postnatal psych Flashcards
how many blood vessels does the umbilical cord contain
1 vein - carries oxygenated blood to baby
2 arteries - carries deoxygenated blood back to placenta
3 shunts in fetal circulation
ductus venous
foramen ovale
ductus arteriosus
first breath of baby
Stimulated by: thorax is squeezed, temp change, sound, physical touch
- Strong first breath is required to expand the previously collapsed alveoli for the first time
Adrenalin + cortisol are released in response to stress of labour, stimulating respiratory effort
First breath expands alveoli, decreasing pulmonary vascular resistance
o This causes a fall in pressure in right atrium
o Left atrial pressure > right -> closes atrial septum, foramen ovale -> fossa ovalis
ductus arteriosus
Prostaglandins are required to keep the ductus arteriosus open
- Increased blood oxygenation causes a drop in circulating prostaglandins
o Causes closure of ductus arteriosus -> ligamentum arteriosum
ductus venosus
Stops functioning because umbilical cord is clamped + there is no blood flow in umbilical veins
It structurally closes a few days later + becomes ligamentum venosum
thermoregulation in utero
Lots of brown fat laid down between scapulae + around internal organs in 3rd trimester
o Less in growth restricted or preterm infants
thermoregulation of babys after delivery
Main source of heat production is non-shivering thermogenesis
o Heat produced by breakdown of stored brown adipose tissue in response to catecholamine
Not efficient in the first 12 hrs of life
- Peripheral vasoconstriction
- No shivering
- New-born babies need help!
glucose haemostasis in utero vs after delivery
In utero
- Glucose comes via placenta
- Glycogen stores created in liver + muscle in preparation for birth
After delivery
- Interruption of glucose supply from placenta
- Very little oral intake of milk
- Drop in insulin, increase in glucagon
- Mobilisation of hepatic glycogen stores for gluconeogenesis
- Ability to use ketones + lactate as brain fuel
transient tachypnoea + management
Babies born by elective C-section when mum has not been in labour + all the hormonal cues to stop lung fluid production in the baby have not happened
o Delay in baby reabsorbing all lung fluid + this makes breathing hard work for the first 12 hrs or so
Management
- Sometimes baby needs o2 or some pressure support
- Generally gets better quite quickly
red flag presentations in postnatal psychiatry
- recent significant change in mental state
- new thoughts or acts of violent self-harm
- new _ persistent expression of incompetentcy as a mother or estrangement from their baby
(^ urgent referral to specialist mental health team)
when should admission to mother + baby unit be considered?
- Rapidly changing mental state
- Suicidal ideation – particularly of violent nature
- Significant estrangement from the infant
- Pervasive guilt or hopelessness
- Beliefs of inadequacy as a mother
- Evidence of psychosis
–> ie lower threshold for admission than general adult service
screening for mental health issues in pregnancy
booking appt - previous tx, FH, identify risk factors (young, single, domestic issues, substance misuse, unplanned)
screening (at every appointment)
o During the last month have you been bothered by feeling down, depressed or hopeless?
o During the last month have you been bothered by having little interest or pleasure in doing things?
o Is this something you feel you need or want help with?
baby blues
50% of women
brief period of emotional instability
tearful, irritable, anxiety + poor sleep confusion
day 3-10, self-liming
Mx = support, reassure
puerperal psychosis
presents within 2weeks of delivery
an emergency
mania, delusions, irrational ideas, confusion
**exclude sepsis
5% suicide risk, 4% infanticide
risk factors for pueral psychosis
bipolar disorder
previous puerperal psychosis
1st degree relative with history of bipolar behaviour
management of puerperal psychosis
admit to specialised mother-baby unit
80% 10yr recurrence
25% go onto develop bipolar disorder
postnatal depression
onset 2-6wks
10% of women, 1/3 lasts a year or linger
effects on bonding, child development, marriage, risk suicide
screened for routinely
25% recurrence, 70% lifetime risk of depression
untreated depression risk to child
low birth weight
pre-term delivery
adverse childhood outcomes - emotional+ conduct problems, ADHD
poor engagement/bonding with child - reduced infant learning + cognitive development
postnatal depression management
mild-moderate - selfhelp, counselling
moderate-severe - psychotherapy + antidepressants
- sertraline or paroxetine -> all secreted in milk but ok
(avoid fluoxetine due to long half life)
general antidepressant recommendations in pregnancy
women at high risk of relapse should be maintained on medication during + after pregnancy
- mod-severe - treat with antidepressanes
make use of priority access to psychological therapies during perinatal period
antidepressants
use is increasingly common
SSRIs 1st line
- decision made of balance of risk
SSRIs in preganncy
sertraline - least placental exposure
fluoxetine - thought to be safest
paroxetine - increased congenital malformations, less safe
risks of SSRIs in pregnancy
1st tri - small increased risk of genital heart defects
3rd tri - persistent hypertension of newborn
lower birth weight
increased early birth - by matter of days
PPH
Risk of GI bleed - esp with NSAID
SSRI drug interactions
- NSAIDs, give PPI
- Warfarin/heparin
- Aspirin
- Triptans – increased risk of serotonin syndrome
- Monoamine oxidase inhibitors (MAOIs) – increased risk of serotonin syndrome
venlafaxine + pregnancy
less evidence
cardiac defects + cleft palate, neonatal withdrawal
antipsychotics + pregnancy
appear to be safe + no evidence of major teratogenicity
olanzapine + quetiapine have best evidence base
risks
- destational diabetes - esp 2nd gen
- reduced fertility due to raised prolaction levels
bipolar affective disorder + pregnancy
high risk of relapse after delivery if mood stabilising mediactions are discontinued, esp in 1st month post partum
there is NO safe mood stabiliser
risks
- induction or csection
- preterm delivery
- small babies
- no increase in malformations
mood stabilisers + pregnancy
NO safe one
valporation + carbamazepine -> most teratogenic
lamotrigine less bad than other anticonvulsants
aim to switch to safer antipsychotic - quetiapine or maybe lamotrigine
litium - ebsteins anomaly
- consider slow reduction preconception
- can be reintroduced in 2nd + 3rd trimester
- reintroduce immediately post partum
anxiety + pregnancy
1st line = SSRIs
Benzodiazepines
o Not major teratogens
o 3rd trimester risk of “floppy baby”
o Generally thought to be problematic + be avoided
Zopiclone – risk
->Make use of priority access to psychological therapies during perinatal period
when is best time to take psychotropic medication when breastfeeding
give doses before longest breaks between feeds
(should be taking lowest possible dose, avoid combos of meds)
summary of psychotropic drugs in pregnancy
antidepressants
- sertraline 1st line
- no need to change from drug used in pregnancy
antipsychotics
- olanzapine, quetiapine
- avoid clozapine - agranulocytosis in infant
mood stbailisers
- antipsychotics
- avoid lithium - secreted in milk
complications of substance abuse in pregnancy
- Nutritional deficiency
- HIV, hep C, hep B
- VTE
- STIs
- Endocarditis/sepsis
- Pour venous access
- Opiate tolerance/withdrawal
- IUGR, stillbirth, SIDs, pre-term labour
miscarriage
foetal alcohol syndrome - facial deformities, lower IQ, neurodevelopmental delay, epilepsy
wenickes/korsakoff
risk of opiate use in pregnancy
neontal withdrawal
IUGR
SIDs
stillbirth
risk of nicotine use in pregnancy
misscarriages
abruption
IUGR
stillbirth + sids
cocaine, amphetamine, ectasy use in pregnancy
death via stroke + arrhythmias
teratogenic - microcephaly, limb defects
pre-eclampsia
abruption
IUGR, preterm labour
miscarriage
developmental delay
SIDs, withdrawal
