Perinatal Psychiatry Flashcards
(143 cards)
1
Q
Risk of spontaneous major malformation in pregenancy?
A
2-3%
2
Q
How many malformations in pregnancy are due to drugs?
A
5 out of every 100 malformations
3
Q
Relationship between pregnancy and MH problems?
A
Increased risk fo suicide & MH problems
4
Q
Risk of psychiatric episode postpartum?
A
Significant increase in first three months; 80% are mood disorder
5
Q
Risk of depression during pregnancy
A
7-15%
6
Q
Risk of depression in women outside perinatal period?
A
7%
7
Q
Relapse rate of depression in patients with a history who are pregnant?
A
50%
8
Q
Risk of postpartum depression?
A
10%
9
Q
Risk factors for postpartum depression
A
Highest in bipolar
Previous depression
10
Q
Risk of postpartum psychosis
A
0.1-0.25%
11
Q
Risk of postpartum psychosis in bipolar
A
50%
12
Q
Risk of postpartum psychosis in patients with a hx of postpartum psychosis
A
50-90%
13
Q
Incidence of puerperal psychosis
A
One per 1000 births
14
Q
What is puerperal psychosis strongly linked to?
A
Bipolar
15
Q
What perinatal episodes are triggers for bipolar?
A
Childbirth
Abortion
Menstruation
16
Q
Recurrence rate of puerperal psychosis?
A
One in four pregnancies
17
Q
Prevalence of disorders of mother-infant relationship?
A
10-25%
18
Q
Relative risk of postpartum psychosis in the first month?
A
20-fold increase
19
Q
Risk of relapse of bipolar in first month postpartum?
A
Eight-fold increase
20
Q
Characteristics of bipolar relapses postpartum?
A
Depressive
21
Q
Negative outcomes for untreated psychiatric illness in the pregnant women
A
Suicide
Alcohol & substance misuse
Poor compliance with perinatal appointments
Unhealthy lifestyle
Poor judgement
Impulsive acts
Impaired selfcafe
22
Q
Risk of untreated psychiatric illness for the fetus
A
Low birth weight & small head circumference (due to anxiety and depression) Preterm birth (depression)
23
Q
Risk to child postpartum if depression continues in mother?
A
Attachment, cognitive and behavioural difficulties
24
Q
Impact of substance misuse in pregnancy to the fetus?
A
Increased intrauterine death
Congenital, cardiovascular and musculosketal abnormalities
Fetal alcohol syndrome
25
When do major malformations occur in pregnancy?
First trimester
26
When do neonatal toxicities occur in pregnancy?
3rd trimester
27
When do teratogenic effects occur?
Dose and time dependent
Organs at greatest risk during period of fastest development
Week 6-10 is most vulnerable period
28
Recommendations of drug treatment during preganncy
```
Monotherapy
Lowest dose
Regular psych & obstetric r/v
Regular medication r/v
If possible avoid all drugs in first trimester
```
29
Drug treatment recommendations as pregnancy advances
Adjust doses; blood volume expands by 30% in 3rd trimester.
| Observe for neonatal withdrawal sx after birth
30
Treatment of schizophrenia in pregnancy
Use antipsychotics at every stage of pregnancy.
31
Most used antipsychotic in pregnancy?
Olanzapine
32
Which antipsychotics are commonly used in pregnancy?
```
Chlorpromazine
Trifluoperazine
Haloperidol
Olanzapine
Clozapine
```
33
Treatment of depression in pregnancy
Explore possibility of delaying treatment until 2nd-3rd trimester e.g. CBT
34
When should pregnant patients be treated with antidepressants if depressed?
High risk of relapse
| Moderate-severe depression and psychological treatment has failed
35
Which antidepressant must be avoided in pregnancy
Paroxetine
36
Recommended antidepressants in pregnancy?
Nortriptyline
Amitriptyline
Impramine
Fluoxetine
37
Which patients with bipolar should continue medication?
Severe illness and high risk of relapse
38
Recommendations re maintenance treatment for bipolar who are pregnant?
Dose reduction and regular review of side effects
39
When should discontinuation of mood stabilisers be considered in the pregnant woman with bipolar?
Only if absolutely necessary and followed by frequent monitoring
40
Which mood stabilisers should be avoided in pregnancy?
Valproate
| Combination of mood stabilisers
41
What should be done if a pregnant women is on Valproate or Carbamazepine?
Folic Acid 5mg OD from at least a month before conception should be px
Vitamin K should be given to mum and neonate after delivery
42
Impact of TCAs on pregnancy
No significant malformations
| High doses in third trimester can lead to reversible withdrawal sx
43
Withdrawal sx in neonate with high dose TCAs?
Irritability
Eating and sleeping difficulties
Convulsions
44
Best TCAs to use during pregnancy
Nortriptyline
Desipramine
(less hypotensive and anticholinergic side effects)
45
Risk of SSRIs in pregnancy
13.3% increase in spontaneous abortion
| Risk of decreased gestational age and low birth weight
46
Which drugs increase risk of spontaneous abortion
SSRIs
Mirtazapine
Bupropion
47
Risk of Paroxetine in pregnancy
1st trimester: VSD and ASD
| 3rd trimester: neonatal complications due to abrupt withdrawal
48
Which antidepressant has least placental exposure?
Sertraline
49
Risks of SSRI if introduced late in pregnancy
Increased risk of persistent pulmonary hypertension of newborn
50
Which antidepressants have high risk of neonatal withdrawal symptoms
Paroxetine
Venlafaxine
(short half-life)
51
Advice if pregnant woman is on MAOI
Limited evidence so should switch to safer antidepressant.
52
Why should MAOIs be avoided in pregnancy?
Risk of hypertensive crisis and congenital malformations
53
Risk of malformation if Lithium used in first trimester?
1 in 10
54
What is Lithium associated with if used in first trimester?
All types of malformation risk increased three-fold
| Cardiac malformations risk increased 8-fold
55
Relative risk of Ebsteins anomaly if on Lithium
10-20 times higher
56
When is risk of malformation greatest when on Lithium?
2-6 weeks after conception
57
Fetal toxicity sx if on Lithium
Hypotonia
Poor reflexes
Respiratory difficulties
Cardiac arrhythmias
58
Risk of relapse if a women stops lithium when pregnancy
70% within 6 months
| Faster discontinuation = higher risk of relapse
59
Risk of relapse of bipolar for women who stop lithium when pregnant vs not pregnant
3 fold higher risk of relapse if pregnant
60
Teratogenic risks of Carbamazepine
0.-1% risk of spina bifida, craniofacial anomalies, growth retardation and decreased head circumference.
61
What is thought to lead to the teratogenic effect of carbamazepine?
Epoxide intermediate
62
Risk of any birth defect while on Sodium Valproate?
7.2%
63
What is risk of valproate related to during pregnancy?
Dose related
| Mainly seen in days 17-30 post conception
64
When is teratogenic risk of valproate increased?
FHx of neural defects
65
Risks of valproate on the fetus
Growth retardation
Hepatotoxicity
Congenital anomalites
66
Congenital anomalies of valproate?
```
Neural tube defect 1-2%
Spina bifida - 10-fold increase
Digital and limb defects
VSG, Pulmonary stenosis - 4-fold increase
Urogenital malformations
Low birth weight
Psychmotor slowness
Mental retardation
```
67
Which neonatal effects are related to valproate concentration in the infant?
Neurological dysfunction
| Hyperexcitability
68
Findings of IQ of children in mothers who took valproate during pregnancy
42% had verbal IQ <80
| 30% needed special educational support compared to 3-6% of those exposed to other antiepileptic drugs
69
Which malformation is Lamotrigine associated with?
Cleft palate
70
Risk of malformations if on Lamotrigine?
3.2%
71
What is the notable study of antipsychotic use in pregnancy?
California Child Health Development Project - study of 19,000 births
72
What are low-potency conventional antipsychotics associated with if used in pregnancy?
Transient perinatal syndrome
Floppy infant
Withdrawal symptoms; hypertonicity, hypotonicity, underdeveloped reflexes, irritability
73
When are conventional antipsychotics associated with congenital malformations?
If used in first trimester; 2-2.4%
74
Which conventional antipsychotic is associated with limb deformities if used in first trimester?
Haloperidol
75
What effects have been reported from clozapine use during pregnancy?
Still birth
| Neonatal seizure
76
Which atypical antipsychotics can lead to gestational diabetes?
Clozapine
| Olanzapine
77
Use of anticholinergic drugs in pregnancy
Associated with teratogenicity; should be avoided.
If must be used, use at lowest dose.
78
Risk of benzo use during first trimester
0.6% risk of cleft palate & CNS & urinary tract malformations
79
Adverse effects of benzo use on the neonate
Neonatal toxicity - withdrawal sx
Respiratory depression
Muscular hypotonia (floppy baby syndrome)
80
Evidence of Zopiclone use in pregnancy
Animal studies show no teratogenicity
81
How often do pregnant women on lithium need serum levels?
Every 4 weeks throughout pregnancy
Lithium dose should be adjusted to match lower end of therapeutic range
82
Recommendations of dosage tapering of lithium in pregnancy
Should not be discontinued abruptly
Prior to delivery dosage should be gradually tapered to 60-70% of original level
83
Positive impact of Lithium use in 2nd and 3rd trimester?
Reduces risk of puerperal psychosis
84
What investigations do pregnant women on lithium require?
Level 2 USS and echo of fetus at 6 and 18 weeks to screen for Ebsteins anomaly
85
When does Lithium need to be increased during pregnancy?
3rd Trimester; total body water increases
86
Effect of anaesthetic agents on pregnancy
Barbituates and atropine can reduce beat-to-beat variability in fetal HR
Atropine can cause fetal tachycardia
87
Effect of pregnancy on ECT
Seizure threshold reduced by oestrogen
| Increased by progesterone
88
Risk of ECT during pregnancy
Prolonged gastric emptying time increases risk of gastric regurgitation and aspiration pneumonitis
89
Risk of ECT on fetus
None
90
Which psychotropics are excreted in breast milk?
All
91
When should medications be taken when breast feeding?
After breast feeding
92
What factors impact the effect of adverse effects of medication on breast fed infants?
Prescribed dose
Level of drug in mothers blood plasma
Level of drug in breast milk
Level of drug in infants serum
93
What factors determine the amount of medication excreted in breast milk?
Medications diffusion capacity across membrane
Molecular weight
Lipid solubility
94
What is used as the upper threshold of risk of drug side effect being low and treatment as safe in breast-feeding?
Concentration in infants plasma of 10% of established therapeutic maternal dose
95
At what point is there a high likelihood that infant will be exposed to drug in breast milk?
Breast milk/mothers plasma ratio >1
96
Which infants are at lower risk of adverse effects of medication in breast milk?
>10 weeks
97
What should be checked if a mother on drugs is psychotropics is breast feeding?
The infants cardiac, renal and hepatic function should be checked before breast feeding
98
What should be checked if a breast-fed infant whose mother is on psychotropics is progressing well?
Milestones and adverse effects i.e. drowsiness, hypotonia, rigidity, tremor and withdrawal symptoms
99
What does colostrum have greater conc of compared to foremilk?
Protein-bound drugs
100
What does hindmilk have greater conc of compared to foremilk?
Lipid soluble drugs
101
What factors need to be considered when giving a breast-feeding mother psychotropics?
Severity and frequency of MI
Benefits of breastfeeding
Impact of untreated maternal illness on mother and infant
Level of family support
Compliance with treatment
Patient and familys ability to recognise early warning signs
Physical health and maturity of infant
Support from statutory and voluntary organisations
102
Which antidepressants are recommended during breast feeding?
Paroxetine
| Sertraline
103
Which antipsychotics are recommended during breastfeeding?
Sulpride
| Olanzapine
104
Which mood stabilisers are recommended during breastfeeding?
Avoid if possible
Valproate if essential
105
Which sedatives are recommended during breastfeeding?
Lorazepam for anxiety
| Zolpidem for sleep
106
Which TCa is not safe in breastfeeding?
Doxepin
107
Which TCAs are safe in breastfeeding?
Amitriptyline
| Imipramine
108
Risk of Doxepin use in breastfeeding
N-desmethyldoxepine is a longer acting metabolite of Doxepin and may accumulate in infants and cause severe drowsiness and respiratory depression.
109
Impact of fluoxetine in breast milk
Detected in plasma and breast milk
| Not detected in infants plasma
110
Impact of fluoxetine on neonatal development
Does not effect development
| Does not cause cognitive dysfunction or neurological abnormality
111
Which SSRI has lower milk/plasma ratio?
Paroxetine
112
Which antidepressant should be stopped in mothers planning to breast feed?
MAOIs
113
Median time to maximum conc in breast milk after maternal ingestion of Moclobemide
3 hours
114
Median time to maximum conc in breast milk after maternal ingestion of olanzapine
5 hours
115
Median time to maximum conc in breast milk after maternal ingestion of Sertraline
7-10 hours
116
Which conventional antipsychotics are recommended during breast-feeding?
High potency as less sedative and less autonomic effect.
117
Which conventional antipsychotics are safe during breast feeding?
Haloperidol
Chlorpromazine
Perphenazine
118
When has delayed development been reported in the use of conventional antipsychotics?
Combination of haloperidol and chlorpromazine
119
Which atypical antipsychotics are safest in breast feeding?
Sulpride
Olanzapine
Risperidone
120
Which atypical antipsychotic is contraindication during breastfeeding and why?
Clozapine
Accumulates in breast milk and fetal serum
121
Why is there a high conc of clozapine in the neonate?
High conc of albumin in fetal blood
122
Adverse effects if clozapine used during breastfeeding
```
Agranulocytosis
Decreased sucking reflex
Drowsiness
Seizures
Irritability
Cardiovascular instability
```
123
Lithium use in breastfeeding?
Contraindicated
124
If Lithium is used in breastfeeding, what needs to e monitored?
Lithium serum conc and FBC
125
How much lithium is exreted into breast milk?
40-50% of maternal serum level
126
How much can infant serum level of lithium rise up to?
200% of maternal serum conc (5-200%)
127
Why is serum level of lithium raised in neonates?
Diminished renal clearance
128
Adverse effects of Lithium use in breastfeeding
Cyanosis
Lethargy
Hypotonia
Heart murmur
129
Infant serum levels in mothers on sodium valproate who are breastfeeding
Range from undetectable to 40%
130
Adverse effects in infants breast-fed by mothers on valproate
Thrombocytopenia
| Anaemia
131
Infant serum range of lamotrigine if breast fed
30% of maternal concentration
132
Adverse effects in infants breast-fed by mothers on lamotrigine
None
133
Infant serum range of Carbamazepine if breast-fed
5-65%
134
Adverse effects in infants breast-fed by mothers on Carbamazepine
```
Cholestatic hepatitis
Transient hepatic dysfunction
Seizures
Irritability
High-pitched crying
Hyperexcitability
Poor feeding
```
135
Benzo use when breastfeeding
Should not be used
| Should be stopped before becoming pregnant
136
Effect of long-acting benzo on neonate
Lethargy
Poor suckling
Weight loss
137
Effect of Clonazepam on the neonate
Persistent apnoea
138
Infant serum range of Diazepam
Undetectable to 15%
139
Which benzos are safe during breastfeeding
Low doses of Temazepam and Oxazepam (short acting)
140
Which benzos should be avoided during breastfeeding?
Diazepam
| Alprazolam
141
Which sedatives are excreted in breast milk and should be avoided?
Buspirone
Zaleplon
Zopiclone
142
Zopiclone serum range in infant?
Up to 50% of maternal plasma level
143
Which sedative is safe during breast feeding?
Zolpidem
