Perinatal Psychiatry Flashcards
Risk of spontaneous major malformation in pregenancy?
2-3%
How many malformations in pregnancy are due to drugs?
5 out of every 100 malformations
Relationship between pregnancy and MH problems?
Increased risk fo suicide & MH problems
Risk of psychiatric episode postpartum?
Significant increase in first three months; 80% are mood disorder
Risk of depression during pregnancy
7-15%
Risk of depression in women outside perinatal period?
7%
Relapse rate of depression in patients with a history who are pregnant?
50%
Risk of postpartum depression?
10%
Risk factors for postpartum depression
Highest in bipolar
Previous depression
Risk of postpartum psychosis
0.1-0.25%
Risk of postpartum psychosis in bipolar
50%
Risk of postpartum psychosis in patients with a hx of postpartum psychosis
50-90%
Incidence of puerperal psychosis
One per 1000 births
What is puerperal psychosis strongly linked to?
Bipolar
What perinatal episodes are triggers for bipolar?
Childbirth
Abortion
Menstruation
Recurrence rate of puerperal psychosis?
One in four pregnancies
Prevalence of disorders of mother-infant relationship?
10-25%
Relative risk of postpartum psychosis in the first month?
20-fold increase
Risk of relapse of bipolar in first month postpartum?
Eight-fold increase
Characteristics of bipolar relapses postpartum?
Depressive
Risk of untreated psychiatric illness in the pregnant women
Suicide
Alcohol & substance misuse
Poor compliance with perinatal appointments
Unhealthy lifestyle
Poor judgement
Impulsive acts
Impaired selfcafe
Risk of untreated psychiatric illness for the fetus
Low birth weight & small head circumference (due to anxiety and depression)
Preterm birth (depression)
Risk to child postpartum if depression continues in mother?
Attachment, cognitive and behavioural difficulties
Impact of substance misuse in pregnancy to the fetus?
Increased intrauterine death
Congenital, cardiovascular and musculosketal abnormalities
Fetal alcohol syndrome
When do major malformations occur in pregnancy?
First trimester
When do neonatal toxicities occur in pregnancy?
3rd trimester
When do teratogenic effects occur?
Dose and time dependent
Organs at greatest risk during period of fastest development
Week 6-10 is most vulnerable period
Recommendations of drug treatment during preganncy
Monotherapy
Lowest dose
Regular psych & obstetric r/v
Regular medication r/v
If possible avoid all drugs in first trimester
Drug treatment recommendations as pregnancy advances
Adjust doses; blood volume expands by 30% in 3rd trimester.
Observe for neonatal withdrawal sx after birth
Treatment of schizophrenia in pregnancy
Use antipsychotics at every stage of pregnancy.
Most used antipsychotic in pregnancy?
Olanzapine
Which antipsychotics are commonly used in pregnancy?
Chlorpromazine
Trifluoperazine
Haloperidol
Olanzapine
Clozapine
Treatment of depression in pregnancy
Explore possibility of delaying treatment until 2nd-3rd trimester e.g. CBT
When should pregnant patients be treated with antidepressants if depressed?
High risk of relapse
Moderate-severe depression and psychological treatment has failed
Which antidepressant must be avoided in pregnancy
Paroxetine
Recommended antidepressants in pregnancy?
Nortriptyline
Amitriptyline
Impramine
Fluoxetine
Which patients with bipolar should continue medication?
Severe illness and high risk of relapse
Recommendations re maintenance treatment for bipolar who are pregnant?
Dose reduction and regular review of side effects
When should discontinuation of mood stabilisers be considered in the pregnant woman with bipolar?
Only if absolutely necessary and followed by frequent monitoring
Which mood stabilisers should be avoided in pregnancy?
Valproate
Combination of mood stabilisers
What should be done if a pregnant women is on Valproate or Carbamazepine?
Folic Acid 5mg OD from at least a month before conception should be px
Vitamin K should be given to mum and neonate after delivery
Impact of TCAs on pregnancy
No significant malformations
High doses in third trimester can lead to reversible withdrawal sx
Withdrawal sx in neonate with high dose TCAs?
Irritability
Eating and sleeping difficulties
Convulsions
Best TCAs to use during pregnancy
Nortriptyline
Desipramine
(less hypotensive and anticholinergic side effects)
Risk of SSRIs in pregnancy
13.3% increase in spontaneous abortion
Risk of decreased gestational age and low birth weight
Which drugs increase risk of spontaneous abortion
SSRIs
Mirtazapine
Bupropion
Risk of Paroxetine in pregnancy
1st trimester: VSD and ASD
3rd trimester: neonatal complications due to abrupt withdrawal
Which antidepressant has least placental exposure?
Sertraline
Risks of SSRI if introduced late in pregnancy
Increased risk of persistent pulmonary hypertension of newborn
Which antidepressants have high risk of neonatal withdrawal symptoms
Paroxetine
Venlafaxine
(short half-life)
Advice if pregnant woman is on MAOI
Limited evidence so should switch to safer antidepressant.
Why should MAOIs be avoided in pregnancy?
Risk of hypertensive crisis and congenital malformations
Risk of malformation if Lithium used in first trimester?
1 in 10
What is Lithium associated with if used in first trimester?
All types of malformation risk increased three-fold
Cardiac malformations risk increased 8-fold
Relative risk of Ebsteins anomaly if on Lithium
10-20 times higher
When is risk of malformation greatest when on Lithium?
2-6 weeks after conception
Fetal toxicity sx if on Lithium
Hypotonia
Poor reflexes
Respiratory difficulties
Cardiac arrhythmias