Perinatal Psychiatry Flashcards
Red flag presentations for psychiatry problems?
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
Describe antenatal screening for mental health issues ?
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?
Is pregnancy protective of existing mental health problems?
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
Describe the baby blues?
Normal 50% women Brief period of emotional instability Tearful, irritable, anxiety, poor sleep & confusion Day 3-10 self-limiting Support and reassurance
Is postpartum/puerperal psychosis an emergency?
yes- need same day referral to psychiatry if suspected
When does postpartum/puerperal psychosis usually present?
within 2 weeks of delivery
What are the symptoms of postpartum/ puerperal psychosis?
early symptoms are sleep disturbance and confusion, irrational ideas, progresses to mania, delusions and hallucinations
5% risk of suicide, 4% risk of infanticide
Treatment and prognosis of postpartum/ puerperal psychosis?
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
Is post natal depression common?
yes
Onset of postnatal depression is usually ______ and it lasts ________
2-6 weeks postnatally
weeks to months
Recurrence rate of postnatal depression?
25% recurrence rate
70% lifetime depression risk
What effects can postnatal depression have?
can have effects on bonding, child development, marriage and there is a risk of suicide
Describe antenatal care of substance abuse in pregnancy?
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
Why may stopping a drug with known teratogenic risk after pregnancy occurred not be worth it?
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
Describe use of antidepressants in pregnancy?
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
Which SSRI has most evidence for safe use in pregnancy?
fluoxetine
Which SSRI is there questions over safety in pregnancy?
paraoxetine- risk of cardiac abnormalities
What antipsychotics have the best evidence base for safety in pregnancy?
2nd generation drugs
e.g. olanzapine and quetiapine
Describe use of antipsychotics in pregnancy?
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
Describe use of mood stabalisers in pregnancy?
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
Mood stabliser with the most evidence for safety in pregnancy?
lamotrigine
3 mood stabalisers that should really be avoided in pregnancy?
valproate, carbamazepine and lithium
Bipolar treatment recommendations in pregnancy?
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
Anxiety treatment recommendations in pregnancy?
SSRIs first line
benzodiazepines not major teratogens but in 3rd trimester there is risk of floppy baby so generally they should be avoided
Describe breastfeeding and medication for psychiatric disorders in pregnancy?
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
List some drugs fine in breastfeeding?
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
Can you breastfeed whilst taking lithium?
no
Can you breastfeed whilst taking valproate?
no
