Perinatal Psychiatry

Question 1

What period defines ‘perinatal’?

Answer 1

First day of becoming pregnant up to 12 months after birth

Question 2

What is the most common medical complication of pregnancy?

Answer 2

Depression

Question 3

What is postpartum depression (PPD)?

Answer 3

A significant mood disorder that can develop at any time up to one year after the birth of a baby.

typically presents with persistent depressive symptoms that may interfere with daily functioning and parenting.

Question 4

Some barriers to diagnosing perinatal mental health problems:

Answer 4

• Stigma
• Wanting to be a good mother
• Fear the child might be taken away
• Don’t recognise that they are ill (lack of insight)
• Healthcare problesms e.g. feeling dismissed

Question 5

Give some potential biological factors that may contribute to PPD

Answer 5

1) Hormonal fluctuations post-delivery –> sudden drops in progesterone, estrogen, and thyroid hormones.

2) Alterations in melatonin and cortisol rhythms

3) Immune-inflammatory processes

4) Genetic predispositions

Question 6

Give some potential psychological factors that may contribute to PPD

Answer 6

1) A history of mood or anxiety disorders, previous episodes of postpartum depression, and certain personality traits such as neuroticism are associated with increased risk.

2) Psychological stress from the transition to parenthood

3) Unrealistic expectations of motherhood

Question 7

Give some potential social factors that may contribute to PPD

Answer 7

1) Lack of social support
2) Relationship issues
3) Life stressors
4) Low socioeconomic status

Question 8

Signs & symptoms of PPD?

Answer 8

• Persistent lowering of mood and reduced enjoyment or interest in activities.
• Lowering of energy levels.
• Biological symptoms of depression like poor appetite and disturbed sleep patterns.
• Concerns related to bonding with the baby, caring for the baby
• In extreme circumstances, thoughts about harming oneself or the baby

Question 9

What is it important to distinguish between when discussing sleep patterns in PPD?

Answer 9

It’s important to distinguish between sleep that is disrupted due to the infant’s sleep cycle and sleep disruption stemming from other causes.

Question 10

‘Baby blues’ vs PPD?

Answer 10

The “baby blues” do not last for more than 2 weeks after giving birth.

Question 11

What are ‘baby blues’?

Answer 11

• Common (around 50%)
• Brief, mild emotional disturbance occurs in first few days after childbirth (not mental illness)
• Peaks at 3rd to 5th postnatal day
• Tearful & emotional

Question 12

Differentials of PPD?

Answer 12

1. Baby blues
2. Postpartum psychosis –> A rare but severe mental illness that can occur after childbirth, marked by rapid mood swings, hallucinations, delusional thinking, and extreme agitation.
3. Adjustment disordes –> These disorders may develop in response to a major life change or stressor, such as having a baby, but the emotional or behavioral symptoms are less severe than in depression.
4. GAD

Question 13

What is a widely accepted screening tool for postnatal depression?

Answer 13

Edinburgh Postnatal Depression Scale (EPDS)

This is a widely accepted screening tool that consists of 10 questions and takes around five minutes to complete. It evaluates the intensity of depressive symptoms over the past seven days.

Question 14

Investigations in potential postnatal depression?

Answer 14

1. EPDS
2. detailed psych history
3. complete physical exam and relevant labs (e.g. hypothyroidism, anaemia)

Question 15

Management of PPD?

Answer 15

1st line –> Typically involve self-help strategies and psychological therapies such as CBT or Interpersonal Therapy (IPT).

2nd line –> Pharmacological treatments, such as antidepressants, are considered in cases of high severity or distinct risks.

In severe cases, admission to a mother and baby inpatient mental health unit might also be necessary.

Question 16

What is postpartum psychosis?

Answer 16

A severe mental health disorder that typically occurs within the first two weeks postpartum (rapid onset), characterised by symptoms including paranoia, delusions, hallucinations, mania, depression, and confusion.

Question 17

Prevalence of PPD?

Answer 17

10-20%

Question 18

Which diagnosis makes a woman most likely to experience a postpartum psychosis?

Answer 18

Bipolar 1 disorder (more mania symptoms)

Question 19

Symptoms of postpartum psychosis?

Answer 19

Paranoia
Delusions
Hallucinations
Manic episodes
Depressive episodes
Confusion

These symptoms come on rapidly and progress rapidly.

Question 20

Why is postpartum psychosis a psychiatric emergency?

Answer 20

Significant risks to mother (suicide) and child (infanticide)

Question 21

Management of postpartum psychosis?

Answer 21

• Antipsychotic medications
• Mood stabilisers in some instances

Medication should be prescribed with careful consideration of the mother’s breastfeeding status and potential for the transfer of drugs to the nursing infant.

Potential referral to mother and baby inpatient mental health unit, especially with command hallucinations, thoughts of self-harm or suicide, or delusional beliefs regarding the baby’s role or identity.

Question 22

Red flags in perinatal

Answer 22

Recent significant change in mental 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 the infant

Question 23

What condition can antipsychotics increase the risk of in the mother?

Answer 23

Gestational diabetes

Question 24

Is lithium safe to take in pregnancy?

Answer 24

Lithium presents significant risks during pregnancy due to its teratogenic properties BUT there must be careful consideration between risks/benefits associated with continuing treatment during pregnancy.

Question 25

What are the main risks associated with lithium use during pregnancy?

Answer 25

• Congenital abnormalities, particularly Ebstein’s anomaly
• Increased risk of miscarriage
• Neurodevelopmental impairments in the offspring

Question 26

How is lithium use during pregnancy monitored?

Answer 26

Management strategies focus on risk mitigation, careful monitoring, and collaboration between healthcare providers.

1) Prenatal ultrasounds: These can detect structural anomalies in the foetus.
2) Neonatal physical examinations: These can identify physical abnormalities post-birth.
3) Genetic testing: This can rule out genetic disorders as the cause of any observed anomalies.

Question 27

Management of lithium use during pregnancy:

Answer 27

1) Risk-benefit analysis: This should involve the patient, psychiatrist, and obstetrician.
2) Regular monitoring: This includes prenatal ultrasounds to detect anomalies and regular mental health check-ups for the mother.
3) Consideration of alternative treatments: If the risk of lithium use is deemed too high, other options for managing the mother’s psychiatric condition should be considered.