Perinatal psychiatry Flashcards
How common is suicide among moms who just delivered?
1 in 7 are suicides; among moms who died between 6 weeks and 1 year after pregnancy
What was noted from those who suicided within 7 weeks of delivery?
- 2/3 had hx of mental health problems
(only half of that had that hx identified)
—–only 1/2 of those who had the identified hx had a management plan in place
When should a lady be referred to a specialist perinatal mental health team?
- recent SIGNIFICANT change in mental state
- new thoughts of acts of violence/self harm
- persistent and new expressions of incompetency as a mom or estrangement from bby
- evidence of psychosis
- pervasive hopelessness
How to ensure mental health is well addressed in a patient?
- routine enquiry at booking about CURRENT/ PAST hx of mental health problems (cover all mental issues)
- GPs should communicate about PAST psychiatric hx in antenatal referral to pt
What is criticial for good quality care for women with mental ill heath?
- good communication between GPs, Antenatal services and psychiatry
What should be addressed in the booking appointment?
- hx of mental health problems, previous rx, family hx
- risk factors to be identified
What risk factors should be identified in a pt at a booking appointment?
- young/single
- domestic issues
- lack of support
- substance abuse
- unplanned/unwanted pregnancy
- pre-existing mental health problem
It is important to screen the pt at EVERY appointment. What qs should be asked?
- past month, have you been bothered by feeling down, depressed or hopeless?
- in the past month, have you been bothered by having little interest or pleasure in doing things?
- something you feel you need help with ?
What is the risk of prolapse with bipolar d.o?
- high rate of relapse Post-natally (50% if untreated)
What are danger a pt with past hx of eating d.o?
- –d.o improvement in pregnancy
- —risks of IUGR, hypokalemia, hyponatremia, metabolic alkalosis, miscarriage, premature delivery
Risk of stopping anti-depressants in pregnancy?
- 68% of relapse > antenatal depression
How to manage antenatal depression?
- consider stopping rx if mild, refer to psychological rx
- self-help strategies: CBT, computerized CBT
- Mild-moderate: GP managed
What is recommended for Severe antenatal depression?
What mental d.os should be considered?
- referral to psychiatry
—–d.os include suicide, psychosis, self-neglect, harm
How would a lady experiencing baby blues present as? And for how long?
- period of emotional instability
(tearful, irritable, anxiety and poor sleep)
—–day 3-10(self-limiting)
- period of emotional instability
What is the prevalence of baby blues?
- seen in 50% of women
What is puerperal psychosis?
- initially: sleep disturbance, confusion, irrational ideas, mania, delusions, hallucinations
- only 0.1% affected
When does puerperal psychosis usually occur?
- within 2wks of delivery
What are the risk factors of puerperal psychosis?
- 50% have bipolar d.o
- previous puerperal psychosis
- 1st degree relative with hx
List 3 ddx for puerperal psychosis.
- bipolar d.o
- unipolar depression
- schizorphrenia
- —-organic brain dysfunction
How is puerperal psychosis managed?
- EMERGENCY
- MUST admit to mother-baby unit
—–antidepressants/ antipsychotics/ mood stabilizers/ ECT
Which condition may recur in 80% of the women?
- puerperal psychosis
How long does post-natal depression last and when may it start?
- 10% of women
- 1/3 lasts a year or more
- —-starts 2-6 weeks post-natally
How does post-natal depression affect the lady’s relationship to bby and partner?
- affects bonding with the baby, child development
- marriage is affected
- suicide risk is present
Moderate and severe post-natal depression would require ______for management
- psychotherapy and anti-depressants
- admission may be needed
What 3 things should be considered when managing perinatal d.os?
- risks of UNTREATED illness
- principles of prescribing in perinatal period
- benefits and harms of diff. rx
What risks arise with untreated perinatal depression?
- Low birth wgt
- Pre-term delivery
- Adverse childhood outcomes (ADHD, emotional and conduct probs)
- Poor engagement/ bonding with child (reduces kid’s cognitive develop.)
What issue should be cautioned in the 1st trimester?
- Risk of Teratogenicity
What issue is a.w 3rd trimester?
- risk of Neonatal withdrawal
WHat risk does breastfeeding while on medication, hold?
- risk of medication passin into milk
—-NOTE: exposure in breast milk is usually LESS than in utero
don’t stop a drug you used during pregn.
What anti-depressant is recommended in 1st trimester?
- Paroxetine
incr. fetal heart defects!
What is antidepress. is used in 3rd trimester?
Sertraline/fluoxetine
TCA: imipramine/ amtriptyline
What effect does SSRi use in 3rd trimester have on the baby?
- risk of neonatal withdrawal
- ^ risk of low birth wgt
- ^ risk of neonatal persistent pulmonary hypertension (if SSRI taken after 20wks)
Best antidepress. to be used when breast feeding:
Sertraline/ paroxetine/ imipramine
—-fluoxetine is uncertain
Why should benzodiazepines be avoided in 1st and 3rd trimester?
1st: incre. risked of fetal malformation
3rd: to avoid risk of FLOPPY baby $ (hypotonia/hypothermia/ depression)
Are benzodiazepines avoid in breastfeeding?
- regular use is NOT recommended!
> risk of lethargy, wgt loss, drug accumulation
What gr. of anti-psychotics are said to be safer?
TYPICAL (Haloperidol/fluphenazine)
- -atypical: Clozapine (risk of agranulocytosis)
- olanzapine (^ risk of GDM and wgt gain)
How to avoid extra-pyramidal SE in pregnany?
- avoid depot antipsychotics
- avoid anticholinergics
Can lithium be given to a pregnant lady?
YES
1st trimester: despite risk of fetal abnormality (60/1000) and ebstein abnormality (10/20000)
—–can be continued if indicated
3rd trimester: monitor serum lithium closely monthly, then weekly from week 36
What condition may lithium toxicity mimic?
- PET
Can lithium be taken with breastfeeding?
NO -high quantities is seen in breast milk
—-should only be re-introduced if not breastfeeding
Does sodium valproate hold any risk for the fetus?
- they have increased risk of NTD
- craniofacial defects+child’s intellectual development
- INCR. risk of Autism
Does a particular dose hold less NTD risk?
- <1000mg
What risk does carbamazepine have on the fetus?
- NTD 20-50/10000
- facial dysmorphism
RIsk of lamotigrine?
- risk of oral cleft (9/1000) —-AVOID IN 1st TRIMESTER or withdraw
Risk of lamotigrine on bby when breast feeding?
-Stevens-Johnson Syndrome
Risks of alcoholism?
- miscarriage
- fetal alcohol $: Facial deformities, lower IQ, epilepsy, hearing, heart and kidney defects
- neonatal withdrawal
- wernicke;s encephalopathy (20% die)
- korsakoff syndrome
Affect of cocaine, amphetamine and ecstasy on fetus.
death via stroke and arrhythmias
- teratogenic/ pre-eclampsia/abruption
- IUGR
- pre-term labour
- miscarriage
- SIDS, withdrawal, develop. delay
What do opiates cause?
- 1-2% maternal deaths
- neonatal withdrawal
- IUGR
- SIDS
- stillbirth
What does nicotine cause?
- miscarriages
- abruption
- IUGR
- stillbirths
- SIDS
How to manage substance abuse in pregnant women?
- consider methadone programme
- child protection and social work referral
- SMEAR hx
- no breastfeeding if on cocaine, has HIV, alcohol intake >8)
- early IV access
- postnatal contraception plan
12wks pregnant Patient X admits to drinking bottle of vodka per day. Who will you refer this patient to?
- alcohol misuse service and social work
What antenatal care should be provided?
- obstetric led care
- routine booking and 20 week scans with growth scans (IUGR risk)
- Nutritionist
- Appointments with midwife
- Nutritional status
- renal and liver fxns
What plans if alcohol abuse continues?
- anticipate withdrawal
- begin withdrawal protocol
Management of hyperemesis in a bulimic pt?
- hydration status
- U&Es
- Anti-emetics
- Steroids
- —assess mental health
Advise for bulimic pregnant girl?
they feel better by 16 weeks
—eating d.o stabilizes in preg.
Post natal plan of a bulimic pt?
- encourage breastfeeding
- high risk of postnatal depression
35 y.o on paroxetine for her depression, is trying to concieve—-still occasionally feels low and poor conc….what should the GP do?
- do not suddenly stop
- continue if paroxetine is the best option
How tell baby blues from post-natal depression?
PND >6wks
Antenatal care plan for a IVDU?
- RED pathway; screen for HEP, HIV, syphilis
