Psychiatry Flashcards
what is the leading cause of maternal deaths occurring within a year after the end of pregnancy
Suicide
what are red flag presentations needing an urgent referral to specialist perinatal mental health team
recent significant change in mental state or emergence of new symptoms
new thoughts or acts of violent self harm
new and persistent expressions of incompetence as a mother or estrangement from their baby
when would you consider admission to a mother and baby psychiatric unit
rapidly changing mental state suicidal ideation significant estrangement from infant pervasive guilt or hopelessness beliefs of inadequacy as a mother evidence of psychosis
questions to ask a mother who may have mental health difficulties
do you have new feelings and thoughts which you have never had before, which make you disturbed or anxious?
are you experiencing thoughts of suicide or harming yourself?
are you feeling incompetent as though you can’t cope or estranged from your baby? are these feelings persistent?
do you feel you are getting worse?
when are mental health issues screened for
booking appointment
EVERY antenatal appointment
how does pregnancy effect pre-existing mental health problems
high rate of relapse for bipolar postnatally
eating disorders often improve in pregnancy (if not risks of IUGR, prematurity etc)
depression often gets worse in pregnancy as mothers want to stop meds. Only stop if v mild and refer for psychological treatment.
what are ‘baby blues’
50% of women
brief period of emotional instability
tearful, irritable, anxiety and poor sleep confusion
day 3-10 - self limiting
need support and reassurance
what causes puerperal psychosis
bipolar, depression, schizophrenia, organic brain dysfunction
what is peurperal psychosis
emergency - needs admission to mother and baby unit
usually presents within 2 weeks of delivery
early symptoms are sleep disturbance and confusion, irrational ideas
mania, delusions, hallucinations and confusion
5% suicide risk
4% infanticide
what is post natal depression
tearfulness, irritable, anxiety, lack of enjoyment, poor sleep, weight loss - can present as concerns re baby
onset 2-6 weeks postnatally - lasts weeks to months
effects on bonding, child development, marriage, risk of suicide
what issues need to be considered in the treatment of perinatal disorders
risks of untreated illness (to mum and baby)
general principles of prescribing in perinatal period
benefits and harms of specific treatments
what risks are there to the baby in untreated depression
Low birth weight
-depends on severity
Pre-term delivery
-depends on severity
Adverse childhood outcomes
-emotional and conduct problems
Poor engagement/bonding with child
-reduced infant learning and cognitive development
general principles of psychiatric prescribing in pregnancy
- try to plan pregnancy
- decisions personal to patient
- discuss toxicology issues
- consider stopping meds, changing meds or lowering dose
- plan (antenatal monitoring and support, contingency plan, place of delivery, postnatal management)
use drugs with low risk lowest dose possible be aware of altered pharmacokinetics increased screening of fetus encourage breast feeding
what do you do if a woman falls pregnant on lithium or sodium valproate
dont stop it
refer to obstetrics asap
what are first line antidepressants used in pregnancy
SSRIs
no major teratogens
which SSRIs to use
sertraline has least placental exposure
fluoxetine is thought to be the safest
risks: hypertension on new born lower birth weight increased early birth PPH
Paroxetine - less safe than others
can you use tricyclics in pregnancy
yes
may be some mid and self limiting neonatal withdrawal
venlafaxine - less evidence
mirtazapine - less evidence
recommendations for antidepressants in pregnancy
stay on same antidepressants during and after pregnancy
unless mother wants to stop
what is the effect of antipsychotics in pregnancy
1st generation - been around a long time
2nd generation - risk of weight gain so increases GDM
reduce fertility due to raised prolactin levels
all appear to be safe - no major teratogenicity
what is the effect of mood stabilisers in pregnancy
need the woman to know she can’t take them during pregnancy before conception
valproate and carbamazepine - most teratogenic, increase neural tube defects
lamotrigine is less bad than other anti-convulsants and mood stabilisers
lithium should be avoided
what are the risks of lithium in pregnancy
known association with Ebstein’s anomaly (20x risk compared to general population, still only 1/1000 risks)
consider slow reduction pre-conception (can be reintroduced un 2nd or 3rd trimester)
be aware of dose changes in 3rd trimester - increases risk of relapse
consider re-introduction immediately postpartum
can be restarted is theres a bad relapse during pregnancy
how do you treat anxiety in pregnancy
SSRIs
try to avoid benzodiazapines as they’re generally problematic
zopiclone
-some suggestion of risk
what is the impact of psychiatric drugs on breast milk
all are exerted in breast milk
mental health is highest priority
lowest dose possible
avoid combinations
time doses to feeds (eg. give dose before longest break between feeds)
less exposure during breast feeding than in utero so it its okay in T3 it’ll be okay in breast feeding
1st line drugs in pregnancy as antidepressants, antipsychotics and mood stabilisers
Antidepressants - sertraline
antipsychotics - olanzapine, quetiapine (acrid clozapine)
mood stabilisers - antipsychotics, avoid lithium NOT valproate
what drug can you definitely not take in breast feeding
lithium
what is at increased risk if theres substance abuse in pregnancy
nutritional deficiency VTE STIs Endocarditis/sepsis Poor venous access Opiate tolerance/withdrawal Drug overdose/death Domestic abuse and suicide IUGR, Stillbirth, SIDs, preterm labour
risks of alcoholism in pregnancy
miscarriage fetal alcohol syndrome (facial deformities, lower IQ, neurodevleopmental delay, epilepsy, hearing, heart and kidney defects) withdrawal wernicke's korsakoff
risks of cocaine, amphetamine and ecstasy in pregnancy
death via stroke and arrhythmias
teratogenic
pre-eclampsia
abruption
IUGR
pre-term labour
miscarriage
developmental delay , SIDS, withdrawal
risks of opiates and nicotine in pregnancy
opiates cause maternal deaths, neonatal withdrawal, IUGR, SIDS, stillbirth
Nicotine causes miscarriages, abruption, IUGR, stillbirths and SIDS
how do you treat substance abuse in pregnancy
Methadone programme
Child protection and social work referral
Smear history
Breastfeeding (unless alcohol, HIV, cocaine)
Labour plan
Early IV access
Postnatal contraception plan
