Perinatal Psychiatry

Question 1

What psychiatric medications are of particular concern during pregnancy?

Answer 1

MOOD STABILISERS
lithium: Do NOT offer in women of childbearing potential and considering conception unless antipsychotics have been ineffective bc risk of fetal heart malformations when lithium is taken in the first trimester, but size of risk is uncertain. breastefeeding-
can develop lithium toxicity. consider stopping if they become pregnant and changing to other antipsychotic, or restarting when in 2nd trimester if responded well to lithium before and not planning to breastfeed. Monitor levels frequently;
sodium valproate- Do NOT offer in women of childbearing potential and considering conception. risk of fetal malformations and neural tube defects outcomes after any exposure in pregnancy therefore if woman bc pregnant change medication.
- carbamezapine: Do NOT offer in women of childbearing potential and considering conception and stop if woman is pregnant and taking bc risk of adverse drug interactions and fetal malformations
- lamotrigine: during pregnancy, check lamotrigine levels frequently during pregnancy and into the postnatal period because they vary substantially at these times.

ANTIDEPRESSANTS
TCAs no known teratogenecity

ANTIPSYCHOTICS
- Measure PRL levels in women who are taking PRL‑raising antipsychotic medication and planning a pregnancy, because raised prolactin levels reduce the chances of conception.

Question 2

What is the difference between Postpartum blues and Postnatal Depression?

Answer 2

Blues affect 50-80% women in postpartum period and resolve after days. Characterized by irritability, mild anxiety, tearfulness, emotional lability. Begins 3-10d post delivery. Attributed to hormonal changes and emotional and physical exhaustion. Generally mild and not pervasive. No intervention required.

Depression is similar to any presentation of Depression i.e. anhedonia, anergia, low mood but also with significant anxiety and pervasive feelings of guilt.
May be preceeded by 3rd trimester depression and anxiety. 3-5% of women have moderate- severe depression postpartum, but up to 15% are affected by depression in some degree. Common presentation 2-4w postpartum and then another peak at 3m post partum. With prompt tx 2/3 will resolve in 2-3m but can take 6m or more with no tx.

Risk of postnatal depression is increased by 50% if patient has previously suffered from postnatal depression/ severe depression.

Question 3

What is postpartum psychosis? Epi, PC, risks, prognosis

Answer 3

Epi- 0.2% in general population. 99% of postpartum psychoses are either due to schizoaffective disorder or bipolar affective disorder.
characterised by sudden onset of behavioural disturbances, hallucinations, delusions, fear and perplexity.
Most present within 16d of delivery but wide window of presentation time- many can develop within a couple of days.
50% risk of postpartum psychosis if bipolar affective disorder or previous postpartum psychosis. Obstetric complications, being single, primiparity are also all risks.

Good short term prognosis but associated with sig morbidity and mortality. Usually requires admission to mother-baby unit.

Question 4

Which psych conditions in woman/ their family would warrant referral for psych evaluation?

Answer 4

1. previous/ current psychosis or schizophrenia
2. bipolar affective disorder (includ fhx)
3. postpartum psychosis
4. severe depression
5. woman fhx schizoaffective disorder/ Bipolar + own psych hx
6. All women on mood stabilizers
7. Women who have been previously seen in secondary care i.e. by a psychiatrist