Psychiatric illness Flashcards

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1
Q

Discuss anxiety in pregnancy
-Incidence (2)
-Screening tools (3)
-Management

A
  1. Incidence
    -1:5 (20%) women in 3rd trimester and for first 6-8 months
    -High levels of anxiety postnatally increase the risk of postpartum depression
  2. Screening tools
    -Good evidence to support screening for anxiety in perinatal period
    -EPDS - 10 questions should be offered routinely in pregnancy on 3 occasions
    -GAD-7 good sensitivity and specificity
    -HADS
  3. Management
    -Psychological therapies - CBT IPT, psychodynamic therapy
    -SSRI first line
    -Benzodiazepines with caution and short duration while SSRI takes effect
    -Can consider quetiapine in small doses
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2
Q

Discuss bipolar in pregnancy
-Incidence in postnatal period (1)
-Effect of bipolar on pregnancy (2)
-Management (12)

A
  1. Incidence in postnatal period
    -50% of women with bipolar have a mood episode PN
  2. Effect of bipolar on pregnancy
    -Poorer outcome related to risky behaviour (drug taking, poor nutrition, poor AN care)
    -Fetal effects associated with medication (lithium and carbamazapine)
  3. Management
    -Early preconception counselling
    -Ask about partner and whaunau support and experience with her illness
    -Monitor for suicide risk - very high
    -Optimise management and stabilisation and maintenance of MH
    -Review medications
    -Review risk factors and mitigate if possible
    -Detailed fetal anatomy scan at 20 weeks given increased risk
    -Serial growth scans
    -Monitor for relapse PP - increased risk with increased duration of stay on ward 1/52
    -Consider safety of meds in breastfeeding
    -Consider interventions to reduce maternal stress
    -Stop lithium 48hrs prior to labour then restart as soon as delivered
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3
Q

Discuss bipolar medications in pregnancy
-Lithium (9)

A

Lithium
-Increased risk of NTD and cardiac abnormalities (Epstein’s anomaly in 2.5%)
-Avoid in Breast feeding where possible. Can have first feed for colostrum and bonding
-Consider weaning off prior to pregnancy if well
-Consider switching to another agent if unwell or withholding to T2
-Monitor levels in pregnancy and check for toxicity
-Withhold 48hrs before labour secondary to high placental transfer and impact of AGARS, and neuromuscluar complications
-Consider IOL for above
-Avoid Ibuprofen for pain relief
-Ensure good hydration to avoid lithium toxicity

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4
Q

Discuss baby blues
-Incidence (1)
-Time course (3)
-Risk factors (2)
-Causes (4)
-Features (5)
-Management (1)

A
  1. Incidence
    -80%
  2. Time course
    -Onset 3-10 days PP
    -Lasts 2-10 days
    -Beyond 2 weeks is a depressive episode
  3. Risk factors
    -Not associated with parity
    -Not associated with breast or bottle feeding
  4. Causes
    -Hormonal factors: withdrawal of progesterone and estrogen PP
    -Sleep deprivation - impacts hormones
    -Anxiety and depression in pregnancy
    -Negative birth experience
  5. Features
    -Emotionally labile, tearfulness, anxiety, irritability
    -Associated with headache 30% of time
  6. Management
    -Reassurance and monitoring
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5
Q

Discuss depression in pregnancy
-Incidence (2)
-Outcomes without treatment (4)
-Risk factors (9)

A
  1. Incidence
    -10% antenatally
    -16% postnatally
  2. Outcomes if left untreated
    -70% will have sx at 6 months
    -25% will develop chronic illness
    -25% will develop recurrent depression
    -30-50% recurrence in future pregnancies
  3. Risk factors
    -Previous mental health history
    -Previous depression - 40% chance of PND
    -Family hx of mood disorders
    -Substance abuse
    -Previous abuse physical / sexual / emotional
    -Limited social supports
    -Younger age
    -Relationship difficulties
    -Lower SES
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6
Q

Discuss the impact of depression on pregnancy
-Maternal impact (5)
-Fetal impact (4)
-Long term impact (4)

A
  1. Maternal impact
    -Reduces engagement in ANC
    -Substance abuse
    -Gestational HTN and PET
    -PND
    -Suicide
  2. Fetal impact
    -IUGR
    -Spontaneous PTB
    -LBW
    -Infanticide
    -Poor cognition, emotional development
  3. Long term impact
    -Developmental delay
    -Antisocial behaviour
    -Impaired mother/child bond
    -Attachment issues
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7
Q

Discuss screening techniques for identifying depression in pregnancy
-When should screening be done
-Which tools should be used

A
  1. Time of screening
    -At first AN visit, another time in pregnancy, 6-8 weeks PP, once in first year
    -Anytime clinically indicated
  2. Screening tools
    -Antenatal risk questionnaire (ANRQ)
    -Edinburgh Postnatal depression scale (EPDS)
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8
Q

Discuss the Edinburgh Postnatal Depression Scale
1. What is it
2. What do the scores mean

A
  1. What it is
    -Asks woman to answer 10 questions about how feeling over last 7 days
  2. Scores
    -Score >13 has NPP of 99% for depressive illness
    -Score 10-12 repeat in 2-4 weeks
    -Answer yes to self harm question refer immediately (Question 10)
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9
Q

Discuss the management of depression in pregnancy (9)

A
  1. Have MDT input
  2. Consider their safety to themselves and baby
  3. Rule out physical disorder as a cause
  4. Consider psychological therapy - CBT, IPT
  5. Consider meds - lowest dose, one agent. SSRI first line
  6. Review medication with breastfeeding
  7. Review medication dosing PP
  8. Ensure social support and FU plan
  9. Monitor baby for adaptation syndrome - first 3 days of life
    -irritability, hypotonia, RDS, hypoglycemia, seizures
  10. Advise women that omega-3 oils have not evidence but are harmless for babies.
  11. Advise mothers that St John’s Wort or Ginko has no evidence but can be harmful and to avoid
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10
Q

What are the RANZCOG recommendations regarding anxiety and depression in pregnancy (11)

A
  1. Women’s health professionals should be trained in mental health assessment
  2. Women should be screened for depression and anxiety sx and risk factors in early pregnancy, later in pregnancy, 6-12 weeks PP and at least once in the first yr PP as well as clinically indicated
  3. Women should be routinely screened with the EPDS
  4. All women should be screened for psychosocial risk factors as early as possible with ANRQ early in pregnancy then 6-12 weeks PP
  5. Substance use should be assessed in early pregnancy
  6. Family violence should be assessed in early pregnancy
  7. Decision making about treatment should be collaborative with the woman
  8. Women identified as at risk of suicide should be immediately referred
  9. Every antenatal/Post natal visit should enquire about emotional wellbeing
  10. Only prescribe medications after careful discussion regarding risks and benefits
  11. Provide timely referral
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11
Q

Discuss postpartum psychosis
-Definition (2)
-Onset (3)
-Incidence (5)

A
  1. Definition
    -Acute psychotic episode arising in early PP period
    -Is a psychiatric emergency
  2. Onset
    -50% by day 7
    -75% by day 16
    -95% by day 90
  3. Incidence
    -1:1000 pregnancies
    -50-60% risk of recurrence in future pregnancies
    -30% risk if bipolar
    -5% risk of suicide
    -4% risk of infanticide
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12
Q

Discuss management of postpartum psychosis
-At time of diagnosis (5)
-Pre-conception (4)
-Antenatally (4)
-Postnatally (7)

A
  1. Management at time of diagnosis
    -Psychiatric emergency
    -Ensure safety of mother and baby
    -Try to avoid sleep deprivation - use zopiclone
    -Seek specialist mental health input asap
    -Transfer care to a mother and baby unit
  2. Preconception
    -Optimise stability on appropriate therapy
    -Ensure counselled about risk of recurrence 30-50%
    -Commence on 5mg folic acid throughout pregnancy
    -Discuss risk and benefits of medications
  3. Antenatal
    -Regular ANC
    -Psychoeducation to woman and family
    -Practical family support
    -Consider preventive measures with pharmacology for those at risk - lithium or quetiapine
  4. Postnatally
    -Involve multiple specialities
    -Ensure safety of mother and baby
    -Admit to mother baby unit
    -Supress breast feeding if required with carbergolin. e.g. if on lithium
    -Manage psychosis with antipsychotics - quetiapine
    -Good prognosis - resolution in 6-12 months
    -Educate on sx to look out for
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13
Q

Discuss schizophrenia in pregnancy
-Impact of pregnancy on schizophrenia (3)
-Impact of schizophrenia on pregnancy (2)

A
  1. Impact of pregnancy on schizophrenia
    -16% risk of postpartum psychosis
    -38% risk of relapse in postnatal period
    -High risk of suicide in first year postnatal
  2. Impact of schizophrenia on pregnancy
    -LBW, SGA, PTB, Stillbirth (Associated with poor ANC and substance abuse
    -Offspring have genetic predisposition
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14
Q

Discuss the management of schizophrenia in pregnancy
-Pre-conception
-Antenatal
-Postnatal

A
  1. Pre-conception
    -Discuss impact of meds on baby
    -Discuss high risk of relapse
    -Optimise control of condition
    -Optimise support systems
    -Folic acid
  2. Antenatal
    -MDT management
    -Document pregnancy plan
    -Continue medication at lowest effect dose. Don’t stop
    -Regular ANC
    -Fetal anomaly scans
    -Maternal GDM screening if on atypical antipsychotics
  3. Postnatal
    -Assess for sx of postpartum psychosis and relapse
    -Ensure supports to allow for adequate sleep
    -Counsel regarding breast feeding depending on antipsychotics
    -Admit to mother and baby unit if relapse
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15
Q

Discuss SSRI use in pregnancy
1.Types (5)
2. Class (ES)
3. Maternal risks in pregnancy
4. Fetal risks
5. Breastfeeding risks

A
  1. Types
    -Paroxetine, fluoxetine, citalopram, escitalopram, sertraline
  2. All Class C except paroxetine = Class D
  3. Maternal risks in pregnancy
    -Serotonin syndrome
    -PPH (low quality data)
    -Miscarriage (with paroxatine)
  4. Fetal risks in pregnancy
    -Cardiac defects 2% with paroxetine
    -PTB
    -Neonatal adaption syndrome
    -Persistent pulmonary HTN of the new born
    -Neonatal convulsions
  5. Breast feeding
    -sertraline, paroxetine, citalopram and escitalopram safe
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16
Q

Discuss SNRI use in pregnancy
-Types (3)
-Class
-Maternal risks in pregnancy
-Fetal risks in pregnancy
-Safety in breastfeeding

A
  1. Types
    -Venlafaxin, duloxetine, mirtazapin
  2. Class
    -All class C
  3. Maternal risks in pregnancy
    -Serotonin syndrome
    -PPH
    -Miscarriage (very small risk)
  4. Fetal risks
    -PTB
    -Neonatal adaptation syndrome
    -Persistent pulmonary HTN
    -Neonatal convulsions
  5. Breast feeding
    -Safe
17
Q

Discuss tricyclic antidepressants in pregnancy
-Types
-Class
-Maternal risks in pregnancy
-Fetal risks in pregnancy
-Breastfeeding

A
  1. Types
    -Amitriptyline, Nortriptyline
  2. Class
    -All class C
  3. Maternal risks in pregnancy
    -Toxicity in overdose
  4. Fetal risks in pregnancy
    -Small risk of miscarriage
  5. Breastfeeding
    -safe in low doses for short duration
18
Q

Discuss benzodiazapines in pregnancy
-Types
-Class
-Maternal risks
-Fetal risks
-Breast feeding

A
  1. Types
    -Lorazepam, diazepam
  2. Class
    -Class D
  3. Maternal risks
    -None
  4. Fetal risks
    -No know major malformations
    -Neonatal adaptation syndrome
  5. Breast feeding
    -Safe but monitor for sedation
19
Q

Discuss mood stabilisers in pregnancy
-Types
-Class
-Maternal risk in pregnancy
-Fetal risk in pregnancy
-Breastfeeding

A
  1. Types
    -Lithium
  2. Class
    -Class D
  3. Maternal risk
    -Lithium toxicity esp. immediately postpartum when levels can abruptly rise. Don’t give in labour
  4. Fetal risks
    -Poor Neonatal adaptation
    -Ebstein’s anomaly (tricuspid valve abnormality)
  5. Breastfeeding
    -Not safe. Don’t breast feed
20
Q

Discuss antipsychotics in pregnancy
-Types
-Class
-Maternal risks in pregnancy
-Fetal risk in pregnancy
-Breastfeeding

A
  1. Types:
    -First generation: Haloperidol
    -Second generation: risperidone, olanzapine, quetiapine, clozapine
  2. Class
    -Class C
  3. Maternal risks in pregnancy
    -Hyperprolactinemia - reduces fertility
    -Weight gain
    -LGA
    -GDM
    -CS
  4. Fetal risks in pregnancy
    -Risperidone - major cardiac malformations (AVOID)
    -Clozapine - agranulocytosis of the newborn, toxic megacolon, myocarditis
    -Neonatal adaption syndrome
  5. Breastfeeding
    -Safe
    -Avoid clozapine (if on monitor neonate WCC weekly for 6 months)
21
Q

Discuss neonatal adaptation syndrome
-Definition (1)
-Signs and symptoms
-Incidence (1)

A
  1. Definition
    -Describes a set of neurobehavioural signs in infants born to mothers on anti-depressants
    -Strongest effect in paroxetine and venlafaxine
  2. Signs and symptoms
    -Insomnia, jittery, somnolence agitation, poor feeding GIT upset
  3. Incidence
    -30% of babies exposed to SSRI at full term
22
Q

Discuss neonatal adaption syndrome
-Management (3)

A

-Consider reduction or stopping SSRI 2 weeks prior to delivery if maternal condition stable
-Educate mother about signs and symptoms
-Encourage skin to skin and frequent feeding