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Perinatal Mental Health
Dr Cressida Manning
Consultant Perinatal Psychiatrist
Florence House Mother and Baby Unit
Contents of Presentation
Confidential Enquiry into maternal deaths.
Risks of untreated illness.
Risk factors for postnatal depression and psychosis.
Discussions around treatment.
Medication.
Recent Case Study
Felicia Boots. 35
Mother of 2 ( 14 months and 10 weeks).
Manslaughter on grounds of diminished responsibility.
Stopped medication as breastfeeding.
Confidential Enquiry
Centre for Maternal and Child Enquiries (CMACE)
Most recent report ‘Saving Mothers Lives’ (2011) 2006-2008
29 suicides 1st 6 months
19 past psychiatric history
9 identified of which 4 had care plan
Saving Mothers Lives
38% Psychosis
21% Severe Depressive Illness
Recommendations - Back to Basics 1Saving Mothers Lives
Anxiety or depression Review in 2 weeks
Consider psych referral if symptoms persist
Refer urgently where:
Suicidal ideation, uncharacteristic symptoms/marked change from normal functioning, morbid fears, profound low mood, personal or family history of serious affective disorder, mental health deterioration, morbid fears, panic attacks and intrusive obsessional thoughts.
Effects of Untreated Illness
Increased morbidity.
Increased risks towards self and others.
Links between maternal anxiety and fetal behaviour and heart rate
Stress/anxiety during pregnancy can have long term effects on child
Associated with an increased incidence of:
Emotional problems - Anxiety/depression
Behavioural problems – ADHD, conduct disorder
Impaired cognitive development, esp language
Sleep problems in infants
Sensitive early mothering important as what happens in utero for child outcome
Effects of antenatal and postnatal depression Children of mothers depressed in perinatal period compared to
children of well mothers:
Lower IQ scores
12x more likely to have a statement of special needs
elevated risk of violence at 11 and 16 years
More likely to suffer separation anxiety at 11 and a diagnosis of depression at 16
Suicide
Majority of deaths secondary to postpartum psychosis or very severe depressive illness
Oates (2008) Suicide rate for ppp 2/1000
Common profile; white, older, 2nd or subsequent pregnancy, married, comfortable circumstances
Likely to die violently
Infanticide
Similar profile
1/3rd mental illness
Death extended suicide or occasionally altruistic based on delusional belief
Highest concern if delusion involves child e.g baby changed, not hers, possessed, evil.
Postpartum Psychosis
1st few weeks highest risk Heron et al (2007) Greater than 80%
1st week Link with BPAD
Bipolar Disorder
52% relapse in 1st 40 weeks after stopping treatment
If pregnant and stable on antipsychotic and likely to relapse without medication continue
Up to 70% relapse if untreated in postnatal period 50% psychotic symptoms day 1 - 3
Postpartum Psychosis – Risk Factors
1st Baby
Single
C- Section
Older
Fertility Problems
Previous episode – 1 in 7
Sleep Loss
Warning Signs
Early signs often non specific
Insomnia, agitation/anxious, perplexed and odd behaviour. Risk overlooked
Can lead to rapid deterioration to Psychotic symptoms
Postnatal Depression
10 -15%
Severe 3%
1/3 to ½ continuation of antenatal anxiety and depression
Onset few days to 6 months
Increased risk in subsequent pregnancies – approx 25 – 50%
Postnatal Depression – Risk Factors
Antenatal anxiety or depression
Past history of psychiatric illness
Life events
Lack of or perceived lack of support
Low income
Domestic violence
FH of psychiatric illness
Childhood abuse
Risk Factors cont…
Obstetric factors
Sleep deprivation
Infant factors –irritability
Personality factors – control, interpersonal sensitivity, ‘neuroticism’
Biological factors – inconsistent results
Early Detection
1st contact;
Past or present mental illness
Previous psychiatric input, including admissions
Family history of severe mental illness
Treatment of pregnant and breast feeding women- NICE guidelines
Importance of balancing risks and benefits
Cautious
Women requiring psychological treatment should be seen for treatment within 1 month of assessment and no longer than 3 months.
NICE
Discussion should include:
Risk of relapse and not treating disorder
Woman’s ability to cope with untreated symptoms
Severity of previous episodes and response to treatment
Woman’s preference
Possibility that stopping drug with teratogenic risk once pregnancy confirmed may not remove risk
NICE
Risks of stopping medication abruptly
Need for prompt treatment due to impact of illness on foetus/child
Increased risk of harm of specific drug treatments
Treatment option that would allow mother to breastfeed
NICE
Prescribing:
Drugs with lowest risk profile
Lowest effective dose
Monotherapy
Risks lower threshold for psychological treatment
Important to put risks from drug treatment in context of the individual woman’s illness
Antidepressants
SSRIs Paroxetine in 1st trimester increase in cardiac malformations (VSD) – planning pregnancy or unplanned advise to stop. Other SSRIs now implicated.
SSRI’s taken after 20 weeks may be associated with an increased risk of persistent pulmonary hypertension of the new born Neonatal withdrawal- normally mild and self limiting
Symptoms include; Irritability Hypertonia Jitteriness Difficulties feeding Tremor Agitation Seizures Tachypnoea Posturing
Tricyclics
Tricyclics have lower known risks during pregnancy than other antidepressants
Have higher fatal toxicity index
CHD with clomipramine
Withdrawal symptoms
No effects on long term neurodevelopmental outcomes
Imipramine
Other antidepressants
Venlafaxine – Conflicting results for congenital malformations – data too limited to say safe. Possible increased neonatal withdrawal and increased risk of high blood pressure at higher doses. Theoretical risk of PPHN
Mirtazapine – Possible association with increased rate of spontaneous abortion. No evidence to link to congenital malformations but data too limited to say safe.
JAMA 13 – Metaanalysis – preterm birth 3 days
- Apgar <0.5
- Weight 75g
- Spontaneous abortion not significant.
Benzodiazepines
Raised risk of oral cleft (7 in 1000; x10)
Withdrawal syndrome – jitteriness, autonomic dysregulation, seizure, floppy baby syndrome
Consider gradually stopping in women who are pregnant
Short term use only for severe agitation and anxiety
Lithium – Ebsteins anomoly (1 in 1000) General population 1 in 20000
Overall risk CHD 0.9-12% vs 0.5-1% general population.
Floppy baby syndrome, thyroid dysfunction, nephrogenic diabetes insipidus.
High quantities in breast milk.
Valproate NTD 100 to 200 in 10000 IUGR Facial dysmorphias Low IQ
Do not routinely prescribe to women of child bearing age. If no option adequate contraception Discontinue if pregnant
Carbamazepinne
Increased risk congenital malformations -6.7% v 2.3%
Craniofacial, GIT, cardiac, urinary tract and digit anomalies
Advice as valproate
Lamotrigine
Cleft palate 8.9/1000
Atypical Antipsychotics
Olanzapine and Quetiapine
Limited data to base assessment of safety in pregnancy, but available data does not suggest a substantially increased risk of congenital malformations or spontaneous abortions
No pattern of malformations observed.
Withdrawal symptoms
Olanzapine – increased birth weight
What Clinicians need to do
Do not assume it is always better to stop medication
Provide prompt and Effective treatment of mental illness in pregnancy and postnatal period
Understand, consider and communicate known risks (and how these will be managed) of medication
Complete risk benefit analysis for individual patient.