Perinatal Psychiatry

Question 1

How common is:

• postpartum blues
• Mild-moderate postpartum depression
• Severe postpartum depression
• PTSD
• Postpartum psychosis

Answer 1

Question 2

What is the first line in PTSD following traumatic labour, stillbirth …?

Answer 2

CBT is first line and some women need an antidepressant

Question 3

Who is OCD more common in?

Answer 3

In women with a history of OCD or anankastic personality traits

Question 4

What do the obsessions focus on in postpartum OCD?

Answer 4

Obsessions usually focus on a mother’s greatest fear of somehow harming her baby, e.g.:

• Thoughts— ‘What if I’ve contaminated my baby?’/‘I’m a paedophile!’
• Images/ urges— of hurling the baby downstairs.

Question 5

What are the consequences of the obesessions?

Answer 5

Obsessions cause terrible anxiety, shame, and guilt, although the woman doesn’t intend to act them out.

She may develop compulsions to decrease anxiety (e.g. cleaning, checking the baby for injury)

Since nobody actually acts on OCD- related thoughts, the greatest risk is from the mother avoiding childcare

Question 6

What is the management of postpartum OCD?

Answer 6

Women with OCD need reassurance and support from relatives and/ or CBT therapists to face

their fears, e.g. to hold and wash their baby.

An antidepressant may help, e.g. sertraline.

Question 7

Describe the presentation of postpartum blues.

Answer 7

Postpartum blues are normal, starting a few days after the birth, and lasting around a week

New mothers may feel weepy, irritable, and muddled; their mood seems ‘all over the place’ (labile) and they may have trouble sleeping.

Question 8

How should we manage postpartum blues?

Answer 8

Explanation and reassurance are usually all that’s needed, although severe blues occasionally progress to postpartum depression

Question 9

Define postpartum depression.

Answer 9

Depression in the year after birth

Question 10

What are the risk factors of PPD?

Answer 10

• FHx or personal hx of PPD, depression or BPAD
• Younger age
• Stressful life events
• Marital discord
• Poor social support

Question 11

How does PPD present?

Answer 11

Symptoms are like any depressive episode.

Although fatigue, irritability, or anxiety may be particularly marked.

Women may feel inadequate, or guilty that they’re not doing or feeling ‘enough’ for the baby.

Obsessional thoughts can arise, as seen in OCD.

Question 12

What is the management of PPD?

Answer 12

Same as depression but take care with drugs used in breastfeeding mothers

o Antidepressants can be secreted in breastmilk
o Recommended SSRIs are sertraline and paroxetine
o Low-dose amitriptyline is probably safe

o Lithium should be avoided if possible

o Sodium Valproate definitely avoided

o Seek specialist advice

Hospital admission should be considered if depression is severe with suicidal or infanticidal ideation or not eating, unable to care for the baby

o Mother and Baby Unit (MBU) is the optimal setting under these circumstances (provide support with childcare, MDT treatment, and risk management.

o Separation should be avoided if possible

Most women respond well to treatment within a month

Use of CBT/IPT has been proven to reduce postpartum depression

Early and effective treatment of PPD is important because it can affect the baby’s attachment and have lasting effects on development and personality

Question 13

How should you counsel the patient on PPD?

Answer 13

Question 14

Define postpartum psychosis.

Answer 14

May be a variant of bipolar affective disorder (BPAD) in which childbirth is the trigger, perhaps due to hormonal changes.

Question 15

What are the risk factors of PPP?

Answer 15

Highest risk have personal or FHx of puerperal psychosis or BPAD (8x more likely to relapse)

Other risks include puerperal infection and obstetric complications (including Caesarean section) + first delivery

Aetiologically, psychosocial factors seem relatively unimportant.

Question 16

Describe the presentation of PPP.

Answer 16

Onset is rapid (usually within 2 weeks of delivery), often beginning with insomnia, restlessness and perplexity.

Later, clear psychotic symptoms emerge in 1 of 3 patterns:

o Delirium

o Affective (psychotic depression or mania or mixed pattern)

o Schizophreniform (like schizophrenia)

Sx can fluctuate dramatically and quickly; brief symptom-free periods can be falsely reassuring.

Organic causes and substance misuse need to be excluded.

Question 17

Describe the management of PPP.

Answer 17

Depending on the presentation, antipsychotics, antidepressants, or lithium may be needed

Benzodiazepines may help for agitation

In severe cases, ECT may be lifesaving (women tend to respond well)

Admission is usually required, preferably to a mother and baby unit

Most patients recover within 6-12 weeks, but psychosis recurs in 50% of women having another baby, and in over 50% of women at another time (unrelated to childbirth)

1st year after pregnancy

o Risk to the baby can be through neglect or violence
o Watch out for depressive delusions (e.g. the baby is evil, possessed or abnormal)

Question 18

How should we manage BPAD in pregnancy?

Answer 18

Do not offer lithium or sodium valproate to women who are planning a pregnancy or pregnant, unless antipsychotic medication has not been effective

If a woman taking lithium becomes pregnant, consider stopping the drug gradually over 4 weeks

o Consider switching to an antipsychotic

o Antipsychotics are safe in pregnancy and breastfeeding (except clozapine)

• Risks

o Risk of foetal heart malformations (Ebstein’s anomaly) but the magnitude of the risk of uncertain

o Lithium may be highly expressed in breastmilk

Monitoring (more frequent)

o Every 4 weeks

o Weekly from the 36th week

Ensure that the woman gives birth in a hospital

Important: antipsychotic use can make it difficult to get pregnant because of hyperprolactinaemia