Perinatal psychiatry Flashcards
What predicts maternal suicide?
Previous psychiatric disorder, other vulnerable factors, family history of BP disorder
Who should get urgent referral to a specialist perinatal mental health team?
Women who report;
- recent significant change in mental state or emergence of new symptoms
- new thoughts or acts of violent self harm
- new and persistent expressions of incompentency as a mother or estrangement from their baby
When should admission to a mother and baby unit be considered?
If a woman has had any of the following;
- rapidly changing mental state
- suicidal ideation
- significant estrangement from the infant
- pervasive guilt or hopelessness
- beliefs of inadequacy as a mother
- evidence of psychosis
What are the risk factors for mental health issues?
- young/single
- domestic issues
- lack of support
- substance abuse
- unplanned/unwanted pregnancy
- pre existing mental health problem
What is the risk of relapse of bipolar disorder if untreated?
50% postnatally
What are the risks of eating disorders in pregnancy?
- IUGR
- prematurity
- hypokalaemia
- hyponatraemia
- metabolic alkalosis
- miscarriage
- premature delivery
Who manages mild-moderate antenatal depression?
GP
What is the baby blues?
Experienced by 50% of women
Brief period of emotional instability
Tearful, irritable, anxiety, confusion and poor sleep
Usually day 3-10 after birth
Self limiting, support and reassure
What is the differential diagnosis of puerperal psychosis?
- bipolar
- unipolar depression
- schizophrenia
- organic brain dysfunciton (2ry to physical illness)
When does puerperal psychosis usually present?
within 2 weeks of delivery
What are the symptoms of puerperal psychosis?
Sleep disturbance & confusion, irrational ideas
Mania, delusions, hallucinations
What is the risk of suicide and infanticide in puerperal psychosis?
5% suicide risk
4% infanticide risk
What are the risk factors for puerperal psychosis?
- bipolar disorder
- previous puerperal psychosis
- 1st degree relative with BP
What is the management of puerperal psychosis?
Emergency
Needs admission to mum and baby unit
Antiderpressants, antipsychotics, mood stabilisers and ECT
What percentage of mums with puerperal psychosis go on to develop bipolar disorder?
25%
How common is postnatal depression?
10% of women
What are the symptoms of post-natal depression?
- tearfulness
- irritability
- anxiety
- anhedonia
- poor sleep
- weight loss
- can often present as concerns about baby
When does postnatal depression occur?
2-6 weeks postnatally, lasts weeks to months
What is the management for postnatal depression?
- Mild-moderate: self-help, counselling
- Moderate-severe: psychotherapy and antidepressants, admission?
What is the lifetime risk of depression after an episode of postnatal depression?
70%
What issues should be considered in the treatment of perinatal disorders?
- risks of untreated illness- to mum and baby
- general principles of prescribing in perinatal period
- benefits and harms of specific treatment
What are the risks of untreated depression to the child?
- low birth weight
- pre-term delivery
- adverse childhood outcomes
- emotional & conduct problems, ADHD
- poor engagement/bonding with child
- reduced infant learning and cognitive development
What is the first line antidepressant in pregnancy?
SSRIs
- sertraline has least placental exposure
- fluoxetine is thought to be safest
What are the risks of SSRI’s in pregnancy?
- persistent hypertension of the newborn
- lower birth weight
- increased early birth (days)
- post partum haemorrhage
Why is paroxetine not used?
Least safe SSRI
Increased congenital cardiac malformations, less safe than others
Describe the use of tricyclics in pregnancy
Don’t seem to cause major problems
May be some mild & self-limiting neonatal withdrawal
Describe the use of venlafaxine in pregnancy
Less evidence
Cardiac defects and cleft palate, neonatal withdrawal
What are the first and second generation antipsychotics?
1st- Chlorpromazine, Haloperidol
2nd- Olanzapine, quetiapine
What are the risks of antipsychotics in pregnancy?
Gestational diabetes
How do antipsychotics decrease fertility?
Raise prolactin levels
Which antipsychotics are recommended in pregnancy?
Olanzapine and quetiapine
What are the risks of bipolar affective disorder ?
Induction or C-section
Pre-term delivery
Small babies
What are the best mood-stabilisers in pregnancy?
There is no safe mood stabiliser
Valproate and carbamazepine (most teratogenic) increase neural tube defects and should be avoided
Lamotrigine is less bad than other anti-convulsants
What should be done if mum is on lithium pre-pregnancy?
- Consider slow reduction preconception
- can be reintroduced in 2nd or 3rd trimester
- consider reintroduction post-partum
What are the recommendations for treatment of bipolar affective disorder?
switch to a safer antipsychotic - Quetiapine
Increased monitoring if lithium is required
May need to consider ECT
What is the first line medication in anxiety?
SSRIs
Describe the use of benzodiazepines for anxiety in pregnancy?
Benzodiazepines
- not major teratogens
- 3rd trimester risk of floppy baby
- generally thought to be problematic and to be avoided
Which drugs are secreted in breast milk?
All psychotropics are excreted in breast milk
Drugs with <__% relative infant dose (RID) are regarded as safe
Drugs with <10% relative infant dose (RID) are regarded as safe
What are the priority of treatment in breastfeeding?
- treatment of mental health is the highest priority, especially if relapse risk is high
- lowest possible dose
- avoid combinations of medications
- time doses to feeds
- give dose before longest break between feeds
- there is LESS exposure during breast feeding than in utero so if a drug has been used in 3rd trimester then if is reasonably safe to continue to use it in breastfeeding
What are the risks of substance abuse in pregnancy?
- nutritional deficiency
- HIV, Hep C, Hep B
- VTE
- STI
- Endocarditis/sepsis
- poor venous access
- opiate tolerance/withdrawal
- drug overdose/death
- domestic abuse and suicide
- IUGR, Stillbirth, SIDs, pre-term labour
RCOG suggests abstinence from alcohol but no evidence than _ units/week is detreimental
2
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 wernnicke’s encepahlopathy- 20% die (B1 deficiency)
- korsakoff syndrome - permanent
How do mums die from cocaine, amphetamines and ecstasy?
Death via steoke and arrhythmias
What are the risks with cocaine, amphetamines and ecstasy?
- teratogenic (microcephaly, cardiac, genitourinary, limb defects)
- pre-eclampsia
- abruption
- IUGR
- pre-term labour
- miscarriage
- developmental delay, SIDS, withdrawal
What do opiates cause?
Maternal deaths, neonatal withdrawal, IUGR, SIDS, stillbirth
What does nicotine cause?
Miscarriages, abruption, IUGR, stillbirths and SIDS
Describe antenatal care in substance abuse?
- consider methadone programme
- child protection and social work referral
- smear history
- breastfeeding (not if alcohol >8, HIV, cocaine)
- labour plan re analgesia and labour ward delivery
- early IV access
- postnatal contraception plan
