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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
women
•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

Source: http://www.earlyyears.org.au/__data/assets/pdf_file/0003/155208/Judd_Fiona.pdf