Perinatal Psychiatry Flashcards
when do half of suicides after pregnancy occur
up to 12 weeks postnataly
what are the red flags for perinatal mental health
recent significant change in mental state or emergence of new symptoms
new thoughts or acts of violent self harm
new and persistent expression of incompetence as a mother or estrangement from their baby
what would make you consider an admission to a mother and baby unit
when a woman has any of:
- rapidly changing mental state
- suicide ideation (particularly of a violent nature)
- significant estrangement from the infant
- pervasive guilt or hopelessness
- beliefs of inadequacy as a mother
- evidence of pyschosis
what are good questions to ask to assess a new mothers 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 you are getting worse?
how is screening for mental health done
Booking appointment:
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
Screening: using questions- 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?
when should you refer to psychiatry
Psychosis/ previous 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
how does pregnancy interact with pre existing mental health problems
generally not protective
- bipolar: high rate of relapse
- ED: may be some improvement, risks of IUGR, prematurity, hypokalaemia, hyponatraemia, metabolic alkalosis, miscarriage, premature delivery
- antenatal depression: 68% relapse if stop meds in pregnancy, but if mild and on treatment consider stopping meds and refer to psychological Tx (CBT). if severe (suicidal, psychosis, self neglect, harm) refer to psychiatry
how is mild to mod depression in pregnancy treated
by GP
CBT/ medication
what is baby blues
50% of women get this
brief period of emotional instability
mothers are tearful, irritable, anxiety and poor sleep confusion
happens at day 3-10
what is the treatment for baby blues
happens days 3-10, is self limiting
support and reassurance
how does puerperal psychosis present
usually within 2 weeks of delivery
early symptoms: sleep disturbance, confusion and irrational ideas
mania, delusions, hallucinations, confusion
what are the risk factors for puerperal psychosis
BPAD, previous psychosis, 1st degree relative with Hx
what are the major risks in puerperal psychosis
5% suicide
4% infanticide
80% 10 year recurrence
25% go onto develop BPAD
what is the management for puerperal psychosis
is an emergency
needs admission to specialised mother baby unit
antidepressants, antipsychotics, mood stabilisers, ECT
how many women get post natal depression
10%
1/3rd last a year/ more
how does post natal depression present
onset 2-6 weeks postnatally
lasts weeks to months
tearfulness, irritability, anxiety, lack of enjoyment, poor sleep, weight loss, can present as concerns re baby
what does postnatal depression affect
bonding
child development
marriage
risk or suicide
what is the Tx for postnatal depression
mild-mod: self help, counselling
mod-severe: psychotherapy, antidepressants, admission?
what is the long term recurrence of postnatal depression
25% recurrence rate
70% lifetime risk of depression
what are the risk to the child in untreated depression
low birth weight
pre term delivery (by few days)
adverse childhood outcomes
poor engagement/ bonding with child (reduced infant learning and cognitive development)
what are the general rules for prescribing in pregnancy
be cautious with abruptly stopping drugs
lowest dose monotherapy - avoid depot
low risk drugs
increased screening for fetus (cardiac and growth)
be aware of altered pharmacokinetics in pregnancy (lithium especially)
encourage breast feeding where possible
risks of a drug can vary in stages of pregnancy/ breastfeeding
stopping a teratogenic drug after pregnancy is confirmed may not remove risk of malformation
what are the main risks with medications at each stage of pregnancy + after birth
1st trim: teratogenicity
3rd trim: risk of neonate withdrawal
breast feeding: medication passing into milk
why is fetal exposure to a drug in breast milk sometimes okay
as levels lower usually than in utero, therefore in general safer to stay on drug if it was used during pregnancy- can help prevent withdrawal effects
what antidepressant class are first line in pregnancy
SSRIs
are antidepressants teratogens
no (not major ones anyway)
which SSRIs are used in pregnancy
sertraline (least placental exposure)
fluoxetine (thought to be the safest)
what are the risks of SSRIs in pregnancy
persistent hypertension in the newborn
lower birth weight
increased early birth (days)
PPH
what is paroxetine and is it safe in pregnancy
SSRI
no- causes cardiac malformations
are tricyclics safe in pregnancy
do not appear to cause major problems
may be some mild and self limiting neonate withdrawal
imipramine and amitriptyline have lower risks than SSRIs
is venlafaxine safe in pregnancy
(SNRI)
less evidence, associated with cardiac defects, clef palate, neonate withdrawal
what is the general rules for depression in pregnancy
women with high risk of relapse should be maintained on medications during and after pregnancy
mod-severe depression should be treated with antidepressants
what antidepressants are safe in breastfeeding
sertraline (SSRI)
paroxetine (SNRI)
imipramine (TCA)
what antidepressants should you avoid in breastfeeding
citalopram (SSRI)
doxepin (TCA)
fluoxetines affect is uncertain (SSRI)
what are the effects of antipsychotics in pregnancy
create risk of gestational diabetes (esp 2nd gen)
reduce fertility due to raised prolactin levels
are antipsychotics safe in pregnancy
yes- no evidence of major teratogenicity
name 2 1st gen (typical) antipsychotics used in pregnancy
chlorpromazine
haloperidol
name 2 2nd gen (atypical) antipsychotics used in pregnancy
olanzipine
quetiapine
what is the advice for antipsychotics in pregnancy
women with repeated relapses are best maintained on medication, avoid rapid discontinuation
olanzapine and quetiapine have best evidence base
seek specialist advice
which antipyschotics are excreted in breast milk- what are the implications of this
all- but no evidence of fetal toxicity/ altered development
monitor for signs of sedation/ lethargy
is clozapine safe in pregnancy
(atypical antipsychotic)
avoid- risk of agranulocytosis to fetus
what is the increased risk of with olanzapine
GDM
weight gain
why should you avoid depot antipsychotics in pregnancy
as prolonges SEs- extra pyramidal side effects in neonates
what are the risk associated with bipolar AD in pregnancy
induction/ CS
pre term delivery
small babies
is there a high risk of bi polar relpase in pregnancy
yes- esp if stop medications and within 1st most postpartum
what is the best management for BPAD and pregnancy
have conversations before conception as no mood stabiliser safe in pregnancy
what mood stabilisers should you never give in pregnancy
SODIUM VALPROATE and carbamazepine (most teratogenic, neural tube defects)
which is the safest anti convulsant used for BPAD in pregnancy
lamotrigine
when does the neural tube close
day 28
what is the advice for sodium valporate
avoid in women of child bearing age
stop 3 months before planned pregnancies
use folate supplements
is sodium valporate safe in breast feeding
is low risk
no evidence of adverse effects
what else can sodium valporate cause
craniofacial defects
impaired intellectual development
what are the risks of lamotrigine
cleft lip a
avoid in 1st trim
risk of SJS in breast feeding
is lithium safe in pregnancy
no - avoid if possible
what can lithium in pregnancy cause
ebsteins abnormality- cardiac malformation (transformation of great vessels)
what is the advice for lithium in pregnancy
consider slow reduction pre conception (avoid sudden cessation)
can be reintroduces in 2nd/3rd trim
consider reintroduction immediately post partum if not breastfeeding
(relapse rates 70% after discontinuation)
monitor levels closely in 3rd trim as changes in vol of distribution- lithium toxicity can mimic PET
what extra montitoring is needed for expectant mothers on lithium
regular echo and enhanced US of fetua (to look for ebstiens abnormality)
is lithium safe in breastfeeding
no- very similar to sodium ion so excreted into milk and can be more concentrated
what is a safe antipsychotic than lithium
quetiapine
what might you need to consider in bipolar AD in pregnancy
ECT
what is the first line for anxiety in pregnancy
SSRIs
are benzodiazepines safe in pregnancy
not major teratogens
3rd trim risk of floppy baby
generally avoided
is zopiclone safe in pregnancy
limited date, some suggested risk
what are the features of floppy baby syndrome
hypothermia
hypotonia
resp depression
withdrawal effects
what are the risk of benzodiazepines when breastfeeding
lethargy
weight loss
which pyschotropic drugs are excreted in breast milk
all
what is the highest priority when breast feeding
treatment of mental health - esp if relaspe risk high
what general rules for prescribing in breast feeding
lowest possible dose
avoid combinations of medications
time doses to feeds (give dose before longest break between feeds)
if a drug has been used in third trim then exposure of fetus to drug will be less so safe to continue into breast feeding (except lithium)
what is the first line antidepressant in preganncy
sertaline
what is first line antipyschotics in pregnancy
olanzapine
quetiapine
what is the first line mood stabilisers in pregnancy
antipsychotics: olanzapine, quetiapine
what other factors do you need to consider in substance abuse in pregnancy
other associated mental illnesses nutritional deficiency HIV, Hep C, Hep B VTE STIs endocarditis/ sepsis poor venous access opiate tolerance/ withdrawal during delivery drug overdose/ death risk of domestic abuse and suicide IUGR, stillbirth, SIDs, pre term labour
what is the advice on alcohol in pregnancy
recommend abstinence, no evidence than 2 units a week is detrimental
what are the risks of alcoholism in pregnancy
miscarriage
foetal alcohol syndrome (facial deformities, lower IQ, neurodevelopmental delay, epilepsy, hearing, heart and kidney defects)
withdrawal
risk of wernickes and korsakoffs
what are the risks of cocaine, amphetamine and ecstasy in pregnancy
death via stroke and arrhythmias
teratogenic (microcephaly, cardiac, genitourinary, limb defects)
pre-eclampsia
abruption
IUGR
pre term labour
miscarriage
developmental delay, SIDS, withdrawal
what are the risks of opiates in pregnancy
cause maternal deaths, neonate withdrawal, IUGR, SIDS, stillbirth
what is the risk of nicotine in pregnancy
miscarriages abruption IUGR stillbirths SIDS
what extra considerations need to be made for antenatal care in mothers with substance abuse in pregnancy
Consider methadone programme
Child protection and social work referral
Smear History- can do from 12 weeks after birth (cant do in pregnancy as false +ves)
Breastfeeding (not if alcohol >8 , HIV, cocaine)
Labour plan re analgesia and labour ward delivery
Early IV access
Postnatal contraception plan
what extra precautions should be taken for a mother with alcohol dependence
Mothers safety- her partner, drug Hx, why is she drinking so much, quantify their smoking, is she already involved with social work, how is she funding alcohol (employed, sex worker?), social and housing situation, does she want to continue with her pregnancy
Alcohol misuse service, social work
Obstetric led care, routine booking, 20 weeks scans an then serial scans after as at risk of IUGR. B12, folic acid, thiamine and iron vitamin support. Community midwife for support. BMI support if low- dietician, supplements. Liver function monitoring
Withdrawal protocol when admitted and thiamine on admission
Baby will have withdrawal – jittery, irritable and slow to feed, plans for its care long term. Mother needs to consider contraception. Discourage breast feeding if mother continuing to drink after birth and baby going home with her. High risk of better PN depression
when does hyperemesis usually improve in pregnancy
16 weeks
