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MRCPsych Part B > Perinatal Psychiatry > Flashcards

Perinatal Psychiatry Flashcards

1
Q

Risk of spontaneous major malformation in pregenancy?

A

2-3%

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2
Q

How many malformations in pregnancy are due to drugs?

A

5 out of every 100 malformations

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3
Q

Relationship between pregnancy and MH problems?

A

Increased risk fo suicide & MH problems

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4
Q

Risk of psychiatric episode postpartum?

A

Significant increase in first three months; 80% are mood disorder

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5
Q

Risk of depression during pregnancy

A

7-15%

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6
Q

Risk of depression in women outside perinatal period?

A

7%

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7
Q

Relapse rate of depression in patients with a history who are pregnant?

A

50%

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8
Q

Risk of postpartum depression?

A

10%

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9
Q

Risk factors for postpartum depression

A

Highest in bipolar

Previous depression

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10
Q

Risk of postpartum psychosis

A

0.1-0.25%

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11
Q

Risk of postpartum psychosis in bipolar

A

50%

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12
Q

Risk of postpartum psychosis in patients with a hx of postpartum psychosis

A

50-90%

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13
Q

Incidence of puerperal psychosis

A

One per 1000 births

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14
Q

What is puerperal psychosis strongly linked to?

A

Bipolar

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15
Q

What perinatal episodes are triggers for bipolar?

A

Childbirth
Abortion
Menstruation

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16
Q

Recurrence rate of puerperal psychosis?

A

One in four pregnancies

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17
Q

Prevalence of disorders of mother-infant relationship?

A

10-25%

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18
Q

Relative risk of postpartum psychosis in the first month?

A

20-fold increase

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19
Q

Risk of relapse of bipolar in first month postpartum?

A

Eight-fold increase

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20
Q

Characteristics of bipolar relapses postpartum?

A

Depressive

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21
Q

Risk of untreated psychiatric illness in the pregnant women

A 
Suicide
Alcohol & substance misuse
Poor compliance with perinatal appointments
Unhealthy lifestyle
Poor judgement
Impulsive acts
Impaired selfcafe
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22
Q

Risk of untreated psychiatric illness for the fetus

A 
Low birth weight & small head circumference (due to anxiety and depression)
Preterm birth (depression)
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23
Q

Risk to child postpartum if depression continues in mother?

A

Attachment, cognitive and behavioural difficulties

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24
Q

Impact of substance misuse in pregnancy to the fetus?

A

Increased intrauterine death
Congenital, cardiovascular and musculosketal abnormalities
Fetal alcohol syndrome

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25
Q

When do major malformations occur in pregnancy?

A

First trimester

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26
Q

When do neonatal toxicities occur in pregnancy?

A

3rd trimester

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27
Q

When do teratogenic effects occur?

A

Dose and time dependent
Organs at greatest risk during period of fastest development
Week 6-10 is most vulnerable period

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28
Q

Recommendations of drug treatment during preganncy

A 
Monotherapy
Lowest dose
Regular psych & obstetric r/v
Regular medication r/v
If possible avoid all drugs in first trimester
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29
Q

Drug treatment recommendations as pregnancy advances

A

Adjust doses; blood volume expands by 30% in 3rd trimester.

Observe for neonatal withdrawal sx after birth

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30
Q

Treatment of schizophrenia in pregnancy

A

Use antipsychotics at every stage of pregnancy.

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31
Q

Most used antipsychotic in pregnancy?

A

Olanzapine

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32
Q

Which antipsychotics are commonly used in pregnancy?

A 
Chlorpromazine
Trifluoperazine
Haloperidol
Olanzapine
Clozapine
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33
Q

Treatment of depression in pregnancy

A

Explore possibility of delaying treatment until 2nd-3rd trimester e.g. CBT

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34
Q

When should pregnant patients be treated with antidepressants if depressed?

A

High risk of relapse

Moderate-severe depression and psychological treatment has failed

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35
Q

Which antidepressant must be avoided in pregnancy

A

Paroxetine

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36
Q

Recommended antidepressants in pregnancy?

A

Nortriptyline
Amitriptyline
Impramine
Fluoxetine

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37
Q

Which patients with bipolar should continue medication?

A

Severe illness and high risk of relapse

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38
Q

Recommendations re maintenance treatment for bipolar who are pregnant?

A

Dose reduction and regular review of side effects

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39
Q

When should discontinuation of mood stabilisers be considered in the pregnant woman with bipolar?

A

Only if absolutely necessary and followed by frequent monitoring

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40
Q

Which mood stabilisers should be avoided in pregnancy?

A

Valproate

Combination of mood stabilisers

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41
Q

What should be done if a pregnant women is on Valproate or Carbamazepine?

A

Folic Acid 5mg OD from at least a month before conception should be px
Vitamin K should be given to mum and neonate after delivery

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42
Q

Impact of TCAs on pregnancy

A

No significant malformations

High doses in third trimester can lead to reversible withdrawal sx

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43
Q

Withdrawal sx in neonate with high dose TCAs?

A

Irritability
Eating and sleeping difficulties
Convulsions

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44
Q

Best TCAs to use during pregnancy

A

Nortriptyline
Desipramine
(less hypotensive and anticholinergic side effects)

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45
Q

Risk of SSRIs in pregnancy

A

13.3% increase in spontaneous abortion

Risk of decreased gestational age and low birth weight

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46
Q

Which drugs increase risk of spontaneous abortion

A

SSRIs
Mirtazapine
Bupropion

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47
Q

Risk of Paroxetine in pregnancy

A

1st trimester: VSD and ASD

3rd trimester: neonatal complications due to abrupt withdrawal

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48
Q

Which antidepressant has least placental exposure?

A

Sertraline

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49
Q

Risks of SSRI if introduced late in pregnancy

A

Increased risk of persistent pulmonary hypertension of newborn

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50
Q

Which antidepressants have high risk of neonatal withdrawal symptoms

A

Paroxetine
Venlafaxine
(short half-life)

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51
Q

Advice if pregnant woman is on MAOI

A

Limited evidence so should switch to safer antidepressant.

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52
Q

Why should MAOIs be avoided in pregnancy?

A

Risk of hypertensive crisis and congenital malformations

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53
Q

Risk of malformation if Lithium used in first trimester?

A

1 in 10

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54
Q

What is Lithium associated with if used in first trimester?

A

All types of malformation risk increased three-fold

Cardiac malformations risk increased 8-fold

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55
Q

Relative risk of Ebsteins anomaly if on Lithium

A

10-20 times higher

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56
Q

When is risk of malformation greatest when on Lithium?

A

2-6 weeks after conception

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57
Q

Fetal toxicity sx if on Lithium

A

Hypotonia
Poor reflexes
Respiratory difficulties
Cardiac arrhythmias

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58
Q

Risk of relapse if a women stops lithium when pregnancy

A

70% within 6 months

Faster discontinuation = higher risk of relapse

59
Q

Risk of relapse of bipolar for women who stop lithium when pregnant vs not pregnant

A

3 fold higher risk of relapse if pregnant

60
Q

Teratogenic risks of Carbamazepine

A

0.-1% risk of spina bifida, craniofacial anomalies, growth retardation and decreased head circumference.

61
Q

What is thought to lead to the teratogenic effect of carbamazepine?

A

Epoxide intermediate

62
Q

Risk of any birth defect while on Sodium Valproate?

A

7.2%

63
Q

What is risk of valproate related to during pregnancy?

A

Dose related

Mainly seen in days 17-30 post conception

64
Q

When is teratogenic risk of valproate increased?

A

FHx of neural defects

65
Q

Risks of valproate on the fetus

A

Growth retardation
Hepatotoxicity
Congenital anomalites

66
Q

Congenital anomalies of valproate?

A 
Neural tube defect 1-2%
Spina bifida - 10-fold increase
Digital and limb defects
VSG, Pulmonary stenosis - 4-fold increase
Urogenital malformations
Low birth weight
Psychmotor slowness
Mental retardation
67
Q

Which neonatal effects are related to valproate concentration in the infant?

A

Neurological dysfunction

Hyperexcitability

68
Q

Findings of IQ of children in mothers who took valproate during pregnancy

A

42% had verbal IQ <80

30% needed special educational support compared to 3-6% of those exposed to other antiepileptic drugs

69
Q

Which malformation is Lamotrigine associated with?

A

Cleft palate

70
Q

Risk of malformations if on Lamotrigine?

A

3.2%

71
Q

What is the notable study of antipsychotic use in pregnancy?

A

California Child Health Development Project - study of 19,000 births

72
Q

What are low-potency conventional antipsychotics associated with if used in pregnancy?

A

Transient perinatal syndrome
Floppy infant
Withdrawal symptoms; hypertonicity, hypotonicity, underdeveloped reflexes, irritability

73
Q

When are conventional antipsychotics associated with congenital malformations?

A

If used in first trimester; 2-2.4%

74
Q

Which conventional antipsychotic is associated with limb deformities if used in first trimester?

A

Haloperidol

75
Q

What effects have been reported from clozapine use during pregnancy?

A

Still birth

Neonatal seizure

76
Q

Which atypical antipsychotics can lead to gestational diabetes?

A

Clozapine

Olanzapine

77
Q

Use of anticholinergic drugs in pregnancy

A

Associated with teratogenicity; should be avoided.

If must be used, use at lowest dose.

78
Q

Risk of benzo use during first trimester

A

0.6% risk of cleft palate & CNS & urinary tract malformations

79
Q

Adverse effects of benzo use on the neonate

A

Neonatal toxicity - withdrawal sx
Respiratory depression
Muscular hypotonia (floppy baby syndrome)

80
Q

Evidence of Zopiclone use in pregnancy

A

Animal studies show no teratogenicity

81
Q

How often do pregnant women on lithium need serum levels?

A

Every 4 weeks throughout pregnancy

Lithium dose should be adjusted to match lower end of therapeutic range

82
Q

Recommendations of dosage tapering of lithium in pregnancy

A

Should not be discontinued abruptly

Prior to delivery dosage should be gradually tapered to 60-70% of original level

83
Q

Positive impact of Lithium use in 2nd and 3rd trimester?

A

Reduces risk of puerperal psychosis

84
Q

What investigations do pregnant women on lithium require?

A

Level 2 USS and echo of fetus at 6 and 18 weeks to screen for Ebsteins anomaly

85
Q

When does Lithium need to be increased during pregnancy?

A

3rd Trimester; total body water increases

86
Q

Effect of anaesthetic agents on pregnancy

A

Barbituates and atropine can reduce beat-to-beat variability in fetal HR
Atropine can cause fetal tachycardia

87
Q

Effect of pregnancy on ECT

A

Seizure threshold reduced by oestrogen

Increased by progesterone

88
Q

Risk of ECT during pregnancy

A

Prolonged gastric emptying time increases risk of gastric regurgitation and aspiration pneumonitis

89
Q

Risk of ECT on fetus

A

None

90
Q

Which psychotropics are excreted in breast milk?

A

All

91
Q

When should medications be taken when breast feeding?

A

After breast feeding

92
Q

What factors impact the effect of adverse effects of medication on breast fed infants?

A

Prescribed dose
Level of drug in mothers blood plasma
Level of drug in breast milk
Level of drug in infants serum

93
Q

What factors determine the amount of medication excreted in breast milk?

A

Medications diffusion capacity across membrane
Molecular weight
Lipid solubility

94
Q

What is used as the upper threshold of risk of drug side effect being low and treatment as safe in breast-feeding?

A

Concentration in infants plasma of 10% of established therapeutic maternal dose

95
Q

At what point is there a high likelihood that infant will be exposed to drug in breast milk?

A

Breast milk/mothers plasma ratio >1

96
Q

Which infants are at lower risk of adverse effects of medication in breast milk?

A

> 10 weeks

97
Q

What should be checked if a mother on drugs is psychotropics is breast feeding?

A

The infants cardiac, renal and hepatic function should be checked before breast feeding

98
Q

What should be checked if a breast-fed infant whose mother is on psychotropics is progressing well?

A

Milestones and adverse effects i.e. drowsiness, hypotonia, rigidity, tremor and withdrawal symptoms

99
Q

What does colostrum have greater conc of compared to foremilk?

A

Protein-bound drugs

100
Q

What does hindmilk have greater conc of compared to foremilk?

A

Lipid soluble drugs

101
Q

What factors need to be considered when giving a breast-feeding mother psychotropics?

A

Severity and frequency of MI
Benefits of breastfeeding
Impact of untreated maternal illness on mother and infant
Level of family support
Compliance with treatment
Patient and familys ability to recognise early warning signs
Physical health and maturity of infant
Support from statutory and voluntary organisations

102
Q

Which antidepressants are recommended during breast feeding?

A

Paroxetine

Sertraline

103
Q

Which antipsychotics are recommended during breastfeeding?

A

Sulpride

Olanzapine

104
Q

Which mood stabilisers are recommended during breastfeeding?

A

Avoid if possible

Valproate if essential

105
Q

Which sedatives are recommended during breastfeeding?

A

Lorazepam for anxiety

Zolpidem for sleep

106
Q

Which TCa is not safe in breastfeeding?

A

Doxepin

107
Q

Which TCAs are safe in breastfeeding?

A

Amitriptyline

Imipramine

108
Q

Risk of Doxepin use in breastfeeding

A

N-desmethyldoxepine is a longer acting metabolite of Doxepin and may accumulate in infants and cause severe drowsiness and respiratory depression.

109
Q

Impact of fluoxetine in breast milk

A

Detected in plasma and breast milk

Not detected in infants plasma

110
Q

Impact of fluoxetine on neonatal development

A

Does not effect development

Does not cause cognitive dysfunction or neurological abnormality

111
Q

Which SSRI has lower milk/plasma ratio?

A

Paroxetine

112
Q

Which antidepressant should be stopped in mothers planning to breast feed?

A

MAOIs

113
Q

Median time to maximum conc in breast milk after maternal ingestion of Moclobemide

A

3 hours

114
Q

Median time to maximum conc in breast milk after maternal ingestion of olanzapine

A

5 hours

115
Q

Median time to maximum conc in breast milk after maternal ingestion of Sertraline

A

7-10 hours

116
Q

Which conventional antipsychotics are recommended during breast-feeding?

A

High potency as less sedative and less autonomic effect.

117
Q

Which conventional antipsychotics are safe during breast feeding?

A

Haloperidol
Chlorpromazine
Perphenazine

118
Q

When has delayed development been reported in the use of conventional antipsychotics?

A

Combination of haloperidol and chlorpromazine

119
Q

Which atypical antipsychotics are safest in breast feeding?

A

Sulpride
Olanzapine
Risperidone

120
Q

Which atypical antipsychotic is contraindication during breastfeeding and why?

A

Clozapine

Accumulates in breast milk and fetal serum

121
Q

Why is there a high conc of clozapine in the neonate?

A

High conc of albumin in fetal blood

122
Q

Adverse effects if clozapine used during breastfeeding

A 
Agranulocytosis
Decreased sucking reflex
Drowsiness
Seizures
Irritability
Cardiovascular instability
123
Q

Lithium use in breastfeeding?

A

Contraindicated

124
Q

If Lithium is used in breastfeeding, what needs to e monitored?

A

Lithium serum conc and FBC

125
Q

How much lithium is exreted into breast milk?

A

40-50% of maternal serum level

126
Q

How much can infant serum level of lithium rise up to?

A

200% of maternal serum conc (5-200%)

127
Q

Why is serum level of lithium raised in neonates?

A

Diminished renal clearance

128
Q

Adverse effects of Lithium use in breastfeeding

A

Cyanosis
Lethargy
Hypotonia
Heart murmur

129
Q

Infant serum levels in mothers on sodium valproate who are breastfeeding

A

Range from undetectable to 40%

130
Q

Adverse effects in infants breast-fed by mothers on valproate

A

Thrombocytopenia

Anaemia

131
Q

Infant serum range of lamotrigine if breast fed

A

30% of maternal concentration

132
Q

Adverse effects in infants breast-fed by mothers on lamotrigine

A

None

133
Q

Infant serum range of Carbamazepine if breast-fed

A

5-65%

134
Q

Adverse effects in infants breast-fed by mothers on Carbamazepine

A 
Cholestatic hepatitis
Transient hepatic dysfunction
Seizures
Irritability
High-pitched crying
Hyperexcitability
Poor feeding
135
Q

Benzo use when breastfeeding

A

Should not be used

Should be stopped before becoming pregnant

136
Q

Effect of long-acting benzo on neonate

A

Lethargy
Poor suckling
Weight loss

137
Q

Effect of Clonazepam on the neonate

A

Persistent apnoea

138
Q

Infant serum range of Diazepam

A

Undetectable to 15%

139
Q

Which benzos are safe during breastfeeding

A

Low doses of Temazepam and Oxazepam (short acting)

140
Q

Which benzos should be avoided during breastfeeding?

A

Diazepam

Alprazolam

141
Q

Which sedatives are excreted in breast milk and should be avoided?

A

Buspirone
Zaleplon
Zopiclone

142
Q

Zopiclone serum range in infant?

A

Up to 50% of maternal plasma level

143
Q

Which sedative is safe during breast feeding?

A

Zolpidem

MRCPsych Part B (64 decks)

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