Psychological aspects of puerperium Flashcards
What is the leading cause of maternal death in the UK?
mental illness (majority due to suicide, associated with perinatal depression)
When do the majority of maternal suicides occur?
between 6 weeks prenatally and 12 weeks postnatally
What is the best predictor of psychiatric disorder in pregnancy?
past history of mental illness
What are 3 aspects of routine mental health screening in pregnancy?
- Personal mental health history
- Other vulnerability factors, including substance misuse
- Family history of bipolar affective disorder (confers genetic vulnerability and a first episode is 7 times more likely to present in the immediate postnatal period)
What are 5 reasons why women suffering with recurrent and severe mental disorders who want to have children may benefit frmo pregnancy planning?
- Relapses are predicted by major life events
- Medication holiday an be tried before conception, avoiding complications of relapse on pregnancy
- Reproductive toxicology of essential medication can be minimised
- Closer antenatal monitoring can be planned in advance
- Contingency plans, including those for child protection, can be made with, and shared by, all the relevant agencies and caregivers
What are 3 anxiety disorders that are relatively common in pregnancy?
- Panic disorder
- Generalised anxiety disorder
- Obsessive-compulsive disorder
What symptoms of anxiety disorders may be present?
pervasive or episodic feafulnes, avoidance, autonomic arousal
excessive reassurance-seeking may be presenting feature
What must you make sure to identify in women who have anxiety in pregnancy?
any concurrent depression requiring treatment
What is high antenatal anxiety a predictor for?
postnatal depression
What is the preferred way of managing anxiety in pregnancy?
psychological management (including cognitive-behavioural therapy) preferable to anxiolytics, but access within timescale of pregnancy may be limited
benzodiazepine use should be avoided
What type of medication should be avoided in anxiety in pregnancy?
benzodiazepines
What proportion of women of childbearing age are affected by schizophrenia?
1%
What are some of the clinical features of schizophrenia that may be present during pregnancy?
delusions, hallucinations, abnormalities of affect, speech and volition
What is the recommended management of schizophrenia during pregnancy?
maintenance medication usually required throughout pregnancy
What is the lifetime risk of schizophrenia for a child with one affected parent?
10%
In addition to maternal risks of schizophrenia, what is another potential outcome to consider?
significant proportion of patients are unable to care for the child
What proportion of women of childbearing age are affected by 1. bulimia nervosa 2. anorexia nervosa?
- 1%
- 0.2%
When can patients with anorexia nervosa become pregnant?
although it is associated with reduced fertility and fecundity, patients with sub-threshold symptoms can become pregnant - require careful monitoring and management
What are 4 possible effects of eating disorders on fetal outcome?
- Fetal growth restriction
- Low birth weight
- Prematurity
- Possible increase in congenital anomalies
How does incidence of depression compare postnatally vs antenatally?
as common antenatally as it is postnatally
What are 8 possible features of depression that may be present during pregnancy?
- low mood
- lack of energy or increased fatigability
- loss of enjoyment or interest in usual activities
- low self-esteem
- feelings of guilt, worthlessness or hopelessness
- poor concentration
- change in appetite (leading to weight loss or gain)
- suicidal ideation
What are 3 examples of anticonvulsant mood stabilisers that carry a risk of fetal harm?
- Carbamazepine
- Lamotrigine
- Sodium valproate
What is the major malformation rate of carbamazepine?
2.2%
What are 3 malformations that can be caused by carbamazepine?
- Neural tube defects (key one)
- Craniofacial abnormalities
- Distal digit hypoplasia
What is the major malformation rate of lamotrigine?
2.1%
What is the key type of malformation that lamotrigine during pregnancy is known to cause?
cleft palate
What problems can lamotrigine cause when the mother is breast-feeding?
dermatological problems in infants
What is the major malformation rate of sodium valproate when taken during pregnancy?
6%
What are 4 fetal affects of sodium valproate when taken during pregnancy?
- High rate of neural tube defects
- Craniofacial abnormalities
- Distal digit hypoplasia
- Neurobehavioural toxicity (22% of exposed infants develop low verbal IQ)
What is the advice regarding sodium valproate in pregnancy?
should not be prescribed
What are 2 reasons why sodium valproate should not be prescribed to women under 18?
- Increased risk of developing polycystic ovary syndrome (PCOS)
- Increased risk of unplanned pregnancy
What are 2 key effects of benzodiazepines in pregnancy?
- Increased congenital abnormalities, especially cleft lip and palate
- Withdrawal symptoms in baby including hypotonia, respiratory problems, poor feeding (floppy baby syndrome)
What proportion of women with bipolar affective disorder stabilised on lithium relapse within 40 weeks of stopping it (e.g. in pregnancy)?
50%
What is a fetal risk of lithium in pregnancy when taken in eary pregnancy?
risk of Ebstein’s anomaly (tricuspid valve malformation - dlesn’t close properly)
What monitoring of lithium needs to be performed during pregnancy?
serum levels of lithium should be checked every 4 weeks until 36 weeks, then weekly
Where should women taking lithium deliver?
consultant-led obstetric unit
Why do levels of lithium needed to be measured more ferquently in late pregnancy (weekly from 36 weeks)?
plasma volume and GFR increase
How can lithium affect a woman in labour and what needs to be done due to this?
- reduced vascular volume and potential dehydration
- this necessitates careful fluid balance and monitoring of serum lithium levels
What are 3 neonatal effects reported in babies when lithium has been taken during pregnancy?
- Floppy baby syndrome
- Neonatal thyroid abnormalities
- Nephrogenic diabetes insipidus
What is recommended in terms of feeding of the newborn in women who are taking lithium?
breastfeeding not recommended
If antipsychotics are needed during pregnancy, which are recommended?
older antipsychotics such as haloperidol preferred - more data available with no strong evidence of increased malformations
not clozapine
Why is clozapine not routinely used in pregnancy and breast-feeding?
due to theoretical risk of agranulocytosis in fetus/ neonatae
What may be an effective alternative to mood stabilisers in women with bipolar affective disorder?
older antipsychotics such as haloperidol
What should prescribers bear in mind when prescribing antidepressants during pregnancy?
safety is not well-understood
Which type of antidepressants have lower known risks than others?
Tricyclic antidepressants (amitriptyline, nortriptyline, imipramine)
TCAs have no strong evidence of increased malformations
How do tricyclics compare with SSRIs when treating depression in pregnancy?
tricyclics have higher fat toxicity index than SSRIs
What is the SSRI with the lowest known risk in pregnancy?
fluoxetine
Which type of SSRI may have an association with cardiac malformations in pregnacy?
paroxetine
What risk have SSRIs in late pregnancy been associated with in the fetus?
increased incidence of persistent pulmonary hypertension in infants
What are 3 risks of venlafaxine if used to treat depression during pregnancy?
- Increased risk of high blood pressure
- Increased toxicity in overdose
- Increased difficulty in withdrawal
Why aren’t SNRIs (duloxetine, venlafaxine) recommended as first-line drugs in pregnancy
What are 2 types of drugs that are present in breastmilk at relatively high concentrations (so potentially avoid)?
- Citalopram
- Fluoxetine
What are 4 types of anti-depressnats that have particularly low concentrations in breastmilk and are recommended for breast-feeding mothers?
- Imipramine (TCAs)
- Nortriptyline (TCAs)
- Sertraline (SSRIs)
- Paroxetine (SSRIs)
How should decisions about psychiatric medication during pregnancy be made?
any decision to stop should be made in consultation with specialist
bear in mind period of maximum vulnerablity has often passed by time pregnancy identified
What 2 things must be balanced when deciding whether to continue or stop psychiatric medication in pregnancy?
- risk to baby - most psychiatric drugs not associated with significant increase in fetal anomalies
- risk of relapse during pregnancy should not be underestimated
What are 5 areas of risks of continuing maternal psychiatric medication to consider?
- early fetal exposure
- late fetal exposure
- delivery and neonatal withdrawal
- breast-feeding
- longer-term neurobehavioural toxicity
What proportion of women are depressed in the postnatal period?
10%
What is a link between the infant and post-natal depression?
link with infant development problems when there are associated difficulties in the mother-infant relationship
What are 4 key features of postnatal depression?
- tearfulness
- irritability
- anxiety
- poor sleep
Why is it important to specifically enquire about postnatal depression?
can easily be missed, especially with milder cases
new mothers with depression often embarrassed by feelings and reluctant to admit to sadness at a time when they fel they are expected to be happy
What are the 3 key points when NICE recommend screning for depression in the mother?
- Antenatally
- 4-6 weeks postnatally
- 3-4 months postnatally
What are the 3 questions that can be used to screen for postnatal depression?
- During the past month, have you often been bothered by feeling down, depressed or hopeless?
- During the past month, have you often been bothered by having little interest or pleasure in doing things?
If yes to both of these -
- Is this something you feel you need or want help with?
In addition to the 3 key questions that can be asked to screen for postnatal depression, how else can you screen for it?
screening questionnaires such a Edinburgh Postnatal Depression Scale (EPDS)
What are 2 methods of management of treatment for mild to moderate postnatal depression?
- Self-help strategies
- Non-directive counselling - ‘listening visits’ by a health visitor
What are 2 ways to manage moderate to severe postnatal depression?
- Antidepressant medication
- Psychotherapy (CBT)
What should be done for a woman with moderate to severe depression who is breastfeeding?
breastfeeding not CI for using antidepressant medication but drugs with low excretion in breast milk such as sertraline are preferred
What are 2 risks of postnatal depression in later life?
- >70% lifetime risk of further depression
- 25% risk of depression following subsequent deliveries
What should be done for a woman who presents in pregnancy with a history of postnatal depression?
will benefit from closer postnatal follow up as 25% risk of recurrence postnatally
What is the definition of post-partum ‘baby blues’?
brief period of emotional instability starting around 3 days after delivery and resolving spontaneously within 10 days
What proportion of women experience the baby blues?
over 50%
What treatment is usually required for post-partum baby blues?
usually responds to support and reassurance
What is puerperal psychosis?
describes a range of psychotic conditions presenting in the immediate postnatal period
most cases are of bipolar affective disorder, although severe unipolar depression, schizophrenia, and acute physical illnesswith associated organic brain syndrome can all present with psychotic symptoms
Within what time frame does puerperal psychosis present?
presents rapidly, usually within 2 weeks of delivery
How common is puerperal psychosis?
following 1-2 in 1000 births
What is the associated 1. suicide rate and 2. infanticide rate in puerperal psychosis?
- 5%
- 4%
What are 4 risk factors for puerperal psychosis?
- Personal history of bipolar affective disorder
- Previous episode of puerperal psychosis
- 1st-degree relative with history of puerperal psychosis
- 1st-degree relative with bipolar affective disorder
What is the risk of puerperal psychosis in a woman with bipolar affective disorder and a personal or family history of puerperal psychosis?
60%
What management should be carried out for women at high risk of puerperal psychosis?
referred to specialist perinatal mental health services antenatally so appropriate care plan can be developed and use of prophylactic medication following delivery may be considered
What is the management of women presenting with puerperal psychosis?
urgent psychiatric assessment and treatment
should be admitted due to risks to baby and mother (neglect as well as direct harm) - ideally to specialist mother and baby unit, where maternal-infant relationship can be protected
any decision to admit baby to mother and baby unit must be child-centred
What is the key thing to consider when deciding whether to admit a baby to a mother and baby unit?
must be child-centred, involve full consideration of longer-term possibility of the baby remaining with the mother if hte mental health problems have been long-standing
What are 3 things that treatment of puerperal psychosis may involve?
- Antidepressant or antipsychotic medication
- Mood stabilisers
- Electroconvulsive therapy (ECT)
What is the prognosis for patients presenting with puerperal psychosis?
most make a full recovery, but the 10 year recurrent rate of psychosis (puerperal and non-puerperal) is up to 80%, 10 year readmission rate 60%
