Perinatal Psychiatry Flashcards
red flag presentations in perinatal period?
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
admission to a mother and baby unit should always be considered where a women presents with what?
rapidly changing mental state suicidal ideation (particularly of a violent nature) significant estrangement from baby pervasive guilt or hopelessness beliefs of inadequacy as a mother evidence of psychosis
who can admit to a mother and baby unit?
only a psychiatrist
important parts of screening for mental health problems
at booking
- history of mental health problems, treatment and family history
- identify risk factors
risk factors for perinatal mental health problems?
young single domestic issues lack of support substance abuse unplanned pregnancy pre-existing mental health problem
screening questions which should be asked at every appointment?
any feeling down, depressed or hopeless in last month?
bothered by having little interest or pleasure in doing things in last month?
is this something you feel you need help with?
psychiatry team must see any woman with any of which features?
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 any moderate mental illness in late pregnancy or early post partum
mild-mod illness but 1st degree relative with bipolar or puerperal psychosis
previous in patient admission to mental health unit
how does pregnancy interact with pre-existing mental health problems?
pregnancy is generally not protective against mental illness
bipolar
- high relapse rate post-natally
eating disorders
- may improve during pregnancy but risks during pregnancy
antenatal depression
- 68% relapse if mother stops meds
risks in pregnancy if eating disorder present?
IUGR prematurity hypokalaemia hyponatraemia metabolic alkalosis miscarriae premature delivery
how is depression managed during pregnancy?
if mild and on treatment - can consider stopping treatment and referring for psychological treatment
mild-mod = GP managed
severe = referral to psychiatry
features of normal baby blues?
occurs in 50% brief period of emotional instability tearful irritable anxiety poor sleep confusion usually 3-10 days self limiting managed with support and reassurance
features of puerperal psychosis?
early - sleep disturbance - confusion - irrational ideas later - mania - delusions - hallucinations - confusion
usually present within 2 weeks of delivery
risk factors for puerperal psychosis?
bipolar
previous episode
1st degree relative with history
how is puerperal psychosis managed?
medical emergency
needs admission to specialised mother baby unit same day
managed with antidepressants, anti-psychotics, mood stabilisers and ECT if needed
long term risks of puerperal psychosis?
80% 10 year recurrence
25% go on to develop bipolar disorder
what is post-natal depression?
episode of depression (more severe than baby blues) following child birth
features of post-natal depression?
onset 2-6 weeks, lasts weeks to months tearfulness irritable anxiety lack of enjoyment poor sleep weight loss can present as concerns re baby effects on bonding, child development, miscarriage risk, suicide
how is post-natal depression managed?
screened for routinely
mild-mod = self help, counselling
mod-severe = psychotherapy and antidepressents, admission if needed
risks to baby in untreated depression?
low birth weight (not massive, associated with severity of depression)
pre-term delivery
adverse childhood outcomes (emotional/conduct problems, ADHD)
poor engagement/bonding with child (causes reduced infant learning and cognitive development)
main points in planning pregnancy in someone with pre-existing mental health disorder?
antenatal monitoring and support
contingency plans - consider advance directive in case capacity becomes compromised
place of delivery
postnatal management and support
important considerations when prescribing in pregnancy?
use lowest dose monotherapy (avoid depot)
be aware of altered pharmacokinetics in pregnancy
increase screening of foetus (cardio and growth etc)
risks and benefits can differ between 1st and 3rd trimester and breastfeeding
risks of stopping teratogenic drugs abruptly?
stopping after pregnancy is confirmed may not remove the risk of malformations (e.g valproate causes neural tube defects but neural tube closes at week 4 so damage is already done)
there are also risks from stopping drug abruptly alone
breastfeeding advice when taking medication?
encourage breastfeeding unless specifically contra-indicated
main drug issue in 1st vs 3rd trimester?
1st = teratogenicity 3rd = risk of neonatal withdrawal
main risk of drug in breastfeeding?
medication passing into breastmilk
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
first line antidepressants in pregnancy?
SSRI
- sertraline gets into the placenta the least
- fluoxetine is thought to be the safest
risksof SSRI in pregnancy?
persistent hypetension of newborn lower birth weight increased early birth post partum haemorrhage increased congenital cardiac..... problems in paroxetine
other antidepressatns in pregnancy and their risks?
tricyclics - dont really cause big problem, may cause mild withdrawal
venlafaxine - less evidence but may cause cardiac problems and cleft palate or neonatal withdrawal
limited evidence of risks of mirtazapine
risks of antipsychotics in pregnancy?
risk of gestational diabetes (esp with 2nd generation)
reduced fertility due to raised prolactin levels in people taking before pregnancy (esp 1st generation)
appear to be generally safe in pregnancy and dont harm baby
best antpsychotics?
generally olanzapine and quetiapine
best to be kept on medication
risks of bipolar in pregnancy?
induction or C section pre-term delivery small babies no increase in vongenital malformations ......
use of mood stabilizers in pregnancy?
no safe mood stabilisers
valproate and carbamazepine are most teratogenic and can cause neural tube defects and should be avoided
lamotrigine is less bad than other anti-convulsants
lithium risk?
should avoid in pregnancy is possible
known association to ebstein’s abnormality
ahould monitor regularly with ECHO and enhanced US
lithium use?
consider slow reduction pre-conception
be aware of dose changes in 3rd trimester
consider re-introduction immediately post-partum
recommendatinos for bipolar in pregnancy?
high relapse rate if medications stopped suddenly
aim to switch to a safer antipsychotic (e.g quetiapine)
valproate and carbamazepine should be avoided
increased monitoring if lithium is required
may need to consider ECT
management of anxiety in pregnancy?
SSRI = first line
benzodiazepines generally avoided but not teratogenic (but can cause 3rd trimester risk of floppy baby)
zopiclone also has evidence of risk
what type of drugs are regarded as safe in breastfeeding?
drugs with RID (relative infant dose) <10%
all psychotropics are secreted in breastmilk
prescribing in breastfeeding?
lowest possible dose
avoid combinations of drugs
times doses to feeds (i.e give dose before longest break between feeds)
generally if a drug is safe in 3rd trimester, its safe in breastfeeding
recommendations in breastfeeding?
antidepressants - SSRI 1st line - no need to change from drug used in pregnancy antipsychotics - olanzapine, quetiapine best evidence but othes probably OK - avoid clozapine (agranulocytosis risk) mood stabilisers - antipsychotics - avoid lithium and valproate
risks in substance abuse in pregnancy?
nutritional deficiency HIV, Hep B/C VTE STIs endocarditis/sepsis poor venous access opiate tolerance/withdrawal drug overdose/death risk of domestic abuse and suicide IUGR, stillbirth, SIDs, pre-term labour
alcohol recommendations in pregnancy?
RCOG suggests abstinence but no evidence that 2 units/week is detrimental
risks to pregnancy in alcoholism?
risks of miscarriage foetal alcohol syndrome withdrawal risk of wernicke's encephalopathy (20% die) korasfoff syndrome (permanent)
features of foetal alcohol syndrome?
facial deformity lower IQ neurodevelopmental delay epilepsy hearing heart and kidney defects
risks to pregnancy in cocaine, amphetamine and ecstsy use?
death via stroke and arrhythmia teratogenic - microcephaly, cardiac, GU and limb defects pre-eclampsia abruption IUGR pre-term labour miscarriage developmental delay SIDS withdrawal
risks of opiates and nicotine in pregnancy?
opiates cause maternal death, neonatal withdrawal, IUGR, SIDS and still birth
nicotine causes miscarriage, abruption, IUGR, stillbirth and SIDs
antenatal care in substance abuse?
consider methadone programme
child protection and social work referral
smear history
breastfeeding (not if >8 units alcohol per week, HIV, cocaine)
labour plan re analgesia and labour ward delivery
early IV access
postnatal contraception plan
