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Repro and Sexual Health > Perinatal Psychiatry > Flashcards

Perinatal Psychiatry Flashcards

1
Q

What is the biggest cause of mortality in the postnatal period?

A

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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2
Q

What predisposes to mental health problems in the postnatal period?

A

Previous psychiatric disorder
Substance misuse
FMHx of bipolar

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3
Q

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

A

Bipolar disorder

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4
Q

What are red flag presentations in the PN period that warrant urgent referral to a specialist perinatal mental health team?

A

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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5
Q

When should admission to a mother and baby unit be considered?

A 
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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6
Q

What are good questions to ask in assessment of maternal mental health?

A

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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7
Q

How are mental health issues screened for at booking appointments?

A

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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8
Q

What women should be referred to the psychiatry team?

A

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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9
Q

Is pregnancy protective against mental health conditions?

A

No

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10
Q

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

A

50% repalse in PN period

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11
Q

What are the risks of EDs in pregnancy?

A 
IUGR
Prematurity
Hypokalaemia
Hyponatraemia
Metabolic alkalosis
Miscarriage 
Premature delivery
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12
Q

What are the relapse rates of depression in pregnancy?

A

68% if medication stopped; so don’t

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13
Q

How many women will experience baby blues?

A

50%

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14
Q

What are the symptoms and duration of baby blue?

A

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

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15
Q

DDx of puerperal psychosis?

A

Episode of bipolar
Unipolar depression
Schizophrenia
Organic brain dysfunction

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16
Q

When will puerperal psychosis present and what are the symptoms?

A

Within 2 weeks of delivery

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

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17
Q

What are the risks with puerperal psychosis?

A

5% suicide risk

4% infanticide risk

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18
Q

What are risk factors for puerperal psychosis

A

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

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19
Q

How is puerperal psychosis managed?

A 
ADs
Antipsychotics
Mood stabilisers
ECT 
EMERGENCY
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20
Q

What are the symptoms of PN depression?

A 
Tearfulness
Irritable
Anxious
Anhedonia
Insomnia
Wt loss 
Can present with irrational concerns re baby
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21
Q

When will PN depression present?

A

2-6 weeks after delivery

Can last for weeks to months

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22
Q

What are issues to consider in the treatment of perinatal mental health disorders?

A

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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23
Q

What are the risks to the child of untreated depression?

A

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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24
Q

What are the principles of prescribing in the perinatal period?

A 
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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25
Q

In terms of drugs, what should be tried when prescribing in pregnancy?

A

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

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26
Q

Which medication is mostly affected by the altered pharmacokinetics in pregnancy?

A

Lithium

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27
Q

What are the risks of drugs in 1st trim?

A

Teratogenicity

28
Q

What are risks of drugs in 3rd trim?

A

Neonatal withdrawal

29
Q

Will drug concentrations be higher or lower in breast milk than in utero?

A

Lower

30
Q

What are 1st line ADs in pregnancy?

A

SSRI; sertraline has least placental exposure but fluoxetine thought to be safest

31
Q

What are the risks associated with SSRIs in pregnancy?

A

Persistent Pulmonary Hypertension of Newborn
Low birth weight
Increased preterm
PPH

32
Q

Should paroxetine be prescribed in pregnancy?

A

No; increased risk of congenital cardiac anomalies

Long withdrawal period

33
Q

Can TCAs be prescribed in pregnancy?

A

Yes; don’t appear to cause major issues

Some mild and self limiting neonatal withdrawal seen

34
Q

What can venlafaxine cause to babies?

A

Cardiac defects
Cleft palate
Neonatal withdrawal

35
Q

What is the risk with atypical antipsychotics in pregnancy?

A

Can cause weight gain and gestational diabetes

Reduced fertility due to raised prolactin levels

36
Q

Which antipsychotics have the biggest and best evidence base for use in pregnancy?

A

Olanzapine

Quetiapine

37
Q

What are the risks of bipolar disorder in pregnancy?

A

Induction of c/s
Preterm
IUGR

38
Q

Is there a safe mood stabiliser?

A

No; lamotrigine thought to be safest

39
Q

What 2 anticonvulsants are a no no in pregnancy?

A

SODIUM VALPROATE

CARBAMAZEPINE

40
Q

What abnormality is lithium known to cause?

A

Ebstein’s anomaly

41
Q

What is ebstein’s anomaly?

A

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.

42
Q

In what trim is lithium most dangerous?

A

1st; consider slow reduction preconception
Re-introduction in 2nd or 3rd trim
Be aware of dose changes in 3rd trim

43
Q

What extra screening is done for women on lithium in pregnancy?

A

Specific cardiac scan at 28 weeks

44
Q

What are the recommendations for bipolar affective disorder in pregnancy?

A

High relapse rates if meds reduced abruptly
Switch to safer antipsychotic; quetiapine
Valproate and carbamazepine AVOIDED
Increased monitoring if lithium
Consider ECT

45
Q

1st line for anxiety in pregnancy?

A

SSRIs

46
Q

Why are BZDs avoided in anxiety?

A 
Floppy baby (hypothermia, hypotonia, resp depression, withdrawal effects)
Cleft palate
47
Q

Which drugs are considered safe in breastfeeding?

A

<10% relative infant dose (RID)

48
Q

How can timing of medications be matched to feeds?

A

Give dose before longest break before feeds

49
Q

Which medication is a NO in breastfeeding?

A

Lithium; actively excreted into breast milk (same as sodium valproate but shouldn’t be on that anyway)

50
Q

Can clozapine be given in pregnancy?

A

No; risk of agranulocytosis in infant

51
Q

Which SSRIs should be avoided in breastfeeding?

A

Citalopram

Doxepin

52
Q

What can depot antipsychotics result in?

A

EPSE in neonates

53
Q

Should anticholinergics be used for EPSE in pregnancy?

A

No

54
Q

What monitoring of lithium levels should be performed in the 3rd trim?

A

Monthly
Weekly from 36 weeks
Again within 24 hours of childbirth

55
Q

What can lithium toxicity mimic in pregnancy?

A

Pre-eclampsia

56
Q

What is substance abuse assoc with?

A 
Mental illnesses; personality, depression, anxiety 
Nutritional deficiency
HIV, Hep B/C
VTE
STI
Endocarditis
Poor venous access
Opiate tolerance 
Drug overdose
57
Q

What are the risks to the baby of substance abuse in pregnancy?

A

IUGR
Stillbirth
SIDs
Preterm labour

58
Q

What does RCOG suggest in terms of alcohol?

A

Abstinence

No evidence that 2 units/ week is detrimental

59
Q

What are the risks associated with alcoholism in pregnancy?

A 
Miscarriage 
FAS
Withdrawal
Wernicke's encephalopathy
Korsakoff syndrome
60
Q

What are the signs of FAS?

A 
Facial deformities
Lower IQ 
Neurodevelopmental delay
Epilepsy 
Hearing
Heart and kidney defects
61
Q

What are the risks to the mother if they abuse cocaine, amphetamine and ecstasy in pregnancy?

A

Death via stroke and/or arrhythmias
Preeclampsia
Abruption

62
Q

What are the risks to the foetus from cocaine, amphetamine and ecstasy abuse in pregnancy?

A 
IUGR
Preterm labour
Miscarriage
Developmental delay
SIDs
Withdrawal
63
Q

What are the teratogenic profiles of cocaine, amphetamine and ecstasy abuse in pregnancy?

A

Microcephaly
Cardiac
GU
Limb defects

64
Q

Risk from opiate use in pregnancy?

A 
Maternal death
Neonatal withdrawal
IUGR
SIDs
Stillbirth
65
Q

Risks from nicotine use in pregnancy?

A 
Miscarriage
Abruption 
IUGR
Stillbirth
SIDs
66
Q

What is the recommended antenatal care for women who abuse substances in pregnancy?

A

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

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