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
