Perinatal Psychiatry

Question 1

What is the puerperium

Answer 1

0 to 6 weeks after birth (associated with an increased risk of mental health disorders)

Question 2

What care do perinatal psychiatry services provide for women who require mental health input

Answer 2

• Prepregnancy planning for women with a history of mental health illness (especially regarding medication)
• Care planning and monitoring of pregnant women at risk of relapse into mental illnesses
• Maternity ward assessment of women with acute mental illness
• Arranging admission to MBU
• Community follow-up after birth, can be up to one year after birth.

Question 3

How do anxiety disorders present perinatally, how are they managed

Answer 3

• The postpartum period can trigger or exacerbate anxiety disorders e.g PTSD in response to traumatic labour or stillbirth.
• CBT is first line treatment and some women will require an antidepressant (PTSD is increased in women who hold their babies after stillbirths.)
• OCD exacerbations are especially common in women with a history of OCD or anankastic traitsà obsessions usually revolve around fear of harming the baby.
• These women will also benefit from exposure and response prevention CBT or sertraline.

Question 4

What are baby blues, how do they present and how can they be managed

Answer 4

• Postpartum blues are normal, starting a few days after the birth, and lasting around a week.
• Affects around 50-75% of mothers.
• Symptoms include: feeling weepy, irritable and in a muddle, emotionally labile, trouble sleeping.
• Explanation and reassurance is usually all that is required. Occasionally baby blues can progress to postpartum depression.

Question 5

When can postpartum depression be diagnosed, how can it present differently to depression in the community

Answer 5

Postpartum depression is depression in the year after birth. Women may avoid seeking help, or minimize symptoms feeling that they shouldn’t be depressed, or fearing negative consequences.

Question 6

What are some risk factors for PPD

Answer 6

• 1 in 10 mothers experience postnatal depression
• RFs include: FHx or personal hx of PND, younger age, recent life events, marital discord and poor social support.

Question 7

How can PPD be managed, when should women be referred to hospital

Answer 7

• Management is the same as for depression, although antidepressants are used cautiously in breastfeeding: Recommended SSRIs are sertraline and paroxetine.
• Hospital admission should be considered if depression is severe with suicidal or infanticidal ideation
  
  • Mother and Baby Unit (MBU) is the optimal setting under these circumstances
  • Separation should be avoided if possible
• Use of CBT and IPT is effective in postnatal depression
• Most women respond to treatment within a month, and rapid treatment is recommended so as not to effect attachment between mother and baby.

Question 8

Peurperal psychosis presentation and risk factors

Answer 8

• Onset is rapid (within 14 days), beginning with insomnia, restlessness and perplexity. Later, psychotic symptoms occur according to one of the following patterns, though symptoms can fluctuate dramatically and quickly with falsely reassuring symptom-free periods:
  
  • Affective (psychotic depression/ mania or mixed)
  • Schizophreniform
  • Delirium
• Follows 1 in 500-1000 births, usually occurring in the fortnight after childbirth
• Highest risk have personal or FHx of puerperal psychosis or BPAD, however, other risks include puerperal infection and obstetric complications.

Question 9

How should peurperal psychosis be managed

Answer 9

• Treatment involves antipsychotics, antidepressants or lithium– may also give benzos to control agitation
• In severe cases ECT can be lifesaving
• Inpatient admission to the MBU is preferred
• Recovery usually occurs within 6-12 weeks, however psychosis recurs in 50% of women after another baby

Question 10

How does the management of BPAD change in pregnancy

Answer 10

• 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
  
  • Consider switching to an antipsychotic such as olanzipine
  • Antipsychotics are safe in pregnancy and breastfeeding (except clozapine)
• Risks include risk of foetal heart malformations (Ebstein’s anomaly) but the magnitude of the risk of uncertain since Lithium may be highly expressed in breast milk
• Monitoring (more frequent) à Every 4 weeks à 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