Factors specific to pregnant women
- Past obstetric and gynaecological history
- Screening for sexually transmitted diseases and blood-borne viral infections
such as HIV and hepatitis B and C - Feelings about the pregnancy and the baby
- Plans for the baby’s future
- Feelings of guilt or self-blame
- Fears about the baby being taken into care
- Existing needs and available resources
Woman becomes pregnant on psych meds
- Attitudes to pregnancy
-wish to continue:options for support
-wish to terminate: capacity to consent for termination - Risk benefit analysis
A) provide adequate info to make an informed decision in regards to continuing or stopping
B) risk of continuing medication vs risk of relapse
C) Maximum risk of malformations is during first 12 weeks (trimester)
D) When pregnancy is identified, this is usually at 8 weeks and maximum risk for congenital malformation has passed
E) Review current meds and cease any unneccessary meds
F) Explain risk of relapse of MI on foetus and mother
G) Priority is to ensure stable MH during pregnancy (poor maternal and foetal outcome such as low birth weight baby, neglect, poor appetite, risk of SI and SH, postnatally impaired attachment and bonding that can impact intellectual development of child)
Antidepressants
Paroxetine - persistent PHTN with exposure in third trimester
Sertraline - safe as least passage through placental barrier, escitalopram also
TCA - avoid, significant passage through placental barrier, cardiotoxicity
Risk of withdrawal syndrome in infant with SSRI use in third trimester
Most studies show SSRIs arent associated w birth defects
Consider postnatal monitoring for >3 days after delivery to detect any neonatal withdrawal syndrome. Fluoxetine - long half life, protracted syndrome. Consider reduction of dose in later stages
Breastfeeding
Ways to change breastfeeding
All meds pass through milk to some extent
Sertraline least passage
Paroxetine, sertraline - amount of drug which baby is exposed to is low. significant complications are rare. very low or non detectable levels of drug in baby serum
overall, small number of case reports - irritability, crying, sleep disturbance, feeding problems
Formula feeds, timing the feeds, expressing breast milk
Methadone in pregnancy
-When combined with a comprehensive psychosocial treatment program, can reduce the incidence of obstetric and foetal complications as well as neonatal morbidity and mortality
-Detoxification from all drugs is unrealistic for this population, methadone should be maintained for entire pregnancy
-Metabolism of methadone increased in pregnancy, can increase dose or use split dose
Clarification of postpartum psychosis dx
- Collateral
- GP
- Family
- Previous notes
- Response to medication
- Investigations
- FBC, U&E, LFT – electrolyte imbalance and infections are common postpartum
- Blood levels – lithium, valproate etc.
- B12, folate
- TFT can exacerbate depression
Tx of postpartum psychosis
- Treatment of illness is highest priority
- Risk-benefit analysis
- Premature infants and infants with renal, hepatic, cardiac or neurological impairment
are at greater risk from exposure to drugs. - Monitor the infant closely for abnormal cries, failure to thrive, abnormal feeding and
sleeping patterns and growth and development - Use the lowest possible dose
- Avoid polypharmacy
- Time feeds to avoid peak levels or express milk
- Mothers taking psychotropics during pregnancy are to be monitored in a mother-baby
unit for three days postpartum for withdrawal symptoms in the baby - Antipsychotics in breast feeding; Sulpiride / olanzapine
- Antidepressants – paroxetine (lowest milk/plasma ratio and shortest half-life) or
sertraline. Avoid doxepin - Mood stabilisers – avoid if possible, valproate if essential
- Sedatives – lorazepam for anxiety, zolpidem for sleep
- Supportive counselling
- Once acute situation is resolved, use psychoeducation of patient and family
- Referral and liaison with neonatology, obstetrician and GP
- Discharge with acute follow up
- Relapse prevention – compliance therapy
- Drug and alcohol counselling if necessary
- Discuss implications of psychosis and medications if planning for further pregnancies
and need to plan
General principles in prescribing in pregnancy
- Discuss possibility of pregnancy
- Importance of planning pregnancies and use of contraception
- Psychoeducation is crucial
- Risk-benefit analysis for each case. - discontinuation of medication abruptly post
conception for women with severe mental illness and those at high rate of relapse is
not recommended - Perinatal services referral
- Involve specialist perinatal psychiatrists if possible
- Avoid drugs in first trimester, use lowest effective dose
- Avoid polypharmacy
- Foetal screening
- Consider changes in body volume resulting in plasma level fluctuations in pregnancy.
Drug doses may need to be adjusted, particularly in third trimester. - Drug dose may be tapered in third trimester depending on patient’s history and
following discussion with patient and her partner.
Antipsychotics /adts in pregnancy - important pts
- Antipsychotics; can increase weight and gestational diabetes. Small risk of slightly lower or heavier weight baby. No evidence of increase in risk of miscarriage or birth defects.
- Antidepressants; fluoxetine (longer half life, less chance for neonatal withdrawal) or citalopram (faster response)
First trimester: early trials showed no teratogenic effects
2nd trimester: small but significant risk of shorter gestational length and lower birth weight
3rd trimester - Increases in mild respiratory distress, irritability and feeding problems. These effects are self-limiting and have generally settled by 14 days. It is unclear whether these neonatal effects are withdrawal or toxic effects - Avoid paroxetine – linked with persistent pulmonary hypertension of the newborn
(PPHN) especially with third trimester administration - Monitor the infant after delivery. Most mother-baby units will have a minimum of
three days after birth to observe for signs of withdrawal; irritability, crying, sluggish
reflexes, fever, poor appetite, failure to thrive and convulsions. Risk is greater with
short half-life drugs such as paroxetine and venlafaxine - ECT is effective for severe psychotic depression
Li in pregnancy
-increased rate of malformation (prescribed at any time)
-cardiac malformations (first trimester esp week 2-6) - can cross the placenta and increase the risk of Ebstein’s anomaly (4-12% risk) - less risk if level<0.64
-does not increase risk of miscarriage
-effective in preventing postpartum relapse
-clearance increases by 50% in third trimester due to increase in GFR, which can cause manic sx
Monthly Li level, weekly from 36 weeks
-need to reduce the dose 1-2 days before delivery as maternal blood volume and GFR returns to normal, to avoid toxicity
If lithium is continued, high resolution ultrasound and echocardiography should be
performed at 6 and 18wks of gestation
Breastfeeding contraindicated - dehydration, passes easily through milk
Epilim in pregnancy
contraindicated in pregnancy due to the risk to the unborn baby (fetus).
Congenital malformations have been estimated to affect between 6.7%1 and 12.4%2 of children exposed to Epilim in the womb. The rate of malformations in the general population is 2-3%. The most common:
-neural tube defects,
-cleft lip and palate,
-heart defects,
-limb defects and
unusual facial features
Developmental delay is also common (30-40%) in children exposed to Epilim in the womb. The IQ of Epilim exposed children is 7-10 points lower than the IQ of children exposed to other anti-epileptics. The risk of autism in children exposed to Epilim has been estimated at 2.5%. This is about five times higher than the rate in the general population.
If continued, low dose with high dose folate
Prophylactic vitamin K to pt and baby after delivery
Note: tegretol also causes increased risk of structural birth defects inc spina bifida
Lamotrigine in pregnancy
Increased risk of cleft palate
Significant dose-related teratogenesis if dose>200
Clearance increases steadily through 32 weeks. should do trough every 2 months
Prevention of post partum
PRIMARY PREVENTION
* Educational programmes about detection and early treatment – media, GP clinics,
community talks
* Folate and vitamin supplementation
* Diet and nutritional advice
SECONDARY PREVENTION
* Antenatal screening
* Intensive monitoring during early postpartum period
* Edinburgh Postnatal Depression Scale (EPDS) (a 10-item self-report scale)
administered two or three times by health visitors during first 6–8 months
TERTIARY PREVENTION
* Relapse prevention strategies as discussed above
* Antidepressant, mood stabiliser, antipsychotic prophylaxis
* Social support
RFs for PND
- Past history of depression
- Psychological issues in pregnancy
- Poor social support and relationship with partner
- Recent adverse life events
- Less well associated factors include:
o Obstetric complications
o Lower socio-economic status
o History of abuse
o Severe postnatal “blues”
Effects of untreated mi in pregnancy
Increased obstetric complications - preterm, low birth weight, stillbirth
Fetal distress
Fetal abnormalities
Parenting difficulties
