Perinatal Psychiatry Flashcards by Arya Nedungadi

What are the red flag presentations indicating urgent referral to 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

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Saving mothers lives recommendations

Routine enquiry at booking about current or past history of mental health issues
GPs should communicate about past psychiatric history to AN referrals
Antenatal services, GPs and psychiatry should communicate with well with each other

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What are the indications for admission to a mother and baby unit?

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

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Screening for mental health issues at booking

History of mental health problems, previous treatment, Family History

Identify risk factors: 
Young/ single 
domestic issues
lack support
substance abuse, unplanned/unwanted pregnancy
pre existing mental health problem

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Screening questions to be used by midwives 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?

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What should a psychiatric team look for when referred?

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

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Which mental health disorder has a high rate of relapse postnatally?

Bipolar disorder

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Which mental health disorder tends to imrpove during pregnancy?

Eating disorders

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What are the risks of eating disorder during pregnancy?

risks of IUGR, prematurity, hypokalaemia, hyponatraemia, metabolic alkalosis, miscarriage, premature delivery

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How to manage antenatal depression

68% relapse if stop meds in pregnancy but if mild and on treatment, consider stopping and referring for psychological treatment

Self help strategies – CBT,

Computerised CBT and self guided help of benefit

Mild-moderate: GP managed

Severe (suicidal, psychosis, self neglect, harm): referral to psychiatry

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Presentation and management of baby blues

50% women
Brief period of emotional instability
Tearful, irritable, anxiety and poor sleep confusion
Day 3-10 self-limiting
Support and reassurance

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When does peurperal psychosis present?

Within 2 weeks of delivery

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What are the early symptoms of peurperal psychosis?

sleep disturbance
confusion
irrational ideas

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What are the symptoms as peurperal psychosis progresses?

Mania, delusions, hallucinations, confusion

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Differential diagnoses of peurperal psychosis

episode of bipolar, unipolar depression, schizophrenia, organic brain dysfunction (secondary to physical illness)

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Risk factors of peurperal psychosis

bipolar disorder (50%), previous puerperal psychosis, 1st degree relative with history

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Managing peurperal psychosis

Is an emergency
Needs admission to specialised mother-baby unit
Antidepressants, antipsychotics, mood stabilizers and ECT
80% 10 year recurrence
25% go onto develop bipolar disorder

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Onset of postnatal depression

Onset 2-6 weeks postnatally, lasts weeks to months

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Presentation of postnatal depression

Tearfulness, irritable, anxiety, lack of enjoyment and poor sleep, weight loss, can present as concerns re baby

Effects on bonding, child development, marriage, risk suicide

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Managing postnatal depression

Mild- moderate: self help, counselling

Moderate-severe: psychotherapy and antidepressants, admission?

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What are the risks to child of untreated depression?

Low birth weight
- Associated with severity of depression

Pre-term delivery
- Associated with severity of depression
Adverse childhood outcomes
e.g. emotional & conduct problems, ADHD

Poor engagement / bonding with child

Reduced infant learning & cognitive development

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General principles of managing mental illness and medication in perinatal period

Ideal: discussing the implications of pregnancy before she gets pregnant (plan the pregnancy)

Individualised care - based on past history, frequency & severity of episode, response to treatment

Discuss toxicology of medication and effect on mother and baby

Consider stopping medication, changing or lowering dose

Plan - antenatal monitoring, contingency plans, delivery, postnatal management

MDT involvement

Support groups

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What types of drugs to be prescribed in pregnancy?

preferentially use drugs with low risk to both mother and foetus
Low dose monotherapy

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Which type of monotherapy to be avoided in pregnancy?

Depot

Which drug has altered pharmacokinetics in pregnancy and needs caution?

Lithium

Can a mother with mental health problems breastfeed?

Yes. Encourage breastfeeding wherever possible

How to care for foetus when mother is on medication?

Increase screening of foetus - cardio and growth (especially with high risk drugs like sodium valproate if mother absolutely needs to be on it)

Risks of mental health prescribing during pregnancy

Risks and benefit can vary between the 1st trimester, the 3rd trimester and breastfeeding Stopping a drug with known teratogenic risk after pregnancy is confirmed may not remove the risk of malformations There are risks from stopping medication abruptly - stop meds gradually

Issues with prescribing in 1st trimester

Risk of teratogenecity

Issues with prescribing in 2nd trimester

Risk of neonatal withdrawal

Issues with prescribing and breastfeeding

Risk of medication passing into breast milk But exposure in breast milk is usually less than in utero therefore, in general, there is no need to stop a drug that was used during pregnancy.

What is the first-line anti-depressant in pregnancy?

SSRI "resaonably certain" that anti-depressants are not major teratogens Risk - benefit analysis

Which SSRI has least placental exposure?

Sertraline

Which SSRI is the safest during preg?

Fluoxetine

Risks of SSRIs to foetus

- persistent HTN of newborn - Low birth weight - increased early birth - PPH

Which is the least safe SSRI?

Paroxetine Increased cardiac malformation, less safe than other SSRIS

Other anti-depressants used in pregnancy

1. Tricyclics - may have mild and self limiting neonatal withdrawal 2. Venalfaxine - less evidence, cardiac defects, cleft palate, neonatal withdrawal

First generation antipsychotics used in pregnancy

Chlorpromazine | Haloperidol

Second generation antipsychotics used in pregnancy

Olanzapine | Quetiapine

Risk of antipsychotics in pregnancy

Weight gain leading to gestational diabetes (esp. second gen) Reduced fertility (raised prolactin levels reduces chances of conception)

Antipsychotics to avoid in pregnancy

Clozapine (may cause agranulocytosis) Anticholinergics for EPSE in pregnancy Depot antipsychotics

Prescription of mood stabilisers in pregnancy

NO SAFE MOOD STABILISER Valproate and carbamazepine (most teratogenic) - increase neural tube defects and should be avoided at all costs (except if only option available) Lamotrigine is "less bad"

Risks of lamotrigine in pergnancy

↑ risk of oral cleft (1.5/1000- 9/1000) – avoid in 1st trimester or withdraw before planned pregnancyrisk of Stevens-Johnson Syndrome etc in infant if breast feeding

Prescription of lithium in pregnancy

Best to avoid lithium as far as possible Consider slow reduction pre-conception Can be re-introduced in 2nd or 3rd trimester Beware of dose change in 3rd trimester Consider re-introduction immediately post-partum

Risk of lithium in 1st trimester

Ebstein's abnormality (exaggerated risk, reasonable risk to hold if mother is okay with it) Can be continued if clinical indication, avoids abrupt discontinuation (increases risk of relapse)

Managing lithium in 3rd trimester

Monitor serum lithium levels closely ( d/t changes in volume distribution) monthly Weekly monitoring from week 36 then within 24hrs of childbirth Lithium toxicity can mimic PET

Lithium in breastfeeding - safe?

Avoid. High quantities in breast milk

Recommendations for mood stabilisers in pregnancy

Switch to safer option (quetiapine) Avoid valproate and carbamazepine in woman of childbearing age If lithium is required - HIGH MONITORING Consider ECT

First line medication for anxiety in pregnancy

SSRI

Benzodiazepine as anxiety treatment in 1st trimester

Avoid due to possible ↑ risk of fetal malformation, e.g. cleft palate

benzodiazepine in 3rd trimeter

Avoid ** ↑ risk of floppy baby syndrome (hypothermia, hypotonia, respiratory depression, withdrawal effects)

Benzodiazepine in breastfeeding

Avoid regular use ** – risks of lethargy & weight loss + accumulation of long acting drugs

Mental illness drugs and breast feeding

All psychotropics are excreted in breast milk Risk and benefit balance Time dose to feed - give dose before longest break between feeds LESS exposure during breastfeeding than in utero so if a drug has been used in 3rd trimester it is reasonably safe to continue using it during pregnancy

Mental ilnesses associated with substance abuse in pregnancy

personality depression anxiety

Risks of substance abuse during pregnancy

``` HIV, Hep C, Hep B VTE STIs Endocarditis/ Sepsis Poor venous access - see anaesthetists Opiate tolerance/ withdrawal Drug overdose/ death At risk of domestic abuse and suicide IUGR, Stillbirth, SIDs, pre-term labour ```

Consequences of alcoholism in pregnancy

Risks of miscarriage Foetal Alcohol Syndrome - facial deformities, lower IQ, neurodevelopmental delay, epilepsy, hearing, heart and kidney defects Withdrawal Risk of Wernicke's encephalopathy- 20% die (B1 deficiency) Korsakoff Syndrome – permanent

Cocaine, amphetamine, ecstasy

Death via stroke and arrythmia ``` Teratogenic Pre-eclampsia Abruption IUGR Pre-term labour Miscarriage Developmental delay, SIDS, withdrawal ```

Antenatal care for substance in pregnancy

Consider methadone programme Child protection and social work referral Smear History Breastfeeding (not if alcohol >8 units , HIV, cocaine) Labour plan re analgesia and labour ward delivery Early IV access Postnatal contraception plan

Read up on cases in the PPT

NOW :)