Perinatal Psychiatry

Question 1

3 red flag perinatal psychiatry presentations?

Answer 1

• Recent significant change in mental state or emergence of new symptoms
• New thoughts or acts of violent self harm
• New and persistent expression of incompetency as a mother or estrangement from their baby

Question 2

Describe how mental health issues should be screened for during pregnancy?

Answer 2

• At the booking appointment identify if they have a history of mental illness and identify risk factors
• At every appointment ask screening questions:
• During the last month have you ever 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 or want help with?

Question 3

Is pregnancy protective of existing mental health problems? expand?

Answer 3

• Generally, pregnancy is not protective
• Bipolar disorder has a high rate of relapse postnatally especially if it is untreated
• Some eating disorders can improve in pregnancy but poor nutrition can have many negative consequences on the pregnancy
• A lot of depression cases will relapse if meds are stopped in pregnancy

Question 4

Explain what the baby blues is?

Answer 4

• This is normal and occurs in 50% of women
• They become tearful, irritable with anxiety, poor sleep and confusion
• Usually spans from day 3-10 post natal and is self-limiting
• These women need support and reassurance

Question 5

Postpartum psychosis usually presents within ______

Answer 5

2 weeks of delivery

Question 6

Symptoms of postpartum psychosis?

Answer 6

Early symptoms are sleep disturbance and confusion, irrational ideas, progresses to mania, delusions and hallucinations

Question 7

Why is postpartum psychosis dangerous?

Answer 7

5% suicide risk and 4% infanticide risk

Question 8

Risk factors for developing postpartum psychosis?

Answer 8

bipolar disorder, previous episode of postpartum psychosis, 1st degree relative with bipolar

Question 9

25% of women with postpartum psychosis go on to develop?

Answer 9

bipolar disorder

Question 10

Management and prognosis of postpartum psychosis?

Answer 10

• Woman needs urgent admission to inpatient mother and baby unit
• Illness responds rapidly to treatment, antipsychotics, antidepressants and mood stabalisers may be used and sometimes ECT
• Prognosis for full recovery is good

Question 11

How common is postnatal depression vs psychosis?

Answer 11

post natal depression much more common, occurs in 10% of women

Question 12

Onset and duration of postnatal depression?

Answer 12

onset is 2-6 weeks postnatally and lasts weeks to months

Question 13

Risks of postnatal depression recurrence?

Answer 13

25% recurrence rate with next pregnancy and 70% lifetime depression risk

Question 14

Treatment of postnatal depression is similar to ____

Answer 14

other types of depression

Question 15

What needs to be considered in antenatal care of a women with substance abuse issues?

Answer 15

• Consider methadone
• Child protection and social work referral
• Smear history
• Breastfeeding (not if drinking alcohol using cocaine or HIV positive)
• Labour plan re analgesia (may need higher dose due to tolerance) and labour ward delivery
• Early IV access should be gained as it may be difficult if the person regularly injects drugs
• A postnatal contraception plan should be discussed

Question 16

Should you always stop drugs with known teratogenic effect in pregnancy?

Answer 16

not necessarily may not remove risk if the person only just found out pregnant e.g. Stopping a drug with known teratogenic risk after pregnancy has occurred may not remove the risk of malformation if already passed that period of development e.g. valproate will affect neural tube development in weeks 4-6, risk already occurred if don’t find out pregnant until week 8

Question 17

Which SSRI has most evidence base for safety in pregnancy?

Answer 17

fluoxetine

Question 18

Which SSRI has questions over risk of cardiac malformations?

Answer 18

paroxetine

Question 19

Are most SSRIs major teratogens?

Answer 19

no can be reasonably certain they are not

Question 20

Use of antidepressants in pregnancy?

Answer 20

• Women with moderate or severe depression or who have a high risk of relapse of depression in pregnancy should be treated with antidepressants

Question 21

Use of antipsychotics in pregnancy?

Answer 21

• 2nd generation drugs olanzapine and quetiapine have the best evidence base
• Overall antipsychotics appear to be safe
• Women with repeated relapses should stay on their medication
• There is an increased risk of GDM with 2nd generation drugs due to weight gain as a drug side effect

Question 22

Use of mood stabilisers in pregnancy?

Answer 22

• There are no safe mood stabalisers
• Valproate and carbamazepine are the most teratogenic as they cause neural tube defects and should be avoided
• Lamotrigine is less bad than other anti-convulsants and appears safer as the evidence base increases
• Lithium should be avoided if possible, associated with cardiac anomalies particularly Ebstein’s anomaly, could consider reintroduction immediately postpartum

Question 23

Specific abnormality for lithium?

Answer 23

Ebstein’s anomaly

Question 24

Bipolar management in pregnancy?

Answer 24

• High relapse rates in women with bipolar if medication is stopped abruptly
• Aim to switch to safer antipsychotic e.g. quetiapine
• Increased monitoring is needed if lithium is required

Question 25

Anxiety recommendations in pregnancy?

Answer 25

• SSRIs are first line
• Benzodiazepines are not major teratogens but in 3rd trimester they risk floppy baby, generally in anxiety they should be avoided anyway and this applies to pregnancy

Question 26

Benzodiazepines in 3rd trimester risk?

Answer 26

floppy baby

Question 27

What is a psychotropic drug?

Answer 27

a drug that affects someones mental state

Question 28

Are psychotropics excreted in breast milk?

Answer 28

all psychotropics are excreted in breast milk

Question 29

What is an important point to think about when breast-feeding and medication

Answer 29

• There is less exposure during breastfeeding than in utero so if a drug has been used in 3rd trimester it should be safe to continue in breastfeeding

Question 30

What 3 drugs should be avoided in breastfeeding?

Answer 30

clozapine, lithium and valproate

Question 31

What are some differences in presentation of postnatal psychosis vs manic psychosis

Answer 31

in post natal often get a prodromal anxiety and there can be more fluctuations in the psychosis
but it does textbook presents as a sort of manic psychosis