Download Psychiatric Illness in Pregnancy and the Postnatal Year

Psychiatric Illness in
Pregnancy and the
Postnatal Year
Dr Alison Wenzerul
Consultant Perinatal Psychiatrist
[email protected]
Objectives for Today






To learn about how severe mental illness
impacts on women in the perinatal period.
Issues around physical treatments for
pregnant women and those who are breast
feeding.
Safeguarding Issues
The impact on the infant and family.
How individual management plans are
developed for at risk women
Communication options between the
maternity and mental health services
Mental Disorders During
Pregnancy and the Postnatal
Period





Severe mental
illness
Schizophrenia
Bipolar Affective
Disorder
Depression
Mild, Moderate,
Severe






Anxiety disorders
Panic Disorder
OCD
GAD
PTSD
Eating Disorders
Parental Severe Mental Illness



25%+ of women with severe mental
illness have dependant children
Same mental health needs as non
mothers with SMI
Normal fertility but more:





Unwanted pregnancies
Pregnancies from sexual assault
Terminations
Sexual partners
Without current partner
The Effects of Severe Mental
Illness on Foetus and Infant:







Babies small for dates
Preterm delivery
Low birth weight
Severity of maternal mental illness is a good
predictor of obstetric complications and later
outcome
Increased incidence of neurological
abnormalities in the newborn baby
Developmental delay: emotional, social, motor,
cognitive and intellectual
Failure to thrive and reduced growth
In Pregnancy and the Postnatal
Period Women are more likely
to:




Stop medication abruptly
Have a relapse or first episode of bipolar
disorder
Need an urgent intervention
Have a more rapid onset of a psychotic
postnatal disorder
Following Childbirth:





The risk of a women suffering from a serious mental
illness is greater in the three months following
childbirth than at any other time in her life.
Over 10% of mothers will suffer an episode of
depressive illness. Approximately 3% will have a
moderate to severe depressive illness
0.2% of mothers will suffer from a puerperal
psychosis.
Suicide is a leading cause of maternal death in the
postnatal period.
Mothers who suffer an episode of severe mental
illness post partum have a 40% chance of a
recurrence with any future pregnancy.
Why Mothers Die
Saving Mothers’ Lives
Key themes when mothers died:






Poor identification of past history (50%)
Poor identification of risk (50% of above)
Poor communication of both by psychiatric
services, GPs, maternity
Misattribution of physical illness to
psychiatric causes (32%)
All but 2 did not receive specialist care
Use of Illicit Substances
Risks to Children





Maternal mental ill health has significant
consequences for children.
There are typically 750 – 800 homicides a year in
England and Wales, of these, 25% are of children
mainly by their parents.
Parental mental illness has been identified as a cause
in a third of these case, 40% of these being
schizophrenia. In addition to this,
Approximately one third of mental illness homicides
are by women and 85% involve their children.
Every year approximately 20 children are killed by
their mentally ill mothers – many of these are babies.
Prediction
At first contact
with maternity
services, ask
specific
questions
about:



Past or present severe
mental illness
Previous treatment by
psychiatrist/specialist
mental health team
Family history of
perinatal mental illness
The Whooley Questions

Can be used at first contact with primary
care, at the booking visit and postnatally:

During the past month, have you often been bothered
by feeling down, depressed or hopeless?
During the past month, have you been bothered by
having little interest or pleasure in doing things?


If the answer is ‘yes’ to either of these
questions, please ask;

Is this something you feel you need or want help with?
Management of depression
Mild or moderate depression
 Self-help strategies
 Counselling (listening visits)
 Brief cognitive behavioural
therapy
 Interpersonal psychotherapy
 Antidepressants
Puerperal Psychosis and
Bipolar Affective Disorder



Puerperal psychosis 0.5-1.0 per 1000
deliveries; risk rises to 1 in 7 if has had a
past episode.
Link between Bipolar Affective Disorder and
Postpartum Psychosis
Women with Bipolar Affective Disorder have
a high risk of recurrence related to
childbirth, with approx 70% experiencing an
episode in the immediate postpartum period
PRE BIRTH PLANNING
MEETINGS






To clarify the treatment package.
To flag up any areas that may be a potential
concern either within the remainder of the
pregnancy, during or following childbirth
To provide a multi - disciplinary seamless
approach and improve communication.
To identify each professionals’ individual roles in
the provision of care
To share relapse signatures
To produce an emergency plan and share
contact details.
Physical Treatments in
Pregnancy





A careful risk-benefit assessment
If possible use non pharmacological
interventions
Avoid first trimester exposure when
possible
Use the lowest effective dose for the
shortest time
Avoid polypharmacy
Pregnancy Pharmacokinetics







Delayed gastric emptying and longer intestinal
transit times: Increased absorption
Reduced blood flow to legs in late pregnancy:
Reduced absorption of IM drugs
Increased plasma volume: Dilution effect on
psychotropics
Increased body fat: Serum lipids may compete
for protein-binding sites and alter unbound drug
concentrations
Increased metabolism: lower serum levels of
psychotropics
Increased CP450 and CYP3A4, reduced
CYP1A2 activity
Increased constipation and lower blood
pressure can potentiate side effects
Factors Affecting Drug
Concentration in Breast Milk






Maternal plasma level
Drug half-life
Lipid solubility, breast milk is fatty and concentrates
lipophilic drugs including psychotropics
Protein binding: free drugs transfer into breast milk
Time since delivery: in early post partum there are
larger gaps between alveolar cells in the breast,
increasing the amount of drug that passes from
maternal blood. After 4 days this reduces
Fat content of milk: lipophilic drugs will show increased
transfer in hind milk rather than fore milk
Factors Affecting Infant
Plasma Drug Levels




Amount of drug ingested
Infant metabolism: neonates have a
reduced capacity to metabolise drugs for at
least the first 2 weeks, this could increase
with a preterm or ill infant
Infant excretion: the neonatal kidney is less
efficient than an adult and only reaches that
level at 2-5 months
CNS exposure: the blood brain barrier of a
neonate is immature
National Guidance to Improve
Care





Recommends a specialist multi-disciplinary service (MDT)
within a managed clinical network for every maternity
locality, which provides:
Direct services
Consultation and advice to maternity services, other mental
health services and community services
Access to specialist expert advice on the risks and benefits
of psychotropic medication during pregnancy and
breastfeeding
Clear referral and management protocols for services
across all levels of the existing stepped care frameworks for
mental disorders to ensure effective transfer of information
and continuity of care
Pathways of care for service users with defined roles and
competencies for all professional groups involved
References





Henshaw C, Cox J & Barton J: Modern Management of
Perinatal Psychiatric Disorders
Lewis G (2007) Saving Mother’s Lives
Lewis G & Drife J (2004) Why Mothers Die 2000-2002
McLennan J & Ganguli R (1999) Family Planning and
Parenthood needs of Women with Severe Mental Illness
The National Teratology Information Service (NTIS)
(http://www.nyrdtc.nhs.uk/Services/teratology/teratology.html)
The End