Perinatal Psychiatry Flashcards by Joanna Mitchell

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

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What predisposes to mental health problems in the postnatal period?

Previous psychiatric disorder
Substance misuse
FMHx of bipolar

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What is the single biggest risk for PN mental health problems?

Bipolar disorder

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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

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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

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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?

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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

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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

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Is pregnancy protective against mental health conditions?

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Is there a high rate of relapse of bipolar disorder in pregnancy?

50% repalse in PN period

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What are the risks of EDs in pregnancy?

IUGR
Prematurity
Hypokalaemia
Hyponatraemia
Metabolic alkalosis
Miscarriage 
Premature delivery

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What are the relapse rates of depression in pregnancy?

68% if medication stopped; so don’t

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How many women will experience baby blues?

50%

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What are the symptoms and duration of baby blue?

Brief period of emotional instability
Tearful, irritable, anxious, poor sleep, confusion
Days 3-10

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DDx of puerperal psychosis?

Episode of bipolar
Unipolar depression
Schizophrenia
Organic brain dysfunction

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When will puerperal psychosis present and what are the symptoms?

Within 2 weeks of delivery

Sleep disturbance, confusion, irrational ideas, mania, delusions, hallucinations

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What are the risks with puerperal psychosis?

5% suicide risk

4% infanticide risk

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What are risk factors for puerperal psychosis

Bipolar disorder (505)
Previous episode
1st degree relative with history

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How is puerperal psychosis managed?

ADs
Antipsychotics
Mood stabilisers
ECT 
EMERGENCY

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What are the symptoms of PN depression?

Tearfulness
Irritable
Anxious
Anhedonia
Insomnia
Wt loss 
Can present with irrational concerns re baby

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When will PN depression present?

2-6 weeks after delivery

Can last for weeks to months

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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

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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

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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

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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?

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