Perinatal Psychiatry

Question 1

List the red flags that would warrant urgent referral to specialist perinatal mental health team.

Answer 1

If a woman reports:
Recent significant change in mental state or emergence of new symptoms.
New thoughts or acts of violent self-harm.
New and persistent expressions of incumbency as a mother or estrangement from their baby.

Question 2

What would make you consider admission of a pregnant woman to the mother and baby unit?

Answer 2

rapidly changing mental state
suicidal ideation (especially of violent nature)
significant estrangement from the infant
pervasive guilt or hopelessness
beliefs of inadequacy as a mother 
evidence of psychosis

Question 3

A brief period of emotional instability …?

Answer 3

Baby blues

Question 4

A first time mum presents to GP 4 days after delivery, tearful, sleep deprived and anxious. Her husband reports her seeming confused at times.
Diagnosis & management?

Answer 4

baby blues

support and reassure

Question 5

What is the time scale of presentation for baby blues?

Answer 5

3-10 days after delivery

Question 6

What is the time scale for puerperal psychosis developing?

Answer 6

within 2 weeks of delivery (but rarely occurs within first 2 days)

Question 7

What are the early symptoms of puerperal psychosis? What develops after these?

Answer 7

sleep disturbance and confusion
irrational ideas

mania, delusions, hallucinations, confusion

Question 8

List the risk factors for puerperal psychosis?

Answer 8

bipolar disorder
previous puerperal psychosis (50%)
1st degree relative with Hx of bipolar disorder

Question 9

A 32 y/o Para 1 woman is in for her booking appointment. She has a Hx of puerperal psychosis; not currently on any medications. she has a good partner and family support. She is extremely worried about recurrence.

What do you tell her about recurrence rates? What is your management plan?

Answer 9

80% 10 year recurrence rate so it is very likely she will get this again.
However, she is able to self-refer to the mother and baby unit if this would put her at ease.

Management - since she is stable and has good support she does not need any antidepressants, antipsychotics or mood stabilisers as of yet; however, she should give birth and stay in the mother and baby unit in the puerperal period where they can monitor her.

Question 10

There is a 25% chance of developing which mental health condition after an episode of puerperal psychosis?

Answer 10

bipolar disorder

Question 11

What is the time scale for onset of post-natal depression?

Answer 11

onset 2-6 weeks postnatally - lasts weeks-months

lasts over a year in 1/3

Question 12

What are some symptoms/signs of postnatal depression?

Answer 12

tearful, irritable, anxiety, lack of enjoyment, poor sleep, weight loss
can present as concerns about the baby

Question 13

What can post-natal depression effect?

Answer 13

bonding, child development, marriage, suicide risk

Question 14

Which class of antidepressants are 1st line?

Answer 14

SSRIs

Question 15

Which SSRI causes least placental exposure?

Answer 15

sertraline

Question 16

Which SSRI is thought to be the safest?

Answer 16

fluoxetine

Question 17

Which SSRI would you generally avoid and why?

Answer 17

paroxetine - more likely to cause heart problems

Question 18

What impact do TCAs have on pregnancy?

Answer 18

don’t appear to cause major problems - used less but if mother is on them since SSRIs didn’t work for her, then there is no point switching her back.

Question 19

What are the risks of having bipolar disorder and being pregnant?

Answer 19

more likely to have IOL or c/section, pre-term delivery, small babies

Question 20

Bipolar disorder increases the risk of congenital malformations? T/F?

Answer 20

FALSE

having bipolar disorder doesn’t cause an increase in malformations

Question 21

Which antipsychotics have best evidence for use in pregnancy?

Answer 21

olanzapine and quetiapine (2nd gen)

Question 22

Which 1st generation antipsychotics appear to be safe in pregnancy?

Answer 22

chlorpromazine and haloperidol

Question 23

Why is there a risk of GDM / macrosomia when using antipsychotics?

Answer 23

(olanzapine) weight gain would result in risk of GDM

Question 24

What effect do antipsychotics have on fertility?

Answer 24

reduced fertility since higher prolactin levels

Question 25

What effects the risk of relapse of bipolar disorder in pregnancy?

Answer 25

high risk fo relapse after delivery if mood stabilisers are discontinued - particularly in 1st month postpartum

Question 26

What is the generally attitude towards mood stabilisers in pregnancy?

Answer 26

no “safe” stabiliser - pre-conception discussions needed

use anti-psychotics instead if possible

Question 27

which mood stabilisers are the most teratogenic?

Answer 27

sodium valproate and carbamazepine

increase neural tube defects and should be AVOIDED

Question 28

which anti-convulsant is less bad vs. the others?

Answer 28

lamotrigine

Question 29

When does the neural tube close in embryological development? What implication does this have on sodium valproate use?

Answer 29

closes day 28

therefore Na valproate can cause NTDs by 4 weeks of pregnancy (hence pre-conception discussions needed)

Question 30

Patient presents who currently uses lithium to control her bipolar disorder. What do you need to consider re her drug treatment if she becomes pregnant?

Answer 30

Slow reduction of lithium preconception - can be reintroduced in 2nd/3rd trimester.
In 3rd trimester the dose would have to change because lithium’s pharmacokinetics will change due to the high increase in fat tissue.
Can try switch her to quetiapine for a short time (safer) but consider re-introduction postpartum.

Question 31

If a patient is on lithium during pregnancy, what tests are needed regularly? (apart from bloods)

Answer 31

regular ECHO and enhanced US

Question 32

Can a mum be on lithium and breastfeed?

Answer 32

NO - it is secreted into breastmilk in uncontrolled levels. (The only time mum has to choose between drug and breastfeeding)

Question 33

Which congenital abnormality is Lithium known to cause?

Answer 33

Ebstein’s anomaly = atrial-septal defect (ASD) and displaced tricuspid valve (small RV)

Question 34

Eating disorders get worse during pregnancy.

T/F?

Answer 34

FALSE

May be some improvement in pregnancy.

Question 35

What are the risks of having an eating disorder and being pregnant?

Answer 35

IUGR, prematurity, hypokalaemia, hyponatraemia, metabolic alkalosis, miscarriage, premature delivery

Question 36

What is 1st line drug treatment for anxiety in pregnancy?

Answer 36

SSRIs

Question 37

What is the 3rd trimester risk of benzodiazepines?

Answer 37

floppy baby

thought to be problematic so avoid if possible

Question 38

which hypnotic/anxiolytic drug has limited data in pregnancy but there is some suggestion of risk?

Answer 38

zopiclone

Question 39

All psychotropics are excreted into breast milk.

T/F?

Answer 39

TRUE

Question 40

Which psychotropics are regarded as safe to use in pregnancy?

Answer 40

drugs with <10% Relative Infant Dose (RID)

Question 41

If a drug was used during 3rd trimester pregnancy, what does this mean about its use during breastfeeding?

Answer 41

since there is greater exposure in utero than in breastfeeding - if a drug was used in 3rd trimester then it should be reasonably safe to use when breastfeeding

Question 42

How should a new mum time her psychotropic drugs with her baby’s feeds?

Answer 42

take drug at start of longest break between feeds

Question 43

Benzodiazepines are teratogenic.

T/F?

Answer 43

FALSE

they are not major teratogens - but still try to avoid