Perinatal Psychiatry Flashcards
What is the leading cause of death in the UK?
Mental illness
When do half of suicides occur?
Up to 12 weeks postnatally
How common are mental health-related deaths after pregnancy?
Almost 1/3 women who die between 6 weeks and 1 year after pregnancy died of mental health related causes = 18% due to suicide
What presentations need an urgent referral to specialist perinatal health team?
Recent significant change in mental health or emergence of new symptoms
New thoughts or acts of violent self harm
new and persistent expressions of incompetency as a mother or estrangement from their baby
What presentations who need admission to a mother and baby unit?
Rapidly changing mental state or suicidal ideation
Significant estrangement from child
Beliefs of inadequacy as mother
Pervasive guilt/hopelessness or evidence of psychosis
What are the risk factors for mental health issues during or after pregnancy?
Young or single, domestic issues, lack support, substance abuse, unplanned/unwanted pregnancy, pre-existing mental health problem
What symptoms should you refer to the psychiatry team?
Psychosis, suicidal, self neglect/harm,
severe anxiety/depression or symptoms with significant interference with daily functioning
What features in a past medical history should you refer to the psychiatry team?
History of puerperal psychosis, bipolar or schizophrenia
Psychotropic medications or previous in-patient admission to mental health unit
When should you refer to the psychiatry team?
If developed moderate mental illness in late pregnancy or early postpartum
Mild/moderate mental illness but first degree relative with bipolar or puerperal psychosis
Is pregnancy protective against mental illness?
No = doesn’t tend to offer protective benefit, eating disorders may improve
How does pregnancy affect bipolar disorder?
High rate of relapse postnatally = 50% if untreated
What are the complications associated with eating disorders during pregnancy?
IUGR, prematurity, hypokalaemia, hyponatraemia, metabolic alkalosis, miscarriage, premature delivery
How does pregnancy affect antenatal depression?
68% relapse is the stop medication during pregnancy
What are the baby blues?
Brief period of emotional instability = self, limiting, occurs from days 3-10 after pregnancy, affects 50%
What are the symptoms and management for the baby blues?
Symptoms = tearful, irritable, poor sleep, confusion Management = support and reassurance
What are the differentials of puerperal psychosis?
Bipolar episode, unipolar depression, schizophrenia, organic brain dysfunction
When does puerperal psychosis tend to present?
Within 2 weeks of delivery
What are the symptoms of puerperal psychosis?
Sleep disturbance, confusion and irrational ideas
Leads to mania, delusions, hallucinations and confusion
How common is puerperal psychosis?
Occurs in 0.1% of women = carries 5% risk of suicide and 4% risk of infanticide
What are the risk factors for puerperal psychosis?
Bipolar disorder, previous puerperal psychosis (50%), first degree relative with history of bipolar
How is puerperal psychosis managed?
Emergency = needs admission to mother-baby unit
Antidepressants, antipsychotics, mood stabilisers, ECT
What can women who suffer from puerperal psychosis go on to develop?
25% go on to develop bipolar disorder
How common is post-natal depression?
10% of women = 1/3 last a year or more, screened for routinely
When is the usual onset of postnatal depression?
2-6 weeks postnatally
What are the symptoms of postnatal depression?
Tearfulness, irritable, anxiety, lack of enjoyment, poor sleep, weight loss, may present as being concerned about baby
What can postnatal depression have an effect on?
Bonding, child development, marriage and suicide risk
How is postnatal depression treated?
Mild-moderate = self help and counselling Moderate-severe = psychotherapy and antidepressants
What is the prognosis of postnatal depression?
25% recurrence and 70% lifetime risk of depression
What are the risk posed to the child by maternal mental illness?
Low birth weight, preterm delivery, adverse childhood outcomes, poor engagement/bonding with child
What should be done when prescribing in the perinatal period?
Preferentially use drugs with low risk to mother/foetus
Lowest dose monotherapy and increase screening
Encourage breastfeeding
Does stopping a known teratogenic drug after pregnancy is confirmed remove the risk?
No = may not remove risks of foetal malformations
What are the first line antidepressants?
SSRIs = sertraline has least placental exposure but fluoxetine thought to be safest
What are the risks of using antidepressants during pregnancy?
Persistent hypertension of newborn, lower birth weight, increased early birth, post partum haemorrhage
What SSRI should be avoided during pregnancy?
Paroxetine = may cause congenital cardiac malformations, less safe than other SSRIs
Can tricyclic antidepressants be used during pregnancy?
Yes = don’t seem to cause major problems, may cause some mild and self limiting neonatal withdrawal
What foetal abnormalities is venlafaxine associated with?
cardiac defects, cleft palate and neonatal withdrawal
What are some examples of antipsychotics?
1st generation = chlorpromazine, haloperidol
2nd generation = olanzapine, quetiapine
What are the risks of using antipsychotics during pregnancy?
Risk of gestational diabetes = especially 2nd gen
Reduce fertility due to raised prolactin levels
What can clozapine cause in the foetus when taken during pregnancy?
Agranulocytosis
When is there high risk of relapse of bipolar disorder?
After delivery is mood stabilisers stopped = especially in first month postpartum
What are the risks of bipolar disorder during pregnancy?
Induction or C-section, preterm delivery, small babies
What are some features of using mood stabilisers during pregnancy?
Carbamazepine most teratogenic
Avoid valproate and carbamazepine = neural tube defects
Lamotrigine is less bad
Why should lithium be avoided during pregnancy?
Associated with Ebstein’s abnormality
How should women taking lithium have their medication stopped?
Consider slow reduction preconception = may reintroduce in 2nd or 3rd trimester or immediately postpartum
How high is the relapse rate of bipolar disorder after lithium is stopped?
Up to 70% after discontinuation
How should women who were taking lithium before becoming pregnant managed?
Regular ECHO and enhanced US scans
What is the first line treatment for anxiety?
Antidepressants = use SSRIs
What are some treatments for anxiety that should be avoided during pregnancy?
Benzodiazepines = 3rd trimester risk of floppy baby
Zopiclone has some suggestion of risk
Are psychotropics usually excreted in breastmilk?
Yes = drugs with <10% relative infant dose (RID) considered safe
How should drugs be prescribed during breastfeeding?
Lowest possible dose and give dose before longest break in feeding
If a drug was used in the 3rd trimester, should it be safe to use when breastfeeding?
Yes = less exposure during breastfeeding than in utero
What is an example of a drug secreted into breastmilk?
Lithium
What is substance abuse?
Mental and behavioural disorder = associated with depression, anxiety and personality disorders
What are the complications of substance abuse?
Nutritional deficiency, HIV, hep B and C, VTE, STIs, sepsis, endocarditis, opiate tolerance/withdrawal, OD, IUGR, SIDs, stillbirth, preterm labour, increased risk of domestic abuse and suicide
What are the risks associated with alcoholism during pregnancy?
Miscarriage, Wernicke’s encephalopathy (20%), foetal alcohol syndrome
What are some features of foetal alcohol syndrome?
Facial deformities, lower IQ, neurodevelopmental delay, epilepsy, heart and kidney defects
What are the risks associated with cocaine, amphetamine and ecstasy use during pregnancy?
Death due to stroke or arrhythmia
Pre-eclampsia, abruption, IUGR, preterm labour, miscarriage, withdrawal, SIDS, developmental delay
Teratogenic = microencephaly, limb/cardiac defects
What are the risk associated with opiate use during pregnancy?
Maternal deaths (1-2%), neonatal withdrawal, IUGR, SIDS and stillbirth
What are the risks associated with nicotine use during pregnancy?
Miscarriage, abruption, IUGR, stillbirths, SIDS
What antenatal care is given to those suffering from substance abuse?
Methadone programme and social work referral
Child protection, smear history and early IV access
When would breastfeeding be contraindicated in someone with substance abuse issues?
If HIV positive, using cocaine of alcohol >8
