Psychiatric disorders of childbirth Flashcards
Classification of types
- Ante-natal psychiatric disorders
a. Schizophrenia (severe form)
b. Bipolar illness (severe form)
c. Depressive illness (mild form)
d. Obsessional compulsive disorder (mild form)
e. Anxiety states (mild form) - Post-natal psychiatric disorders
- Postpartum (baby) blues
- Postpartum psychosis (PPP)
- Postpartum depression (PPD)
+ Severe and mild form
Antenatal psychiatric disorders
- Features
a. Affecting 15% of pregnancies
b. Rate and range are the same as in the non-pregnant population - Disorders
a. Schizophrenia (severe form)
b. Bipolar illness (severe form)
c. Depressive illness (mild form)
d. Obsessional compulsive disorder (mild form)
e. Anxiety states (mild form)
Postpartum (baby) blues
emotional lability, exhaustion and anxiety common in the period of
3-10 days following pregnancy.
Associated with difficult deliveries mostly. Require only
attention and understanding of the mother.
Postpartum psychosis (PPP)
- Features and symptoms
a. Features
i. Very rare but most serious condition
ii. High association with bipolar disorder
iii. Sudden onset in early post-delivery days or within 3 months
Sx:
Psychosis, Delusions
Fear and perplexity
Confusion
Hallucinations
Delirium - acute confusion state with loss of awareness or inability to pay
attention
Postpartum psychosis (PPP) Management
i. Recovery ranges from 6 months – 1 year
ii. Antipsychotic drugs and mood stabilizing drugs
iii. Family and social worker support
Postpartum depression (PPD)
Definition + features
a. Definition: range of subtypes of depressive illness with different severities.
b. Features
i. Can affect both sexes
ii. Incidence of 10% of all new mothers
Compare 2 types of Postpartum depression (PPD)
Postpartum depression (PPD) Diagnosis
at least 5 of the following nine symptoms within a 2 weeks period
i. Feelings of sadness
ii. Emptiness
iii. Hopelessness
iv. Loss of interest or pleasure in activities
v. Weight loss or decreased appetite
vi. Changes in sleep patterns
vii. Feelings of restlessness
viii. Loss of energy
ix. Feelings of guilt
x. Loss of concentration
xi. Recurrent thoughts of death
Screening
- History taking
a. Family history
b. Drug abuse (substance misuse)
c. Current mental health (early pregnancy and also on later occasions)
d. Whooley questions
i. During the past month have you often been bothered
by feeling down, hopeless or depressed?
ii. During the past month have you often been bothered
by having little interest or pleasure in doing things?
iii. Do you feel you need or want help with this?
- Edinburgh Postnatal Depression Scale (EPDS)
a. 10 screening questions that can indicate whether mother has symptoms that are
common in depression and anxiety.
Management principles
Principles
a. Mild disorders may improve as pregnancy progresses
b. Serious disorders who have not shown relapse in more than 2 years are not considered
to be for high-risk antenatal recurrence (the opposite is also true)
c. Serious disorders who have not shown relapse in more than 2 years are considered to
be for high-risk postnatal illness
d. Women under medications are considered for high-risk of both antenatal and
postpartum relapse
e. For new-onset symptomatic disorders “watch-and-wait” approach (for 2 weeks)
f. Relapse is common after recent illness or stopping medication intake
g. Some medications are safe to use while others should be stopped before conception or
reduced and slowly withdrawn
Management Non-medication
a. Psychological treatment
b. Counselling
c. Cognitive behavior therapy
d. Family and other health professional care providers involvement
e. Lifestyle change
Management Medication
- Antidepressants
- Antipsychotic - for schizophrenia and bipolar illness
- Mood stabilizers and anti-epileptics – for bipolar disorders
Antidepressants
i. Monoamine oxidase inhibitors (MAOIs)
* Not used due to risk of drug and food interactions
ii. Tricyclic antidepressants (TCAs) – amitriptyline, imipramine, clomipramine,
doxepin
- No risk for fetal abnormalities (except for clomipramine)
iii. Selective serotonin reuptake inhibitors (SSRIs) – fluoxetine, paroxetine, sertaline
- Risk for cardiac abnormalities (ventricular septal defects)
Antipsychotic - for schizophrenia and bipolar illness
i. Typical “older” drugs (chlorpromazine, trifluoperazine)
- No risk for fetal abnormality but associated with poor obstetric
outcome (e.g. early delivery and increased C-section rate)
ii. Atypical “newer” drugs (olanzapine, quetiapine, risperidone)
- No risk for fetal abnormality but associated with gestational diabetes,
venous emboli and weight gain
Mood stabilizers and anti-epileptics – for bipolar disorders
i. Valporate (lithium containing agents)
ii. Risk for cardiac abnormalities, neural tube defects, fetal hypothyroidism and
polyhydramnios.
iii. If no evident relapse for the last 2 years medication should not be used.
Otherwise it can be used but alternatives should be explored.
