Perinatal psychiatry |

Question 1

What are 5 recommendations to prevent post-natal psychiatric deaths?

Answer 1

1. All women should be screened at antenatal booking for a previous history of or current psychiatric disorder.
2. Women with a previous history of serious affective disorder or other psychoses should be referred in pregnancy for psychiatric assessment and management even if they are well.
3. Psychiatric services should have priority care pathways for pregnant and postpartum women. These will include a lowered threshold for referral and intervention, including admission and a rapid response time for women in late pregnancy and the first 6 weeks following delivery.
4. Risk assessments of pregnant or postpartum women should be modified to take account of risk associated with previous history, the distinctive clinical picture of perinatal disorders and the violent methods of suicide.
5. Caution needs to be exercised when diagnosing psychiatric disorder if the only symptoms are either unexplained physical symptoms or distress and agitation. This is particularly so when the woman has no prior psychiatric history or when she does not speak English or comes from an ethnic minority.

Question 2

In the puerperium, which women are referred to specialist psychiatric services (3)?

Answer 2

1. All women with previous or current:
   - schizophrenia or psychosis
   - bipolar disorder
   - postpartum psychosis
   - severe depression
2. All woman on mood stabilisers.
3. Any women with a family history of bipolar affective disorder or schizoaffective disorder AND a personal history of any psychiatric disorder

Question 3

What are the 2 stages of screening a woman for psychiatric illnesses in the puerperium?

Answer 3

Stage 1: Does the woman you are booking have a history of mental illness or a FH of serious mental illness?

• > No -> Monitor MSE
• > Yes -> Stage 2

Stage 2: Is there a history or FH of:
1. Schizophrenia/psychosis
2. Bipolar disorder
3. Puerperal psychosis
4. Severe depression
or Rx mood stabilisers
-> No -> Monitor MSE
-> Yes -> PSYCH REFERRAL

Question 4

Who do the perinatal psychiatric services care for?

Answer 4

Women with psychiatric disorders complicating pregnancy, childbirth and the postpartum period. Also includes women with pre-existing psychiatric illness

Question 5

Are psychiatric disorders common in pregnancy?

Which trimester are the disorders increased in, compared to gen pop?

Answer 5

Common

1st trimester

Question 6

What is usually the management of milder psychiatric disorders during pregnancy?

Answer 6

Usually respond to psychosocial interventions and likely to improve

Question 7

Is the first onset of serious mental illness common in pregnancy?

Answer 7

No

Question 8

What do you need to consider if depression and anxiety occur in the 3rd trimester/.

Answer 8

May continue in the postpartum as postnatal depression

Question 9

What fraction of deliveries are complicated by psychiatric morbidity?

Answer 9

1/3

Don't learn:
15-30%	"Depression"
10% 	   Depressive episode
3-5%	Moderate/severe depressive episode
2%	Referred psychiatry
0.2%    Psychosis

Question 10

What are the ‘pinks’ in the post partum period?

How does it present?

What is the course?

Answer 10

Normal phenomena occurring 48 hours postpartum

Characterised by:

1. Excitement
2. Sense of euphoria
3. May be mildly over-talkative and overactive
4. Insomnia

Usually resolves without intervention

Question 11

What are the ‘blues’ postpartum? How common is it?

How does it present?

What is the course?

Answer 11

Common occurrence in the postpartum period, 50-80%.
Most frequently present about day 5 but can be between day 3-10. Due to hormonal changes plus physical and emotional exhaustion

1. Emotional lability
2. Tearfulness
3. Mild anxiety
4. Irritability

Symptoms usually mild and not pervasive. Generally last 48 hours and no specific treatment required

Question 12

What is the peak onset of depressive illness in the postpartum period?
Primary peak
Secondary peak

Answer 12

1. 2-4 weeks post partum

2. Secondary peak at 3 months postpartum

Question 13

What is the prognosis of depressive illness in postpartum period?

Answer 13

1. With prompt and appropriate treatment two-thirds of illnesses will resolve within 2 to 3 months.
2. Without treatment, it can take 6 months or longer to recover.

Question 14

If a woman has suffered from a previous severe depressive illness or postnatal depressive illness, what is the risk of developing further illness following the current delivery?

Answer 14

50%

Question 15

In the general population, what is the risk of postpartum psychosis aka puerperal psychosis?

What is the risk in a patient with bipolar affective disorder/previous postpartum psychosis?

Answer 15

2%

50%

Question 16

What are the symptoms of postpartum psychosis (5)?

Answer 16

1. Sudden onset of behavioural disturbances
2. Hallucinations
3. Delusions
4. Fear
5. Perplexity

Often present early and sudden onset

99% of postpartum psychoses are either bipolar or schizoaffective disorder

Question 17

When do symptoms of postpartum psychosis usually start?

Answer 17

50% present by day 7
75% present by day 16
95% present by day 90

Question 18

What is the prognosis of postpartum psychosis?

Where do they need to be treated?

Answer 18

Good short-term progress, but associated with significant morbidity and mortality -> associated with bipolar in the future

Postpartum psychosis generally requires admission to a Mother and Baby Unit for high intensity physical and psychological care. Early identification is important

Question 19

At what gestation should a birth plan be given to the mother to prepare for the possible severe and abrupt onset of serious mental illness in the peripartum period?

What should the plan include?

Answer 19

35 weeks

1. Monitoring her mental health immediately following delivery
2. A requirement for liaison between all health professionals
3. Use of prophylactic medication, where appropriate
4. Consideration of child protection
5. Emergency contact details

Question 20

What is the treatment of a woman who during pregnancy or in post-partum period, presents with:

1. mild to moderate depression, in pregnancy or the postnatal period
2. For a woman with a history of severe depression who initially presents with mild depression in pregnancy or the postnatal period
3. For a woman with moderate or severe depression in pregnancy or the postnatal period

Answer 20

1. Facilitated self-help based on CBT
2. consider a TCA, SSRI or (S)NRI
3. High intensity psychological intervention e.g. CBT
   A TCA, SSRI or (S)NRI if the woman understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and:
   -she has expressed a preference for medication or
   -she declines psychological interventions or
   -her symptoms have not responded to psychological interventions

Question 21

What is the treatment of a woman who during pregnancy or in post-partum period, presents with:

1. Bipolar disorder
2. Develops mania or psychosis and is not taking psychotrophic medication
3. If a woman with psychosis or schizophrenia becomes pregnant and is at risk of relapsing from stress associated with pregnancy/post-partum period, or change or stopping medication
4. If a woman with bipolar becomes pregnant and is stopping lithium or plans to breastfeed

Answer 21

1. Psychological interventions
   - CBT/IPT and behavioural couples therapy
2. Offer anti-psychotic
3. Consider psychological interventions (CBT or family intervention)
4. Offer anti-psychotic

Question 22

Which medications should prevent the mother from breastfeeding?

Answer 22

Carbamazepine, clozapine or lithium (valproate is not recommended to treat a mental health problem in women of childbearing potential)