Psychiatric Disorders in Pregnancy and Postpartum

Psychiatric Disorders in Pregnancy and Postpartum

Abstract

Psychiatric disorders in pregnancy present additional complex issues during diagnosis and treatment considerations. During the perinatal period both the safety for mother and baby must be considered. However, deterring treatment during the perinatal period can present additional safety issues as well.

 

Overview

During the perinatal period physiological changes are presented that change treatment approaches to both medical and psychological issues. Pregnancy increases the maternal blood volume, increases metabolic processing, increases kidney and liver clearance, and also increases hormonal interference.

 

Psychiatric Disorders during pregnancy and the postpartum period have recently became known as Perinatal Mood and Anxiety Disorders (PMAD). This category covers psychiatric disorders during pregnancy as well as postpartum depression (PPD) and anxiety disorders.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Screening Tools

Edinburgh Postnatal Depression Screen

10 item questionnaire

Questions not somatically focused

Best tool during and after pregnancy

 

 

 

 

 

 

 

 

 

 

 

 

 

Prevalence

15% of women will experience PPD and 50% of their partners

Depression is the most common complication of pregnancy

Very under diagnosed and under treated

 

 

 

 

 

Treatment Considerations

Psychotherapy/Therapy is the first line tx option for any PMAD. Behavioral management should be a focus of therapy to:

Good sleep hygiene is crucial

Increase support available in all aspects

Increase healthy nutrition and activity status

 

Medication Management is the second line tx option to consider. Risks versus benefits is the overall concern with medication management during pregnancy and the postpartum period for any PMAD diagnosis.

 

Medication Considerations:

Minimize poly-pharmacy and minimize multiple exposures

Use what works if possible at minimum effective dose

 

** Worst Case Scenario = exposure without benefit

 

Dosage increases in 2nd trimester may be needed due to increased metabolism

Dosage decreases directly following birth may be needed due to physiologic and metabolic changes after birth

 

Prevalence and Evidence-Based Treatment Considerations

Name: School of Nursing

Treatment Considerations Cont.

Pharmacology Choices:

SSRIs

Most pregnancy data collected on these medications

No trends observed of increased risks

Sertraline/ Zoloft utilizes greater number of cytochrome P450 enzymes

Paroxetine/ Paxil-increased risk of cardiac malformation

Risk for withdrawal syndrome in both mother and baby.

Benzodiazepines

Data is limited

Risk for neonatal abstinence syndrome (NAS)

Mood Stabilizers

More data available r/t treating seizure disorders

Antipsychotic

Less data available about risks

 

Lactation During Postpartum

SSRIs or SNRIs

Sertraline /Zoloft low concentration in breast milk

Fluoxetine/ Prozac and Citalopram/ Celexa greater concentration in breast milk

Benzodiazepines

Considered compatible for breastfeeding

Monitor baby closely, consider shortest acting first

Mood Stabilizers

VPA-shown low to no concentration in breast milk

Lithium-pumping and dumping at peak levels

Antipsychotics

Quetiapine/ Seroquel considered safe

 

 

Conclusion

Treating psychiatric disorders in pregnancy and postpartum can be complex. The lack of evidence adds to the complexity of treatment. However, data collected can be of assistance. The best option proves to be a combination of both therapy and medications. Close monitoring of mother and baby is needed in all situations. Research and prevalence supports screening of all pregnant women during the perinatal period and in postpartum period for risk factors, early detection and diagnosis of any PMAD issue.

 

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PMAD and S/Sx

Postpartum Anxiety

Persistent anxiety about wellbeing of baby

Persistent anxiety about being a good parent

Sleep difficulties even when baby is sleeping

Intrusive thoughts/, episodes of panic

Postpartum OCD

Intrusive thoughts/Obsessions

Unusual morbid thoughts of baby being hurt

Postpartum Depression

Persistent depressed mood, anxiety, panic, guilt

Feeling disconnected from baby

Difficulty with concentration, sleep difficulties

Poor appetite

Suicidal thoughts

Postpartum Psychosis

Develops rapidly, Psychiatric Emergency

Risk for suicide and infantcide

Irritability, paranoia, mania, sleeplessness

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Previous Mental Health Disorders can change s/sx during pregnancy

Bipolar and Schizophrenia Disorders during pregnancy

Preconception counseling

High risk of mood disorder/psychosis

Risk of pregnancy denial

Increased risks of poor outcomes