This blogpost is a compilation of random facts about peripartum mental health which is one of an important aspect of women care. As a health care provider it is pertinent to provide optimum care for the mental health of the woman. Mental health disorders are prevalent and a woman is vulnerable during pregnancy and in the post part period. According to MBRRACE Suicide is now considered a direct cause of maternal death.
This post should be used as an adjunct to your study material for this topic as only random facts are given here.
I hope this is helpful for you all.
Thanks
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Psychiatric Disorders
- Common up to 20%
- 3-5% severely affected
- 2015 MBRRACE almost quarter of deaths due to this in 6wks - 1year postpartum
- Psychotic disorders more common than another time in a woman’s life
- Peak onset <7days
- Highest rate of adverse consequences of antenatal exposure Sodium Valproate
- Postpartum psychosis most commonly associated with bipolar affective disorder
- Approximate risk of developing postnatal depression with h/o depression + 1st degree family member with h/o postnatal depression 40%
The most common mental problems during pregnancy
- Depression 12% Anxiety 13%
- Both also affect 15-20% woman in the first year after birth
Psychiatric Assessment vital screening tool
Risks short term or long term
Red Flags Symptoms
- Rapid alteration in mental status
- New symptoms Psychotic symptoms
- Thoughts of violent self harm New ideas
- Guilt Hopelessness
- Acts of violent self harm
- Not eating well Insomnia
- Psychomotor retardation
Suicide risk found → trigger urgent assessment
- Local safe-guarding + infant protection issues
Screening Tools
- Wholly questions
- Edinburgh depression scale most frequently used
- Sensitivity 34-100% Specificity 44-100% PPV 57% NPV 99%
- PHQ-9 Patient Health Questionnaire 0-3
- GAD-2 & 7 Anxiety Screening tools
- Cut off scores — Mild 5 Moderate 10 Severe 15
- GAD -7 Sensitivity 89% Specificity 82%
- Moderately effective for panic disorders, social anxiety disorders, post traumatic stress disorders
Indications for Referral
- Current illness with symptoms of psychosis, severe anxiety, severe depression, sociality, self-neglect, harm to others or significant interference with daily functioning
- H/o bipolar disorder / Schizophrenia
- Hi/o serious postpartum mental illness like puerperal psychosis
Referral considered
- Illness of moderate severity
- Current illness of moderate or mild with h/o first degree relative with bipolar or puerperal psychosis
- Information should be shared with primary health care, any evidence of mood disturbance— antenatal and postnatal screening
- Communication is key
Perinatal Depression
- Very common 11% in pregnancy
- Up To 13% first 3 months
- 30% affected have depression beyond first year
- Risk of relapse Up To 40%
- Women commonly discontinue medication
- Pregnancy is not protective
- Half of women suffering from postnatal depression develop their symptoms before or during pregnancy
- Domestic violence increases the risk
- Symptoms same as outside pregnancy
- Untreated antenatal depression significantly increases risk of subsequent postnatal depression
Risk factors for Antenatal Depression
- Previous history of psychiatric disorders
- Previous h/o postnatal depression
- Family history
- Chronic illness
- Childhood abuse
- Substance misuse
- Young age
- Domestic violence
- Unplanned pregnancy
- Single motherhood
- Preterm birth
- Low birth weight
Postnatal Depression
- 10-15 per 100 women after childbirth
- 3% deliveries affected severely
- Gradual onset in first 2 weeks
- Peak presentations 2-4 wks and 10-14 wks
- H/o major depression + family history of postnatal depression more likely to develop
- H/o postnatal episodes in first-degree relative important predictive risk factor
- Greatest risk with family history is in first 6-8 weeks
- Risk of recurrence 1:2 - 1:3
Treatment
Mild —Referral to local psychology services IAPT (Improving access to psychological therapies) or
- Primary care mental health services offered
- Course lasts 9-12 weeks 6-8 sessions
Moderate —High intensity psychological intervention Pharmacological or Both
Severe —Switching antidepressants Augmenting, Electroconvulsive therapy
Postnatal Blues
- Very common 50-80%
- Occurs in 3-10 days Lasts 48 hours Peaking day 5
- Symptoms mild, self-limiting
- Requires reassurance and monitoring
Anxiety Disorders
Mild-Moderate
- Self help
- CBT recommended as first line for PTSD
Moderate to Severe
- High intensity psychological intervention, pharmacological or combination
Severe Episode
- Switching antidepressants or augmenting with anti depressants
- Anti-psychotics + short-term t/m with benzodiazepines
- Severe OCD admitted in MBU for inpatient t/m
Tochophobia
- Book for consultant-led care
- Trusting relationship
- Develop plan of care , women to be part of decision making process
Psychotic disorders
- 20-30% with bipolar will develop postpartum psychosis
- All with h/o psychotic disorders should be under care of a psychiatric team — Perinatal mental health team
- Preconception counselling, discussion about medications
Birth planning meeting at 32 weeks with aim for late-pregnancy care planning
- Identify triggers
- Alert physicians to early warning signs
- Strategies to reduce relapse risk
- Use of psychological therapy and medications during labour / postnatal period
- Involve patent and family
- Plan of assessment / monitoring
- Consider admission to MBU as prophylaxis
- Discuss referral to child and family social care services
Bipolar Disorder
- Affects approx. 1% of population
- Mean age of onset b/w 17-22 yrs
- Characterised by episodes of low mood and mania
- High risk of postpartum psychosis 25-50% deliveries (same with schizophrenia)
Treatment — Relapse prevention, pharmacological, CBT
Postpartum Psychosis
- 1-2 per 1000 deliveries
- More with family history and bipolar (74% chance when both)
Onset is early 50% by day 7 75% by day 16 95% by day 90
Psychiatric emergency,
- women require assessment by trained psychiatrist
- Up to 78% have delusional ideas about infant
- Admission to MBU Medication ECT
Risk of recurrence up to 50% or 1 in every 2 women
- 35-65% who suffer from one episode will develop bipolar disorder
- Mood stabilisers are recommended for long term t/m
Suicide
- Highest risk time pregnancy & 12 wks postpartum
- Risk with puerperal psychosis 2 per 100
- Leading cause of maternal death
- More violent methods used HANGING
- Confidential enquiry into maternal deaths
- 2/3 had previous psychiatric history
- 1/3 had bipolar (history identified only in < 1/2 )
Anorexia
- Has the highest mortality of all psychiatric conditions
- Six fold increase in perinatal mortality in anorexia
Few facts about the commonly used medicines
SSRI & SNRI
- Risk of exposure → increased rate of congenital malformations, small increase risk of persistent pulmonary hypertension in newborn
- Significant association b/w antidepressants and poor neonatal adaption syndrome (PNAS)
- Paroxetine linked to fetal cardiac abnormalities
- Breast feeding
- Sertaline and Paroxetine — Safe
- TCA Doxepin should be Avoided
Lithium
- In utero exposure → increased risk of Ebstein's anomaly & poor neonatal adaption syndrome
- NICE recommends → lithium should not be offered to pregnant or considering pregnancy unless and antipsychotic has been ineffective
- Increased risk of relapse if stopped the drug in pregnancy
- Lithium monitoring required in pregnancy 4wkly till 36wks and then weekly
- Toxicity → if >1.2 mmol/l — most common ECG finding T-wave flattening
- Using lithium women should give birth in the hospital
- Should be withheld during labour and child birth due to high placental transfer
- Levels checked again 12 hrs post delivery before being reinstated
- Not advised in breast feeding
Sodium valproate
- Highest risk of teratogenicity & adverse fetal outcome
- NICE→ should no longer be offered to women of child bearing age
- If become pregnant while using it→ urgent referral to specialist mental health team
- Low IQ, poor language skills, poor motor functioning, impaired emotional functioning, increased risk of autism
Medication with associated adverse consequences
- Fluoxetine→ poor neonatal adaption
- Lithium→ toxicity
- Lorazepam→ drug withdrawal
- Olanzapin→ metabolic syndrome
- Risperidone→ hyperprolactinemia
- Sodium valproate→ persistent low IQ
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