Perinatal psychiatry Flashcards
Timecourse of ‘baby blues’
Onset 2-4d after birth, lasts a few days
Management of baby blues
Self-limiting, needs only reassurance
Possible aetiology of baby blues
Fall in sex steroids post-partum
Prevalence of baby/maternity blues
50-75% of mothers
Prevalence of post-partum depression
Mild-moderate: 10-15%
Severe: 3%
Time of onset of postpartum depression
within 6mo (peak at 3-4 weeks, most within 12w)
Prognosis/duration of postpartum depression
90% <4weeks
4% >1yr
Suicide risk lower than general population
Management of postpartum depression
Screening: Edinburgh postnatal depression scale + thoughts of self-harm, harm to baby
Conservative: Education + support networks
Psychological: CBT
Pharmacological: Antidepressants (caution if breastfeeding!)
Risk factors for postpartum depression
PPH: Hx of depression/anxiety (more recent = higher risk), post-partum psychosis, severe baby blues
FHx: Family Hx of depression, poor relationship with mother
Personal: Unwanted/ambivalent pregnancy, poor social support, domestic violence, single mother, very young/very old
Prevalence of postpartum psychosis
1.5/1000 live births
Time of onset of postpartum psychosis
1-2w postpartum
Risk factors for postpartum psychosis
Personal/FHx of postpartum psychosis
Bipolar disorder/major psychiatric condition (30-40% of cases are with BPD)
Primiparity
Poor social support
Single parenthood
Clinical features of postpartum psychosis
Prominent affective symptoms
Develop acutely (over hours)
Perplexity, disorientation (delirium-like) c.f. other psychoses
Lability of symptoms
Thoughts of suicide/infanticide, paranoia about baby’s safety
Management of postpartum psychosis
Treatment with antipsychotic
Admission (to mother-baby unit if possible)
Mood stabiliser (esp carbamezapine)
Low threshold for ECT
Prognosis for postpartum psychosis
25% risk of relapse in subsequent deliveries
50% lifetime risk of relapse
Effect of pregnancy on neuroses
Phobias: Tokophobia + needle phobia may have issues
OCD: Symptoms worsen during pregnancy, esp ‘contamination’ fears
Risk factors for maternal suicide
Late midwife booking
Domestic abuse
Emotional instability, chaoti lifestyle
Loss of custody of baby
Risks to child with antenatal depression
Premature delivery
IUGR
Emotional problems, depression, disorganised attachment
LD
Risks to child with postnatal depression
Emotional dysregulation
Insecure attachment
ADHD sx
adolescent depression
Slower cognitive + developmental milestones
Risks to child with schizophrenia
Prematurity
Infant mortality
LD
Antidepressant prescribing in pregnancy
Stick with what works if possible to minimise exposure
SSRIs and TCAs considered safe, sertraline first-line choice
Possible teratogenicity of fluoxetine/paroxetine (persistent pulmonary hypertension)
Antipsychotic prescribing in pregnancy
May cause EPSEs in baby if taken near-term
Unclear risk of adverse outcomes due to confounding by indication
Obstetric complications more likely
Olanzapine largest evidence base for safety
Mood stabilisers in pregnancy
Valproate: 10% teratogenicity, contraindication
Lamotrigine: Unlikely teratogenic, possible oral cleft
Lithium: 1/1000 risk of Ebstein’s anomaly, hypothyroidism/arrhythmias in neonate. Only use as 2nd line, antipsychotics preferred.
Li needs weekly monitoring due to changes in circulating volume (esp in 3rd trimester)
Anxiolytics in pregnancy
Benzos possibly teratogenicity (oral cleft, gut atresia, floppy baby)
Promethiazine used for insomnia (extrapolated from use of other antihistamines)
Treatment of comorbid opiate abuse in pregnancy
Withdrawal –> risk of spontaneous abortion/neonatal death
Use substitute prescribing (opiates not teratogenic, but safety/lifestyle concerns)
Treatment of alcohol dependece in pregnancy
Window of opportunity
Medically supervised detox (high seizure risk) + encourage abstinence
Antidepressants for use with breastfeeding
Sertraline, TCAs (esp amitryptilline)
Avoid MAOIs
Mood stabilisers for use in breastfeeding
Avoid lithium
Carbamazepine, lamotrigine likely safe
Antipsychotics for use in breastfeeding
Olanzapine, quetiapine (sedating to baby!)
Avoid clozapine
Risks for antenatal depression
6-8% prevalence
Hx of depression/anxiety
Unplanned pregnancy
Domestic abuse
Lack of social support
Multiple life stressors
