Perinatal Psychiatry Flashcards
What is the leading cause of maternal death in the UK?
Mental illness
Half of all maternal suicides occur up to ___ weeks post-natal
12 weeks
The rate of maternal death by suicide remains unchanged since 2003 and maternal suicides is now the leading cause of direct maternal deaths occurring within a year after the end of pregnancy
T
Suicide is the leading cause of maternal death occurring within a year of the end of pregnancy
T
2/3rd of women who kill themselves following birth have already suffered a mental health condition at some stage in their life
T
Women who report what are given an urgent referral to a specialist perinatal mental health team?
- 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.
A woman with significant change in mental state or emergency of new symptoms …
Urgent referral to a specialist perinatal mental health team
A woman with new thoughts or acts of violent self-harm
Urgent referral to a specialist perinatal mental health team
A woman with a new and persistent feeling of incompetency as a mother or estrangement from baby
Urgent referral to a specialist perinatal mental health team
What should always be discussed at booking?
Current or past history of mental health problems
When should admission to a mother and baby unit always be considered?
If a woman presents with any of the following …
- 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.
Good questions to ask include …
Do you have new feelings and thoughts which you have never had before, which make you disturbed or anxious?
Are you experiencing thoughts of suicide or harming yourself in violent ways?
Are you feeling incompetent, as though you can’t cope, or estranged from your baby? Are these feelings persistent?
Do you feel you are getting worse?
With regard to screening for mental health issues, what should be done/addressed at the booking appointment?
- History of mental health problems, previous treatment and family history.
- Identification of risk factors.
What are the risk factors for mental health issues in relation to pregnancy?
- Young/single.
- Domestic issues.
- Lack support.
- Substance abuse.
- Unplanned/unwanted pregnancy.
- Pre-existing mental health problem.
** What screening questions should be used at every appointment? **
- 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?
In what situations should the psychiatric team see a woman?
- Psychosis
- Severe anxiety, depression, suicidal, self-neglect, self-harm
- Symptoms with significant interference with daily functioning
- History of bipolar or schizophrenia
- History of puerperal psychosis
- Psychotropic medications
- If developed moderate mental illness in late pregnancy or early postpartum
- Mild- moderate illness but 1st degree relative with bipolar or puerperal psychosis
- Previous in-patient admissions to mental health unit
Pregnancy is/is not protective against maternal mental health conditions
IS NOT
How does pregnancy tend to affect bipolar disorder?
It is associated with a high rate of relapse postnatally (50% if untreated).
How might eating disorders be affected by pregnancy?
They may be improved
What risks are associated with pregnancy in someone with an eating disorder?
- IUGR.
- Prematurity.
- Hypokalaemia.
- Hyponatraemia.
- Metabolic alkalosis.
- Miscarriage.
- Premature delivery.
What % of women with antenatal depression will relapse if they stop meds in pregnancy?
68%
What self-help strategies may be used in the treatment of antenatal depression?
CBT
If a woman with antenatal depression has a mild relapse, what can be done?
If mild and on treatment, consider stopping and referring for psychological treatment
If antenatal depression is mild-moderate, who might it be managed by?
GP
What would qualify as severe antenatal depression
- Suicidal
- Psychosis
- Self-neglect
- Harm
What should be done if a woman presents with severe antenatal depression?
Refer to psychiatry
What % of women experience baby blues?
50%
What are baby blues?
A brief period of emotional instability
List the symptoms of baby blues.
- Tearful
- Irritable
- Anxiety
- Poor sleep
- Confusion
When does baby blues usually occur?
Day 3-10
Baby blues are usually self-limiting
T
How are baby blues managed?
Support + reassurance
When does Puerperal Psychosis usually present?
2 weeks after birth
List some early symptoms of Puerperal Psychosis?
Sleep disturbance and confusion, irrational ideas
Except from sleep disturbance and confusion, list some other symptoms of puerperal psychosis?
- Mania
- Delusions
- Hallucinations
- Confusion
What are the main symptoms pf puerperal psychosis?
- Sleep disturbance
- Confusion
- Irrational ideas
What % of women get puerperal psychosis?
0.1%
What % of women with puerperal psychosis commit suicide?
5%
What % of women with puerperal psychosis kill their child?
4%
What are the risk factors for puerperal psychosis?
- Bipolar disorder (50%)
- Previous puerperal psychosis
- 1st degree relative with history
Puerperal psychosis is treated as an __________
EMERGENCY !!!
How is puerperal psychosis managed?
- Needs admission to a specialised mother-baby unit.
* Antidepressants, antipsychotics, mood stabilisers and ECT.
What is the 10 year recurrence rate of puerperal psychosis?
80%
What do 25% of women with puerperal psychosis go on to develop?
Bipolar disorder
What % of women get postnatal depression?
10%
Of all postnatal depression cases, how many last >1 year?
1/3
What are the signs and symptoms of postnatal depression?
- Tearfulness
- Irritable
- Anxiety
- Lack of enjoyment
- Poor sleep
- Weight loss
When does postnatal depression usually onset?
2-6 post birth
Postnatal depression is screened for routinely
T
What can postnatal depression have impacts on?
- Bonding
- Child development
- Marriage
- Suicide risk
How is mild-moderate postnatal depression managed?
With self-help and counselling
How is moderate-severe postnatal depression managed?
With psychotherapy and antidepressants
Admission might be needed
In women who have had postnatal depression, what % will have a recurrence?
25%
What is the lifetime risk of depression in women who have had postnatal depression?
70%
What are some of the risks to a baby, in a mum with untreated depression?
- Low birth weight
- Preterm delivery
- Adverse childhood outcomes
- Poor engagement/bonding with the child.
LBW and preterm delivery are associated with the ___________ of depression
Severity
In a pregnant lady with depression, what should there be increased screening of?
- Foetal cardio
* Foetal growth
What is the main prescribing risk in the 1st trimester?
Risk of teratogenicity
What is the main prescribing risk in the 3rd trimester?
Risk of neonatal withdrawal
The passage of drug from mother to baby is less via breastmilk than in utero
T
What antidepressant is associated with increased risk of ofetal heart defects in the 1st trimester?
Paroxetine
In the 3rd trimester, what is there a risk of with SSRIs taken after 20weeks (+ venlafaxine)?
Increased risk of neonatal persistent pulmonary hypertension
In the 3rd trimester, what do antidepressants also increase the risk of?
Low birth weight/prematurity
What is the SSRI with lowest risk?
SERTALINE / fluoxetine
What drugs are lower risk than SSRI’s?
TCA’s e.g. imipramine/amitriptyline
All (SSRIs + TCAs) are in breast milk to some extent, although there have been no reports of adverse effects on neonatal development
T
It is ok for a woman on SSRI or TCA to breastfeed?
T
What are thought to be the ‘better’ antidepressants to use when breastfeeding?
- SERTRALINE
- Paroxetine
- Imipramine
What drug are we uncertain about the safety of in breastfeeding mothers?
Fluoxetine
What antidepressants should NOT be used in breastfeeding?
Citalopram/doxepin
Don’t use BZD’s ….
- 1st trimester - foetal malformations e.g. cleft palate.
* 3rd trimester - floppy baby syndrome.
What is floppy baby syndrome?
- Hypothermia
- Hypotonia
- Respiratory depression
- Withdrawal effects
BZD’s should not be used 1st or 3rd trimester
T
Should you avoid BZD’s in breastfeeding?
Yes - risk of lethargy and weight loss
What ‘side effect’ of antipsychotic used may reduce chances of conception?
Raised prolactin levels
What hormone does antipsychotics increase?
Prolactin
Where are antipsychotics excreted?
ALL are excreted in breast milk
Which antipsychotic should be avoided at all time points? Why?
Clozapine – due to risk of agranulocytosis
What is the risk with clozapine?
Agranulocytosis
What does olanzapine increase the risk of?
Gestational diabetes and weight gain
What type of antipsychotics (in terms of mode of delivery) should be avoided? Why?
DEPOT antipsychotics – due to prolonged effects e.g. EPSE in neonates.
Why should anticholinergics be avoided?
Due to risk of EPSE in pregnancy. (extrapyramidal side effects)
In the 1st trimester, what are the risks associated with lithium?
- Increased risk of foetal abnormality.
* Increased risk of Ebstein’s abnormality.
What is Ebstein’s abnormality?
A congenital heart defect in which the septal and posterior leaflets of the tricuspid valve are displaced towards the apex of the right ventricle of the heart
What should you not do with lithium?
Suddenly stop it
Can lithium be given in pregnancy?
Yes - if needed
In the 3rd trimester, what needs to be monitored in someone on lithium?
Serum lithium levels
Due to changes in vol of distribution.
Monthly, then weekly from week 36, then within 24 hours of childbirth.
Is lithium safe when breastfeeding?
No – avoid due to high quantities in breast milk
In the 1st trimester, what does sodium valproate increase the risk of?
Neural tube defects
When does the neural tube close?
Day 28
Sodium valproate should not be prescribed to women of childbearing age unless all other options fail
T
What does sodium valproate have long term effects on?
Neurological development – increased risk of autism
Sodium valproate increases the risk of ________
Autism
Sodium valproate – definitely NOT in early pregnancy, but ok in breastfeeding
T
Can sodium valproate be used when breastfeeding?
Yes – low risk, with no evidence of adverse effects in breast feeding
If a woman on sodium valproate says she wants to get pregnant, what should be done?
- Stop if possible before planned pregnancy.
* Use folate supplements
What physical features might Carbamazepine result in?
- Facial dysmorphism.
* Fingernail hypoplasia
When should lamotrigine be avoided?
1st trimester
What is the risk associated with the use of lamotrigine in the 1st trimester?
Oral cleft
If a woman on lamotrigine is breastfeeding, what is there an increased risk of?
Stevens Johnson syndrome
Who causes death in mothers on coke, ket or eccies?
Stroke and arrhythmias
Wernicke’s is a ____ deficiency
B1
Wernicke’s is temporary. What is it called when it becomes permanent?
Korsakoff
Although the RCOG suggests abstinence, there is no evidence that how many units of alcohol per week is detrimental?
2 units
What are the risks/potential negative side effects of alcoholism in a pregnant mother?
- Miscarriage
- Foetal alcohol syndrome
- Withdrawal.
- Risk of Wernicke’s encephalopathy – 20% die (B1 deficiency).
- Korsakoff Syndrome – permanent.
List some signs of foetal alcohol syndrome.
- Facial deformities
- Lower IQ
- Neurodevelopmental delay
- Epilepsy
- Hearing
- Heart and kidney defects
