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Year 3 Clinical > Perinatal Psychiatry > Flashcards

Perinatal Psychiatry Flashcards

(59 cards)

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1
Q

Occurrence of suicide post-natally?

A

Half of suicides occur up to 12 weeks post-natally

Suicide is the leading cause of direct maternal death, occurring within a year of the end of pregnancy

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2
Q

Red flags presentations peri-natally?

A

Urgent referral to a specialist perinatal mental health team is required for women who report:
• Recent significant change in mental state or emergence of new symptoms
• New thoughts or acts of violent self-harm
• New and persistent expressions of incompetency as a mother or estrangement from their baby

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3
Q

Recommendations for good quality healthcare for mental ill health in pregnancy women?

A

At booking appointment, there should be a routine enquiry about a current or PMH

GPs should communicate past psychiatric history in antenatal referral

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4
Q

When should admission to a mother and baby unit always be considered for a woman?

A
  1. Rapidly changing mental state
  2. Suicidal ideation (part. of a violent nature)
  3. Significant estrangement from the infant
  4. Pervasive guilt or hopelessness
  5. Beliefs of inadequacy as a mother
  6. Evidence of psychosis
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5
Q

Psychiatric questions to ask a new mother?

A

Do you have new feelings and thoughts which you have never had before, which make you feel disturbed or anxious?

Are you experiencing thoughts of suicide or harming yourself in violent ways?

Are you feeling incompetent, as though you cannot cope, or estranged from your baby? Are these feelings persistent?

Do you feel you are getting worse?

NOTE - screening for mental health issues should be done at every appointment

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6
Q

Risk factors for mental health issues perinatally?

A

Young / single woman

Domestic issues

Lack of support

Substance abuse

Unplanned / unwanted pregnancy

Pre-existing mental health problem

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7
Q

When must the psychiatry team see a woman perinatally?

A

Symptoms that significantly interfere with daily functioning

If she has a history of or currently has:
• Psychosis
• Severe anxiety, depression, suicidal, self-neglect, self-harm
• History of bipolar or schizophrenia
• History of puerperal psychosis

Psychotropic medications

If the patient develops moderate mental illness in late pregnancy or early post-partum

Mild-moderate illness but 1st degree relative with bipolar or puerperal psychosis

Previous inpatient admissions to mental health unit

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8
Q

How does pregnancy affect pre-existing mental health conditions?

A

Generally, pregnancy is not protective

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9
Q

Effect of pregnancy on BPAD?

A

High rate of relapse post-natally

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10
Q

Effect of pregnancy on eating disorders?

A

May improve during pregnancy, although there are assoc. risks of:
• IUGR
• Prematurity
• Hypokalaemia, hyponatraemia, metabolic alkalosis
• Miscarriage

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11
Q

Effects of pregnancy on antenatal depression?

A

Many patients relapse when drugs are stopped

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12
Q

Mx of antenatal depression?

A

Advise on self-help strategies

If mild-moderate, it is a GP managed condition

If mild and on treatment, consider cessation and referral for psychological treatment

If severe, i.e: patient is suicidal, psychotic, self-neglect or harm is involved, refer to psychiatry

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13
Q

Occurrence of baby blues?

A

50% of women

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14
Q

Describe baby blues

A

Brief period of emotional instability; it is SELF-LIMITING, lasting 3-10 days

Patient is tearful, irritable, anxious and has poor sleep confusion

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15
Q

Mx of baby blues?

A

Support and reassurance

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16
Q

What is puerperal psychosis?

A

AKA post-partum psychosis; usually present within 2 weeks of delivery

It is a psychiatric EMERGENCY that occurs in 0.1% of women

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17
Q

Risk factors for puerperal psychosis?

A

BPAD (50%)

Previous puerperal psychosis

1st degree relative with a history

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18
Q

Symptoms and signs of puerperal psychosis?

A

Early symptoms of sleep disturbance, confusion and irrational ideas

Mania, delusions, hallucinations and confustion

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19
Q

Consequences of puerperal psychosis?

A

5% suicide risk and 4% infanticide

10 year recurrence rate of 80%

25% of patients go on to develop BPAD

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20
Q

Differentials of puerperal psychosis?

A

Episodes of bipolar

Unipolar depression

Schizophrenia

Organic brain dysfunction, i.e: secondary to a physical illness

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21
Q

Mx of puerperal psychosis?

A 
Requires ADMISSION to a specialised mother-baby unit for:
• Anti-depressants
• Anti-psychotics
• Mood stabilisers
• ECT
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22
Q

Occurrence of post-natal depression?

A

Occurs in 10% of women and it can last for a year or more in 1/3rd of these women

It is routinely screened for

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23
Q

Duration of post-natal depression?

A

Onset 2-6 weeks post-natally

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24
Q

Symptoms of post-natal depression?

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A

Tearfulness, irritability and lack of enjoyment

Poor sleep

Weight loss

Can present as concerns regarding the baby

25
Consequences of post-natal depression?
Effects on bonding, child development Risk of suicide 25% recurrent rate 70% lifetime risk of depression
26
Mx of post-natal depression?
Mild-moderate: • Self-help • Counselling Moderate-severe: • Psychotherapy • Anti-depressants • Consider admission
27
Risks of untreated depression to the child?
Low birth weight (assoc. with the severity of depression) Preterm delivery (assoc. with the severity of depression) Adverse childhood outcomes, e.g: • Emotional • Conduct problems • ADHD Poor engagement / bonding with the child: • Reduced infant learning • Reduced cognitive development
28
General principles of psychiatric care during pregnancy?
Ideally, the pregnancy is planned; consider stopping the drug, changing the drug or lowering the dose Prepare contingency plans and place of delivery Antenatal monitoring and support Postnatal Mx and support
29
General principles of prescribing in the perinatal period?
Preferentially use drugs with low risk to both mother and fetus; use the lowest dose monotherapy (avoid depot) Increase screening of foetus, e.g: CV defects, growth Encourage breastfeeding whenever possible
30
Effect of stopping a drug, with known teratogenic risk, after pregnancy is confirmed?
May not remove the risk of malformations Also, there are risks assoc. with abruptly stopping drugs
31
Issues that occur with medications at specific times during the pregnancy and post-natal period?
1st trimester - risk of teratogenecity, due to organ formation and development 3rd trimester - risk of neonatal withdrawal Breastfeeding - risk of drug passing into the breast milk; however, exposure in the breast milk is usually less that in utero, so, in general, no need to stop a drug that was used during the pregnancy
32
Effects of anti-depressants during the 1st trimester?
Generally, there is no increase in major malformations or spontaneous abortion However, paroxetine does confer an increased risk of foetal heart defects
33
Effects of anti-depressants during the 3rd trimester?
Risk of neonatal withdrawal (usually mild and self-limiting) With SSRIs and venlafaxine taken after 20 weeks, there is an increased risk of neonatal persistent pulmonary hypertension Increased risk of LBW / prematurity, however this also occurs with untreated depression
34
Which anti-depressants have the lower risk in the 3rd trimester?
SSRIs - lowest risk with sertraline / fluoxetine TCAs - imipramine / amitriptyline lower risk than SSRIs
35
Effects of anti-depressants while breastfeeding?
All anti-depressants (SSRIs & TCAs) are in breast milk to some extent; there are no reports of adverse effects on neonatal development
36
Which anti-depressants are better while breastfeeding?
Better drugs are sertraline / paroxetine / imipramine Uncertain with fluoxetine Avoid citalopram / doxepin
37
Effects of benzodiazepines during 1st trimester?
Avoid due to possible increased risk of foetal malformation, e.g: cleft palate
38
Effects of benzodiazepines during 3rd trimester?
``` Avoid due to increased risk of floppy baby syndrome: • Hypothermia • Hypotonia • Respiratory depression • Withdrawal effects ```
39
Effects of benzodiazepines during breastfeeding?
Avoid regular use, as their are risks of lethargy and weight loss + accumulation of long-acting drugs
40
Why do anti-psychotics pose issues in pregnancy and post-natally?
All are excreted in breast milk, although there is no evidence of foetal toxicity or altered development Monitor for signs of sedation or lethargy
41
Which anti-psychotics are preferred peri-natally?
More evidence for the safety of typicals than atypicals
42
Anti-psychotics that are avoided peri-natally?
Avoid clozapine at all times (risk of agranulocytosis) Avoid olanzapine (increased risk of GDM and weight gain) Avoid depot anti-psychotics (prolonged effects, e.g: EPSE in neonates) Avoid anti-cholinergics for EPSE in pregnancy
43
Effects of lithium during the 1st trimester?
Increased risk of foetal abnormality, inc. Ebstein's abnormality (transposition of the great vessels)
44
Use of lithium during pregnancy?
Can be continued into the 1st trimester, if there is a clinical indication Avoid sudden discontinuation
45
Monitoring lithium during the 3rd trimester?
Monitor serum Li levels closely, due to changes in the Vd Initially, monthly monitoring; from week 36, this is weekly and then within 24 hours of childbirth
46
What conditions can be mimicked by Li toxicity?
Can mimic PET
47
Use of Li post-natally?
Avoid if breastfeeding Consider prophylactic reintroduction, if the patient is not breastfeeding post-natally
48
Effects of sodium valproate during the 1st trimester?
Increased risk of NTDs, craniofacial defects and effects on the child's intellectual development NOTE - the neural tube closes on day 28 embryologically There are also long-term risks on neurological development, e.g: increased risk of autism Risks are reduced with lower doses
49
Use of sodium valproate during pregnancy?
If possible, stop before a planned pregnancy (as it is teratogenic) AVOID in women of child-bearing age; if necessary to use, risks must be explained and adequate contraception provided
50
Use of sodium valproate while breastfeeding?
Low risk, with no evidence, of adverse effects while breastfeeding
51
Mood stabilisers other than lithium or sodium valproate (anti-convulsant) and what are their assoc. risks?
Carbamazapine - increased risk of: • NTDs but there is less clear evidence of the GI tract and cardiac abnormalities • Facial dysmorphism • Fingernail hypoplasia Lamotrigine - increased risk of: • Oral cleft (avoid it in 1st trimester or withdraw before planned pregnancy) • SJS in breastfeeding infant
52
Occurrence of substance abuse in pregnancy?
Mental and behavioural disorder; it is assoc. with other psychiatric illnesses, e.g: personality disorders, depression, anxiety A significant proportion of women of child-bearing age have: • Alcohol dependence • Illicit drug dependence
53
Other conditions assoc. with substance abuse in pregnancy?
Nutritional deficiency HIV, Hep C, Hep B, STIs VTE Endocarditis, sepsis Poor venous access Opiate tolerance / withdrawal Drug OD and death Assoc. risk of domestic abuse and suicide IUGR, stillbirth, SIDs, preterm labour
54
Recommended alcohol guideline during pregnency?
Abstinence is best
55
Risks of alcoholism during pregnancy?
Miscarriage ``` Foetal alcohol syndrome: • Facial deformities • Lower IQ • Neurodevelopmental delay • Epilepsy • Hearing • Heart and kidney defects ``` Withdrawal Wernicke's encephalopathy (20% die) - occurs due to thiamine (vitamin B1) deficiency Korsakoff's syndrome (permanent)
56
Risks assoc. with cocaine, amphetamines and ecstasy during pregnancy?
Death via stroke and arrhythmias Teratogenic (microcephaly, cardiac, GU and limb defects) Pre-eclampsia Placental abruption IUGR, preterm labour, miscarriage Developmental delay, SIDS (Sudden Infant Death Syndrome), withdrawal
57
Risks assoc. with opiates during pregnancy?
Maternal death Neonatal withdrawal IUGR SIDS Stillbirth
58
Risks assoc. with nicotine during pregnancy?
Miscarriage Placental abruption IUGR Stillbirth SIDS
59
Antenatal care for substance abuse in pregnancy and post-natally?
Consider the methadone programme, child protection and social referral Breastfeeding - avoid if: • Alcohol >8 • HIV • Cocaine Labour plan (analgesia and delivery) Early IV access Post-natal contraception plan

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