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Perinatal Psychiatry Flashcards

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1
Q

when do half of suicides after pregnancy occur

A

up to 12 weeks postnataly

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2
Q

what are the red flags for perinatal mental health

A

recent significant change in mental state or emergence of new symptoms
new thoughts or acts of violent self harm
new and persistent expression of incompetence as a mother or estrangement from their baby

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3
Q

what would make you consider an admission to a mother and baby unit

A

when a woman has any of:

  • rapidly changing mental state
  • suicide ideation (particularly of a violent nature)
  • significant estrangement from the infant
  • pervasive guilt or hopelessness
  • beliefs of inadequacy as a mother
  • evidence of pyschosis
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4
Q

what are good questions to ask to assess a new mothers mental health

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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5
Q

how is screening for mental health done

A

Booking appointment:
History of mental health problems, previous treatment, Family History
Identify risk factors: Young/ single, domestic issues, lack support, substance abuse, unplanned/unwanted pregnancy, pre existing mental health problem

Screening: using questions- every appointment!
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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6
Q

when should you refer to psychiatry

A

Psychosis/ previous 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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7
Q

how does pregnancy interact with pre existing mental health problems

A

generally not protective

  • bipolar: high rate of relapse
  • ED: may be some improvement, risks of IUGR, prematurity, hypokalaemia, hyponatraemia, metabolic alkalosis, miscarriage, premature delivery
  • antenatal depression: 68% relapse if stop meds in pregnancy, but if mild and on treatment consider stopping meds and refer to psychological Tx (CBT). if severe (suicidal, psychosis, self neglect, harm) refer to psychiatry
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8
Q

how is mild to mod depression in pregnancy treated

A

by GP

CBT/ medication

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9
Q

what is baby blues

A

50% of women get this
brief period of emotional instability
mothers are tearful, irritable, anxiety and poor sleep confusion
happens at day 3-10

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10
Q

what is the treatment for baby blues

A

happens days 3-10, is self limiting

support and reassurance

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11
Q

how does puerperal psychosis present

A

usually within 2 weeks of delivery
early symptoms: sleep disturbance, confusion and irrational ideas
mania, delusions, hallucinations, confusion

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12
Q

what are the risk factors for puerperal psychosis

A

BPAD, previous psychosis, 1st degree relative with Hx

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13
Q

what are the major risks in puerperal psychosis

A

5% suicide
4% infanticide

80% 10 year recurrence
25% go onto develop BPAD

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14
Q

what is the management for puerperal psychosis

A

is an emergency
needs admission to specialised mother baby unit
antidepressants, antipsychotics, mood stabilisers, ECT

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15
Q

how many women get post natal depression

A

10%

1/3rd last a year/ more

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16
Q

how does post natal depression present

A

onset 2-6 weeks postnatally
lasts weeks to months
tearfulness, irritability, anxiety, lack of enjoyment, poor sleep, weight loss, can present as concerns re baby

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17
Q

what does postnatal depression affect

A

bonding
child development
marriage
risk or suicide

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18
Q

what is the Tx for postnatal depression

A

mild-mod: self help, counselling

mod-severe: psychotherapy, antidepressants, admission?

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19
Q

what is the long term recurrence of postnatal depression

A

25% recurrence rate

70% lifetime risk of depression

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20
Q

what are the risk to the child in untreated depression

A

low birth weight
pre term delivery (by few days)
adverse childhood outcomes
poor engagement/ bonding with child (reduced infant learning and cognitive development)

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21
Q

what are the general rules for prescribing in pregnancy

A

be cautious with abruptly stopping drugs
lowest dose monotherapy - avoid depot
low risk drugs
increased screening for fetus (cardiac and growth)
be aware of altered pharmacokinetics in pregnancy (lithium especially)
encourage breast feeding where possible
risks of a drug can vary in stages of pregnancy/ breastfeeding
stopping a teratogenic drug after pregnancy is confirmed may not remove risk of malformation

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22
Q

what are the main risks with medications at each stage of pregnancy + after birth

A

1st trim: teratogenicity
3rd trim: risk of neonate withdrawal
breast feeding: medication passing into milk

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23
Q

why is fetal exposure to a drug in breast milk sometimes okay

A

as levels lower usually than in utero, therefore in general safer to stay on drug if it was used during pregnancy- can help prevent withdrawal effects

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24
Q

what antidepressant class are first line in pregnancy

A

SSRIs

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25
are antidepressants teratogens
no (not major ones anyway)
26
which SSRIs are used in pregnancy
sertraline (least placental exposure) | fluoxetine (thought to be the safest)
27
what are the risks of SSRIs in pregnancy
persistent hypertension in the newborn lower birth weight increased early birth (days) PPH
28
what is paroxetine and is it safe in pregnancy
SSRI | no- causes cardiac malformations
29
are tricyclics safe in pregnancy
do not appear to cause major problems may be some mild and self limiting neonate withdrawal imipramine and amitriptyline have lower risks than SSRIs
30
is venlafaxine safe in pregnancy
(SNRI) | less evidence, associated with cardiac defects, clef palate, neonate withdrawal
31
what is the general rules for depression in pregnancy
women with high risk of relapse should be maintained on medications during and after pregnancy mod-severe depression should be treated with antidepressants
32
what antidepressants are safe in breastfeeding
sertraline (SSRI) paroxetine (SNRI) imipramine (TCA)
33
what antidepressants should you avoid in breastfeeding
citalopram (SSRI) doxepin (TCA) fluoxetines affect is uncertain (SSRI)
34
what are the effects of antipsychotics in pregnancy
create risk of gestational diabetes (esp 2nd gen) | reduce fertility due to raised prolactin levels
35
are antipsychotics safe in pregnancy
yes- no evidence of major teratogenicity
36
name 2 1st gen (typical) antipsychotics used in pregnancy
chlorpromazine | haloperidol
37
name 2 2nd gen (atypical) antipsychotics used in pregnancy
olanzipine | quetiapine
38
what is the advice for antipsychotics in pregnancy
women with repeated relapses are best maintained on medication, avoid rapid discontinuation olanzapine and quetiapine have best evidence base seek specialist advice
39
which antipyschotics are excreted in breast milk- what are the implications of this
all- but no evidence of fetal toxicity/ altered development | monitor for signs of sedation/ lethargy
40
is clozapine safe in pregnancy
(atypical antipsychotic) | avoid- risk of agranulocytosis to fetus
41
what is the increased risk of with olanzapine
GDM | weight gain
42
why should you avoid depot antipsychotics in pregnancy
as prolonges SEs- extra pyramidal side effects in neonates
43
what are the risk associated with bipolar AD in pregnancy
induction/ CS pre term delivery small babies
44
is there a high risk of bi polar relpase in pregnancy
yes- esp if stop medications and within 1st most postpartum
45
what is the best management for BPAD and pregnancy
have conversations before conception as no mood stabiliser safe in pregnancy
46
what mood stabilisers should you never give in pregnancy
SODIUM VALPROATE and carbamazepine (most teratogenic, neural tube defects)
47
which is the safest anti convulsant used for BPAD in pregnancy
lamotrigine
48
when does the neural tube close
day 28
49
what is the advice for sodium valporate
avoid in women of child bearing age stop 3 months before planned pregnancies use folate supplements
50
is sodium valporate safe in breast feeding
is low risk | no evidence of adverse effects
51
what else can sodium valporate cause
craniofacial defects | impaired intellectual development
52
what are the risks of lamotrigine
cleft lip a avoid in 1st trim risk of SJS in breast feeding
53
is lithium safe in pregnancy
no - avoid if possible
54
what can lithium in pregnancy cause
ebsteins abnormality- cardiac malformation (transformation of great vessels)
55
what is the advice for lithium in pregnancy
consider slow reduction pre conception (avoid sudden cessation) can be reintroduces in 2nd/3rd trim consider reintroduction immediately post partum if not breastfeeding (relapse rates 70% after discontinuation) monitor levels closely in 3rd trim as changes in vol of distribution- lithium toxicity can mimic PET
56
what extra montitoring is needed for expectant mothers on lithium
regular echo and enhanced US of fetua (to look for ebstiens abnormality)
57
is lithium safe in breastfeeding
no- very similar to sodium ion so excreted into milk and can be more concentrated
58
what is a safe antipsychotic than lithium
quetiapine
59
what might you need to consider in bipolar AD in pregnancy
ECT
60
what is the first line for anxiety in pregnancy
SSRIs
61
are benzodiazepines safe in pregnancy
not major teratogens 3rd trim risk of floppy baby generally avoided
62
is zopiclone safe in pregnancy
limited date, some suggested risk
63
what are the features of floppy baby syndrome
hypothermia hypotonia resp depression withdrawal effects
64
what are the risk of benzodiazepines when breastfeeding
lethargy | weight loss
65
which pyschotropic drugs are excreted in breast milk
all
66
what is the highest priority when breast feeding
treatment of mental health - esp if relaspe risk high
67
what general rules for prescribing in breast feeding
lowest possible dose avoid combinations of medications time doses to feeds (give dose before longest break between feeds) if a drug has been used in third trim then exposure of fetus to drug will be less so safe to continue into breast feeding (except lithium)
68
what is the first line antidepressant in preganncy
sertaline
69
what is first line antipyschotics in pregnancy
olanzapine | quetiapine
70
what is the first line mood stabilisers in pregnancy
antipsychotics: olanzapine, quetiapine
71
what other factors do you need to consider in substance abuse in pregnancy
``` other associated mental illnesses nutritional deficiency HIV, Hep C, Hep B VTE STIs endocarditis/ sepsis poor venous access opiate tolerance/ withdrawal during delivery drug overdose/ death risk of domestic abuse and suicide IUGR, stillbirth, SIDs, pre term labour ```
72
what is the advice on alcohol in pregnancy
recommend abstinence, no evidence than 2 units a week is detrimental
73
what are the risks of alcoholism in pregnancy
miscarriage foetal alcohol syndrome (facial deformities, lower IQ, neurodevelopmental delay, epilepsy, hearing, heart and kidney defects) withdrawal risk of wernickes and korsakoffs
74
what are the risks of cocaine, amphetamine and ecstasy in pregnancy
death via stroke and arrhythmias teratogenic (microcephaly, cardiac, genitourinary, limb defects) pre-eclampsia abruption IUGR pre term labour miscarriage developmental delay, SIDS, withdrawal
75
what are the risks of opiates in pregnancy
cause maternal deaths, neonate withdrawal, IUGR, SIDS, stillbirth
76
what is the risk of nicotine in pregnancy
``` miscarriages abruption IUGR stillbirths SIDS ```
77
what extra considerations need to be made for antenatal care in mothers with substance abuse in pregnancy
Consider methadone programme Child protection and social work referral Smear History- can do from 12 weeks after birth (cant do in pregnancy as false +ves) Breastfeeding (not if alcohol >8 , HIV, cocaine) Labour plan re analgesia and labour ward delivery Early IV access Postnatal contraception plan
78
what extra precautions should be taken for a mother with alcohol dependence
Mothers safety- her partner, drug Hx, why is she drinking so much, quantify their smoking, is she already involved with social work, how is she funding alcohol (employed, sex worker?), social and housing situation, does she want to continue with her pregnancy Alcohol misuse service, social work Obstetric led care, routine booking, 20 weeks scans an then serial scans after as at risk of IUGR. B12, folic acid, thiamine and iron vitamin support. Community midwife for support. BMI support if low- dietician, supplements. Liver function monitoring Withdrawal protocol when admitted and thiamine on admission Baby will have withdrawal – jittery, irritable and slow to feed, plans for its care long term. Mother needs to consider contraception. Discourage breast feeding if mother continuing to drink after birth and baby going home with her. High risk of better PN depression
79
when does hyperemesis usually improve in pregnancy
16 weeks

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