Week 4 - E - Perinatal Psychiatry - Baby blues, puerperal psychosis, postnatal depression and drugs in pregnancy

Question 1

What is the leading cause of maternal death in the uK? What is the commonest medical problem during pregnancy? Perinatal mental health problems are those which occur during pregnancy or in the first year following the birth of a child.

Answer 1

The leading cause of maternal death in the UK is mental illness The commonest medical problem during pregnancy is hypertension

Question 2

The rate of maternal death by suicide remains unchanged since 2003 and maternal suicides is now the leading cause of direct maternal deaths occurring within a year after the end of pregnancy. When do half of the maternal death suicides occur?

Answer 2

Half of the suicides occur up to 12 weeks post-natally

Question 3

Mental illness is the leading cause of maternal death in the year post-natally, with half of the suicides occuring up to 12 weeks postnatally How many women who die between 6 weeks and one year after pregnancy died of mental health related cause?

Answer 3

Almost 1 in 4 (23%) women who die between 6 weeks and one year post pregnancy is due to mental health related causes

Question 4

There are some red flag presentations in perinatal psychiatry that requires urgent referral to specialist perinatal health team What are the three red flags that require urgent referral?

Answer 4

Women who report: * Recent significant change in mental state or emergence of new symptoms * New thoughts or acts of violent self harm * New and persistent expressions of incompetency as a mother or estrangement from their baby

Question 5

Good communication between primary care, mental health and maternity services is critical to good quality care for women with mental ill health, in particular What should be asked about during the booking appointment for pregnnacy?

Answer 5

During the booking appointment, ask about a current or past history of mental health problems - not just depression

Question 6

What are the reasons for urgent perinatal psychiatry referral again?

Answer 6

* 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 moth or estrangement from their baby

Question 7

rapidly changing mental state suicidal ideation (particularly of a violent nature) significant estrangement from the infant pervasive guilt or hopelessness beliefs of inadequacy as a mother evidence of psychosis Where the mother has any of these symptoms, where should she be referred to? What are the three main symptoms for urgent referral?

Answer 7

Admit to a mother and baby unit Urgent referral to perinatal psychiatry if women presents with: * Recent significant changes or emergnece of new symptoms * New thoughts or acts of violent self harm * New persistent expressions of incompetency as a mother or estrangement from their baby

Question 8

How could you ask about if the mother had had a change in mental state? How could you ask about thought or acts of violent self harm? How could you ask if the mother felt incompetent or if she was estranged from her baby?

Answer 8

Do you have new feelings thoughts which you have never had previously, thoughts which make you anxious or disturbed? Have you ever had thoughts of suicide or harming yourself in a violent way? Do you feel like your are coping/are competent as a mother? DO you ever feel estranged from your baby and are these feelings persistent?

Question 9

How often during pregnancy, should mental health issues be screen for?

Answer 9

Screen for mental health issues at the booking visit and then screen at every appointment Is this something you fee you need or want help with is a good question

Question 10

For women with pre-existing mental health problems, is pregnancy usually protective against these? ( ie does pregnnacy relieve the sympotms of pre-existing mental health problems)

Answer 10

Pregnancy is not protective for pre-existing mental health issues - for most conditions treatment should be continued throughout pregnancy (as long as it is not teratogenic)

Question 11

During the first week after childbirth, many women get what’s often called the ‘baby blues’. Women can feel down or depressed at a time when they expect they should feel happy at having a baby to look after. ‘Baby blues’ are probably due to the sudden hormonal and chemical changes that take place in your body after childbirth. * Wht are symptoms of baby blues? * How many women are affected? * When do the baby blues usually start and what is the treatment?

Answer 11

Baby blues is when women can feel down or depressed after pregnancy when they expect they should feel happy It occurs in 50% of women with women feeling tearful, irritable, anxious and having poor sleep confusion Baby blues usually occurs around days 3-10 after pregnancy and are self limiting so just support and reassure

Question 12

Postpartum psychosis (puerperal psychosis) is a psychiatric condition which occurs after birth in a small percentage of women. When do the symptoms of this condition usually occur? What are the early symptoms?

Answer 12

Peruperal psychosis presents usually within 2 weeks after delivery Ealry symtpoms include sleep disturbance, confusion and irrational ideas but can present to mania and delusions/hallucinations

Question 13

Postpartum psychosis is a rare but serious mental health illness that can affect a woman soon after she has a baby. Many women will experience mild mood changes after having a baby, known as the “baby blues”. This is normal and usually only lasts for a few days. But postpartum psychosis is very different from the “baby blues”. It’s sometimes called puerperal psychosis or postnatal psychosis. When should you seek help for peurperal psychosis?

Answer 13

Pueperal psychosis should be treated as a medical emergency as it is a risk to the mother and to the child (ie neglect or worse)

Question 14

What are the risk factors associated with peuperal psychosis? What are the sympotms again?

Answer 14

Bipolar disorder (50% of cases) Previous peuperal psychosis 1st degree relative with a history of the disease Sleep disturbance and confusion, irritational ideas Mania, hallucinations, delusions, confusion

Question 15

Peuperal psychosis is an emergency and requires admission to a specialized mother-baby-unit What are the different treatment options for the condition? (think about the syptoms that reequire treatment) puerperal psychosis is also able to be distinguished from postnantal depression due to the high suicidal drive

Answer 15

Antidepressans - helps the symptoms of depression Antipsychotics - helps the psychosis Mood stabilizers - to stabilise mood Sometimes ECT is required (Electroconvulsive therapy (ECT)) but this is very rare for very severe symptoms

Question 16

What percentage of people with puerperal psychosis go on to develop bipolar disorder?

Answer 16

25% of patients go on to develop bipolar disorder There is also a high recurrence rate of the psychosis in the years following the inital episode

Question 17

most women with postpartum psychosis do make a full recovery. How long can it take to recover from pueperal psychosis?

Answer 17

Can take up to 6to12 months to make a full recovery from the condition

Question 18

Sum up all the info you have on puerperal psychosis

Answer 18

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Question 19

Postnatal depression is very common What percentage of women does it occur in? When is onset usually?

Answer 19

Postnatal depression occurs in 10% of women and onset is usually 2-6 weeks postnatally

Question 20

How long does it usually take for postnatal depression to resolve? What are causes of the depression? What are the symptoms?

Answer 20

Postnatal depression usually occurs within 2-6weeks postnatally and resolves within 6 months Can be caused by sleep distubances, genetic or hormonal changes Symptoms include increasing tiredness, irritability and anxiety and a lack of enjoyment and poor sleep, weight loss They postnatal depression can show due to concerns with the baby

Question 21

What effects can postnatal depression have between the mother and infant?

Answer 21

Can decrease the bonding between mother and child as well as have an impact on the child development - cognitive and social skills

Symptoms have to last at least 2 weeks in postnatal depression and can have Suicidal ideation can be depression

• Suicidal intent is psychoses

Question 22

Mild-moderate postnatal depression usually requires conselling/self help What does moderate to severe postnatal depression require? 70% lifetime risk of depression after having postnatal depression

Answer 22

Moderate-severe may require congnitive behavioural therapy (psychotherapy) and antidepressants

Question 23

What anti-depressants is usually a good choice for a mother with postnatal depression? (SSRIs and Tricyclics are usually rarely detectable in breast ,milk)

Answer 23

The SSRI (selective serotonin reuptake inhibitor) Sertraline and paroxetine

Question 24

In the treatment of perinatal disorders Baby blues Postnatal (puerperal) psychosis Postnatal depression There are different issues to consider. What are the usual issues to consider?

Answer 24

* Risk of untreated illnesses * The general principles in prescribing in perinatal period * Benefits and harms of specific treatments

Question 25

Risks of untreated illnesses can affect both the mother and the child What are the risks to the child with untreated maternal depression?

Answer 25

* Low birth weight and pre-term delivery associated with the severity of the depression * Adverse childhood outcomes * Impaired infant cognitive and social skills - due to poor bonding with the child

Question 26

There are general principles of prescribing in the perinatal period such as planning the pregnancy and monitoring the patients medication (especially for teratogenics used in the treatment for mental illnesses) What are the preferential drugs to be used for the perinatal psychiatry conditions?

Answer 26

Preferentially use drugs with low risk to both mother and fetus and increase the screening in the foetus

Question 27

The risk and benefit of certain drugs can vary between the 1st and 3rd trimester Should all teratogenic drugs be stopped abruptly?

Answer 27

Not all teratogenic should be stopped abruptly as there are risks such as withdrawal associated here

Question 28

What are usually the risks of different drugs in 1st trimester and the drugs in the 3rd trimester? In general if a drug was able to be used in pregnancy, can it be used during breastfeeding?

Answer 28

1st trimester - there is a risk of teratogenecity 3rd trimester - there is a risk of neonatal withdrawal Breastfeeding - there is usually less exposure than in utero therefore in general, no need to stop a drug during breastfeeding that was used during pregnancy

Question 29

Antidepressants generally have no major malformations or spontaneous abortion risks What is a spontaneous abortion? Which anti-depressant is known for causing an increased risk of foetal heart defects if used in the 1st trimester however?

Answer 29

Spontaneous abortion - also known as a miscarriage is the loss of a pregnancy before 23 weeks gestation Paroxetine - an SSRI is known to cause an increase in the foetal heart defects if used in the 1st trimester of pregnancy

Question 30

The risk of neonatal withdrawal is usually mild and self limiting when using anti-depressants in the 3rd trimester Do SSRIs or Trcicylics have a greater risk of neonatal withdrawal in the 3rd trimester? Name two of each that have the lowest risk

Answer 30

SSRIs - fluoxetine/sertraline Tricyclics - imipramine/amitriptyline - lowest risk Tricyclics have the lowest risk of cuasing neonatal withdrawal out of the anti-depressants

Question 31

Again name the two SSRIs and Tricyclcis with the lowest risk of neonatal withdrawal? What can they increase the risk of?

Answer 31

SSRIs - fluoxetine/sertraline Tricyclics - imapramine/amitriptyline They can increase the risk of neonatal pulmonary hypertension (Persistent pulmonary hypertension of the newborn (PPHN) )with SSRIs taken after 20 weeks Both can increase risk of low birth weight / prematurity

Question 32

Patient with untreated and treated depression have an increased risk of a low birth weight baby / premature birth Is there any adverse affects of anti-depressants on breastfeeding? What anti-depressants should be avoided?

Answer 32

Although all (SSRIs and TCAs) are in breast milk to a small extent, there are no adverse effects reported Avoid citalopram

Question 33

With the use of benzodiazepines in pregnant women, why are they avoided in both 1st and 3rd trimester?

Answer 33

1st trimesster - avoid due to possible increased risk of foetal malformation ie cleft palate 3rd trimester - avoid due to increased risk of floppy baby syndrome

Question 34

Benzos can increase the risk of floppy baby syndrome if used in the 3rd trimester WHat is floppy baby syndrome? Can benzos be used during breastfeeding?

Answer 34

Floppy baby syndrome is a syndrome characterised by hypotonia, hypothermia and respiratory depression (usually due to the sedative effect of the benzo) in a new born baby Benzos should not be used regularly during breastfeeding as they increase weight loss and lethargy

Question 35

What are symptoms of floppy baby syndrome?

Answer 35

The baby cannot form a good latch for breastfeeding as its moth muscles are too week Its head is limp as well

Question 36

What chemical do antipsychotics mainly act on? Why does this reduce the chances of conception? Which type of antipsychotics is safer in pregnancy?

Answer 36

Antipsychotics mainly act on dopamine levels (as well as various other chemicals in the brain) By reducing the dopamine levels, this causes an increase in prolactin levels which negatively feedsback to reduce the GnRH (gonadotropin releasing hormone) levels which decrease FSH/LH levels - hence the reduced chances of concetion More evidence for saftey of typicals (older - first gen) than atypicals (newer - second gen)

Question 37

What antipsyhcotic should be avoided at all points due to the risk of agranulocytosis? Is it a typical or atypical antipsychotic? What is agranulocytosis?

Answer 37

Avoid clozapine - an atypical anitpsychotic at all points as it causes agranulocytosis Agranulocytosis is when there is a severe leukopenia (white blood cell count decreasing) mainly the neutrophils

Question 38

Depot antipsychotic are avoided due to the prolonged effects they can have, even on the neonate What are the common effect that all antipsychotics can have but particulary if a depot injection?

Answer 38

These are extrapyramidal side effects (EPSE) - parkinsonism depot antipsychotics can cause EPSE in neonates

Question 39

Lithium is a common drug used as a mood stabiliser - eg in bipolar disorder If given in 1st trimester it can cause an increase risk in a heart anomaly WHat is this anaomly known as? a congenital heart defect in which the septal and posterior leaflets of the tricuspid valve are displaced towards the apex of the right ventricle of the heart.

Answer 39

This is Ebstein’s anomaly

Question 40

The use of lithium in the third trimester should be closely monitored What can lithium toxicity mimic? Why is lithium avoided during breastfeeding?

Answer 40

Lithium toxicity can mimic pre-eclampsia in the 3rd trimester of pregnancy Avoid in breastfeeding as it is present in high quantity=ies

Question 41

What are the different uses of sodium valproate? What adverse effects can it have on a pregnnacy?

Answer 41

Can be used to treat epilepsy, bipolar disorder and migraines (it is a broad spectrum anti-convulsant) Can cause neural tube defects, craniofacial defects and effects on chidl’s intellectual development if used in pregnnacy

Question 42

Who should sodium valproate be avoided in? When does the neural tube close? Can it be used in breast feeding?

Answer 42

Neural tube closes on day 28 Sodium valproate should be avoided women of child bearing or if it is necessary, use adequate contraception Breast feeding Low risk with no evidence of adverse effects in breast feeding

Question 43

Other mood stabiliser include carbamezapine and lamotrigine WHat can these cause if used during pregnnacy? What does lamotrigine carry the risk of cause in infant if breast feeding?

Answer 43

Carbamezapine has an increased risk of cause neural tube defects Lamotrigine has an increased risk of causing orofacial defects eg cleft lip Lamotrigine can cause Steven Johnson Syndrome in infant if breast feeding

Question 44

Substance abuse in pregnancy is a mental and behavioural disorder substance abuse poses a health risk to both mothers and foetal well being What factors make a mother more likely to substance abuse?

Answer 44

Social deprivation Poor communication Poor history taking Lack of contraception Mothers more likely to substance abuse in these circumstances during pregnancy

Question 45

Royal college of obstetricians and gynaecologists recommends abstinence but what is the minimum alcohol intake per week where there is no evidence showing that it is detrimental? What can alcoholism during pregnancy cause?

Answer 45

No evidence that 2 units/week is detrimental Alcoholism can cause Risk of miscarriage Feotal alcohol syndrome Alcohol withdrawal Risk of Wenicke’s encephalopathy Korsakoff syndrome

Question 46

What does foetal alcohol syndrome look like? How does alcoholism cause Wernicke’s encephlopathy?

Answer 46

Foetal alcohol syndrome severity usually depends upon the alcohol intake of the mother 0 can result in facial deformities and lower IQ, neurdevelopmental delay and cardiac/kidney defects - also epilepsy and hearing defects Alcohol causes a vitamin B1 deficiency which cause a disease known as Wernick’es encephlopathy

Question 47

What are the usual three cardinal signs of wernick’es encephalopthy?

Answer 47

Ocular disturbances Change in mental state - confusion Unsteady stance and gait (ataxia)

Question 48

What is the difference between Wernicke’s encephalopthy and Korsakoff’s syndrome?

Answer 48

Alcoholism is the no. 1 cause of WKS because people with the condition generally have a poor diet. Alcohol also prevents vitamin B-1 absorption and storage. Wernicke’s encephalopathy is the initial presentation before it progresses to Korsakoff’s syndrome if left untreated - this is where there is acute memory loss and korsakoffs is irreversible

Question 49

Cocaine, amphetamine and ecstasy substance abuse can all cause death via stroke and arrythmias and are teratogenic What can opiates cause?

Answer 49

Opiates can cause maternal deaths, neonatal withdrawal, IUGR, SIDS (sudden infant death syndrome), stillbirth

Question 50

If a patient is taking heroin is it wise to stop them immediately? What can be given to wean the person off? What is given if the person undergoes a heroin overdose?

Answer 50

It is not wise, this can cause withdrawal Can give methadone to steadily wean the mother off heroin Nalaxone is given for an opiate overdose

Question 51

24 year old prim attends for a booking appointment at 12 weeks gestation. She admits to drinking a bottle of vodka per day. She smokes. This was an unplanned pregnancy. What additional history do you wish to clarify?

Answer 51

Clarify how long she has been smoking for and how many per day Clarify if she understand sthe risks of smoking and alcohol when pregnnat

Question 52

What are the risks of alcoholsim and nicotine abuse when pregnant?

Answer 52

Alcoholism - Miscarriage

• * Foetal alcohol syndrome - facial malformations, neurodevelopmental delays, heart and kidney defects etc
• * Wernick’s encephalopathy & Korsakoff syndrome
• * Withdrawal

SMoking

• * Placental abruption
• * IUGR
• * Stillbirths and SIDS, miscarriages

Question 53

24 year old prim attends for a booking appointment at 12 weeks gestation. She admits to drinking a bottle of vodka per day. She smokes. This was an unplanned pregnancy. On admission to hospital for an IOL at 37 weeks for IUGR what plans should be made if she continues to drink alcohol ?

Answer 53

Contact social work and child protection services

Question 54

A 35 year old is seen by her GP for a routine appointment. She admits to currently trying to conceive. She is currently taking Paroxetine for depression. She admits to occasionally feeling low in mood having poor concentration and feelings of guilt. She has had previous in patient admissions for treatment of depression and has occasionally self harmed. What should the GP do re Paroxetine? Who should she be referred to?

Answer 54

Paroxetine is dangerous to take in the 1s trimester as it increases the likelihood of foetal cardiac defects and therefore suggest changing to a different anti-depressant eg fluoxetine She should be referred to the psychiatry team

Question 55

A 32 year old para 2 presents to antenatal clinic following her anomaly scan. She is currently taking low dose fluoxetine which she has taken for over a year for depression. She is happy to be pregnant and reports no concern about her mood. What additional history do you want? What do you advise? What are the risks of stopping fluoxetine?

Answer 55

Additonal history Ask if she has ever had any thoughts or acts of violent self harm? As if she feels she is coping wellwith the pregnancy Risks of stopping fluoxetine are simply withdrawal and risk of low birth weight/premature birth

Question 56

A 24 year old prim is seen for her booking appointment at 12 weeks. This is an unplanned pregnancy. She has bipolar affective disorder. Having found out she was pregnant 5 days ago she is delighted to be pregnant and has stopped her meds for fear of affecting her baby. Previously she has been on long term lithium treatment. What do you need to assess? What risks antenatal risks need discussed?

Answer 56

Need to assess if there is a clinical indication to continue the medication as sudden discontinuation of lithium is not advised Refer her to psychiatry team

Question 57

A community midwife does a house visit to see a patient 3 days postnatally. She is extremely worried about her baby who she is struggling to breast feed. She has very sore nipples and sore right breast. Her partner reports that she is emotionally labile and seems confused at times What is the most likely diagnosis? What should the midwife do?

Answer 57

Within 3t10 days is usually baby blues Reassure the mother that this is normal in 50% of women and is usually self-limiting

Question 58

A 32 year old Para 1 women is seen for her booking appointment. She has a history of puerperal psychosis. She is not currently on any medications. She has good partner and family support. She is extremely worried about recurrence. What do you tell her? Which members of MDT do you contact? What plans do you make for the postnatal period?

Answer 58

Tell her that their is a high recurrence rate in 10 years but if she has symptoms then we can admit her to the specilised mother baby unit and contact the psychiatry team 80% have a 10year recurrence of puerperal psychosis

Question 59

A 36 year old para 1 is seen in antenatal clinic following a reassuring anomaly scan. She wishes to discuss her previous delivery. She tells you she had a forceps delivery and a massive PPH. She is currently feeling very stressed about labour and wishes to restart diazepam to help her sleep. What do you advise her re benzodiazepines? What delivery plans do you offer?

Answer 59

Advise her that benzos can be dangerous if taing them in the third trimester as can cause floppy baby syndrome Also regular use during breast fleeding is also dangerous Offer the women a caesearan section