Perinatal Psychiatry

Question 1

What is the leading cause of death in the UK?

Answer 1

Mental illness

Question 2

When do half of suicides occur?

Answer 2

Up to 12 weeks postnatally

Question 3

How common are mental health-related deaths after pregnancy?

Answer 3

Almost 1/3 women who die between 6 weeks and 1 year after pregnancy died of mental health related causes = 18% due to suicide

Question 4

What presentations need an urgent referral to specialist perinatal health team?

Answer 4

Recent significant change in mental health 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

Question 5

What presentations who need admission to a mother and baby unit?

Answer 5

Rapidly changing mental state or suicidal ideation
Significant estrangement from child
Beliefs of inadequacy as mother
Pervasive guilt/hopelessness or evidence of psychosis

Question 6

What are the risk factors for mental health issues during or after pregnancy?

Answer 6

Young or single, domestic issues, lack support, substance abuse, unplanned/unwanted pregnancy, pre-existing mental health problem

Question 7

What symptoms should you refer to the psychiatry team?

Answer 7

Psychosis, suicidal, self neglect/harm,

severe anxiety/depression or symptoms with significant interference with daily functioning

Question 8

What features in a past medical history should you refer to the psychiatry team?

Answer 8

History of puerperal psychosis, bipolar or schizophrenia

Psychotropic medications or previous in-patient admission to mental health unit

Question 9

When should you refer to the psychiatry team?

Answer 9

If developed moderate mental illness in late pregnancy or early postpartum
Mild/moderate mental illness but first degree relative with bipolar or puerperal psychosis

Question 10

Is pregnancy protective against mental illness?

Answer 10

No = doesn’t tend to offer protective benefit, eating disorders may improve

Question 11

How does pregnancy affect bipolar disorder?

Answer 11

High rate of relapse postnatally = 50% if untreated

Question 12

What are the complications associated with eating disorders during pregnancy?

Answer 12

IUGR, prematurity, hypokalaemia, hyponatraemia, metabolic alkalosis, miscarriage, premature delivery

Question 13

How does pregnancy affect antenatal depression?

Answer 13

68% relapse is the stop medication during pregnancy

Question 14

What are the baby blues?

Answer 14

Brief period of emotional instability = self, limiting, occurs from days 3-10 after pregnancy, affects 50%

Question 15

What are the symptoms and management for the baby blues?

Answer 15

Symptoms = tearful, irritable, poor sleep, confusion
Management = support and reassurance

Question 16

What are the differentials of puerperal psychosis?

Answer 16

Bipolar episode, unipolar depression, schizophrenia, organic brain dysfunction

Question 17

When does puerperal psychosis tend to present?

Answer 17

Within 2 weeks of delivery

Question 18

What are the symptoms of puerperal psychosis?

Answer 18

Sleep disturbance, confusion and irrational ideas

Leads to mania, delusions, hallucinations and confusion

Question 19

How common is puerperal psychosis?

Answer 19

Occurs in 0.1% of women = carries 5% risk of suicide and 4% risk of infanticide

Question 20

What are the risk factors for puerperal psychosis?

Answer 20

Bipolar disorder, previous puerperal psychosis (50%), first degree relative with history of bipolar

Question 21

How is puerperal psychosis managed?

Answer 21

Emergency = needs admission to mother-baby unit

Antidepressants, antipsychotics, mood stabilisers, ECT

Question 22

What can women who suffer from puerperal psychosis go on to develop?

Answer 22

25% go on to develop bipolar disorder

Question 23

How common is post-natal depression?

Answer 23

10% of women = 1/3 last a year or more, screened for routinely

Question 24

When is the usual onset of postnatal depression?

Answer 24

2-6 weeks postnatally

Question 25

What are the symptoms of postnatal depression?

Answer 25

Tearfulness, irritable, anxiety, lack of enjoyment, poor sleep, weight loss, may present as being concerned about baby

Question 26

What can postnatal depression have an effect on?

Answer 26

Bonding, child development, marriage and suicide risk

Question 27

How is postnatal depression treated?

Answer 27

``` Mild-moderate = self help and counselling Moderate-severe = psychotherapy and antidepressants ```

Question 28

What is the prognosis of postnatal depression?

Answer 28

25% recurrence and 70% lifetime risk of depression

Question 29

What are the risk posed to the child by maternal mental illness?

Answer 29

Low birth weight, preterm delivery, adverse childhood outcomes, poor engagement/bonding with child

Question 30

What should be done when prescribing in the perinatal period?

Answer 30

Preferentially use drugs with low risk to mother/foetus Lowest dose monotherapy and increase screening Encourage breastfeeding

Question 31

Does stopping a known teratogenic drug after pregnancy is confirmed remove the risk?

Answer 31

No = may not remove risks of foetal malformations

Question 32

What are the first line antidepressants?

Answer 32

SSRIs = sertraline has least placental exposure but fluoxetine thought to be safest

Question 33

What are the risks of using antidepressants during pregnancy?

Answer 33

Persistent hypertension of newborn, lower birth weight, increased early birth, post partum haemorrhage

Question 34

What SSRI should be avoided during pregnancy?

Answer 34

Paroxetine = may cause congenital cardiac malformations, less safe than other SSRIs

Question 35

Can tricyclic antidepressants be used during pregnancy?

Answer 35

Yes = don't seem to cause major problems, may cause some mild and self limiting neonatal withdrawal

Question 36

What foetal abnormalities is venlafaxine associated with?

Answer 36

cardiac defects, cleft palate and neonatal withdrawal

Question 37

What are some examples of antipsychotics?

Answer 37

1st generation = chlorpromazine, haloperidol | 2nd generation = olanzapine, quetiapine

Question 38

What are the risks of using antipsychotics during pregnancy?

Answer 38

Risk of gestational diabetes = especially 2nd gen | Reduce fertility due to raised prolactin levels

Question 39

What can clozapine cause in the foetus when taken during pregnancy?

Answer 39

Agranulocytosis

Question 40

When is there high risk of relapse of bipolar disorder?

Answer 40

After delivery is mood stabilisers stopped = especially in first month postpartum

Question 41

What are the risks of bipolar disorder during pregnancy?

Answer 41

Induction or C-section, preterm delivery, small babies

Question 42

What are some features of using mood stabilisers during pregnancy?

Answer 42

Carbamazepine most teratogenic Avoid valproate and carbamazepine = neural tube defects Lamotrigine is less bad

Question 43

Why should lithium be avoided during pregnancy?

Answer 43

Associated with Ebstein's abnormality

Question 44

How should women taking lithium have their medication stopped?

Answer 44

Consider slow reduction preconception = may reintroduce in 2nd or 3rd trimester or immediately postpartum

Question 45

How high is the relapse rate of bipolar disorder after lithium is stopped?

Answer 45

Up to 70% after discontinuation

Question 46

How should women who were taking lithium before becoming pregnant managed?

Answer 46

Regular ECHO and enhanced US scans

Question 47

What is the first line treatment for anxiety?

Answer 47

Antidepressants = use SSRIs

Question 48

What are some treatments for anxiety that should be avoided during pregnancy?

Answer 48

Benzodiazepines = 3rd trimester risk of floppy baby | Zopiclone has some suggestion of risk

Question 49

Are psychotropics usually excreted in breastmilk?

Answer 49

Yes = drugs with <10% relative infant dose (RID) considered safe

Question 50

How should drugs be prescribed during breastfeeding?

Answer 50

Lowest possible dose and give dose before longest break in feeding

Question 51

If a drug was used in the 3rd trimester, should it be safe to use when breastfeeding?

Answer 51

Yes = less exposure during breastfeeding than in utero

Question 52

What is an example of a drug secreted into breastmilk?

Answer 52

Lithium

Question 53

What is substance abuse?

Answer 53

Mental and behavioural disorder = associated with depression, anxiety and personality disorders

Question 54

What are the complications of substance abuse?

Answer 54

Nutritional deficiency, HIV, hep B and C, VTE, STIs, sepsis, endocarditis, opiate tolerance/withdrawal, OD, IUGR, SIDs, stillbirth, preterm labour, increased risk of domestic abuse and suicide

Question 55

What are the risks associated with alcoholism during pregnancy?

Answer 55

Miscarriage, Wernicke's encephalopathy (20%), foetal alcohol syndrome

Question 56

What are some features of foetal alcohol syndrome?

Answer 56

Facial deformities, lower IQ, neurodevelopmental delay, epilepsy, heart and kidney defects

Question 57

What are the risks associated with cocaine, amphetamine and ecstasy use during pregnancy?

Answer 57

Death due to stroke or arrhythmia Pre-eclampsia, abruption, IUGR, preterm labour, miscarriage, withdrawal, SIDS, developmental delay Teratogenic = microencephaly, limb/cardiac defects

Question 58

What are the risk associated with opiate use during pregnancy?

Answer 58

Maternal deaths (1-2%), neonatal withdrawal, IUGR, SIDS and stillbirth

Question 59

What are the risks associated with nicotine use during pregnancy?

Answer 59

Miscarriage, abruption, IUGR, stillbirths, SIDS

Question 60

What antenatal care is given to those suffering from substance abuse?

Answer 60

Methadone programme and social work referral | Child protection, smear history and early IV access

Question 61

When would breastfeeding be contraindicated in someone with substance abuse issues?

Answer 61

If HIV positive, using cocaine of alcohol >8