perinatal psych Flashcards
red flag presentations requiring referral to a specialist perinatal mental health team
recent significant change in mental health state or emergence of new symptoms
new thoughts or acts of violent self harm
new and persistent expressions of incompetency as a mother or estrangement from their baby
when to admit to a mother and baby unit
rapidly changing mental state
suicidal ideation (particularly of a violent nature)
significant estrangement from the infant
pervasive guilt or hopelessness
beliefs of inadequacy as a mother
evidence of psychosis
good questions to ask when assessing mental health state relating to post natal period
do you have new feelings and thoughts which you have never had before, which make you disturbed or anxious?
are you experiencing thoughts of suicide or harming yourself in violent ways?
are you feeling incompetent, as though you can’t cope, or estranged from your baby?
do you feel you are getting worse?
risk factors for mental health issues
young/single domestic issues lack of support substance abuse unplanned/unwnated pregnancy pre-existing mental health problem
screening questions to be used in every appointment
during the last month have you been bothered by feeling down, depressed or hopeless?
during the last month have you been bothered by having little interest or pleasure in doing things?
is this something you feel you need or want help with?
when to refer to psychiatry
psychosis
severe anxiety, depression, suicidal, self-neglect, self harm
symptoms with significant interference with daily functioning
history of bipolar or schizophrenia
history of puerperal psychosis
psychotropic medication
if developed moderate illness in late pregnancy or early post partum
mild-moderate illness but with 1st degree relative with bipolar or puerperal psychosis
previous inpatient admissions to mental health unit
effects of pregnancy on bipolar
high rate of relapse postnatally
effects of pregnancy on eating disorders
may be some improvement
risks of IUGR, prematurity, hypokalaemia, hyponatraemia, metabolic alkalosis, miscarriage, premature delivery
effects of pregnancy on antenatal depression
often relapse if stop meds in pregnancy
management of antenatal depression during pregnancy
mild - self help strategies
mild-moderate - GP managed
severe - referral to psych
differential diagnosis of puerperal psychosis
episode of bipolar
unipolar depression
schizophrenia
organic brain dysfunction
when does puerperal psychosis present
within 2 weeks of delivery
early symptoms of puerperal psychosis
sleep disturbance
confusion
irrational ideas
late symptoms of puerperal psychosis
mania
delusions
hallucinations
confusion
risk factors for puerperal psychosis
bipolar disorder
previous puerperal psychosis
1st degree relative with history
management of puerperal psychosis
admission to specialised mother-baby unit
antidepressants, antipsychotics, mood stabilisers, ECT
typical symptoms of postnatal depression
tearfullness irritable anxiety lack of enjoyment and poor sleep weight loss can present as concerns re baby
usual onset of post natal depression
2-6 weeks
lasts weeks to months
how to differentiate baby blues from postnatal depression
baby blues - week 1
depression weeks 2-6
management of postnatal depression
mild-moderate - self help, counselling
moderate-severe - psychotherapy and antidepressants, admission?
risks to child of untreated depression
low birth weight
preterm delivery
adverse childhood outcomes
poor engagement/bonding with child
risks of medication during 1st trimester
teratogenicity
risks of medication in 3rd trimester
neonatal withdrawal
risks of medication in breast feeding
medication passing into breast milk
exposure is less in breast milk than in utero, so if a drug was fine antenatally it should be fine postnatally
antidepressants in 1st trimester
generally no increase in major malformation or spontaneous abortion
antidepressants in 3rd trimester
risk of neonatal withdrawal (mild)
increase risk of neonatal persistent pulmonary HTN with SSRIs taken after 20 weeks
increased risk of low birth weight/prematurity
antidepressants and breast-feeding
all are in breast milk to some extent but no reports of adverse effects on neonatal development
paroxetine in the first trimester
increased risk of fetal heart defects
lowest risk SSRIs in 3rd trimester
sertraline or fluoxetine
lowest risk TCAs in 3rd trimester
imipramine/amitriptyline
lower risk than SSRIs
better anti-depressants for breastfeeding
sertraline
paroxetine
imipramine
BZDs in 1st trimester
avoid due to possible increased risk of fetal malformation eg cleft palate
BZDs in 3rd trimester
avoid due to increased risk of floppy baby syndrome
hypothermia, hypotonia, respiratory depression, withdrawal effects
BZDs in breastfeeding
avoid regular use - risks of lethargy and weight loss and accumulation of long acting drugs
which antipsychotics should be avoided in pregnancy and why
clozapine due to risk of agranulocytosis
risks of olanzapine in pregnancy
increased risk of gestational diabetes and weight gain
lithium in 1st trimester
increased risk of abnormality
avoid sudden discontinuation
lithium in 3rd trimester
monitor lithium levels closely due to changes in volume of distribution
lithium toxicity can mimic PET
lithium in breastfeeding
high quantities in breast milk
AVOID
sodium valproate in 1st trimester
increased risk of neural tube defects, craniofaical defects and effects on child’s intellectual development
less risk with doses <1000 mg
increased risk of autism
sodium valproate in breastfeeding
low risk with no evidence of adverse effects in breast feeding
carbamazepine in pregnancy
increased risk of neural tube defects
facial dysmorphism, fingernail hypoplasia
lamotrigine in pregnancy
increased risk of oral cleft
risk of Stevens-Johnson syndrome in infancy if breast feeding
effects of substance abuse in pregnancy
IUGR
stillbirth
SID
pre-term labour
effects of alcohol on pregnancy
risks of miscarriage
foetal alcohol syndrome (facial deformities, lower IG, neurodevelopment delay, epilepsy, hearing, heart and kidney defects)
withdrawal
risks of wernicke-korsakoff
risks of cocaine, amphetamine and ecstasy in pregnancy
death via stroke and arrhythmias teratogenic (microcephaly, cardiac, GU, limb defects) pre-eclampsia abruption IUGR preterm labour miscarriage developmental delay SID withdrawal
effects of opiates in pregnancy
maternal deaths neonatal withdrawal IUGR SIDs stillbirth
effects nicotine in pregnancy
miscarriages abruption IUGR stillbirths SIDs
