Managing mental health in pregnancy
Heavy Menstrual Bleeding : Management in Primary Care
Ovarian Hyperstimulation Syndrome
Managing mental health in pregnancy
Dr A Pilkington
MBChB; MRCOG; PGDipMedEd
Table of content
1. Introduction
2. Preconception
3. Antenatal period
4. Medications
5. Postnatal period
6. Postnatal depression
7. Postnatal Psychosis
8. Essential points for General practitioners
9. Reference
Introduction
Mental health problems can be a common occurrence in pregnancy – pre-existing or developing in the antenatal/postnatal period
Up to 15% of women suffer with depression in pregnancy
Symptoms are similar to outside of pregnancy but suicide can be carried out by more violent/horrific means
Women with severe pre-existing conditions should be referred to a secondary service
Pre-conception
Women with a pre-existing condition should be counselled with regard to:
Treatment and its impact upon the pregnancy/condition
Effective contraception if not wishing to get pregnant
Risk of relapse
How treatment may affect parenting
Do not prescribe sodium valproate to women of child-bearing age in view of the risk of malformation
Antenatal Period: General Themes
Support from family/carers is paramount to good outcome
Discuss medication use and its potential risks to pregnancy/breastfeeding
Refer to secondary care – women with severe and enduring mental health conditions
Starting new medication – choose those with the lowest risk/side effect profile
Co-ordinate care between obstetrician/GP/psychiatrist
Antenatal Depression / Suicide
In the 200-2002 CMACE report, suicide was the leading cause of maternal death
The MBRACE report of 2015 emphasised that 25% of all maternal deaths up to 1 year postpartum were due to psychiatric causes
Pregnancy is a major life event which may along with other stressors lead to antenatal depression
Symptoms are the same as outside of pregnancy
Antenatal depression can lead to postnatal depression
Medications: Tricyclic antidepressants / Selective serotonin reuptake inhibitors / Selective-norepinephrine reuptake inhibitor
Potential risk of cardiac malformation & persistent pulmonary hypertension in the neonate
However, if woman already stabilised on this, advise not to stop
Refer to specialist perinatal mental health service
Medications: Benzodiazepines
Consider gradually stopping BDZ & do not offer as a new course, unless for a short period to help with anxiety
Medications: Anti-psychotics
Assess risks/benefits of commencing anti-psychotics, unless already stabilised on this
Limited data on safety – discuss with the woman
If other risk factors for diabetes, refer for GTT
Do not offer Depot meds unless guided by a psychiatrist
Postnatal Period
Women can present with mental health problems in the postnatal period – and may be seen by a number of healthcare staff
Women may be reluctant to disclose information/reluctant to engage
The Edinburgh Postnatal Depression Scale and GAD (Generalised Anxiety Disorder) scale may be used to assess by both health visitors and midwives
Postnatal Depression
Affects 10-15% of women
Again, similar symptoms to outside of pregnancy
Risk of recurrence in future pregnancies – 1:2 to 1:3
Treatment can be with psychological interventions such as CBT or medications as described above
Postpartum Psychosis
Occurs in 1-2 per 1000 deliveries
Risk of suicide – 2%
May be related to bipolar disorder as those with this condition have a higher risk
Can initially start with non-specific signs/symptoms but then develop rapidly into florid psychosis
More likely to have manic symptoms
Requires prompt recognition, referral to psychiatry and management
Safeguarding of infant
Essential Points for GPs
Women with a pre-existing condition should be counselled appropriately before embarking upon pregnancy
Do not prescribe sodium valproate to women of child-bearing age in view of the risk of malformation
Support from family/carers is paramount to good outcome
Discuss medication use and its potential risks to pregnancy/breastfeeding
Refer to secondary care – women with severe and enduring mental health conditions
Starting new medication – choose those with the lowest risk/side effect profile