Perinatal Mental Heatlh

Question 1

What is the perinatal period? What sub-periods are there?

Answer 1

• From conception to age 1 years (of the baby; the time before and after birth)
• Antenatal; conception - childbirth
• Postnatal; childbirth - age 1 years

Question 2

What is perinatal mental health important?

Answer 2

• Suicide is main cause of death for women during pregnancy to one year after (perinatal stage)
• 50% pregnancies are unplanned
• 10-20% women have anxiety/depression during perinatal period (and 10% of their partners)
• 1:1000 women develop postpartum psychosis postnatal

Women w/mental health more likely to:

• Smoke/drink
• Not eat as well (diet)
• Not attend appointments

Question 3

Why is perinatal mental health challenging?

Answer 3

• Studies problematic
• Research limited (SPC gives poor information for pregnancy/breast-feeding as a result)
• Data scarce

Question 4

What needs to be considered re. the risks of taking psychotropics in pregnancy?

Answer 4

• Potential benefits
• Potential consequences
• Possible harms
• Treatment changed/stopped

(Risks in taking them, but also risks in stopping them)

Question 5

What are NICE’s key findings re. Antenatal and postnatal mental health (Dec 2014)?

Answer 5

• Uncertainty surrounding risks (inform patient)
• Explain the risks; has risk been confirmed? Just suspected? Theoretical?
• Risk of relapse
• Risk of stopping medicines suddenly; neonatal withdrawal/relapse

Question 6

Not treating mental health problems during pregnancy carries risks. What are they?

Answer 6

1) Pregnancy complications:
E.g. depression:
- Agitation
- Lethargy
- Anxiety

Could lead to:
> Missed scans
> Poor nutrition
> Smoking

2) Maternal complications
3) Relapse

Question 7

How common are miscarriages? How often are congenital abnormalities due to drug?

Answer 7

• 1 in 5 pregnancies are miscarriages

- 2-3% chance of congenital abnormality; of this, drugs are responsible for 1-2% (very little)

Question 8

What are the risks associated with timing of medication in pregnancy?

Answer 8

Consider period of gestation; avoid all drugs in first trimester if possible:
1st Trimester - Avoid
Days 17-60 - Major Teratogenicity (AVOID)
2nd & 3rd Trimester - Low dose, neurological delay

Question 9

What antidepressant, antipsychotic, mood stabilisers and hypnotics are associated w/the lowest risk in pregnancy?

Answer 9

Antidepressant:
- Sertraline

Antipsychotics:
- Chlorpromazine, Trifluoperazine, Haloperidol, Olanzapine

Mood stabilisers:
- Antipsychotics

Hypnotics:
- Promethazine

Question 10

What are the general principles of prescription drug use in pregnancy?

Answer 10

• Lowest effective dose
• Consider stage of pregnancy
• Previous response to drugs?
• Lowest known risk
• AVOID polypharmacy
• AVOID CI drugs
• Dose adjustment as pregnancy progresses
• Avoid new drugs (little data known)

Question 11

What is the advice for antipsychotic use during pregnancy?

Answer 11

• Discuss a planned pregnancy
• Hyperprolactinemia (drug reduces chances of conception)
• Potential for repeated relapses
• Depots (NICE does not recommend during pregnancy)
• Risk
• Antipsychotic discontinuation syndrome

When using:
> Monitor for alterations in foetal growth
> Monitor for blood glucose abnormalities required w/Olanzapine or Clozapine

Question 12

What psychotropic/anticonvulsant is strongly recommended to be avoided during pregnancy?
What are the potential complications?

Answer 12

Valproate (Sodium Valproate)
- 4 in 10 babies at risk of developmental disorders
- 1 in 10 at risk of birth defects e.g. neural tube defects
- Dose related risk of foetal abnormality/adverse neurodevelopment
»> Switch to atypical drugs; cleaner profile in pregnancy
»> Robust contraception advice if female of child-bearing age using
»> High folic acid dose if pregnant woman taking

Question 13

What is the risk of Lithium and pregnancy?

Answer 13

• Used for bipolar disorder etc.
• RIsk of cardiac abnormalities in pregnancy (Ebstein’s Anomaly)
  »> BUT, no clear evidence base to suggest it causes it for definite.

Question 14

What are the prescribing considerations in breastfeeding?

Answer 14

• Avoid taking medicines w premature/low birth weight baby
• Avoid new drugs
• Side effect profile; sedative? Sedation in baby?
• Half-life of drug
• Sedating medication; e.g. Olanzapine advice
• Reference source

Question 15

What are the pharmacokinetic considerations of prescribing in breast-feeding?

Answer 15

Acidic:
- Breast milk is more acidic than plasma; basic compounds retained in milk/accumulate (infant has immature hepato/renal clearance)

Protein binding:
- Higher protein binding, isolated maternal circulation

Relative Infant Dose (RID; mg/kg/day):
- <10% regarded safe

Molecular weight:
- SMW (< 200) can pass into breast milk; choose HMW

Adult Half Life:

• Short in adults
• But long half life drugs can accumulate in breast milk; avoid slow release/depot

Question 16

What are some common drugs that can and can’t go into breast milk?

Answer 16

Benzodiazepines; lipophilic/fat soluble, thus can go into the milk.

Insulin/warfarin; large molecules (>200), doesn’t get into breast milk.

Question 17

Which antidepressants achieve a low (<10%) RID (Relative Infant Dose) in breastfeeding?

Answer 17

• Sertraline
• Paroxetine
• Mirtazapine
• Nortriptyline
• Duloxetine

Question 18

Which antidepressants achieve a high (>10%) RID (Relative Infant Dose) in breastfeeding?

Answer 18

• Citalopram
• Escitalopram
• Fluoxetine
• Venlafaxine
  »> CONTRA-INDICATED

Question 19

What antidepressant, antipsychotic, mood stabilisers and hypnotics are associated w/the lowest risk in breast-feeding?

Answer 19

Antidepressants:
- Sertraline
(CI: Doxepin/Fluoxetine)

Antipsychotics:
- Sulpiride
- Olanzapine
(CI: Clozapine - blood dyscrasia)

Mood stabilisers:
- Olanzapine
- Quetiapine
(CI: Lithium, Lamotrigine)

Hypnotics:
- Promethazine
- Benzodiazepines
(CI: Long-acting benzodiazepines; accumulate)