CONTENTSComEd's Hourly Pricing Program Program Benefits Comparing Your Rate Options Managing Costs with Hourly Pricing Tools to Help You Save Understanding Your Bill Hourly Pricing Program Guide COMED'S HOURLY PRICING PROGRAM ComEd's Hourly Pricing program is an electricity supply option available for residential customers. This program allows you to pay the hourly,
Dans la pharmacie en ligne Viagra-représenté Paris large éventail de la dysfonction érectile anti-plus consommée. Générique Levitra (vardenafil), Cialis (tadalafil) et achat viagra pour homme, dont le prix est acceptable pour tous les budgets.1
En internet farmacia empecé a pedir porque en la farmacia de al lado nunca había deseado surtido de medicamentos levitra generico Muy cómodo en el uso de la farmacia. Estuvimos en el restaurante a. aquí la tableta con la entrega en el lugar de.
Maternal perinatal mental
Perinatal mental health • Pregnancy and 12 months postpartum – Women with pre-existing mental health problems who become pregnant – Women who develop mental health problems antenatally – Women who develop mental health problems postnatally – And their children and family How common are
mental disorders in
•12 month prevalence
• Any anxiety disorder 17.9% •Any affective disorder 7.1% •Any substance use disorder 3.3% •Schizophrenia and related disorders 0.5-1.0% •Bipolar disorder •Type 1 0.8-1.0% •Type 11 2-3% •Personality traits/disorders
The uncommon but serious problems in pregnancy The uncommon but serious problems in pregnancy • Schizophrenia and bipolar disorder – Diagnosis usually predates pregnancy – Illness may have an impact on • Planning pregnancy • Maternal ante-natal obstetric care • The pregnancy and health of the foetus • The delivery and immediate post-delivery period • The mother-infant relationship – The pregnancy may have an impact on maternal mental health Women with schizophrenia • Fertility of women with schizophrenia=general population • Pregnancy more often unplanned and/or unwanted • Pregnancy often accompanied by a range of risk factors – The effects of the maternal psychotic illness – The effects of maternal psychotropic medication – Poor nutrition – Substance abuse-nicotine, alcohol, illicit drugs – Poverty – Homelessness – Poor social support – Being victims of violence – Poor attendance for ante-natal obstetric care Women with schizophrenia • Impact of mental illness on pregnancy- – present late, avoid maternity care – IUGR due to poor self care – ↑ rates preterm delivery, antepartum haemorrhage and placental abruption – More difficulty managing labour, and higher rates of caesarian section • Impact of mental illness on neonatal outcomes- – ↑ rates of • cardiovascular and other congenital abnormality • stillbirth and neonatal death • failure to thrive Women with schizophrenia • Impact of pregnancy, childbirth on mental health – ↑ risk of relapse – Risk of incorporation of pregnancy and baby in delusional system • Effects of psychotropic medication – During pregnancy • On mother e.g. increased risk of gestational diabetes • On foetus – With breastfeeding • Impact of maternal mental illness on attachment and parenting abilities Women with bipolar disorder • Impact of mental illness on pregnancy – risks of untreated depression – untreated mania poses clear risks due to impulsivity and poor judgement – Mania resulting in poor self care is dangerous for both mother and child • Impact of mental illness on neonatal – Risks of untreated depression – Specific risks of untreated bipolar disorder are not known, little research available Women with bipolar disorder • Impact of pregnancy, childbirth on mental health – Risk of relapse in pregnancy and post-partum is high- • Of women currently receiving treatment, 23% have illness episode in pregnancy and 52% in the postpartum period (Viguera et al 2011) • First lifetime episode occurred in the perinatal period in 7.6% • Risk is increased if cease mood stabilizers, esp if cease • Post-partum relapse esp first 24-36 hours, and continuing high risk for 3 weeks Women with bipolar disorder • Effects of psychotropic medication – During pregnancy-mood stabilizers may have teratogenic effects – With breastfeeding-some risks to neonate • Avoid lithium and lamotrigine • Care with carbamazepine and valproate • Impact of maternal mental illness on attachment and parenting abilities Effects of parental mental illness • Parenting and parent-infant interaction – Illness-related deficits may include: • lack of emotional warmth and intimacy; • attentional deficits; • Impaired maternal competence – Lack of confidence – Poor decision making and functional ability – Neglect – Infrequent, but important, may be clear risk of
harm to baby -omission or commission
• Attachment relationship Improving maternal perinatal mental health of women with schizophrenia and bipolar disorder • Include consideration of reproductive choices in routine care • Early detection and monitoring of pregnancy • Team approach in pregnancy and postpartum Healthy Babies for Mothers with Serious Mental Illness: A Case Management Framework for Mental Health Clinicians Women with schizophrenia and bipolar disorder • Include consideration of reproductive choices in routine care – Contraception-woman „at risk‟ of or wanting to become pregnant – Unplanned or unwanted pregnancy- TOP option – Plan for pregnancy-preconception advice • Treatment of mental illness- GP, mental health clinician, psychotropic medication and other treatments • Lifestyle- nutrition, smoking, alcohol, illicit drugs • Housing, safety, social support Women with schizophrenia and bipolar disorder • Early detection and monitoring of pregnancy – (obstetric) „high risk‟ pregnancy-specialist obstetric care – High risk time for management of mental illness-specialist psychiatric care • Team approach- midwife, obstetrician, GP, mental health; birth plan • Early consideration of parenting capacity • Post-birth-baby with mother • Supports in community, treating team incl MCHN, GP, mental health, child protection, child and family support • Parenting capacity and attachment relationship The common mental health problems during and following pregnancy The common mental health problems during and following pregnancy – Depressive symptoms are common during pregnancy, peak during T3 and fall following delivery • 25% have high rates of depressive symptoms, • 10% have depressive disorder during pregnancy – Postpartum „blues‟ • Time-limited mood disturbance in the postpartum period-prevalence rate up – Postnatal depression • Rates of non-psychotic depression are greater than rates during reproductive years outside childbirth-up to 15% • Half of the women depressed postpartum were depressed antenatally i.e. only 50% of cases of depression in postpartum are new onset The common mental health problems during and following pregnancy – Rates of GAD and OCD are higher in perinatal population cf general population; but rates of PD and PTSD are similar – And >10% experience significant anxiety symptoms- but do not meet criteria for disorder – Pregnancy-specific anxiety common-? Prevalence • Fear of giving birth • Fear of having a physically or mentally handicapped child • Concern about one‟s own appearance – Commonly co-occurs with depression Women with depression • Impact of depression on the pregnancy – Lack of care about the pregnancy, late and/or irregular attendance antenatal care – poor health behaviours-smoking, alcohol – Risk of suicide, foeticide – Increased rate of spontaneous abortion – Increased risk gestational hypertension and subsequent preeclampsia • Poor maternal-foetal attachment Women with anxiety and • Impact of anxiety and depression on the baby – Foetus-greater arousal during pregnancy - • foetal heart rate variability (a marker for fetal distress), • foetal movement patterns-more body movements during REM sleep • foetal sleep-wake cycles-greater wakefulness – Neonatal outcomes- Increased frequency of – IUGR (<2500gm) – spontaneous preterm birth (<37 weeks) – low APGAR scores, – admission to NICU – neonatal growth retardation Women with anxiety and • Infants exposed to antenatal anxiety and/or depression – are highly reactive, have poorer interaction with mother, and have poorer scores on infant development measures • Poorer long term developmental outcomes for the child – Developmental delay – Lowered IQ in adolescence – Impaired language development – increased rate of emotional and behavioural problems – increased rate of ADHD – Association with criminality Women with anxiety and psychotropic medication – During pregnancy – breastfeeding Women with anxiety and • Impact of depression and anxiety on attachment and parenting abilities • Depression-negative themes of being a „bad mother‟ – Not „liking‟ the baby; not having a bond; inability to tolerate crying – Infant does not love them; thinks they are a „bad mother‟ – Feelings of failure, that partner is better parent (jealousy) – Sense of helplessness and hopelessness – about not being "perfect"; about other people‟s perceptions of self as a mother – Preoccupation with baby‟s health e.g., that baby will stop breathing in the night (checking++), that baby is not putting on weight/ feeding enough – Obsessional thoughts about harming the baby e.g., in the bath or while out in pram (traffic, trains) – Difficulty in separating from baby Effects of parental mental • Mothers with high levels of depression – Interact differently with their infants v non-depressed women • Show less behavioural synchrony with their infant • Less responsive to their infant‟s cues • Less affirming of their infant‟s behaviour – Are less likely to feel confident in the mothering role • And in turn, infants of depressed mothers are more likely to display insecure attachment relationships Personality problems/disorders • Personality style per se ± co-morbidity • Cluster B most problematic – esp borderline traits- instability of interpersonal relationships, self-image and affect, and marked impulsivity • Co-morbidity-depression, alcohol and drug use • Attachment difficulties-often require interventions to promote maternal responsiveness and secure attachment Management of women with perinatal mental health problems Management-general principles • Intervene early if you can-prevention/minimisation of problems • Treat the presenting complaint/ illness using the same approach or techniques used in non-pregnant women • but remember: – There is (or soon will be) an infant – Assess maternal competence & be mindful of the risks • When concerns or „at risk‟ consider extended post-natal stay • Reduce over-stimulation & sleep deprivation • Establish breastfeeding (if appropriate) • Assist maternal confidence – If acutely unwell consider Acute Inpatient Unit VS Mother Baby Unit VS permanent separation at birth • Be aware of some of the logistical & practical limitations for a pregnant woman / new mother Management-general principles • Where possible meet the partner – provide psycho-education – address issues within the relationship – another perspective • Mobilise available of social supports • Useful resources – mothers‟ groups, play groups, specific parenting supports for mothers with mental illness, PANDA, peer support • Clinical services – If possible, a system/network – Antenatal and postnatal may vary but include General Practitioners • Family support • Psychologist/psychiatrist (public and private) Management- general principles • Treatment should be guided by a risk-benefit analysis – Risk to mother of treating/not – Risk to foetus/newborn of treating/not • Untreated maternal mental illness poses a risk to both mother and child • Psychological therapies-e.g. ST, CBT, IPT are safe, but not effective for more severe disorders • Medications should be prescribed with caution for appropriate indications • Any management plan should include the partner (where Management-general principles • Maternal mental illness can affect – Maternal parenting abilities – Mother-infant attachment • Parent-infant perinatal intervention may be Psychotropics in Pregnancy • Pregnancy not protective for mental illness • Relapse of schizophrenia or bipolar disorder poses risks for mother and baby • Antenatal depression and anxiety have adverse effects on mother and baby • Postnatal depression is common and is associated with significant morbidity • Risk benefit analysis-prescribe v not prescribe • Risk to mother/pregnancy • Risk to infant • If disorder is mild-moderate use a non-pharmacological • Routes of foetal exposure – Placental transfer-measure cord: maternal ratios – Amniotic fluid-generally measures of amniotic fluid: maternal serum ratios not reliable Are psychotropic drugs safe in • Reproductive loss – miscarriage, FDIU, stillbirth • Pregnancy complications – hypertension, pre- eclampsia, gestational diabetes • Neonatal outcomes – preterm birth, low or excessive birth weight, sedation, withdrawl effects • Structural abnormalities – Baseline rate 3-5% • Neurodevelopmental Australian categorisation of drugs – taken by large no of women – no evidence increased risk malformations or other direct or indirect harmful effects on foetus or neonate – caused or suspected of causing harmful effects on foetus or neonate – may be reversible – no malformations Australian categorisation of drugs • Category B (limited no of women) human data are
lacking or inadequate and so subcategorisation is based on animal studies. • Allocation to category B does NOT imply greater safety • Category B-no increase in malformation or other harmful – B1 animal studies support this – B2 animal studies inadequate or lacking – B3 animal studies show evidence increased occurrence foetal damage (unknown significance in humans) Australian categorisation of drugs – cause/suspected of causing malformations or irreversible damage to foetus – Note in some cases assigned D as „suspected‟ – Note, not necessarily contraindicated e.g. anticonvulsants • Category X (high risk permanent damage) Timing of exposure effects risk • Structural abnormalities are typically associated with early pregnancy exposure-period of maximum vulnerability is 3-12 weeks – Drug is considered teratogenic if it raises the risk of congenital physical malformations over the baseline level of birth defects which is 3-5% • Detrimental effects on neurobehavioural, motor and cognitive development are potentially associated with exposure throughout or later in pregnancy The decision to prescribe or not mother/pregnancy – Of medication – Of untreated maternal • Studies-multiple case reports, limited prospective observational and cohort studies • Reproductive loss – No evidence of increased rate of spontaneous abortion or SB in women with psychiatric disorders treated with antipsychotics • Pregnancy complications – Increased rate of gestational diabetes in women treated with a variety of antipsychotics; also more likely to require caesarian section • Neonatal outcomes – Increased rates pre-term birth and lower birth weight (FGAs) – Increased birth weight SGAs esp olanzapine and clozapine – Low APGAR at birth, respiratory difficulty – Extapyramidal SEs- FGAs • Structural abnormalities – Case reports of variety of abnormalities – On balance little evidence antipsychotics are teratogenic- but the studies are problematic • Definition of malformation, exposure dose and duration, smoking and substance abuse, poor antenatal care, medical co-morbidity, genetic factors • No clear risk can be attributed to FGAs in pregnancy • Insufficient data re SGAs to inform prescribing policy except on a case-by-case basis • Neurodevelopmental outcomes – Limited studies, no consistent findings – haloperidol, droperidol, chlorpromazine, zuclopenthixol, flupenthixol, fluphenazine • B 1 category • B2 category • B3 category – Risperidone, olanzapine, paliperidone, trifluoperazine, amisulpiride, aripiprazole, ziprasidone, quetiapine • Balanced against risk to mother and infant of untreated maternal schizophrenia or related disorders Mood stabilisers-antiepileptics • Retrospective and prospective cohort studies, registry cohorts • Neonatal outcomes – Reduced head circumference-CBZ (VPA) – Lower birth weight-CBZ (VPA) – Neonatal hypoglycaemia- VPA – Sedation, withdrawl, toxicity – Neonatal hepatotoxicity LTG, CBZ – Coagulation defects (Vit K) CBZ Mood stabilisers- lithium • Pregnancy complications – Lithium toxicity – polyhydramnios • Neonatal outcomes – Prematurity – Poor respiratory effort and cyanosis – Increased birth weight (large for gestation) – Hypotonicty, lethargy, hyperglycaemia, hyperbilirubinaemia – Goitre, hypothyroidism – Nephrogenic diabetes Mood stabilisers-lithium • Structural abnormalities – Increase Ebstein‟s anomaly (displacement of tricuspid valve into RV)-occurs in 1 in 20,000 general population; risk is 1 in 1,000 following lithium exposure • Neurodevelopmental outcomes – Limited data re outcomes of children exposed to lithium in utero Mood stabilisers • Polytherapy increases risk of structural abnormality • Risk of malformations reduced if folate taken throughout • Early pregnancy investigations- – high resolution morphological ultrasound with assessment of nuchal translucency to assess for NTD and other malformations – Lithium exposure-high resolution ultrasound and foetal echocardiogram at 16W – Foetal growth surveillance Mood stabilisers • D Category -carbamazepine, valproate, lamotrigine • D Category -lithium • Balanced against risk to mother and infant of untreated maternal bipolar or related disorders • Meta-analyses, retrospective and prospective cohort studies, case-controlled studies • Reproductive loss – Apparent increase in spontaneous abortion- but studies did not control for psychiatric illness state; and they controlled variably for factors such as age, smoking, drug use – No suggestion of increased risk of FDIU or SB • Pregnancy complications – One study has shown an increased risk of hypertension and possibly pre-eclampsia in women exposed to SSRIs beyond the first trimester • Neonatal outcomes – Studies have shown a significant increase in pre-term births (<37 weeks gestation) • Seen with TCA and SSRI, SNRI • Longer exposures are more likely to decrease gestational age • Infants exposed to either SSRI or depression are more likely to be born prematurely than those who are unexposed or partially exposed • Neonatal outcomes – Poor neonatal adaptation-jitteriness, irritability, temperature instability, hypotonia, tachypnoea, feeding problems, GI symptoms, hypoglycaemia – Low initial APGAR score-TCAs, SSRIs – Persistent pulmonary hypertension (PPHN)- in babies of mothers exposed to SSRIs • Base rate 0.5-2 per 1000; fatal in 10% of cases • Risk elevated to 3-6 per 1000 with maternal SSRI use • Structural abnormalities-variable results – Major congenital malformations-paroxetine – Cardiac malformations- increased risk with paroxetine, fluoxetine, TCAs, tetracyclics [VSD paroxetine] – Eye abnormalities- paroxetine – Ventricular outflow defects- SSRIs – Anencephaly, craniosynostosis, omphalocele-SSRIs esp – Overall, no consistent data on SSRI exposure to support specific morphological teratogenic risks – Limb reduction abnormalities-TCAs • Neurodevelopmental outcomes – Major limitations of studies examining possibility of neurodevelopmental adverse effects of Anti-D‟s • Instruments used • Age children assessed • Maternal compliance with medication • Pregnancy exposure to other medications, alcohol, nicotine, illicit • Maternal IQ, socioeconomic status, maternal depression – Studies have failed to demonstrate any in utero effects of SSRIs or TCAs on later infant cognitive development – Two studies have suggested impaired psychomotor development following in utero exposure to SSRIs-but both have methodological problems – TCAs, SSRIs except paroxetine – Mianserin, venlafaxine, desvenlafaxine, tranylcypromine – Mirtazepine, duloxetine, moclobemide,phenelzine • Balanced against risk to mother and infant of untreated maternal Psychotropics in pregnancy- • No blanket rules-tailor to individual patient, involve partner where possible • Careful risk-benefit assessment • Use psychological interventions when possible and • Avoid 1st trimester exposure when possible • Use the lowest effective dose for shortest appropriate/sufficient time • Avoid polypharmacy if at all possible • Remember that serious mental illness has independent adverse effects on pregnancy/infant • We want to keep the woman well • Collaborative approach with range of health providers Psychotropics and Breastfeeding – Bottle-fed infants are more prone to infections, allergies, being overweight at school entry, more likely to develop type-1 diabetes – Mothers who don‟t breast feed are at increased risk of obesity, osteoporosis, and ovarian and breast cancer later in life – Breast feeding can promote mother-infant interaction and increase maternal self-esteem • Generally recommended that breast feeding should be Breast feeding and • Most drugs pass into breast milk-the amount is influenced by – Maternal plasma level-dependent upon dose, timing and route of administration, maternal metabolism and excretion – Drug half-life – Lipid solubility-breast milk is fatty so concentrates lipophilic drugs such as psychotropics – Protein binding- drugs with low plasma protein binding transfer into breast milk – Amount of drug ingested-is baby exclusively breast fed or not, timing since last maternal dose – Infant metabolism-neonates have reduced capacity to metabolise drugs for at least the 1st 2 weeks-this may be extended if the infant is preterm or ill – Infant excretion-neonatal kidney is less efficient than that of an Breast feeding and psychotropics • What is a safe dose for the infant? – Generally a dose which is < 10% of that received by the mother (on a mg/kg basis) – A lower value is used for drugs with greater inherent toxicity – Consider each case on its own merits as factors such as maternal dose and infant clearance vary widely The decision to prescribe or not • Risks to Infant – Of medication – Of untreated maternal • FGAs: some excretion occurs, monitor infant for sedation • SGAs: – olanzapine- reports of sedation, jaundice, poor feeding and lethargy, cardiomegaly and shaking – Risperidone & Quetiapine -low M:P ratios and no adverse effects – Clozapine- not recommended -breast milk concentration higher than maternal serum (lipophilic)-reports of sedation, agranulocytosis, cardiovascular instability. IF need to continue and breastfeed then regular FBE from infant and mother Mood stabilisers • Avoid polypharmacy and use lowest possible dose • Monitor for SEs such as sedation, poor suckling, rashes • Lithium- should be avoided when breastfeeding • Carbamazepine-considered safe BUT there have been reports of hepatotoxicity, seizure, poor suckling • Valproate-considered safe BUT there have been reports of thrombocytopenic purpura and anaemia • Lamotrigine-extensive passage into breast milk – Is metabolised by glucuronidation which is immature in neonate and so could lead to accumulation of drug in the infant‟s system – theoretical concern about Stevens Johnson syndrome Antidepressants • Most of the antidepressants are excreted in small amounts in breast milk-so amount ingested by infant likely to be clinically insignificant • Monitor for SEs including sedation, irritability, poor feeding • TCAs- have been widely prescribed, appear to be relatively safe, levels in infant serum low or undetectable (possible exception of doxepin)-but beware sedation – Remember toxic in O/D- mother, other small children • SSRIs-appear safe, mostly low levels excreted in milk – Avoid long half life drugs if possible • Venlafaxine-limited data, data are reassuring • Newer antidepressants-limited data • LT studies on cognitive & behavioural development of infants exposed in breast milk are lacking Psychotropics in breastfeeding- general guidelines • No blanket rule, individual decision, informed consent, involve partner when possible • Sick or preterm infants are at risk cf healthy full-term • If possible use drugs with short half-life; time feeds when maternal serum levels are lowest i.e. just before next dose. May also express milk when serum levels highest and discard milk • Monitor the feeding activity, sleep and conscious level of any breastfed infant whose mother is on psychotropics • Remember if mother has to stop breastfeeding guilt and self-blame are common For more information • About medication – and RWH Pharmacy Information Line 8345 3190 • General information and advice – Centre for Women‟s Mental Health, RWH
Guidelines for the Use of Subcutaneous Medications in Acknowledgments These guidelines have been adapted for local use with kind permission from NHS Greater Glasgow and Clyde. Drug compatibility data has been extracted from the revised (2009) version of the Lanarkshire Palliative Care Guidelines. Contents Part 1 - Bolus Administration 1.