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B1 Obstetrics > Perinatal mental health > Flashcards

Perinatal mental health Flashcards

1
Q

Define ‘baby blues’:

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

Peaks day 3-6 postpartum.
Resolves completely by day 10-14 postpartum.

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2
Q

Define ‘postnatal depression’

A

DSM IV criteria:

  • 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

Onset: usually 1-3 months postpartum; anytime in 1st year.
Usually resolves within 3-6 months but can extend up to 1 year.

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3
Q

Define ‘puerperal psychosis’

A
  • Anxiety
  • Poor sleep
  • Irrational or frightening beliefs/delusions (persecution, grandiose, guilt)
  • Preoccupied, suspicious, difficult to engage, restless, distractible, disorganised
  • Tangenital thoughts
  • May express suicidal thoughts or threaten to harm baby
  • Lack of insight
  • Fluctuating symptoms and insight
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4
Q

What % of mothers are affected by the baby blues?

A

80%

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5
Q

What % of mothers are affected by depression antenatally?

A

10%

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6
Q

What % of mothers are affected by anxiety?

A

16%

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7
Q

What % of mothers are affected by depression postnatally?

A

16%

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8
Q

What % of fathers of affected by anxiety or depression?

A

10-16% (similar to mothers)

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9
Q

How common is puerperal psychosis?

A

1 in 1000 women

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10
Q

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

A

> 50%

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11
Q

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

A

30%

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12
Q

What % of women are affected by PTSD after childbirth?

A

2-3%

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13
Q

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

A
  • 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.
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14
Q

What are the impacts of MMH issues on:

  • Mother
  • Infant
A

Maternal effects:
- Poor mother-infant attachment

Infant effects:

  • Preterm birth
  • Low BW
  • Admission to SCBU
  • Emotional and behavioural disorders in children
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15
Q

How would you screen for perinatal depression?

A
  • Use Edinburgh Postnatal Depression Scale (EPDS)
  • Enquire about woman’s emotional wellbeing at ever visit.
  • Complete postnatal screening 6-12 weeks after birth and repeat at least once in first year.
  • 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
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16
Q

How would you screen for perinatal anxiety?

A
  • Use items 3,4,5 in EPDS or use general anxiety disorder 7 item scale.
17
Q

How would you assess a woman for risk of suicide?

A
  • Suicidal thoughts, plan, lethality and means.
  • Protective and risk factors
  • Strength of supports
  • History of past behaviour
  • Mental state
  • Substance use
18
Q

Outline your general approach to detecting MMH issues:

A
  • 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
19
Q

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

A

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
20
Q

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

A
  • Discuss potential benefits and risks with woman and ideally her significant other.
  • Benefits: take into account severity of illness
  • Risks: mother, fetus, infant, breastfeeding.
  • Consider response to previous medications.
  • Possibility of sudden onset or relapse particularly in first few weeks after birth.
  • Need for prompt instigation of tx or monitoring of tx response due to effects on fetus/baby and woman’s ability to transition optimally to parenting role.
  • Side-effects: weight gain and increased risk of GDM from antipsychotics.
  • Ensure she is aware of risk of relapse with stopping medication; if stops needs to do it gradually under supervision of mental health professional.
  • Breastfeeding options; support non-breastfeeding too.

Special considerations with psychoactive medication use in pregnancy:

  • Tertiary anatomy scan
  • Monitor infants for first 3 days postpartum.
  • Plan review in early postpartum period for women who cease psychotrophic meds during pregnancy
21
Q

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

A
  • Psychoeducation
  • Support groups
  • Mild-moderate depression: CBT and IPT
  • Mother-infant difficulties: relationship interventions
22
Q

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

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

A

1st line: SSRI
Avoid paroxetine in pregnancy.

Risks:
- 1st trimester use up to 20 weeks: increased risk of miscarriage.
Note: not with fluoxetine, sertraline.
- Small increased risk of neonatal convulsions, persistent pulmonary HTN, RDS.

Not associated with:

  • SGA
  • Congenital malformations
  • Neonatal mortality
23
Q

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

A
  • 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.
24
Q

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

A

Doxylamine (antihistamine).

Category A.

25
Q

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

A
  • Severe PND resistant to medication.

If used during pregnancy, need MFM input and CTG monitoring.

26
Q

Outline your management of a woman with puerperal psychosis:

A
  • Immediate management plan
  • Pharmacotherapy
  • Psychoeducation
  • Future pregnancy planning
27
Q

Describe your immediate management plan for a woman with puerperal psychosis:

A
  • Urgent assessment/care: try to destigmatise mental health issues.
  • Ensure safety
  • Address sleep deprivation; start urgent hypnotic (zopiclone, doxylamine). Safe for BFing.
  • Discuss possible admission to mother-baby unit.
  • Seek advice and handover care to psychiatry team.
28
Q

Describe your pharmacotherapy plan for a woman with puerperal psychosis:

A
  • Use sedating antipsychotic e.g. quetiapine.
  • 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.
29
Q

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

A

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
30
Q

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

A
  • 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.
31
Q

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

A
  • 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.
  • 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.
  • Olanzapine: weight gain, GDM

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.
32
Q

What special considerations are there for lithium use in pregnancy?

A
  • Seek advice/supervision from psychiatrist.
  • Dose requirements increase with pregnancy; monitor maternal drug levels
  • Prior to onset of labour: reduce dose
  • Recommence pre-pregnancy dose immediately after birth.
  • Breastfeeding not recommended with lithium use.
33
Q

Regarding cognitive behavioural therapy (CBT):

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

A

Indication:

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

Benefits:
- Effective for mild depression

Risks/disadvantages:
- Limited access

34
Q

Regarding interpersonal therapy (IPT):

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

A

Indication:

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

Benefits:
- Effective for mild depression

Risks/disadvantages:
- Limited access

35
Q

Regarding SSRIs:

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

A

Indication:
- First line for moderate-severe depression

Benefits:

  • Effective for moderate-severe depression
  • No increased risk of congenital malformations (except paroxetine).
  • Citalopram: no long term development issues when used during breastfeeding.

Risks/disadvantages:

  • Increased risk of miscarriage in first 20 weeks (except sertraline, fluoxetine).
  • Increased risk of PPH.
  • Associated with poor neonatal adjustment syndrome.
  • Recommended delivery setting: hospital.
  • Breastfeeding: sleepiness and weight loss in infant.
36
Q

Regarding benzodiazpines:

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

A

Indication: awaiting onset of action of SSRI/TCA for moderate-severe depression and anxiety

Benefits:
- Not associated with congenital or cardiac malfromations

Risks/disadvantages:

  • Increased risk of respiratory suppression if used around time of birth.
  • Poor neonatal adjustment syndrome.
37
Q

What is neonatal adaptation syndrome?

AKA neonatal abstinence syndrome

A

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

  • RDS
  • feeding difficulty
  • jitteriness, tremors, shivering
  • irritability
  • temperature instability
  • sleep problems
  • convulsions
  • jaundice
  • hypoglycaemia

Current evidence suggests that NAS may not be a result of drug withdrawal (old theory) but rather, it may result from overstimulation of the serotonergic system during development when fete uses are exposed to high levels of serotonin in matenral blood.

38
Q

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

A

Persistent pulmonary hypertension

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

39
Q

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

A

Paroxetine

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

B1 Obstetrics (21 decks)

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