Reproductive mental health Flashcards
Prevalence of mental illness in pregnancy
~20% or 1 in 5 women develop a mental illness during their pregnancy or the 1st year post-partum
Pre-existing bipolar disorder, other serious affective disorder and/or personal history of puerperal psychosis predicts a 50% risk of early postpartum major mental illness
Post-natal depression vs “baby blues”
Baby blues effects >50% of new mothers, and typically starts 3-4 days following delivery
Baby blues do not last >2 weeks from delivery
If depressive symptoms last beyond 2 weeks, or start at a point later than 2 weeks post-natally, this is suggestive of post-natal depression (can start at any time in the first year following childbirth)
PN depression prevelance
Effects 10-15% of mothers in the first year following childbirth
Suicide is the leading cause of maternal death in the UK in the 1 year following childbirth
What is used to screen for PN depression
Edinburgh Post-natal Depression Scale (EPDS) can be used to screen for post-natal depression i.e. at 6 week post-natal check with GP
Score >=13 suggestive of depressive illness of some variety
EPDS score alone is NOT diagnostic
Post-natal psychosis prevalence
~1-2: 1000 mothers
Post-natal psychosis RF
Previous episode of post-natal psychosis
» If +, this is the strongest risk factor for MULTIPS
» 50% chance of recurrence in future pregnancies after single previous episode
Personal history of bipolar affective disorder (type I)
» Strongest risk factor in PRIMIPS or those without a history of post-natal psychosis
» ~20% risk of post-natal psychosis in first pregnancy if no other risk factors
» If bipolar type I and concurrent family history of post-natal psychosis this risk rises to ~50%
» reduced to ~10% for future pregnancies if previous pregnancy completed WITHOUT post-natal psychosis symptoms
Family history of post-natal psychosis (mother or sister)
Primiparity
Insomnia
(>50% of cases, no risk factor is identified )
PN Psychosis clinical course/ features
Symptoms have sudden onset, usually within first 2 weeks of delivery (most often within hours or days)
Compared to post-natal depression, post-natal psychosis is characterised by presence of hallucinations, delusions and/or mania
Early symptoms / signs:
Labile mood
Sleep disturbance
Agitation/ irritability
Established symptoms:
Confusion
Delusions
Depersonalisation
Depression/ anxiety
Hallucinations
Mania
Suicidal ideation
PN psychosis complications
5% risk of suicide
4% risk of infanticide
More than half of women who have had post-natal psychosis with have another future episode of psychosis NOT associated with childbirth
OCD
Background risk in general population is 1%
Rises to 2-3% in post-natal period
Mental health act - sections relevant to PN mental health
Section 2: for admissions up to 28 days
Section 3: for admissions up to 6 months
Section 4: for emergency detention powers of up to 72 hours only
Section 136: police holding powers to transport from public place –> place of safety (for further assessment)
Antidepressant use in pregnancy
For women with mild-moderate mental health conditions who are amenable to gradually reducing and withdrawing their treatment, this should be discussed and facilitated
For women with severe mental illness currently stable on treatment, the risk of treatment interruption and mental state deterioration likely outweighs the risk of harm to the fetus from continued treatment
In utero exposure to SSRIs at >20/40 may be associated with persistent neonatal pulmonary hypertension
Paroxetine use within the first trimester may be associated with congenital heart defects
SSRI use around delivery may slightly increase risk of PPH
All antidepressants carry the risk of withdrawal in the neonate, however this is usually mild and self-limiting
There is more evidence around SSRI use > SNRI use in pregnancy, however NICE recommends due to similar properties of the agents, data and risk profiles can be extrapolated to some extent
If SNRI use required venlafaxine has more of an evidence base for use in pregnancy > duloxetine
There is very minimal evidence for use of duloxetine in pregnancy and this should be avoided wherever possible
Which SSRI has the most evidence during pregnancy
and what is the catch
Fluoxetine SSRI has the most evidence of safety for use in pregnancy and is the only SSRI licensed for use in pregnancy for this reason
However has the longest t ½ of SSRIs and passes into breast milk to a much higher degree
Not SSRI of choice if initiation in established breast feeding, however it’s continuation may be acceptable on a risk-benefit decision for those already using it to good effect
Which SSRI pass into the breast milk least?
Sertraline – short t ½ in comparison to other SSRIs, alongside paroxetine; these pass into breastmilk the least
BNF recommends sertraline or paroxetine for use in those who are breastfeeding for this reason
Other SSRIs are not generally recommended to be initiated in breastfeeding mothers, but can be considered as per individual circumstances i.e. established treatment with another agent during pregnancy, or previously history of being successfully treated with another agent
Note: Amitriptyline is a tricyclic antidepressant and is found in breastmilk in only small amounts (no reported safety issues)
Which SSRI/SNRI pass into breast milk in high levels
Citalopram (SSRI) is present in breastmilk at relatively high levels
Venlafaxine (SNRI) passed into breastmilk at relatively high levels
Lithium and pregnancy
Narrow therapeutic index and can cause tox even in non preg
first trimester –> associated with congenital heart defects
» Absolute risk of 2.25% with a possible one dose effect observed
»Right ventricular outflow tract obstruction (good evidence)
» Ebstein’s anomaly – failed development of right sided tricuspid valve (some evidence)
NICE recommend where Lithium use is continued during pregnancy, levels should be checked monthly until 36 weeks, and weekly from 36 weeks –> delivery
Maternal dehydration if pregnancy related sickness –> increased levels
Increased clearance later in pregnancy –> reduced levels
Neonatal lithium level is recommended following delivery
Olanzapine and pregnancy
Antipsychotic
can be associated with gestational diabetes -> fetal macrosomia
In general population it increases risk of CVD and needs lipid monitoring etc so this makes sense
