Psychiatric illness Flashcards
Discuss anxiety in pregnancy
-Incidence (2)
-Screening tools (3)
-Management
- 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 - 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 - 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
Discuss bipolar in pregnancy
-Incidence in postnatal period (1)
-Effect of bipolar on pregnancy (2)
-Management (12)
- Incidence in postnatal period
-50% of women with bipolar have a mood episode PN - 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) - 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
Discuss bipolar medications in pregnancy
-Lithium (9)
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
Discuss baby blues
-Incidence (1)
-Time course (3)
-Risk factors (2)
-Causes (4)
-Features (5)
-Management (1)
- Incidence
-80% - Time course
-Onset 3-10 days PP
-Lasts 2-10 days
-Beyond 2 weeks is a depressive episode - Risk factors
-Not associated with parity
-Not associated with breast or bottle feeding - Causes
-Hormonal factors: withdrawal of progesterone and estrogen PP
-Sleep deprivation - impacts hormones
-Anxiety and depression in pregnancy
-Negative birth experience - Features
-Emotionally labile, tearfulness, anxiety, irritability
-Associated with headache 30% of time - Management
-Reassurance and monitoring
Discuss depression in pregnancy
-Incidence (2)
-Outcomes without treatment (4)
-Risk factors (9)
- Incidence
-10% antenatally
-16% postnatally - 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 - 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
Discuss the impact of depression on pregnancy
-Maternal impact (5)
-Fetal impact (4)
-Long term impact (4)
- Maternal impact
-Reduces engagement in ANC
-Substance abuse
-Gestational HTN and PET
-PND
-Suicide - Fetal impact
-IUGR
-Spontaneous PTB
-LBW
-Infanticide
-Poor cognition, emotional development - Long term impact
-Developmental delay
-Antisocial behaviour
-Impaired mother/child bond
-Attachment issues
Discuss screening techniques for identifying depression in pregnancy
-When should screening be done
-Which tools should be used
- Time of screening
-At first AN visit, another time in pregnancy, 6-8 weeks PP, once in first year
-Anytime clinically indicated - Screening tools
-Antenatal risk questionnaire (ANRQ)
-Edinburgh Postnatal depression scale (EPDS)
Discuss the Edinburgh Postnatal Depression Scale
1. What is it
2. What do the scores mean
- What it is
-Asks woman to answer 10 questions about how feeling over last 7 days - 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)
Discuss the management of depression in pregnancy (9)
- Have MDT input
- Consider their safety to themselves and baby
- Rule out physical disorder as a cause
- Consider psychological therapy - CBT, IPT
- Consider meds - lowest dose, one agent. SSRI first line
- Review medication with breastfeeding
- Review medication dosing PP
- Ensure social support and FU plan
- Monitor baby for adaptation syndrome - first 3 days of life
-irritability, hypotonia, RDS, hypoglycemia, seizures - Advise women that omega-3 oils have not evidence but are harmless for babies.
- Advise mothers that St John’s Wort or Ginko has no evidence but can be harmful and to avoid
What are the RANZCOG recommendations regarding anxiety and depression in pregnancy (11)
- Women’s health professionals should be trained in mental health assessment
- 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
- Women should be routinely screened with the EPDS
- All women should be screened for psychosocial risk factors as early as possible with ANRQ early in pregnancy then 6-12 weeks PP
- Substance use should be assessed in early pregnancy
- Family violence should be assessed in early pregnancy
- Decision making about treatment should be collaborative with the woman
- Women identified as at risk of suicide should be immediately referred
- Every antenatal/Post natal visit should enquire about emotional wellbeing
- Only prescribe medications after careful discussion regarding risks and benefits
- Provide timely referral
Discuss postpartum psychosis
-Definition (2)
-Onset (3)
-Incidence (5)
- Definition
-Acute psychotic episode arising in early PP period
-Is a psychiatric emergency - Onset
-50% by day 7
-75% by day 16
-95% by day 90 - Incidence
-1:1000 pregnancies
-50-60% risk of recurrence in future pregnancies
-30% risk if bipolar
-5% risk of suicide
-4% risk of infanticide
Discuss management of postpartum psychosis
-At time of diagnosis (5)
-Pre-conception (4)
-Antenatally (4)
-Postnatally (7)
- 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 - 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 - Antenatal
-Regular ANC
-Psychoeducation to woman and family
-Practical family support
-Consider preventive measures with pharmacology for those at risk - lithium or quetiapine - 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
Discuss schizophrenia in pregnancy
-Impact of pregnancy on schizophrenia (3)
-Impact of schizophrenia on pregnancy (2)
- 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 - Impact of schizophrenia on pregnancy
-LBW, SGA, PTB, Stillbirth (Associated with poor ANC and substance abuse
-Offspring have genetic predisposition
Discuss the management of schizophrenia in pregnancy
-Pre-conception
-Antenatal
-Postnatal
- Pre-conception
-Discuss impact of meds on baby
-Discuss high risk of relapse
-Optimise control of condition
-Optimise support systems
-Folic acid - 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 - 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
Discuss SSRI use in pregnancy
1.Types (5)
2. Class (ES)
3. Maternal risks in pregnancy
4. Fetal risks
5. Breastfeeding risks
- Types
-Paroxetine, fluoxetine, citalopram, escitalopram, sertraline - All Class C except paroxetine = Class D
- Maternal risks in pregnancy
-Serotonin syndrome
-PPH (low quality data)
-Miscarriage (with paroxatine) - Fetal risks in pregnancy
-Cardiac defects 2% with paroxetine
-PTB
-Neonatal adaption syndrome
-Persistent pulmonary HTN of the new born
-Neonatal convulsions - Breast feeding
-sertraline, paroxetine, citalopram and escitalopram safe
