Perinatal Psychiatry Flashcards
(24 cards)
What is perinatal psychiatry?
- Preconception advice - women who have a mental health problem and are planning a pregnancy
- Early detection and treatment - women who are at risk from, or are suffering from a mental health problem in the perinatal period (during pregnancy or in first year after birth)
Describe attachment vs bonding
Attachment:
- Flows from infant to caregiver
- Develops over first year
Bonding:
- Flows from caregiver to infant
- Develops quickly
What is baby blues?
Common psychological problem typically occurring around the third day post partum. It is not a psychiatric disorder and should not be considered abnormal; however must be distinguished from postnatal depression (which is a psychiatric issue).
Occur in at least 50% of women
What are associations/RFs for baby blues?
- Women who have previously suffered with premenstrual syndrome
- Primigravidae
- Anxiety and depression during pregnancy
- Fear of labour
- Poor social adjustment
NOT ASSOCIATED WITH OBSTETRIC FACTORS
What are the S/S of baby blues?
- Symptoms begin within the first 10 days post partum, typically from the third to fifth day
- Lability of mood is particularly characteristic, with rapid alterations between euphoria and misery
- May complain of feeling confused but cognitive function is normal
- Tearfulness, irritability
- Symptoms resolve by 10-14d
What is the management for baby blues?
- Medication is not required
- Reassurance, explanation and family support are key features
- Antenatal education that provides warning for women and their partners is helpful
What is postnatal depression?
AKA puerperal depression.
Depression arising in the months following childbirth. It is not qualitatively different from depression occurring at other times.
What are associations/RFs for postnatal depression?
- Past psychiatric history, especially depression
- Psychological problems during pregnancy
- Family history of postnatal depression
- Recent adverse life events
What are the S/S of postnatal depression?
- May have developed insidiously over several weeks or as an exacerbation of baby blues
- Similar features to general depressive illness
- Cognitive features are more sensitive indicators and are usually based around motherhood, e.g. feels guilty for not coping as mother, gains no pleasure from the child, feels angry with the child
- Biological sx are less sensitive indicators as these can occur normally after child birth
- There may be obsessional thoughts (often of causing harm to the baby).
What are the investigations for postnatal depression?
Same as depression
What is the management of postnatal depression?
> Screening for depression should be incorporated into a 6 week postnatal check
- Most cases are mild / don’t require psychiatric intervention
- Respond to additional support and counselling
- Moderate depression usually managed at home
Antidepressant medication:
- Take care with drugs used in breastfeeding mothers - can be secreted in breast milk
- Recommended SSRIs are sertraline and paroxetine
- Low-dose amitriptyline is probably safe
- Lithium should be avoided if possible
- Sodium Valproate definitely avoided
- Seek specialist advice
Also
- Multidisciplinary care - liaise with GP and midwife/health visitor
- Use of CBT/IPT has been proven to reduce postnatal depression
- Early and effective treatment of PND is important because it can affect the baby’s attachment and have lasting effects on development and personality
When is hospital admission considered for postnatal depression?
- If depression is severe with suicidal or infanticidal ideation
- Mother and Baby Unit (MBU) is the optimal setting under these circumstances
- Separation should be avoided if possible
> Most women respond well to treatment within a month
What are the complications of postnatal depression?
- Bonding failure
- Rejection/neglect of the baby
- Marital/relationship problem
- Detrimental effect on child’s language skills, social and emotional development in the first year of life
- Insecure attachments at 18 months
- Maternal suicide
- Infanticide
What is puerperal psychosis?
A psychotic disorder arising after childbirth.
What are the RFs for puerperal psychosis?
- Past history of puerperal psychosis
- Existing bipolar affective disorder
- Family history of bipolar affective disorder and puerperal psychosis
- Primigravida
What are the S/S of puerperal psychosis?
- Onset often within first 2 weeks
- Rapidly changing mood
- Usually marked restlessness and fear
- Mixture of manic and depressive symptoms
- Delusions and hallucinations may be based around the baby, e.g. paranoid delusions that her baby has been swapped with someone else’s and auditory command hallucinations instructing her to kill the baby
- There is marked perplexity but no detectable cognitive impairment
- Paranoid psychosis
What are the perinatal red flags?
- Do you have new feelings and thoughts which you haven’t had before that make you disturbed or anxious?
- Are you experiencing thoughts of suicide or harming yourself in violent ways?
- Are you feeling incompetent, as though you can’t cope, or estranged from your baby?
- Do you feel you are getting worse or are at risk of getting worse?
What are the investigations for puerperal psychosis?
- Rule out delirium due to infection
- History and collateral history
- Risk assessment of mother to child
What is the management of puerperal psychosis?
- Admit to hospital (if appropriate using MHA), preferably a mother and baby unit
- Rarely, can be managed at home with frequent reviews from community psychiatric nurse (CPN)
- Urgent treatment with antipsychotics +/- rapid tranquillisation
- Consider other medication as appropriate (antidepressants, mood stabilisers)
- ECT may be useful if medication has failed
- Supportive psychotherapy may be helpful during recovery to help the woman come to terms and understand the nature of the illness, and allow her to eliminate any feelings of guilt or failure
What are the complications of puerperal psychosis?
1st year after pregnancy:
- Risk to the baby can be through neglect or violence
- Watch out for depressive delusions (e.g. the baby is evil, possessed or abnormal)
Can lithium or sodium valproate be taken in pregnancy?
- Do not offer lithium or sodium valproate to women who are planning a pregnancy or pregnant, unless antipsychotic medication has not been effective
- If a woman taking lithium becomes pregnant, consider stopping the drug gradually over 4 weeks
- Consider switching to an antipsychotic - safe in pregnancy and breastfeeding (except clozapine)
What are the risks of taking lithium in pregnancy?
- Risk of foetal heart malformations (Ebstein’s anomaly) but the magnitude of the risk of uncertain
- Lithium may be highly expressed in breast milk
What monitoring needs to occur if a mother is taking lithium during pregnancy?
> More frequent
- Every 4 weeks
- Weekly from the 36th week
- Ensure the woman gives birth in hospital
Can SSRIs be used in pregnancy?
Weigh up benefits and risks when deciding whether to use SSRIs
1st trimester: increased risk of CHDs
3rd trimester: increased risk of PPH of the newborn
> SSRIs that are generally considered safe are sertraline, citalopram and fluoxetine
> Paroxetine has an increased risk of congenital malformations, particularly in the 1st trimester
