Psychiatric Consultation to the

SFGH Ob/Gyn Service

Psychiatric Consultation to the

SFGH Ob/Gyn Service

Sudha Prathikanti, MD

UCSF Dept of Psychiatry

Ob/Gyn Population at SFGHOb/Gyn Population at SFGH

• Ethnically diverse; some over-representation of Latinas

• Over 1200 deliveries / year, often with significant prenatal morbidities

• SFGH provides prenatal services for patients from county jails, BAPAC, homeless clinics

Ob/Gyn Clinical Sites Within SFGH

Ob/Gyn Clinical Sites Within SFGH

• 5M Outpatient Women’s Clinic• Gyn Clinic• Teen Clinic• Nurse-midwife Prenatal Clinic• High Risk (MD) Prenatal Clinic

• 6G Women’s Options Clinic• 6C Labor and Delivery (inpatient)• 6C Triage Area (outpatient)

Psych Interface with Hi-Risk OBPsych Interface with Hi-Risk OB

• Thursday AM: Anna Spielvogel and psych residents available in 5M Clinic until noon

• “one-stop shopping” : outpatients coming for prenatal care get regular co-follow from Anna et al for mental illness or for severe drug abuse/psychosocial stressors

• Anna et al hold weekly rounds with OB team and keep written log of all active patients

• Formal psych tx plan placed in prenatal chart• NO automatic follow-up when woman delivers, but

Anna/residents often available by page and will see patient at 2wk postpartum check

Core Ob/Gyn Knowledge for the Psychiatric Consultant

Core Ob/Gyn Knowledge for the Psychiatric Consultant

• Common Acronyms/Terminology• Contraceptive Technology• Conception Technology• Normal Fetal Development by Trimester• Evidence of Fetal Problems / Fetal Distress • Stages of Labor• HIV Transmission & Treatment in Pregnancy• State Abortion Timelines• Classification System for Drugs in Pregnancy

Emergent Consult Questions Emergent Consult Questions

• Suicidal or Homicidal Ideation• Psychosis/ Agitation during Labor/Delivery

• Consider etiology-pain, primapara, drugs, culture• Use Haldol IM if necessary• Avoid hypotension!

• Capacity for Medical Decision-making : • Requesting Abortion • Refusing Vital Procedures (esp fetal monitering)• Leaving AMA

Some Non-Emergent Consult Questions

Some Non-Emergent Consult Questions

• Diagnostic issues • Is this postpartum depression?

(assuming no suicidal ideation)

• Psychotropic meds during pregnancy/lactation• Should we stop this woman’s Paxil?

• Capacity to parent• Is this schizophrenic woman a “fit mother”?

• Behavioral treatment plan• How can we get this woman to stay in bed?

• Outpatient resources • Ashbury House, Iris Center, BAPAC

Psych HPI : Questionsfor the Pregnant PatientPsych HPI : Questions

for the Pregnant Patient• Was this a planned pregnancy?• Was the pregnancy the result of a sexual

assault/incest?• When did you first discover you were pregnant?

What was your reaction?• Do you know who the father is?• What has the father’s role been during the

pregnancy?• Do you want to carry the baby to term?• What do you hope will happen after the pregnancy?

Core Psychiatric Knowledge re: OB/Gyn Patients

Core Psychiatric Knowledge re: OB/Gyn Patients

• Gender theory

• Societal vulnerabilities for girls/women

• Development thru the life cycle

• Developmental tasks of pregnancy

• Psychiatric disorders : prepartum, peripartum, postpartum

• Psychotropic medications during pregnancy/breastfeeding

Gender TheoryGender Theory

• Gender identity: core sense of femaleness or maleness well established by 18 mos

• Gender role: conscious expectations and behaviors considered appropriate for a given gender in a given culture

• Gender personality: largely unconscious way of relating to world/self/others as a result of early attachment experiences (Chodorow -object relations theorist)

Societal VulnerabilitiesSocietal Vulnerabilities

• Rape (6-26% lifetime prevalence)• Only 1/5 raped by stranger• Stranger rape less likely to lead to other injuries

• Incest (12% of girls under 17)

• Domestic Violence (20-30% life prev)• Almost half of murdered women killed by

partners• Account for large number of ER visits

Life CycleLife Cycle

• Menarche

• Reproductive capacity

• Infertility

• Loss of desired pregnancy

• Birth experience

• Menopause

Tasks of Normal PregnancyTasks of Normal Pregnancy

Pregnancy: key opportunity to revive/ re-work core identity, unresolved childhood conflicts

• First Trimester• Acknowledge pregnancy, decide what to do• Confidence greatly influenced by own mother• Confirms femaleness regardless of decision

• Second Trimester• Assimilate altered body image (fertility vs. control)• Affective bond with fetus can resolve ambivalence

• Third Trimester• Anticipation vs. dread (pain, health, change in role)• Ambivalence/rejection of fetus can signal serious prob

Psych Disorders and Reproductive Life Cycle

Psych Disorders and Reproductive Life Cycle

• Much higher risk for mood disorders in the year following birth• Fluid, electrolyte, hormonal shifts?• Psychosocial stress + biologic diathesis?

• Otherwise, no convincing data linking severe psych conditions to biological cycle• “Minor” depression/anxiety prepartum• PMDD• Menopausal depression

Postpartum PsychosisPostpartum Psychosis

• Rare ( 0.1-0.4% ) but severe w/ rapid onset

• Elevated risk up to one year postpartum

• Most significant etiologic factor is genetic loading for Bipolar Disorder

• Diff dx: Schizophrenia, MDD, drugs

• May involve bizarre delusions re: infant

• Must remove from infant until tx complete

• 50% recurrence in later pregnancies

Postpartum DepressionPostpartum Depression

• Common: 20% incidence• Often undetected due to mom’s shame• Gradual onset 2 wks-1 yr postpartum;

most commonly month 3 and month 9• Same diagnostic criteria as MDD• Risk of suicide/infanticide rare, but high

risk of neglect and inadequate parenting• Recurrence depends on initial severity and

psychosocial stressors

Post Partum BluesPost Partum Blues

• Extremely common (50%)

• Considered normal

• NO link to other psych disorders

• Sx appear within days of delivery, peak from day 3-7, resolve within 2 wks

• High rate of recurrence: provide mom reassurance and support

Medications during PregnancyMedications during Pregnancy

• Traditionally withheld due to fears of teratogenicity

• Consider risks of untreated psych illness• Poor nutrition/low birth weight• Poor prenatal care• Precipitous delivery/self-delivery• Neonatal neglect/abuse

Psych Meds during PregnancyPsych Meds during Pregnancy

• Review of FDA Classification• More data emerging re: safety of TCAs, some

SSRIs, high-potency neuroleptics• Avoid benzos / mood stabilizers in first trimester• Definite teratogenic effects of mood stabilizers

• Lithium- cardiovasc anomalies• Valproate-neural tube defects• Carbamazapine-craniofacial anomalies

Handy ReferencesHandy References

• Ob/Gyn Basic Knowledge• HIV and Pregnancy• Key Textbooks• Review Articles on Psychopharm during Pregnancy and Lactation• Review Articles on Mood Disorders

during Pregnancy

Patient InformationReproRisk Database