Perinatal psychiatry Flashcards
Who is the pre-conceptual appointment mainly aimed at?
For women at high perinatal risk e.g. previous postnatal psychosis, severe Bipolar Affective Disorder, complex medication regimen
What are the purposes of a pre-conceptual appointment?
Outline risks to allow a more informed decision as to whether to try to get pregnant or not
Allow a plan e.g. to reduce / change medication PRIOR to pregnancy
- E.g. risk of postnatal psychosis in a future pregnancy if it occurred in earlier one = 50%
- E.g. reduce and stop Lithium in a planned way prior to pregnancy
What trimester of pregnancy is there the highest risk of teratogenicity?
1st trimester
Harm may already have been done prior to presentation e.g. neural tube closes at day 28; cardiac anatomy is formed by 7-8 weeks
Why is it important to assess the mothers mental health?
Maternal mental health problems (e.g. depression, anxiety) have adverse effects on the developing foetus so need to balance this against teratogenicity risk
For the booking appointment on the mothers mental health, what is important to check for?
History of mental health problems, previous treatment, Family History
Identify risk factors: Young, single, domestic issues, lack support, substance abuse, unplanned/unwanted pregnancy, pre existing mental health problem
During mental health screening appointment, what questions on depression are commonly used?
During the last month have you 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 you need or want help with?
What are 3 issues to consider in the treatment of perinatal disorders?
- Risks of untreated illness
- To mother and to infant - General principles of prescribing in perinatal period
- Benefits and harms of specific treatments
What risks present to the child in untreated maternal depression?
Low birth weight
- Associated with severity of depression
Pre-term delivery
- Associated with severity of depression
Adverse childhood outcomes
- e.g. emotional & conduct problems, ADHD
Poor engagement / bonding with child
- Reduced infant learning & cognitive development
What group of antidepressants are first line for maternal depression?
SSRI’s
What SSRI has the least placental exposure?
Sertraline - reduced placental drug transfer to foetus
What SSRI is thought to be the safest?
Fluoxetine - thought to be the “safest” as it has been used longest there is lots of data for it
What SSRI is thought to be less safe than the other SSRI’s?
Paroxetine - potential increased risk of congenital cardiac malformations
Risks of taking SSRI’s in pregnancy?
Persistent hypertension of the newborn
Lower birth weight
Increased early birth (by a matter of days)
Post partum haemorrhage
What other antidepressants can be used in pregnancy?
Tricyclics antidepressants (i.e. imipramine and amitriptyline)
- do not appear to cause major problems
- may be some mild & self-limiting neonatal withdrawal
Venlafaxine (SNRI)
- less evidence
- cardiac defects and cleft palate, neonatal withdrawal
Mirtazapine (tetracylic antidepressants)
- limited evidence
Antidepressant recommendations during pregnancy?
Woman with high risk of relapse should be maintained on medication during and after pregnancy
Moderate to severe depression should be treated with antidepressants
Several antidepressants have lots of evidence related to safety profiles
Make use of priority access to psychological therapies during perinatal period
1st generation (typical) antipsychotic examples?
Haloperidol, chlorpromazine
2nd generation (atypical) antipsychotic examples?
Olanzapine, quetiapine
What a risk of antipsychotic use in pregnancy (especially with 2nd gen)?
Risk of gestational diabetes
Antipsychotics are medications that prove high risk of teratogenicity. true/false?
False
Appear to be safe and not evidence of major teratogenicity
How can antipsychotics reduce fertility?
Raised prolactin levels
With antipsychotic use, hyperprolactinemia can lead to reduced oestrogen levels in women and gonadal dysfunction.
Can lead to amenorrhea, menstrual irregularities, and infertility.
In bipolar affective disorder, is there a risk of relapse after delivery of baby?
High risk of relapse after delivery if mood stabilising medications are discontinued, particularly in the 1st month postpartum
What risks can bipolar affective disorder have on pregnancy?
- Induction of labour or C-section
- Pre-term delivery
- Small babies
- No increase in malformations
Discussions regarding mood stabilisers are preferably made during pre-conception. True/false?
True
What main 2 mood stabiliser medications are avoided in pregnancy and why?
Sodium Valproate and Carbamazepine (most teratogenic) increase neural tube defects
What mood stabiliser medication is preferred due to it being better and safer?
Lamotrigine
What antipsychotics are also safe for use as mood stabilisers in pregnancy?
Quetiapine / Olanzapine are safe options, Aripiprazole has less robust evidence of safety
Lithium has a known association to Ebstein’s anomaly. True/false?
True
What is Ebstein’s anomaly?
A rare heart problem that’s present at birth.
Valve that separates the top and bottom right heart chambers does not form correctly. Valve is called the tricuspid valve. As a result, the valve does not close as it should.
Can lithium be re-introduced during pregnancy?
Yes can slowly be introduced in the 2nd and 3rd trimesters of pregnancy.
Dose changes should be noted in 3rd trimester
Reintroduction of lithium should be considered immediately post-partum (after birth). true/false?
True
Lithium can be used by mother during breastfeeding. True/false?
False
NOT to be used if mother is breast-feeding – Lithium is excreted into breast milk (like Sodium)
First line for anxiety in pregnancy?
SSRI’s
Benzodiazepines are thought to be majorly teratogenic during pregnancy. True/false?
False
Not major teratogens
3rd trimester risk of “floppy baby”
Generally thought to be problematic and to be avoided
What is tokophobia?
A pathologically extreme fear of childbirth / pregnancy
What is tokophobia usually associated with?
Often related to previous trauma but can be associated with other mental health problem – e.g. depression, OCD
What is primary and secondary tokophobia?
Primary tokophobia in someone who has never given birth
- e.g. associated with childhood trauma / sexual abuse
Secondary – following on a previous traumatic birth / stillbirth etc
Management of tokophobia?
Psychological intervention & may include an elective Caesarean section
Can be associated with wanting a termination
How can ASD (autism spectrum disorder) and ADHD add additional challenges during antenatal and postnatal period?
ADHD – fears about being responsible for a baby – increased stress, increased forgetfulness and distraction, increased irritability
ASD – childbirth can be itself traumatic (multiple people coming into the room, lots of physical contact and intimate examination) and having a baby can disrupt routine, require more physical contact with baby and add to demands from wider family
Features of postnatal baby blues?
- Occurs in 50% women
- Brief period of emotional instability
- Tearful, irritable, anxiety, poor sleep and confusion
- Occurs usually from day 3-10 and is self-limiting
- Management is support and reassurance
What are red flag presentations during or after pregnancy?
Urgent referral to a specialist perinatal mental health team for women who report:
- 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 their baby
When should admission to a mother and baby unit be considered?
- rapidly changing mental state
- suicidal ideation (particularly of a violent nature)
- significant estrangement from the infant
- pervasive guilt or hopelessness
beliefs of inadequacy as a mother
evidence of psychosis
For antipsychotic use, what drugs are the best options?
Olanzapine and Quetiapine are best due to increased evidence but others appear to be adequate as well
What antipsychotic (atypical) should be avoided in pregnancy?
Clozapine (risk of agranulocytosis in infant)
Why is lithium to be avoided unless necessary?
secreted into breast milk
During pregnancy, is 2 units of alcohol per week ok?
Yes
No evidence to suggest that 2 units of alcohol is detrimental however abstinence is strongly preferred.
What are the risks of alcohol consumption in pregnancy?
Risks of miscarriage
Foetal Alcohol Syndrome - facial deformities, lower IQ, neurodevelopmental delay, epilepsy, hearing, heart and kidney defects
Withdrawal
Risk of Wernicke’s encephalopathy- 20% die (B1 deficiency)
Korsakoff Syndrome – permanent
Most common cause of death in pregnancy due to cocaine, amphetamine and ecstasy?
Death via stroke and arrhythmias
Risks of cocaine, amphetamine and ecstasy in pregnancy?
Teratogenic (microcephaly, cardiac, genitourinary, limb defects)
Pre-eclampsia
Abruption
IUGR (intra-uterine growth restriction)
Pre-term labour
Miscarriage
Developmental delay, SIDS, withdrawal
What % of maternal deaths occur due to opiates and what are the risks of opiate intake in pregnancy?
Opiates cause maternal deaths (1-2%), neonatal withdrawal, IUGR, SIDS, stillbirth
What risks can occur due to nicotine intake in pregnancy?
Nicotine causes miscarriages, abruption, IUGR, stillbirths and SIDS (sudden infant death syndrome)
Antenatal care options for substance abuse during pregnancy?
Consider methadone programme
Child protection and social work referral
Smear History
Breastfeeding (not if alcohol >8 , HIV, cocaine)
Labour plan re analgesia and labour
ward delivery
Early IV access
Postnatal contraception plan
