post partum Flashcards
prevalence or perinatal depression
Major depression during pregnancy
9.4 – 12.7%
- 1% in first 3 months
- 9% in first 12 months
prevalence of depression in MDD
25%-30% of women with history of MDD are at risk for postpartum depression
postpartum blues peaks
Features: tearfulness, lability, reactivity
different than postpartum depression
Peaks 3-5 days after delivery
Present in 50-80% of women
Common for women to feel this after their baby’s birth, but for 1 in 7 women this progresses to more serious mood disorder of PPD
blues correlate with the magnitude of the drop in
estrogen
these recptors are concentrated in the brain during pregnancy and the experience
how to progesterone play a role in blues
allopregnalone is the progesterone metabolite
this is a GABA agonists and CNS GABA levels & sensitivity may decrease during pregnancy as an adaptation
The reduced brain GABA may recover more slowly in women with “blues”
oxytocin
1 thing that helps uterus go back to normal post delivery
Peripheral effects include uterine contraction and milk ejection
disruption in oxytocin affects maternal behavior negatively
The normal heightened emotional responsiveness caused by oxytocin may predispose to depression in the context of high stress and low social support
criteria for MD
At least one of the following (by self-report or others’ observations) for 2 weeks
Depressed mood most of the day, nearly every day
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
four or more:
Changes in weight and appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feeling worthless or guilty Impaired concentration, indecisiveness Thoughts of death
Clinical Features of Postpartum Depression
Depressed, despondent and/or emotionally numb
Sleep disturbance, fatigue, irritability
Loss of appetite
Poor concentration
Feelings of inadequacy
Ego-dystonic thoughts of harming the baby
clinical presentation peaks
Clinical presentation peaks 3-6 months after delivery
by DSM -IV definition postpartum depression beings when
Begins within 4 weeks of birth
by DSM-IV definition
Postpartum period considered up to 1 year
Related to environmental stressors
Postpartum Psychoses
Bipolar disorder
Major depression with psychotic features
Schizophrenia spectrum disorders
Medical conditions (e.g. thyroid disease, low B12)
Drugs (e.g. amphetamines, hallucinogens, bromocriptine
1-2 per 1,000 women giving birth
About 35% of women with bipolar diathesis
onset of postpartum psychoses
Onset usually within 3 weeks postpartum
sxs of psychoses
Delusions (e.g. baby is possessed by a demon)
Hallucinations (e.g. seeing someone else’s face instead of baby’s face)
Insomnia
Confusion/disorientation (more than non-postpartum psychoses)
Rapid mood swings (more than non-postpartum psychoses)
Waxing and waning (can appear and feel normal for stretches of time between psychotic symptoms)
Factors That May Contribute To Risks Associated With Antenatal Depression
Indirect effects
Reduced prenatal care
Less optimal nutrition
Poor appetite and weight loss
Socioeconomic deprivation
Increased use of cigarettes and alcohol
Direct effects
Changes in cortisol & HPA
axis development
Effects of Untreated Depression on Obstetric Complications
Low birth weight
Premature birth
Pre-eclampsia
effects of antenatal depression
Newborns cry excessively and are more inconsolable
Babies (up to age 1) have poorer growth and increased risk of infection
Children (up to age 5) have more difficult temperaments, more distress, sadness, fear, shyness, frustration
Early Consequences of Untreated Postpartum Depression for Offspring
Sometimes none
Disturbed mother-infant relationship
Cortisol elevation (baby and mother)
Failure to thrive
Physical injury/death
Later Consequences of Prolonged Maternal Depression for Offspring
Depression
Behavioral disturbance, including conduct disorder
Reduced cognitive abilities
More school problems (truancy, dropping out)
Role reversal
Effects of Maternal Stress and Anxiety During Pregnancy (5)
Altered fetal hemodynamics and movement
Lower gestational age
Lower infant birth weight
Lower Apgar scores
Enduring changes in cortisol measures in offspring – so far observed up to age 10
Potential Effects of Postpartum Depression on Relationships
Altered roles within the couple
Altered roles within the extended family
Establishing alternate caregiver patterns that become difficult to change later
Impaired communication
Psychiatric symptoms in the partner
increase risk of suicide in post partum depression
Pregnancy is unwanted, especially when woman wanted an abortion but could not obtain one
Partner abandoned woman during pregnancy
Woman has had prior pregnancy loss and/or death of children
prevalence of thoughts of harm: low risk
Common in non-psychotic PPD – 41% of depressed mothers vs 7% of controls
ego-dystonic (obsessive in nature & odd/frightening to mother)
Mother has taken steps to protect baby (distance)
Thoughts of Harming Baby: High Risk
Mother has delusional beliefs about the baby
e.g. that the baby is a demon
Thoughts of harming baby are ego-syntonic
mother thinks they are reasonable and/or feels tempted to act on them
Mother has a history of violence
Mother has labile mood and/or impulsive behavior
attachment theroy impacts
Infants of depressed mothers are at high risk for developing an insecure attachment
Relational problems between infants and their caregivers are connected to early social, emotional, and behavioral problems for children
child views caretaker as unresponsive (possibly rejecting) and her/himself unworthy of love
Insecure attachment
Insecurely attached child at risk for later behavior disorders, mood disorders, and delayed cognitive development
Screening for Peripartum Depression should include
Edinburgh Postnatal Depression Scale (EPDS)
disadvantages of EPDS
Screening for Peripartum Depression
Hoe to use EPDS
Maximum score: 30
Always look at item 10 [suicidal thoughts]
Sensitivity and specificity vary according to the chosen cut-off score
Validated cut off score of 10-
13
Use an assessment tool to further evaluate women with high scores
which item in the PEDS is responsible for suicidal thoughts
10
benefits of PHQ9
Ability to treat according to DMSV
What are you looking for with treatment associated with DSM V
(what is positive and how should the score change after treatment)
A score of 5 or above out of 27 is considered positive
Initial treatment response: drop in score of 5 or more from pre-treatment baseline after 4 weeks of treatment
50% decrease in score after 8 weeks of treatment
what should remission look like of PHQ9
Remission: post-treatment score < 5
Best validated screening for peripartum populations
EPDS
Enoxaparin
is an anticoagulant used in the treatment of venous thromboembolic disease. Although pulmonary embolism is on the differential for a pregnant patient with shortness of breath and hypoxia, preeclampsia is more likely in this clinical scenari
why would Furosemide not be indicated in preeclampsia
(a loop diuretic) is not first line in the treatment of preeclampsia since the pathophysiology involves vasoconstriction and hemoconcentration, not fluid overload
What underlying process should be suspected if preeclampsia develops in the first trimester of pregnancy?
molar pregnancy
When membrane rupture occurs before 37 weeks gestation*
PROM
nitrazine testing that would indicate PROM*
a pH of 7.1–7.3 as opposed to a normal pH of 3.5–6.0
Chorioamnionitis *
Chorioamnionitis, an inflammation of the fetal membranes (amnion and chorion) due to a bacterial infection.
brexanolone
progesterone analog
hormonal component dn injection instead of just a SSRI
What is the most common cause of postpartum hemorrhage?
uterine atony
when the uterus fails to contract after the delivery of the baby
Postpartum hemorrhage (PPH) is defined as
> 500 mL of blood loss after vaginal delivery or > 1,000 mL of blood loss after cesarean delivery
brexanolone
progesterone analog
hormonal component dn injection instead of just a SSRI
What is the most common cause of postpartum hemorrhage?
uterine atony
when the uterus fails to contract after the delivery of the baby
Postpartum hemorrhage (PPH) is defined as
> 500 mL of blood loss after vaginal delivery or > 1,000 mL of blood loss after cesarean delivery
