Perinatal Psychiatry Flashcards
Maternal suicide is the leading cause of direct maternal deaths for how long after delivery of a pregnancy?
Leading cause of maternal death for 1 year after birth
What symptoms reported by pregnant women would indicate urgent referral is needed to the perinatal mental health team?
- significant change in mental state OR new symptoms
- New thoughts / acts of violent self harm
- New / persistent expressions of incompetency as a mother or estrangement from their baby
What recommendations does the “Saving Mother’s Lives” campaign make with regards to communication in perinatal psychiatry?
- At booking enquire about current/ PMHx of mental health problems
- If women visit their GP during pregnancy, GPs should communicate about past psych. history in antenatal referral
- Antenatal services, GPs and psychiatry should communicate with well with each other
When should admission to a mother and baby unit be considered?
- rapidly changing mental state
- suicidal ideation
- significant estrangement from infant
- pervasive guilt/ hopelessness
- beliefs of inadequacy as a mother
- evidence of psychosis
How should mental health disorders be screened for at booking appointments?
- Check for Hx of mental health problems
- Previous treatment
- Family Hx
- Risk factors:
- Young/ single
- domestic issues
- lack support
- substance abuse
- unplanned/unwanted pregnancy
- pre existing mental health problem
What questions about mental health problems should be screened for at every antenatal 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?
What mental health symptoms or conditions during or after pregnancy should be referred to a psychiatrist?
- Psychosis
- Severe anxiety, depression, suicidal, self-neglect, self harm
- Symptoms impairing daily functioning
- History of bipolar/ schizophrenia/ puerperal psychosis
- Psychotropic medications
- Developed moderate mental illness in late pregnancy or early postpartum
Pregnancy can cause previous mental health problems to get better? TRUE/FALSE?
FALSE
- Pregnancy is not protective
- Some may improve slightly (e.g. eating disorder) but risk of relapse is high
What are the risks of a mother suffering from an eating disorder during pregnancy?
- IUGR
- prematurity
- hypokalaemia
- hyponatraemia
- metabolic alkalosis
- miscarriage
If a patient experiences mild to moderate depression and wishes to come off her medication during pregnancy, what options can be offered?
- Stop medication and refer for psychological treatment during this time
- Promote self help strategies – CBT (computerised)
How long does Baby Blues normally last?
- Day 3-10 postnatal
- self-limiting
What symptoms are commonly experienced in Baby Blues?
Tearful irritable anxiety poor sleep confusion
HOw is Baby Blues treated?
Support and reassurance
When does Puerperal psychosis normally present?
Usually presents within 2 weeks of delivery
What symptoms are often seen in puerperal psychosis?
- Early symptoms = sleep disturbance, confusion, irrational ideas
- Late symptoms = Mania, delusions, hallucinations, confusion
Why is puerperal psychosis a big risk to both mother and baby?
Increased risk of both suicide (5%) and infanticide (4%)
How is puerperal psychosis managed?
Refer for admission to specialised mother-baby unit
Antidepressants, antipsychotics, mood stabilizers and ECT can be used
What does one episode of puerperal psychosis increase the long term risk of?
80% = 10 year recurrence 25% = develop bipolar disorder
What symptoms are common to post-natal depression?
Tearfulness irritable anxiety lack of enjoyment poor sleep weight loss
When does post-natal depression normally start and how long does this last for?
Onset 2-6 weeks postnatally
Lasts weeks to months
Post-natal depression can affect more than just the mother. What else can it affect?
Bonding with child
child development
marriage
suicide risk
How is post-natal depression treated?
Mild-moderate = self help/counselling
Moderate-severe = psychotherapy and antidepressants
or admission if req’d.
What long term consequences result from post-natal depression?
25% recurrence
70% lifetime risk depression
Untreated depression in the mother poses what risk to the child?
- Low birth weight
- Pre-term delivery
- Adverse childhood outcomes
- Poor engagement / bonding with child
What should be considered before prescribing in the perinatal period?
- ideally plan the pregnancy to have everything organised first
- Base prescribing decisions on past history, frequency & severity of episodes
- Discuss toxicology of some medications
- Consider stopping medication, changing medication or lowering dose
How can prescribing in the perinatal period be made as safe as possible?
- use drugs with low risk to both mother and foetus
- Lowest dose monotherapy (avoid depot)
- Be aware of altered pharmacokinetics in pregnancy
- Increase screening of foetus - cardio and growth
- Encourage breastfeeding
- Don’t abruptly stop medication
What SSRIs are recommended in pregnancy?
Sertraline or Fluoxetine
Paroxetine = last resort as may cause foetal heart defects
Why should benzodiazepine use be avoided in late pregnancy?
Can cause “floppy baby” syndrome
- sedated, poor breathing and feeding etc
What are the side effects of second generation antipsychotics and why is this a risk in pregnancy?
Cause weight gain
=> increased risk of Gestational diabetes
Why should clozapine be avoided in pregnancy and breastfeeding?
Small risk of agranulocytosis to foetus
Why should depot injection antipsychotics be avoided in pregnancy?
Prolonged effects can cause complications such as Extra Pyramidal Side Effects in neonates
Why is lithium thought to be a risk in pregnancy?
Small association with Ebsteins anomaly (Transposition of Great Vessels)
Can lithium be taken when breastfeeding?
NO
What Mood stabilisers are teratogenic and should be avoided in pregnancy?
Sodium Valproate and Carbamazepine
What mood stabiliser is safer for use in pregnancy but still must be monitored?
Lamotrigine
What problems may substance abuse cause during pregnancy?
- Nutritional deficiency
- HIV, Hep C, Hep B
- VTE
- STIs
- Endocarditis/ Sepsis
- Poor venous access
- Opiate tolerance/ withdrawal
- IUGR, Stillbirth, Sudden Infant Death, pre-term labour
What complications of pregnancy are due to alcoholism?
- Risks of miscarriage
- Foetal Alcohol Syndrome - facial deformities, lower IQ, neurodevelopmental delay, epilepsy, hearing, heart and kidney defects
- Withdrawal
- Wernicke’s encephalopathy
- Korsakoff Syndrome (permanent)
What complications in pregnancy can occur due to illicit drug use of cocaine, amphetamine and ecstasy?
- Death via stroke and arrhythmias
- Teratogenic (microcephaly, cardiac, genitourinary, limb defects)
- Pre-eclampsia
- Abruption
- IUGR
- Pre-term labour
- Miscarriage
- Developmental delay, SIDS, withdrawal
What antenatal care should be offered to mothers struggling with substance abuse?
- methadone programme
- Child protection/ social work referral
- Smear History
- Encourage breastfeeding if meeting criteria (not if alcohol >8 units/week , HIV with positive titre, cocaine)
- Labour plan re analgesia and labour ward delivery
- Early IV access (consult anaesthetist)
- Postnatal contraception plan
