Perinatal Mental Health (John Lawton)

Question 1

What is the most common psychoactive drug taken during pregnancy?

Answer 1

Caffeine - stimulant, potentially addictive, can cause withdrawal symptoms

Question 2

What are the side effects of caffeine?

Answer 2

Agitation
Depression 
Inc HR and BP
Weight gain 
Muscle aches 
Insomnia 
Ulcers
Oesophageal problems

Question 3

What risks are associated with not treating mental health problems in pregnancy?

Answer 3

Pregnancy complications
Maternal complications
Relapse

Question 4

What are the problems associated with depression in pregnancy?

Answer 4

Missed appointments 
Poor habits / diet
Self harm 
Neglect
Use of smoking, alcohol / illicit substances

Question 5

What should be considered in deciding on treatment during pregnancy?

Answer 5

Which drug, previous response, safety, dose (lowest and shortest time). Chance of relapse if medication is discontinued.

Question 6

What is monitored during pregnancy if medication is necessary?

Answer 6

Dose, foetal screening, hepatic enzymes, monitoring the neonate

Question 7

What is a period of gestation and when is it recommended?

Answer 7

First trimester

Period of non treatment because teratogenic risk greatest

Question 8

Why is poly-pharmacy contraindicated?

Answer 8

Increased risk of teratogenicity

Question 9

Which antidepressants are associated with lower risk?

Answer 9

Sertraline

Question 10

Which antipsychotics are associated with lower risk?

Answer 10

Chlorpromazine, trifluoperazine, haloperidol

Olanzapine

Question 11

Which hypnotics are associated with lower risk?

Answer 11

Promethazine

Question 12

What general advice would you give to a patient taking anti-depressive medication that is newly pregnant?

Answer 12

Personalised assessment of benefit and risk needed
Do no abruptly discontinue medication
Without clear evidence then the best option is not to switch.

Question 13

What is generally done if medication is required?

Answer 13

Lowest risk medication is chosen

Regularly review and rationalise choices

Question 14

What are anti-psychotics monitored for during pregnancy?

Answer 14

Alterations in foetal growth

Monitoring for blood glucose abnormalities where olanzapine or clozapine is prescribed.

Question 15

Which drugs should be avoided in pregnancy?

Answer 15

Valproate - foetal abnormality and adverse neurodevelopment

As a result, it should not be given to women of child bearing age; an alternative is needed with increased folic acid.

Question 16

How can drug pharmacokinetics be manipulated?

Answer 16

Avoid breastfeeding at the Tmax of the drug

Question 17

What form of compounds are retained in milk / accumulate?

Answer 17

Basic compounds because breast milk is > acidic that plasma.

Question 18

What effect does half life have on breast milk content?

Answer 18

Short T1/2 is ok

Long half life means can accumulate in breast milk - avoid slow release or depot injections.

Question 19

How can Mw effect drug concentration in breast milk?

Answer 19

Small molecular weight can cross easier

Choosing high Mw is preferable

Question 20

What are the prescribing considerations in breastfeeding?

Answer 20

Avoid premature or low birth weight 
Avoid new drugs 
Side effect profile 
Half life of the drug 
Sedating medication advice 
Reference source (specialist advice)

Question 21

Which drugs should be avoided in pregnancy?

Answer 21

Fluoxetine
Clozapine
Lithium
BZD