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Obstetrics and Gynaecology > Perinatal psychiatry > Flashcards

Perinatal psychiatry Flashcards

1
Q

When do you do urgent referrals to a specialist mental health team?

A

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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2
Q

When should the admission to a mother and baby unit be considered?

A

When a mom has any of the following: (admit the baby and mom)

  • rapidly changing mental state
  • suicidal ideation (particularly of a violent nature)
  • significant estrangement from the infant
  • pervasive guilt or hopelessness
  • beliefs of inadequacy as a mother
  • evidence of psychosis
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3
Q

Important Qs to ask moms

A

Do you have new feelings and thoughts which you have never had before, which 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? Are these feelings persistent?
Do you feel you are getting worse?

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4
Q

Risk factors for mental health issues in pregnant women

A

<18, single , domestic issues, substance abuse, unplanned pregnancy, pre-existing mental heatlh problems

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5
Q

What is done during a booking appointment?

A

Screening for mental health disorder: History of mental health problems, previous treatment, family history and identify the previous rik factors

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6
Q

What screening Qs are asked at every appointment?

A

During the last month have you been bothered by feeling down, depressed or hopeless?
During the last month have you been bothered by having little interest or pleasure in doing things
Is this something you feel you need or want help with?

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7
Q

When do you refer moms to a psychiatry team?

A

Psychosis
Severe anxiety, depression, suicidal, self-neglect, self harm
Symptoms with significant interference with daily functioning
History of bipolar or schizophrenia
History of puerperal psychosis
Psychotropic medications
If developed moderate mental illness in late pregnancy or early postpartum
Mild- moderate illness but 1st degree relative with bipolar or puerperal psychosis
Previous in-patient admissions to mental health unit

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8
Q

Is pregnancy protective from mental health disorders?

A

No

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9
Q

What happens to ppl with eating disorders in pregnancy?

A

Mostly some improvement

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10
Q

What happens if you stop depression meds during pregnancy?

A

68% relapse if they stop meds! -Do not STOP abruptly!

Mild/ moderate - GP

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11
Q

How is mild-moderate depression treated?

A

treated by the gp

mild and on treatment, consider stopping and referring for psychological treatment

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12
Q

How is severe depression treated during pregnancy?

A

refer to psychiatry

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13
Q

What are the initial symtpoms of psychosis?

A

Sleep disturbance and confusion

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14
Q

What is baby blues?

A

50% women
Brief period of emotional instability
Tearful, irritable, anxiety and poor sleep confusion

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15
Q

How long does it take for baby blues to go away?

A

Day 3-10, self-limiting

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16
Q

What happens if a midwife sees a sleep deprived and confused patient, how does she differentiate btw someone with baby blues and psychosis?

A

Daily monitoring

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17
Q

How many women develop post-natal depression?

A

1/10

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18
Q

Differential diagnosis for puerperal psychosis?

A

episode of bipolar, unipolar depression, schizophrenia, organic brain dysfunction (secondary to physical illness)
Usually presents within 2 weeks of delivery
Early symptoms are sleep disturbance and confusion, irrational ideas
Mania, delusions, hallucinations, confusion

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19
Q

How to manage pueperal psychosis?

A

Is an emergency
Needs admission to specialised mother-baby unit
Antidepressants, antipsychotics, mood stabilizers and ECT
80% 10 year recurrence
25% go onto develop bipolar disorder

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20
Q

What are the features of postnatal depression?

A

10% women, 1/3 lasts a year or more
Tearfulness, irritable, anxiety, lack of enjoyment and poor sleep, weight loss, can present as concerns re baby
Onset 2-6 weeks postnatally, lasts weeks to months

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21
Q

How to manage mild-moderate postnatal depression?

A

Self-help, counseling

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22
Q

How to manage moderate-severe postnatal depression?

A

Psychotherapy and antidepressants

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23
Q

Drugs usually used in post-natal depression?

A

Sertraline

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24
Q

What is the recurrence rate in patients with postnatal depression?

A

25%

25
Q

What are the risks to child of a mother with untreated depression?

A 
Low birth weight-
Associated with severity of depression
Pre-term delivery(few days)- 
Associated with severity of depression
Adverse childhood outcomes-
e.g. emotional &amp; conduct problems, ADHD
Poor engagement / bonding with child-
Reduced infant learning &amp; cognitive development
26
Q

What would you do with respect to medications in mental health issues in pregnancy?

A

consider stopping meds, reduce dose or changing meds

- depends on the mother

27
Q

Prescribing in the perinatal period

A

Preferentially use drugs with low risk to both mother and fetus
Lowest dose monotherapy (avoid depot)
Be aware of potential for altered pharmacokinetics in pregnancy
Increase screening of fetus - cardio and growth
Encourage breastfeeding whenever possible
Risks and benefit can vary between the 1st trimester, the 3rd trimester and breastfeeding
Stopping a drug with known teratogenic risk after pregnancy is confirmed may not remove the risk of malformations (sodium valproate or lithium)
There are risks from stopping medication abruptly

28
Q

When should teratogenic drugs be stopped?

A

Before week 4

29
Q

What happens if you suddenly stop lithium in week 12?

A

other side effects but it wont change much with respect to the cardiac malformations

30
Q

IS the usage of anti-depressants increasing or decreasing in pregnancy?

A

Increasing

31
Q

What are the 1st line drugs as antidepressants in pregnancy?

A

SSRIs

32
Q

Which SSRI has the least placental exposure?

A

Sertraline

33
Q

What is the safest SSRI in pregnancy?

A

Fluoxetine

34
Q

Which is the unsafe SSRI in pregnanyc?

A

Paroxetine - increased cardiac malformations

35
Q

Why is paroxetine risky in pregnancy?

A

increased cardiac malformations

36
Q

What are the drugs treatments for depression in pregnancy?

A

1st - SSRI
2nd - Tricyclics
3rd- Venlafaxine and mirtazapine

37
Q

Anti-depressants in pregnancy

A

woman with high risk of relapse should be maintained on meds during and after pregnancy

moderate to severe depression should be treated with AD

38
Q

Antipsychotics in pregnancy - order of usage:

A

1st gen (chlorpromazine, halopridol)

2nd gen - Olanzapine, Quetiapine

39
Q

What are the risks with antipsychotics?

A

gestational diabetes with 2nd generation

40
Q

highest risk of postnatal psychosis

A

BPAD

41
Q

Are mood stabilizers safe in pregnany?

A

No - valproate and carbamazepine (most teratogenic) increase nerual tube defects and should be avoided

Lamotrigine - less bad than others

42
Q

What happens if a woman of the reproductive age is taking valproate?

A

Annual disclaimer - written signed consent that she is aware of the risks, taking a reliable contraceptive

43
Q

What is the cardiac defect caused my lithium?

A

Ebstein’s anomaly - transposition of the great vessels

relative risk - 20x more likely

44
Q

Should you stop lithium suddenly?

A

No - or else high relapse post-natal psychosis! Consider slow reduction in preconception - 2nd and 3rd trimester.
Stop it in the 1st trimester and start again in 2nd trimester, but keep close monitoring in 3rd trimester

45
Q

How would you treat BPAD in pregnant women?

A

high relapse in women with BPAD if medications reduced abruptly - anti-epileptocs, anti-psychotics (safer anti-psychotic Quetiapine, avpid valproate and carbazepine, lithoum is better ish)

46
Q

1st line treatment for anxiety?

A

SSRIs

47
Q

Risk of benzodiazepines in babys?

A

Floppy baby in 3rd trimester - problematic and best avoided

48
Q

What anti-psychotics can be given if:
1- not pregnany
2- pregnant
3- after pregnancy

A

1- before pregnancy quetiapine okay, not the best
2- changed to lithium - worked great
3- wanted to have a baby - switched to quetiapine for a few months
4- after pregnancy switched to lithium again

49
Q

What is the general principle wrt drugs in breastfeeding?

A

Whatever is given to mom goes to the baby - drugs with <10% relative infant dose (RID) are safer

50
Q

Antidepressants in breastfeeding

A

1st line - sertraline

51
Q

Can lithium be taken during breastfeeding?

A

No, More uncontrolled levels of lithium in breastmilk (than in utero): hence either breastfeeding or lithium

52
Q

Substance abuse rates in pregnancy

A
  1. 7% women of child bearing age have alcohol dependence

2. 2% women of childbearing age have illicit drug dependence

53
Q

Diseases associated with substance abuse in pregnancy

A

higher risk of STI, HIV, Hep C, Hep B (continue checking in all scans if at hisher risk), endocarditis, sepsis, DVT, poor venous access (central line), overdose, death, risk of domestic abuse and suicide

54
Q

Is alcohol safe in pregnancy?

A

Absitinence - RCOG< but no evidence that 2 units/ week is bad

55
Q

Risks with alcoholism in pregnancy?

A

Risks of miscarriage
Foetal Alcohol Syndrome - facial deformities, lower IQ, neurodevelopmental delay, epilepsy, hearing, heart and kidney defects
Withdrawal
Risk of Wernicke’s encephalopathy- 20% die (B1 deficiency)
Korsakoff Syndrome – permanent

56
Q

Risks of cocaine, amphetamine and ecstasy in pregnancy

A

Teratogenic (microcephaly, cardiac, genitourinary, limb defects)
Pre-eclampsia
Abruption

IUGR
Pre-term labour
Miscarriage
Developmental delay, SIDS, withdrawal

57
Q

Risks of opiates and nicotine in pregnancy

A

Opiates cause maternal deaths (1-2%), neonatal withdrawal, IUGR, SIDS, stillbirth

Nicotine causes miscarriages, abruption, IUGR, stillbirths and SIDS

58
Q

Can you take smears during pregnancy?

A

No, as you can get false-positives. Can do it 12 weeks after labour

59
Q

How to manage substance abuse in pregnancy antenatal care?

A

Consider methadone programme
Child protection and social work referral
Smear History
Breastfeeding (not if alcohol >8 , HIV, cocaine)
Labour plan re analgesia and labour ward delivery
Early IV access
Postnatal contraception plan

Kids not given to the mom if they are not stable

Obstetrics and Gynaecology (2 decks)

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