Psychiatric Disorders in Pregnancy Flashcards by Kerry Hendrie

List red flag presentations for perinatal mental health problems

Recent significant change in mental state or emergence of new symptom
New thoughts or act of violent self-harm
New and persistent expressions of incompetency as a mother or estrangement from their baby

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Give examples of screening questions used in pregnancy for mental health issues

During last month have you been bothered by feeling down, depressed or hopeless?
During last month, have you been bothered by having little interest/ pleasure in doing things?
Is this something you feel you need or want help with?

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List some risk factors for mental illness in pregnant women

Young female/ Single mother
Domestic issues
Lack of support
Substance misuse
Unplanned pregnancy
Pre-existing mental illness
Personal or family history of mental illness

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List indications for referral to psychiatry team in pregnancy

Psychosis
Severe anxiety/depression/suicidal/self-harm
History of bipolar/schizophrenia
History of puerperal psychosis
If on psychiatric medication
Previous admission to mental health unit

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When does puerperal psychosis typically onset?

Within 2 weeks of delivery

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List clinical features of puerperal psychosis

Sleep disturbance
Confusion
Delusions, hallucinations
Irrational ideas
Mania

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Puerperal psychosis is an emergency. True/False?

True

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List major risk factors for puerperal psychosis

Bipolar disorder (50%)
Previous puerperal psychosis
1st degree relative with history

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Outline management options for puerperal psychosis

Needs urgent admission to mother-baby unit

Antidepressants, antipsychotics, mood stabilisers, ECT

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What is the percentage risk of puerperal psychosis recurrence in further pregnancies?

80%

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Postnatal depression occurs in __ of women

10%

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When does postnatal depression typically onset?

2-6 weeks postnatally

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List clinical features of postnatal depression

Anxiety, irritability, tearfulness
Lack of enjoyment
Poor sleep
Weight loss
Concerns re baby

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How does postnatal depression differ from “baby blues”?

Baby blues is more brief and self-limiting

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Baby blues occur in __ of women

50%

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When does baby blues usually occur?

Day 3-10 post-partum

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How are baby blues managed?

Support from MDT
Reassurance and education
Warning signs of post-natal depression

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How is mild-moderate postnatal depression managed?

Self help

Counselling

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How is moderate-severe postnatal depression managed?

Psychotherapy
Antidepressants (option to start at 36 weeks partum)
Consider admission

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What is the percentage risk of postnatal depression recurrence in further pregnancies?

25%

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Outline risks to child of untreated perinatal mental health disorders

Low birth weight
Preterm delivery
Adverse childhood outcomes e.g. ADHD
Poor engagement/ bonding with child

What is the principle of psychiatric treatment in pregnancy?

Low dose monotherapy, consider stopping/changing
Increased screening of fetus (cardiac, growth scans)
Contingency plans if they get unwell

When should a foetal anomaly scan be carried out in someone pregnant and on psychiatric medication?

16 weeks

What is the main risk associated with psychiatric medications during the 1st trimester?

Risk of teratogenicity

What is the main risk associated with psychiatric medications during the 3rd trimester?

Risk of neonatal withdrawal

What is the main risk associated with psychiatric medications during breastfeeding?

Risk of medications passing into breast milk

Breastfeeding should be encouraged whenever possible in psychiatric pregnant patients. True/False?

True | Medications used in pregnany should be continued (generally in utero risk greater than exposure in milk)

Which antidepressant can cause fetal heart defects in an infant during the 1st trimester?

Paroxetine

All antidepressants can cause withdrawal and toxicity in neonates. True/False?

True | Usually self-limiting though

What is the main risk to the fetus of using SSRI's after 20 weeks?

Neonatal pulmonary hypertension

State the lowest risk SSRIs and TCAs respectively, safe to use during pregnancy

SERTRALINE, fluoxetine | Imipramine, amitriptyline

SSRIs are generally safe during breastfeeding. Which should be avoided?

Citalopram | Doxepin

Why should benzodiazepines be avoided in pregnancy and breastfeeding?

Fetal malformations Floppy baby syndrome Lethargy, weight loss

Which antipsychotics - typical or atypical - are generally safe to use in pregnancy?

Typicals

Which antipsychotics are contraindicated in pregnancy?

Clozapine can cause agranulocytosis | Olanzapine can cause GDM and weight gain

Can anticholinergic drugs be used in pregnancy?

What foetal defect can lithium cause?

Ebstein's anomaly

Is lithium contraindicated in breastfeeding?

Yes

What foetal defects can sodium valproate cause?

``` Neural tube defects Craniofacial defects IUGR Reduced IQ Cleft ```

Sodium valproate is safe to use in breastfeeding. True/ False

True | However, should be stopped before planning pregnancy and avoided in women of child-bearing age

It is normally ok to breastfeed if you are on an anticonvulsant. True/False?

True

What effect does carbamazepine have on the newborn?

Vitamin K deficiency | Haemorrhagic disease of newborn

Which mood stabiliser/anticonvulsant is considered safest to use in pregnancy?

Lamotrigine

List risks to mother of substance abuse during pregnancy

``` Other mental health conditions HIV, Hep B, Hep C Nutritional deficiency VTE STIs Endocarditis/ sepsis Poor venous access Opiate tolerance/ withdrawal Drug overdose/ death Risk of domestic abuse ```

What is the RCOG advice on alcohol during pregnancy?

Abstinence best but no evidence that 2 units a week is detrimental

List risks associated with alcoholism during pregnancy

``` Miscarriage Foetal alcohol syndrome Withdrawal Wernicke's encephalopathy (B1 deficiency) Korsakoff syndrome ```

List features of foetal alcoholic syndrome

``` Facial deformity Lower IQ Neurodevelopmental delay Epilepsy Hearing defect Cardiac + renal defects ```

List fetal risks of substance abuse during pregnancy

``` Teratogenic Abruption IUGR Preterm labour, miscarriage Developmental delay Withdrawal ```

What should be considered management-wise if substance abuse is occurring in pregnancy?

``` Methadone programmes Social work/child protection Labour planning - analgesia, anaesthesia Postnatal contraception plan Smear history ```

Breastfeeding is contraindicated in which cases of substance misuse?

Alcohol intake >8 units Maternal HIV Use of cocaine