Perinatal Psychiatry

Question 1

Red flag presentations for psychiatry problems?

Answer 1

recent significant change in mental state 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

Question 2

Describe antenatal screening for mental health issues ?

Answer 2

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?

Question 3

Is pregnancy protective of existing mental health problems?

Answer 3

No, generally it is not protective
bipolar disorder has a high rate of relapse postnatally
some eating disorders can improve though but poor nutrition has effects on the pregnancy
a lot of depression cases will relapse

Question 4

Describe the baby blues?

Answer 4

Normal
50% women
Brief period of emotional instability
Tearful, irritable, anxiety, poor sleep & confusion
Day 3-10 self-limiting
Support and reassurance

Question 5

Is postpartum/puerperal psychosis an emergency?

Answer 5

yes- need same day referral to psychiatry if suspected

Question 6

When does postpartum/puerperal psychosis usually present?

Answer 6

within 2 weeks of delivery

Question 7

What are the symptoms of postpartum/ puerperal psychosis?

Answer 7

early symptoms are sleep disturbance and confusion, irrational ideas, progresses to mania, delusions and hallucinations
5% risk of suicide, 4% risk of infanticide

Question 8

Treatment and prognosis of postpartum/ puerperal psychosis?

Answer 8

urgent admission to inpatient mother and baby unit is necessary
illness responds rapidly to treatment
antipsychotics, antidepressants and mood stabalisers may be used and sometimes ECT
prognosis for a full recovery is good

Question 9

Is post natal depression common?

Answer 9

yes

Question 10

Onset of postnatal depression is usually ______ and it lasts ________

Answer 10

2-6 weeks postnatally

weeks to months

Question 11

Recurrence rate of postnatal depression?

Answer 11

25% recurrence rate

70% lifetime depression risk

Question 12

What effects can postnatal depression have?

Answer 12

can have effects on bonding, child development, marriage and there is a risk of suicide

Question 13

Describe antenatal care of substance abuse in pregnancy?

Answer 13

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 (as will need higher doses of analgesia due to toelrance)
Early IV access (as may be difficult if injected drugs)
Postnatal contraception plan

Question 14

Why may stopping a drug with known teratogenic risk after pregnancy occurred not be worth it?

Answer 14

if period of teratogenic risk has passed then it doesnt make a difference, the malformation if going to occur has occurred so may as well stay on the medication

Question 15

Describe use of antidepressants in pregnancy?

Answer 15

SSRIs are first line with most evidence
fluoxetine has most evidence
reasonably certain SSRIs arent major teratogens
paroxetine in question
women with moderate severe or high risk of relapse of depression in pregnancy should be treated with antidepressants

Question 16

Which SSRI has most evidence for safe use in pregnancy?

Answer 16

fluoxetine

Question 17

Which SSRI is there questions over safety in pregnancy?

Answer 17

paraoxetine- risk of cardiac abnormalities

Question 18

What antipsychotics have the best evidence base for safety in pregnancy?

Answer 18

2nd generation drugs

e.g. olanzapine and quetiapine

Question 19

Describe use of antipsychotics in pregnancy?

Answer 19

2nd generation drugs olanzapine and quetiapine have the best evidence base
overall antipsychotics appear to be safe
women with repeated relapses should stay on medicine
increase in GDM in 2nd generation due to weight gain as a drug side effect

Question 20

Describe use of mood stabalisers in pregnancy?

Answer 20

there are no safe mood stabalisers in pregnancy
valproate and carbamazepine are most teratogenic as cause neural tube defects and should be avoided
lamotrigine is less bad than other anti-convulsants and appears safer as evidence base increases
lithium should be avoided if possible, associated with cardiac anomalies particularly ebsteins anomaly (problem with tricuspid valve), could consider reintroduction immediately post partum

Question 21

Mood stabliser with the most evidence for safety in pregnancy?

Answer 21

lamotrigine

Question 22

3 mood stabalisers that should really be avoided in pregnancy?

Answer 22

valproate, carbamazepine and lithium

Question 23

Bipolar treatment recommendations in pregnancy?

Answer 23

high relapse rates in women with bipolar if medication is stopped abruptly
aim to switch to safer antipsychotic e.g. quetiapine
increased monitoring if lithium required

Question 24

Anxiety treatment recommendations in pregnancy?

Answer 24

SSRIs first line
benzodiazepines not major teratogens but in 3rd trimester there is risk of floppy baby so generally they should be avoided

Question 25

Describe breastfeeding and medication for psychiatric disorders in pregnancy?

Answer 25

all psychotropic drugs are excreted in breastmilk
drugs with <10% relative infant dose are regarded as safe
balance risk vs benefits of breastfeeding
give lowest dose possible and times doses between gaps in feed
there is less exposure during breast feeding than in utero so if a drug has been used in 3rd trimester safe to continue breastfeeding

Question 26

List some drugs fine in breastfeeding?

Answer 26

SSRIs fine
antispsychotics generally fine, quetiapine and olanzapine best evidence for safety
avoid clozapine as risk of infant get agranulocytosis
don’t breastfeed with lithium or valproate

Question 27

Can you breastfeed whilst taking lithium?

Answer 27

no

Question 28

Can you breastfeed whilst taking valproate?

Answer 28

no