Perinatal Psychiatry Flashcards
What is the biggest cause of mortality in the postnatal period?
Suicide; almost one in 3 women who died between 6 weeks and 1 year of pregnancy died of mental health related causes
18% suicide
What predisposes to mental health problems in the postnatal period?
Previous psychiatric disorder
Substance misuse
FMHx of bipolar
What is the single biggest risk for PN mental health problems?
Bipolar disorder
What are red flag presentations in the PN period that warrant urgent referral to a specialist 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 new mother or estrangement from baby
When should admission to a mother and baby unit be considered?
Rapidly changing mental state Suicidal ideation Significant estrangement from infant Pervasive guilt or hopelessness Beliefs of inadequacy as a mother Evidence of psychosis
What are good questions to ask in assessment of maternal mental health?
Do you have new feelings and thoughts which you have never had before, which make you disturbed or anxious
Are you experiencing thoughts of suicide or harming yourself in violent ways
Are you feeling incompetent, as though you can’t cope, or estranged from your baby? Are these feelings persistent?
Do you feel as if you are getting worse?
How are mental health issues screened for at booking appointments?
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
What women should be referred to the psychiatry team?
Psychosis or previous psychosis
Severe anxiety, depression, suicidal, self-neglect or self harm
Symptoms with significant interference with daily functioning
History of bipolar or schizophrenia
Psychotropic medications
Mod mental illness in late pregnancy or early PP
Mild-mod illness with 1st degree relative with bipolar or puerperal psychosis
Previous inpatient admissions to mental health unit
Is pregnancy protective against mental health conditions?
No
Is there a high rate of relapse of bipolar disorder in pregnancy?
50% repalse in PN period
What are the risks of EDs in pregnancy?
IUGR Prematurity Hypokalaemia Hyponatraemia Metabolic alkalosis Miscarriage Premature delivery
What are the relapse rates of depression in pregnancy?
68% if medication stopped; so don’t
How many women will experience baby blues?
50%
What are the symptoms and duration of baby blue?
Brief period of emotional instability
Tearful, irritable, anxious, poor sleep, confusion
Days 3-10
DDx of puerperal psychosis?
Episode of bipolar
Unipolar depression
Schizophrenia
Organic brain dysfunction
When will puerperal psychosis present and what are the symptoms?
Within 2 weeks of delivery
Sleep disturbance, confusion, irrational ideas, mania, delusions, hallucinations
What are the risks with puerperal psychosis?
5% suicide risk
4% infanticide risk
What are risk factors for puerperal psychosis
Bipolar disorder (505)
Previous episode
1st degree relative with history
How is puerperal psychosis managed?
ADs Antipsychotics Mood stabilisers ECT EMERGENCY
What are the symptoms of PN depression?
Tearfulness Irritable Anxious Anhedonia Insomnia Wt loss Can present with irrational concerns re baby
When will PN depression present?
2-6 weeks after delivery
Can last for weeks to months
What are issues to consider in the treatment of perinatal mental health disorders?
Risk of untreated illness to mother and baby
General principles of prescribing in perinatal period
Benefits and harms of specific treatment
What are the risks to the child of untreated depression?
Low birth weight
Preterm delivery by a couple of days
Adverse childhood outcomes; emotional and conduct disorder, ADHD
Poor engagement/ bonding with child; reduced infant learning and cognitive development
What are the principles of prescribing in the perinatal period?
PLAN PLAN PLAN Base decisions on individuals past history, frequency and severity of episodes (response to treatment) Discuss toxicology issues Consider stopping medications, changing or lowering dose MDT involvement Support groups
In terms of drugs, what should be tried when prescribing in pregnancy?
Use drugs with a low risk to mother and foetus
Lowest dose monotherapy (avoid depot)
Be aware of altered pharmacokinetics in pregnancy
Increased screening of foetus; cardiac, neural tube and growth
Encourage breastfeeding
Which medication is mostly affected by the altered pharmacokinetics in pregnancy?
Lithium
What are the risks of drugs in 1st trim?
Teratogenicity
What are risks of drugs in 3rd trim?
Neonatal withdrawal
Will drug concentrations be higher or lower in breast milk than in utero?
Lower
What are 1st line ADs in pregnancy?
SSRI; sertraline has least placental exposure but fluoxetine thought to be safest
What are the risks associated with SSRIs in pregnancy?
Persistent Pulmonary Hypertension of Newborn
Low birth weight
Increased preterm
PPH
Should paroxetine be prescribed in pregnancy?
No; increased risk of congenital cardiac anomalies
Long withdrawal period
Can TCAs be prescribed in pregnancy?
Yes; don’t appear to cause major issues
Some mild and self limiting neonatal withdrawal seen
What can venlafaxine cause to babies?
Cardiac defects
Cleft palate
Neonatal withdrawal
What is the risk with atypical antipsychotics in pregnancy?
Can cause weight gain and gestational diabetes
Reduced fertility due to raised prolactin levels
Which antipsychotics have the biggest and best evidence base for use in pregnancy?
Olanzapine
Quetiapine
What are the risks of bipolar disorder in pregnancy?
Induction of c/s
Preterm
IUGR
Is there a safe mood stabiliser?
No; lamotrigine thought to be safest
What 2 anticonvulsants are a no no in pregnancy?
SODIUM VALPROATE
CARBAMAZEPINE
What abnormality is lithium known to cause?
Ebstein’s anomaly
What is ebstein’s anomaly?
A congenital heart defect in which the septal and posterior leaflets of the tricuspid valve are displaced towards the apex of the right ventricle of the heart.
In what trim is lithium most dangerous?
1st; consider slow reduction preconception
Re-introduction in 2nd or 3rd trim
Be aware of dose changes in 3rd trim
What extra screening is done for women on lithium in pregnancy?
Specific cardiac scan at 28 weeks
What are the recommendations for bipolar affective disorder in pregnancy?
High relapse rates if meds reduced abruptly
Switch to safer antipsychotic; quetiapine
Valproate and carbamazepine AVOIDED
Increased monitoring if lithium
Consider ECT
1st line for anxiety in pregnancy?
SSRIs
Why are BZDs avoided in anxiety?
Floppy baby (hypothermia, hypotonia, resp depression, withdrawal effects) Cleft palate
Which drugs are considered safe in breastfeeding?
<10% relative infant dose (RID)
How can timing of medications be matched to feeds?
Give dose before longest break before feeds
Which medication is a NO in breastfeeding?
Lithium; actively excreted into breast milk (same as sodium valproate but shouldn’t be on that anyway)
Can clozapine be given in pregnancy?
No; risk of agranulocytosis in infant
Which SSRIs should be avoided in breastfeeding?
Citalopram
Doxepin
What can depot antipsychotics result in?
EPSE in neonates
Should anticholinergics be used for EPSE in pregnancy?
No
What monitoring of lithium levels should be performed in the 3rd trim?
Monthly
Weekly from 36 weeks
Again within 24 hours of childbirth
What can lithium toxicity mimic in pregnancy?
Pre-eclampsia
What is substance abuse assoc with?
Mental illnesses; personality, depression, anxiety Nutritional deficiency HIV, Hep B/C VTE STI Endocarditis Poor venous access Opiate tolerance Drug overdose
What are the risks to the baby of substance abuse in pregnancy?
IUGR
Stillbirth
SIDs
Preterm labour
What does RCOG suggest in terms of alcohol?
Abstinence
No evidence that 2 units/ week is detrimental
What are the risks associated with alcoholism in pregnancy?
Miscarriage FAS Withdrawal Wernicke's encephalopathy Korsakoff syndrome
What are the signs of FAS?
Facial deformities Lower IQ Neurodevelopmental delay Epilepsy Hearing Heart and kidney defects
What are the risks to the mother if they abuse cocaine, amphetamine and ecstasy in pregnancy?
Death via stroke and/or arrhythmias
Preeclampsia
Abruption
What are the risks to the foetus from cocaine, amphetamine and ecstasy abuse in pregnancy?
IUGR Preterm labour Miscarriage Developmental delay SIDs Withdrawal
What are the teratogenic profiles of cocaine, amphetamine and ecstasy abuse in pregnancy?
Microcephaly
Cardiac
GU
Limb defects
Risk from opiate use in pregnancy?
Maternal death Neonatal withdrawal IUGR SIDs Stillbirth
Risks from nicotine use in pregnancy?
Miscarriage Abruption IUGR Stillbirth SIDs
What is the recommended antenatal care for women who abuse substances in pregnancy?
Consider methadone programme
Child protection and social work referral
Smear history
Breastfeeding (not if alcohol >9, HIV, cocaine, lithium)
Labour plan re analgesia and labour ward delivery
Early IV access
PN contraception plan
