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Armed Forces college oF medicine

Psychiatric disorders associated with Pregnancy

by

MohaMed a. Elkariony

Abd elrAhmAn h. IsmAIl

Introduction Mood disorders are twice as common in women compared to men and

the prevalence increases during childbearing years.

Pregnancy either induces or exacerbates pre-existing stress and in turn

stress seems to have a negative effect on pregnancy, especially in the

first trimester .

The prevalence of depression has been reported to be between 10

and 16% during pregnancy

“Tyano S, Keren M, Herrman H 2017”

Stress and pregnancy:

With many pictures like:- Major depression

- Maternal postpartum psychiatric disorders

- Bipolar disorder

- Anxiety disorder

- Psychotic disorders

- Panic attacks

- OCD

Stress cause many problems to mother but how?

Reaction to sustained anxiety and depression. Stress factors may affect

uterine circulation, in turn decreasing blood flow reaching the decidua, and

thus affecting the implantation site. Catecholamines play a role in the

emotional centers of the brain as well as in steroidogenesis That is called:

Hypothalamic-pituitary-adrenal axis (HPA)

“Cloitre M, Yonkers KA, Pearlstein T 2011”

The question is how signals of maternal stress may reach the fetus has not been dealt with so far ?

So any change in mother will affect fetus causing PTL ?

Increased fetal cortisol may inhibit growth and differentiation of the

developing nervous system, may damage the brain, and may affect the fetal

neuroendocrine system resulting in the permanent disorders.

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Major depressive disorder in pregnancy: May have Many symptoms:

- Sleep and appetite disturbance

- Diminished libido, and low energy.

- Anhedonia, feelings of guilt and hopelessness

- Suicidal thoughts.

Some medical disorders commonly seen during pregnancy, such as anemia, gestational

diabetes, and thyroid dysfunction, may be associated with depressive symptoms and may

complicate the diagnosis of depression during pregnancy.

Observed in about one third of pregnant women with first episode.

“Pulson and Bazemore 2016”

Risk factors for antenatal depression include:

-Marital discord or dissatisfaction

-Inadequate psychosocial supports

-Recent adverse life events

-Lower socio-economic status

-Unwanted pregnancy

Impact of maternal depression on the family unit:

- Interpersonal difficulties, disruptions in mother-child interactions and attachment

due to maternal depression may have a profound impact on infant development.

- Children of depressed mothers are more likely to have behavioral problems and

exhibit disruptions in cognitive and emotional development.

- Depression during pregnancy significantly by its turn increases a woman’s risk for

postpartum maternal disorders.

“Wilson and Durbin 2015”

Maternal postpartum psychiatric disorders: Diagnosed by overwhelming emotions such as:

- Anticipation, excitement, happiness and sleep disturbance

- Fulfillment, anxiety, frustration, confusion and sadness/guilt.

Include: * Postpartum blues and Postpartum depression

* changing in Co-morbidity, severity of anxiety, obsessionality

and the period

Affecting approximately 10–15% of adult mothers yearly

May lead to Postpartum psychosis

“ Brockington I. Postpartum psychiatric disorders 2017”

Maternal postpartum psychosis: Diagnosed by:

- Restlessness, Irritability, Insomnia.

- Auditory hallucinations that instruct the mother to

harm herself or her infant.

- Suicidal thoughts and Function impaired Observed in :

-1 to 2 per 1000 women after childbirth

- 5% suicide

- 1% infanticide

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Infanticide: It is one of the most serious risks of postpartum psychosis.

The rate of maternal infanticide is 8 per 100,000 in the United States.

The stressor of new infant care can increase the risk of infanticide after

delivery in a mother with psychosis.

Infanticide may also occur in the context of severe PPD, caused by neglect

and abuse, because of the child being unwanted or as revenge against the

infant’s father.

“Child homicide and infanticide in New Zealand 2014”

Infanticide: Between 16% and 29% of mothers who kill their children also kill

themselves.

Neonaticide is defined as killing a newborn infant within 24 hours of

birth and is associated with denial of pregnancy, lack of prenatal care,

dissociation, depersonalization, and intermittent amnesia of delivery.

Paternal postpartum depressionMen’s emotional health can be overlooked during their partner’s pregnancy

and throughout the first postpartum year

Postpartum depression, once expected only in new mothers, is now

estimated to occur in 4-25% of new fathers

New fathers may seem more angry and anxious than sad.

The father's anxiety and depression may even translate into violent

behaviors toward his partner.

“Redloff 1977 & Ramchandani 2010”

Paternal postpartum depression Limiting men’s capacity to provide emotional support to their partners and children.

May be accompanied by fear of financial problems he may face in the future.

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Bipolar disorder: Diagnosed by :

- Hyperactivity and increased sexual energy- Decreased need for sleep and hypertalkativeness -Depression episodes ,delusions, hallucinations and incoherence.

Pregnancy and especially the post-partum period are stressful periods for women, and

increase the risk of relapse for women with bipolar disorder.

Bipolar disorder affects 0.5-1.5% of pregnant women.

It is important to access history of hypomania or mania when determining diagnosis in

any woman presenting with psychological symptoms. “Carter J, Stabile C, Gunn A 2013”

Anxiety disorder Studies indicate that 31% of women will develop some type of anxiety disorder during

their lifetime.

The prevalence rates for panic disorder in women and men are 5%.

Fluctuations in reproductive hormone levels during the female life-cycle are thought to be

responsible for modulating anxiety. Pregnancy appears to be a protective period for some

anxiety disorders, including panic, while for others such as OCD, it may be a trigger

Hormonal changes during pregnancy, such as increased prolactin, oxytocin and cortisol

may contribute to the suppression of stress response that occurs during this period.

“Carter J, Stabile C, Gunn A 2013”

Anxiety disorder Childbirth qualifies an extreme traumatic stressor that can result in post–

traumatic stress disorder.

The reported prevalence of post-traumatic stress disorder after childbirth

ranges from 1.5 to 6%.

Mothers with post–traumatic stress disorder attributable to child-birth

struggle to survive each day while battling terrifying nightmares and

flashbacks of the birth, anger, anxiety, depression and painful isolation from

the world of motherhood.

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Obsessive-compulsive disorder Affects 1 in 50 women of childbearing age and can develop for the first time in pregnancy.

It is characterized by escalating anxiety in the context of recurrent, intrusive egodystonic ideas

such as hand-washing.

Obsessional ideas can focus on the health of the unborn baby during pregnancy and cause

significant maternal distress as a result. This can sometimes lead to excessive reassurance

seeking from the midwife or obstetrician.

“Righetti PL, Romagnolo C, Panizzo 2016’’

Pregnancy and schizophreniaSchizophrenia occurs in1% percent of the population during the reproductive years.

fertility rate of schizophrenic patients is below average. It is variously estimated to be 30% to

80% of the general population's. for many factors :

-Psychotropics, suppress ovulation through their effect on the

hypothalamus.

-Most important reason for reduced fertility is a lack of opportunity

for sexual intercourse

“Faisal-Cury A, Menezes P, Araya R, Zugaib M 2012”

What are the key risks of pregnancy and the postpartum period in women with schizophrenia?

Delayed recognition of pregnancy, labor, less prenatal care and poor nutrition.

The postpartum period is a time of exacerbation of schizophrenia. Symptoms of schizophrenia

can also adversely affect parenting capability, which leads to high rates of custody loss.

At times, delusions or hallucinations about the baby directly interfere with bonding and

parenting.

Negative symptoms of schizophrenia, such as difficulty expressing emotions, may contribute to

neglect of a baby.

Schizophrenic's Child

The children of two schizophrenic parents have a 40% chance of developing schizophrenia

while of one schizophrenic parent have a 7 to 17% .

Children of normal women married to schizophrenic men are also at increased risk for lower

IQs; this fact indicates that both genetics and suboptimal environment affect development.

Poor mother-infant interaction may correlate with the amount of medication the mother was

on, or with severity of mother's illness.

“Faisal-Cury A, Menezes P, Araya R, Zugaib M 2012”

The family doctor is often should monitor the physical, emotional, and intellectual development of the child with a schizophrenic parent and should pay attention to unexplained physical injuries, evidence of neglect.

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Obstetrician and psychiatric disorders

Keeping in mind the need to treat pregnant women with psychiatric disorders effectively, the

obstetrician/gynecologist should be able to recognize psychiatric disorders based on the symptoms

presented.

The prognosis of postpartum disorders is generally good:if diagnosed early and adequately treated

The chances of recurrence are also very high can be as high as 25–40%.

“Kessler RC, Mc Gonagle KA 2009’’

Prenatal management Rule of Thumb:

-Medication changes should be done prior to pregnancy if possible.

-The mother-to-be should be stable psychiatrically for at least three

months before attempting pregnancy.

-Use older medications is usually better. why?

-Minimize the number of medication exposures

-Consider breastfeeding when planning for pregnancy.

-Make sure both your Ob-Gyn and pediatrician are in communication

-If your physician approves, avoid medication during the first trimester“Wisner KL, Hanusa BH, Pandl KS 2018”

If failed:Leading to medications during pregnancy and post natal

Treatment of psychiatric disorders during pregnancy:

We have two concerns, we should respect:

a) Psychotropic medications cross the placenta respecting following factors:

1. Teratogenesis

2. Toxicity to the neonate3. Neurobehavioral sequelae

4. Risk of no treatment

5. Risk of medication discontinuation

“Wisner KL, Hanusa BH, Pandl KS 2018”

b)Treatment of specific psychiatric disorders:

(1) Major depression:

First method “Psychotherapies”

- Interpersonal therapy (IPT) and Cognitive behavior therapy (CBT)

- It is ideal for the treatment of the depressed pregnant women reducing the severity of

depressive symptoms

Second method “Antidepressant”

- Indicated for women whose symptoms interfere with maternal well being and functioning

- Fluoxetine is usually the first line antidepressant choice

- We can use TCAS, desipramine and SSRIs

Third method “Electro-convulsive therapy”

- During pregnancy is found to be safe and efficacious

- May cause PROM in some reports

Treatment of psychiatric disorders during pregnancy:

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b)Treatment of specific psychiatric disorders:

(2)Bipolar disorder:

- Depending on mood stabilizers lithium carries the lowest risk.

- Anticonvulsants are the other choice for treating bipolar disorder

but reported to have higher risk for multiple congenital anomalies

could be overcome by high dose of folic acid and US to detect

anomalies early.

- Women with a history of a single episode of mania may be able to

remain off psychotropics during pregnancy ,putting in mind recurrence

could place both mother and fetus at risk

Treatment of psychiatric disorders during pregnancy:

b)Treatment of specific psychiatric disorders:(3) Anxiety disorders:

- First method “Psychotherapies”

CBT is found to be efficacious for panic disorder and OCD in both

pregnant and non-pregnant women.

-Second method “Anxiolytics”

Fluoxetine or a TCA is a reasonable treatment option

Treatment of psychiatric disorders during pregnancy:

b)Treatment of specific psychiatric disorders:

(4)Psychotic disorders:

- Neuroleptics should be considered as psychosis can be an

obstetric and medical emergency.

- Hence in pregnant women with psychotic illnesses, higher

potency agents are recommended over lower potency neuroleptics

- A recent review showed that olanzapine and clozapine apparently do

not increase the teratogenic risk if administered to pregnant women,

while evidence on quetiapine, risperidone, aripiprazole, and ziprasidone

is still limited.

Treatment of psychiatric disorders during pregnancy:

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