in first 24-48 hours after delivery