Maternal mental health

Question 1

How common are perinatal mental health conditions?

Answer 1

Affects 1:10 women
15-20% anxiety depression
3-5% require specialist input through perinatal mental health team

Question 2

How is perinatal mental health identified?

Answer 2

Pre-conception counselling if pre-existing condition - explain how illness will affect pregnancy, medication alterations
Booking appointment
Antenatal period - PHQ2 screening
Acute presentation - MSE

Question 3

What conditions require pre-conception counselling?

Answer 3

Severe depression
Bipolar
Schizophrenia

Question 4

What happens at the booking appointment and when is it?

Answer 4

10 weeks
Full medical history
Drug history and substance abuse
Family history - first degree relatives with schizophrenia/postnatal depression/bipolar
Domestic/sexual abuse
Bloods
BMI

Question 5

When should someone be referred to perinatal mental health team?

Answer 5

Pre-existing psychiatric condition - severe depression, bipolar, schizophrenia
FHx of first degree relative with schizophrenia, postnatal depression, bipolar

Question 6

What questionnaire is used to diagnose post-natal depression?

Answer 6

Edinburgh post-natal depression score

Question 7

What are the effects of perinatal depression on the baby?

Answer 7

Pre-term delivery
Emotional disorders and depressive illness in child
Behavioural difficulties

Question 8

What are the effects of perinatal anorexia nervosa on the baby?

Answer 8

Low birthweight

Question 9

What are the effects of schizophrenia on the baby?

Answer 9

Low birthweight
Preterm delivery
Stillbirth

Question 10

What are the effects of post-natal depression on the baby?

Answer 10

Emotional disorders in child
Increased risk of depression

Question 11

What effect can maternal mental health have on the foetus?

Answer 11

Epigenetic impact
Genetic processes - neurobiological processes

Question 12

What effect can poor perinatal mental health have on the mother?

Answer 12

More women die of psychiatric illness than pre-eclampsia and amniotic fluid embolism
Suicide leading cause of maternal death up to 1 year post-delivery

Question 13

How common is depression in the perinatal period?

Answer 13

Affect 12%

Question 14

What are the S&S of perinatal depression?

Answer 14

Difficulty bonding with child
Suicidal ideation
Self-neglect
Anhedonia
Tiredness
Difficulty concentration

Question 15

How is perinatal depression diagnosed?

Answer 15

PHQ9

Question 16

What is the risk of recurrence of perinatal depression?

Answer 16

1:2 to 1:3 risk of postnatal depression

Question 17

Why should perinatal depression be treated?

Answer 17

Reduces risk of postnatal depression which affects bonding with baby

Question 18

What is the management of perinatal depression?

Answer 18

SSRIs - safe in pregnancy
SNRIs - can take during pregnancy but limited data
TCAs- risk in overdose

Question 19

What is important to ensure in babies born to mothers on SSRIs?

Answer 19

Risk of persistent pulmonary hypertension if used > 20 weeks - must deliver in hospital and baby monitored for 24 hours
Risk of neonatal adaptation syndrome - tapering dose if appropriate - crying, jittery

Question 20

What is important to take into account with SSRI treatment and breast feeding?

Answer 20

Readily transfer into milk but in low doses
Sertraline lowest dose so mothers often on this
Fluoxetine highest levels

Question 21

How common is anxiety in pregnant women?

Answer 21

13%

Question 22

What are the symptoms of anxiety?

Answer 22

Chronic excessive worry (not situational)
Hyperarousal

Question 23

What is the screening tool for anxiety?

Answer 23

GAD-2

Question 24

What is the diagnosis of anxiety?

Answer 24

GAD-7

Question 25

What are the common anxiety disorders in pregnancy?

Answer 25

Generalised anxiety disorders PTSD - flashbacks (can be a result of previous pregnancy, due to previous sexual abuse and routine examinations during pregnancy/labour) OCD Tocophobia

Question 26

What is tocophobia?

Answer 26

Morbid dread and fear of childbirth

Question 27

What are the two different types of tocophobia?

Answer 27

Primary - never delivered before Secondary

Question 28

What are the symptoms of tocophobia?

Answer 28

Request an elective CS Identify underlying cause

Question 29

What is the management of mild/moderate anxiety during pregnancy?

Answer 29

GAD- active/psychoeducation, self help OCD - CBT, exposure therapy, self help PTSD - trauma focussed CBT, EMDR

Question 30

What is the management of severe anxiety during pregnancy?

Answer 30

GAD - CBT/applied relaxation/medication/combined therapy Panic disorders - CBT/anti-depressants/self help OCD - antidepressants/combined therapies/ECT PTSD - drug treatment

Question 31

What medications can be used in anxiety in pregnancy?

Answer 31

Anti-depressants (SSRIs) Benzodiazepines - for short term management

Question 32

What are the dangers of benzodiazepines during pregnancy?

Answer 32

Associated with cleft palate, neonatal withdrawal syndrome, floppy baby syndrome

Question 33

How do you deal with the risks of benzodiazepines during pregnancy?

Answer 33

Lowest dose possible for shortest time possible Avoid in third trimester

Question 34

What are the risks of psychotic illness in pregnancy?

Answer 34

Increased risk of puerperal psychosis

Question 35

How are mothers with psychotic illnesses managed?

Answer 35

Perinatal mental health team Preconception Birth planning meeting (32/40) Intrapartum and postnatal care Elective mother and baby unit admission - not always required - to prevent deterioration of mother MDT management

Question 36

How common is bipolar?

Answer 36

1% of population Mean age of onset 17 to 22

Question 37

What is bipolar?

Answer 37

Characterised by episodes of low mood and mania

Question 38

What are the risks of bipolar in pregnancy?

Answer 38

25-50% risk of puerperal psychosis - emergency

Question 39

What are the psychological managements of bipolar?

Answer 39

Relapse prevention CBT Psychoeducation

Question 40

What are the pharmacological managements for bipolar?

Answer 40

Antipsychotics Mood stabilisers Benzodiazepines

Question 41

Can antipsychotics be used in pregnancy?

Answer 41

Yes

Question 42

Can antipsychotics be used in pregnancy?

Answer 42

Yes - not teratogenic

Question 42

Can antipsychotics be used in pregnancy?

Answer 42

Yes - not teratogenic but possible link with cardiac malformation (1-1.5%)

Question 43

What about antipsychotics should be avoided during pregnancy and why?

Answer 43

Depots - changed pharmacokinetics in pregnancy

Question 44

Which antipsychotics should be avoided during pregnancy/perinatal period and why?

Answer 44

Olanzapine - increased risk of weight gain and gestational diabetes Risperidone - raised prolactin so difficulty conceiving

Question 45

Which mood stabiliser should not be used in women of child bearing age?

Answer 45

Sodium valproate

Question 46

What are the risks of lithium to the foetus?

Answer 46

Ebstein anomaly

Question 47

What is Ebstein anomaly?

Answer 47

ASD Abnormal tricuspid valve Enlarged RA Right ventricular outflow tract obstruction

Question 48

Can lithium be given during pregnancy and if so, when should it be avoided and how?

Answer 48

Yes Avoid in first trimester and when breastfeeding Switch to antipsychotic if possible Lithium assays weekly - can easily get out of therapeutic range during pregnancy

Question 49

What are the red flag mood symptoms during pregnancy?

Answer 49

Suicidal ideation Feelings of incompetence as a parent Estrangement from child Hallucinations

Question 50

How common is schizophrenia?

Answer 50

1% population

Question 51

What are the positive symptoms of schizophrenia?

Answer 51

Hallucinations Delusions Thought disorders

Question 52

What are the negative symptoms of schizophrenia?

Answer 52

Lack of empathy/drive Catatonia

Question 53

What are the risks of schizophrenia in pregnancy?

Answer 53

Risk of relapse post-delivery and puerperal psychosis (emergency)

Question 54

What is the psychological management of schizophrenia?

Answer 54

Relapse prevention CBT Psychoeducation

Question 55

What is the pharmacological management of schizophrenia?

Answer 55

Antipsychotics Mood stabilisers Antidepressants (for schizo-affective) Benzodiazepines

Question 56

What are the two main overarching reasons that women may experience post-natal mood changes?

Answer 56

Biological and psychological

Question 57

What biological causes can cause post-natal mood changes?

Answer 57

Genetics - 50% risk if first degree relative had post-natal depression Hormone changes

Question 58

What psychosocial changes can cause post-natal mood changes?

Answer 58

Stressors Support Relationships Finances Housing

Question 59

Which is the most important question on the Edinburgh postnatal depression score?

Answer 59

No 10 - thoughts of self harm Even if score low on everything else needs acting on

Question 60

How common are baby blues?

Answer 60

50-85% women affected

Question 61

When is baby blues most common?

Answer 61

Days 3 to 10 Peak symptoms day 5

Question 62

What are the symptoms of baby blues?

Answer 62

Crying Irritability Anxiety

Question 63

What is the management of baby blues?

Answer 63

Self-limiting so reassurance and support Physiological

Question 64

How common is puerperal psychosis?

Answer 64

1-2 in 1000 women

Question 65

When is the onset of puerperal psychosis?

Answer 65

Early post natal 50% by day 7 75% by day 16 95% by day 90 Often out of hospital so rely on reports from families

Question 66

What are the risk factors for puerperal psychosis?

Answer 66

Bipolar Previous postnatal psychosis > 50% risk FHx postnatal psychosis/bipolar Schizophrenia

Question 67

What are the signs of puerperal psychosis?

Answer 67

Vague - insomnia, tearfulness, agitation Delusions (most about baby), hallucinations Mania Rapidly changing mental state

Question 68

What is the management of puerperal psychosis?

Answer 68

Exclude physical illness eg stroke/space occupying lesion Psychiatric emergency - refer to crisis team May need diazepam Admission to mother and baby unit/psychiatric ward under mental health act

Question 69

What is the risks of puerperal psychosis?

Answer 69

2% suicide risk Infanticide risk - one to one care

Question 70

What is the treatment for puerperal psychosis?

Answer 70

Antipsychotics Antidepressants Mood stabilisers ECT Psychotherapy/relapse prevention Contraception

Question 71

What is the prognosis of puerperal psychosis?

Answer 71

50% risk recurrence 65% may develop bipolar

Question 72

Name 3 forms of loss of a child

Answer 72

Intrauterine death/stillbirth Miscarriage Non-viable pregnancy so termination Neonatal death Removed child by social services Ectopic pregnancies

Question 73

What can partners mental health be like after birth?

Answer 73

Mirrors mothers experiences Offer support so mother has full support