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Reproduction > Perinatal Psychiatry > Flashcards

Perinatal Psychiatry Flashcards

1
Q

when do half of suicides after pregnancy occur

A

up to 12 weeks postnataly

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2
Q

what are the red flags for perinatal mental health

A

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

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3
Q

what would make you consider an admission to a mother and baby unit

A

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
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4
Q

what are good questions to ask to assess a new mothers 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 you are getting worse?

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5
Q

how is screening for mental health done

A

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?

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6
Q

when should you refer to psychiatry

A

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

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7
Q

how does pregnancy interact with pre existing mental health problems

A

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
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8
Q

how is mild to mod depression in pregnancy treated

A

by GP

CBT/ medication

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9
Q

what is baby blues

A

50% of women get this
brief period of emotional instability
mothers are tearful, irritable, anxiety and poor sleep confusion
happens at day 3-10

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10
Q

what is the treatment for baby blues

A

happens days 3-10, is self limiting

support and reassurance

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11
Q

how does puerperal psychosis present

A

usually within 2 weeks of delivery
early symptoms: sleep disturbance, confusion and irrational ideas
mania, delusions, hallucinations, confusion

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12
Q

what are the risk factors for puerperal psychosis

A

BPAD, previous psychosis, 1st degree relative with Hx

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13
Q

what are the major risks in puerperal psychosis

A

5% suicide
4% infanticide

80% 10 year recurrence
25% go onto develop BPAD

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14
Q

what is the management for puerperal psychosis

A

is an emergency
needs admission to specialised mother baby unit
antidepressants, antipsychotics, mood stabilisers, ECT

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15
Q

how many women get post natal depression

A

10%

1/3rd last a year/ more

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16
Q

how does post natal depression present

A

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

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17
Q

what does postnatal depression affect

A

bonding
child development
marriage
risk or suicide

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18
Q

what is the Tx for postnatal depression

A

mild-mod: self help, counselling

mod-severe: psychotherapy, antidepressants, admission?

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19
Q

what is the long term recurrence of postnatal depression

A

25% recurrence rate

70% lifetime risk of depression

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20
Q

what are the risk to the child in untreated depression

A

low birth weight
pre term delivery (by few days)
adverse childhood outcomes
poor engagement/ bonding with child (reduced infant learning and cognitive development)

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21
Q

what are the general rules for prescribing in pregnancy

A

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

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22
Q

what are the main risks with medications at each stage of pregnancy + after birth

A

1st trim: teratogenicity
3rd trim: risk of neonate withdrawal
breast feeding: medication passing into milk

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23
Q

why is fetal exposure to a drug in breast milk sometimes okay

A

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

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24
Q

what antidepressant class are first line in pregnancy

A

SSRIs

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25
Q

are antidepressants teratogens

A

no (not major ones anyway)

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26
Q

which SSRIs are used in pregnancy

A

sertraline (least placental exposure)

fluoxetine (thought to be the safest)

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27
Q

what are the risks of SSRIs in pregnancy

A

persistent hypertension in the newborn
lower birth weight
increased early birth (days)
PPH

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28
Q

what is paroxetine and is it safe in pregnancy

A

SSRI

no- causes cardiac malformations

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29
Q

are tricyclics safe in pregnancy

A

do not appear to cause major problems
may be some mild and self limiting neonate withdrawal

imipramine and amitriptyline have lower risks than SSRIs

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30
Q

is venlafaxine safe in pregnancy

A

(SNRI)

less evidence, associated with cardiac defects, clef palate, neonate withdrawal

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31
Q

what is the general rules for depression in pregnancy

A

women with high risk of relapse should be maintained on medications during and after pregnancy
mod-severe depression should be treated with antidepressants

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32
Q

what antidepressants are safe in breastfeeding

A

sertraline (SSRI)
paroxetine (SNRI)
imipramine (TCA)

33
Q

what antidepressants should you avoid in breastfeeding

A

citalopram (SSRI)
doxepin (TCA)
fluoxetines affect is uncertain (SSRI)

34
Q

what are the effects of antipsychotics in pregnancy

A

create risk of gestational diabetes (esp 2nd gen)

reduce fertility due to raised prolactin levels

35
Q

are antipsychotics safe in pregnancy

A

yes- no evidence of major teratogenicity

36
Q

name 2 1st gen (typical) antipsychotics used in pregnancy

A

chlorpromazine

haloperidol

37
Q

name 2 2nd gen (atypical) antipsychotics used in pregnancy

A

olanzipine

quetiapine

38
Q

what is the advice for antipsychotics in pregnancy

A

women with repeated relapses are best maintained on medication, avoid rapid discontinuation
olanzapine and quetiapine have best evidence base
seek specialist advice

39
Q

which antipyschotics are excreted in breast milk- what are the implications of this

A

all- but no evidence of fetal toxicity/ altered development

monitor for signs of sedation/ lethargy

40
Q

is clozapine safe in pregnancy

A

(atypical antipsychotic)

avoid- risk of agranulocytosis to fetus

41
Q

what is the increased risk of with olanzapine

A

GDM

weight gain

42
Q

why should you avoid depot antipsychotics in pregnancy

A

as prolonges SEs- extra pyramidal side effects in neonates

43
Q

what are the risk associated with bipolar AD in pregnancy

A

induction/ CS
pre term delivery
small babies

44
Q

is there a high risk of bi polar relpase in pregnancy

A

yes- esp if stop medications and within 1st most postpartum

45
Q

what is the best management for BPAD and pregnancy

A

have conversations before conception as no mood stabiliser safe in pregnancy

46
Q

what mood stabilisers should you never give in pregnancy

A

SODIUM VALPROATE and carbamazepine (most teratogenic, neural tube defects)

47
Q

which is the safest anti convulsant used for BPAD in pregnancy

A

lamotrigine

48
Q

when does the neural tube close

A

day 28

49
Q

what is the advice for sodium valporate

A

avoid in women of child bearing age
stop 3 months before planned pregnancies
use folate supplements

50
Q

is sodium valporate safe in breast feeding

A

is low risk

no evidence of adverse effects

51
Q

what else can sodium valporate cause

A

craniofacial defects

impaired intellectual development

52
Q

what are the risks of lamotrigine

A

cleft lip a
avoid in 1st trim
risk of SJS in breast feeding

53
Q

is lithium safe in pregnancy

A

no - avoid if possible

54
Q

what can lithium in pregnancy cause

A

ebsteins abnormality- cardiac malformation (transformation of great vessels)

55
Q

what is the advice for lithium in pregnancy

A

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

56
Q

what extra montitoring is needed for expectant mothers on lithium

A

regular echo and enhanced US of fetua (to look for ebstiens abnormality)

57
Q

is lithium safe in breastfeeding

A

no- very similar to sodium ion so excreted into milk and can be more concentrated

58
Q

what is a safe antipsychotic than lithium

A

quetiapine

59
Q

what might you need to consider in bipolar AD in pregnancy

A

ECT

60
Q

what is the first line for anxiety in pregnancy

A

SSRIs

61
Q

are benzodiazepines safe in pregnancy

A

not major teratogens
3rd trim risk of floppy baby
generally avoided

62
Q

is zopiclone safe in pregnancy

A

limited date, some suggested risk

63
Q

what are the features of floppy baby syndrome

A

hypothermia
hypotonia
resp depression
withdrawal effects

64
Q

what are the risk of benzodiazepines when breastfeeding

A

lethargy

weight loss

65
Q

which pyschotropic drugs are excreted in breast milk

A

all

66
Q

what is the highest priority when breast feeding

A

treatment of mental health - esp if relaspe risk high

67
Q

what general rules for prescribing in breast feeding

A

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)

68
Q

what is the first line antidepressant in preganncy

A

sertaline

69
Q

what is first line antipyschotics in pregnancy

A

olanzapine

quetiapine

70
Q

what is the first line mood stabilisers in pregnancy

A

antipsychotics: olanzapine, quetiapine

71
Q

what other factors do you need to consider in substance abuse in pregnancy

A 
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
72
Q

what is the advice on alcohol in pregnancy

A

recommend abstinence, no evidence than 2 units a week is detrimental

73
Q

what are the risks of alcoholism in pregnancy

A

miscarriage
foetal alcohol syndrome (facial deformities, lower IQ, neurodevelopmental delay, epilepsy, hearing, heart and kidney defects)
withdrawal
risk of wernickes and korsakoffs

74
Q

what are the risks of cocaine, amphetamine and ecstasy in pregnancy

A

death via stroke and arrhythmias
teratogenic (microcephaly, cardiac, genitourinary, limb defects)
pre-eclampsia
abruption

IUGR
pre term labour
miscarriage
developmental delay, SIDS, withdrawal

75
Q

what are the risks of opiates in pregnancy

A

cause maternal deaths, neonate withdrawal, IUGR, SIDS, stillbirth

76
Q

what is the risk of nicotine in pregnancy

A 
miscarriages 
abruption 
IUGR
stillbirths 
SIDS
77
Q

what extra considerations need to be made for antenatal care in mothers with substance abuse in pregnancy

A

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

78
Q

what extra precautions should be taken for a mother with alcohol dependence

A

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

79
Q

when does hyperemesis usually improve in pregnancy

A

16 weeks

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