Download Perinatal psychiatry for the MRCPsych Course

Perinatal psychiatry
for the
MRCPsych Course
Dr David Middleton
ST6 to Dr Fiona Blake
29th November 2011
Learning objectives
• To be able to describe the most important
perinatal psychiatric conditions
• To list treatment principles during
pregnancy and breastfeeding
• To be able to state malformations
associated with commonly used
psychotropics
• To state the recommended medications
during pregnancy and breast-feeding for
psychosis, depression, BPAD, anxiety and
insomnia
Psychiatric considerations
• Classic triad
-“Baby Blues”
(50-75%)
- Postnatal depression (10-15%)
- Puerperal psychosis (0.1%)
• Pre-existing active psychiatric disorder eg
Schizophrenia, Bipolar disorder, Anxiety Disorder
• New disorder in pregnancy
• Substance/alcohol abuse, personality disorder
• Disorder associated with childbirth eg PTSD,
attachment disorder
Postnatal depression
• 10-15% pregnant women  depressive
episode
• 16%  self-limiting depressive reaction
• Onset 2 weeks – 6 months
• Previous depressive illness  risk
• Highest risk in women with BPAD
• Other risks include lack of confidante,
conflict with partner, life events, poor
support network
• Affective illness may  risk of pre-term
delivery
Psychosis
• Severe – usually a psychiatric emergency
• Early onset –often within 2-4 days
postpartum most within 1 month
• Often begins with confusion, ‘perplexity’
• Later characteristics of mania, depression
or schizophrenia symptoms evident
• Resolves within weeks but recurs
postnatally
• Non puerperal and menstrual relapses
also occur
Case study – Dr Emson
In October 2000 Dr Emson stabbed herself and her
baby, set light to them both and died of extended
suicide
She had a h/o bipolar disorder – 5 hospital
admissions, 3 courses of ECT, 1 serious suicide
attempt, treatment with antidepressants and lithium
prior to pregnancy
Well during pregnancy
CPN and consultant involved but no specific plan
Prior to death consulted with poor sleep and low mood
Treatment started days before death (3 months
postpartum)
Link to full report
Medication in pregnancy
‘Normal’ pregnancy
• Remember baseline complication rates!
− spontaneous abortion 10-20%
− spontaneous malformation rate 2-3%
• Smoking/alcohol/diet affects on foetus
• Caffeine  low birth weight
• Pre-pregnancy obesity  neural tube
defects
Psychiatric considerations
• Psychiatric illness in pregnancy is and
independent risk factor for congenital
malformation
• Does not protect against mental illness: a
myth!
• Affective illness  premature delivery
• Medications account for only 5%
abnormalities
Categories of abnormality
1. Major malformations (1st trimester)
2. Neonatal toxicity (3rd trimester)
3. Longer term neurobehavioural effects
•
•
•
Medication safety cannot be assessed by
RCTs, unethical
Sometimes only data is from animal
studies
Therefore must weigh up risks/benefits
All women of child bearing age
• Always discuss possibility of pregnancy
• Avoid prescribing contraindicated
medications e.g. valproate
• Consider prophylactic folate
Mental illness newly diagnosed
during pregnancy
• Try to avoid all drugs in the 1st trimester
unless benefits > risks
• Use non-medication treatments e.g. CBT
• If medication deemed necessary, use
lowest effective dose and as monotherapy
Planning pregnancy
• Remember, 50% pregnancies
unplanned…
• Consider discontinuation of medication if
− currently well
− low risk of relapse
• If high risk of relapse:
− consider switch to low risk medication
− NB risk of relapse during switch
Pregnancy discovered whilst
taking psychotropic medication
• Do not abruptly stop medication!
− high risk of relapse
• Consider continuation of current treatment
to avoid exposure to many drugs
All pregnant women
•
•
•
•
Involve patient and family in decisions
Use lowest dose of lowest risk medication
Aim for monotherapy
Anticipate dose adjustment in 3rd trimester:
− blood volume  30%
− CYP2D6 activity  50%, therefore reduced
levels of TCAs, SSRIs, FGAs etc
− CYP1A2 activity  70&, therefore accumulation
of olanzapine, haloperidol etc
• Refer to specialist team and involve O&G
• Consider foetal screening and withdrawal
Depressive illness
Depression - treatment
• Use of antidepressants in pregnancy
common (as high as 8% in USA)
• Mostly SSRIs
• High relapse rates if medication
discontinued (68% vs 26%)
Depression - treatment
• Tricyclic antidepressants
− high exposure to foetus but not apparently
teratogenic
− antidepressant of choice in pregnancy
−  risk of pre-term delivery
− 3rd trimester use  withdrawal symptoms
including agitation, seizures, respiratory
distress Usually mild and self-limiting
Depression - treatment
• SSRIs
− sertraline  least foetal exposure
− do not appear to be teratogenic, fluoxetine
seems safest
− 1st trimester use of paroxetine  cardiac
malformations
− pre-term delivery, spontaneous abortion, low
birth weight, pulmonary hypertension
− 3rd trimester use of SSRIs:
1. Serotonergic toxicity
2. Discontinuation (esp. paroxetine)
3. Pre-term delivery
Depression - treatment
• Others
‒ Moclobemide, reboxetine and venlafaxine do
not appear to be teratogenic
‒ Trazodone, bupropion and mirtazapine little
data
‒ MAOIs, avoid! Teratogenic and risk from
hypertensive crisis
‒ ECT:
‒ no evidence of harm but usual anaesthetic risks.
‒ NICE recommends instead of antidepressant
combinations
Depression - treatment
• Recommendations
1. On antidepressant and high risk of relapse
 maintain
2. Moderate/severe depressive illness during
pregnancy  antidepressant
3. Amitriptyline, imipramine and fluoxetine most
data/experience of use
4. Avoid paroxetine and MAOIs
5. Reduce discontinuation by mixed breast and
bottle feeding (especially venlafaxine and
paroxetine, short t1/2
Psychotic illness
Psychosis - incidence
• Myth: pregnancy protects against relapse
• Risk of post partum psychosis 0.1 – 0.25%
but in BPAD 50%
• In month after delivery relative risk of
psychosis is 20x
• Risk of recurrence of postpartum
psychosis 50-90%: assume it will happen!
Psychosis - treatment
• Typical antipsychotics
− minimal teratogenic risk
− possible link between limb defects and
haloperidol
− neonatal dyskinesia reported
− neonatal jaundice reported
• Recommended typical antipsychotics
1. Chlorpromazine
2. Trifluoperazine
3. Haloperidol
sedation/constipation
Psychosis - treatment
• Atypical antipsychotics
− foetal exposure olanzapine > risperidone >
quetiapine
− most data for olanzapine
 low birth weight
 macrosmia
 gestational diabetes (increased birth weight!)
 few congenital malformations
 hip dysplasia, meningocele, anjyloblepharon and
neural tube defects (? due to obesity)
Psychosis - treatment
• Atypical antipsychotics
− risperidone/quetiapine, no evidence of
teratogenicity
− clozapine, no increased risk of malformations
but:
 gestational diabetes
 neonatal seizures
 NICE recommend switch (but often on clozapine
due to treatment resistence!)
Psychosis - treatment
• Recommended atypical antipsychotics
1. Olanzapine
2. Clozapine
gestational diabetes
• NICE states avoid depot and
anticholinergics
• Discontinuation syndrome:
−
−
crying, agitation
mixed bottle/breast feeding reduces severity
Bipolar illness
Bipolar affective disorder
• Relapse rates high (2x) if medication
discontinued during pregnancy
• Post-partum relapse rates 8x in first month
• Consider effects of relapse on foetus,
obstetric outcomes and child development
BPAD - treatment
• Lithium
‒ Ebstein’s anomaly relative risk  10-20x (but
incidence relatively low, 1 in 1000)
‒ Displacement of tricuspid valve towards apex of
right ventricle
‒ Also  ASD and VSD
‒ Highest risk is 2-6 weeks (often before
pregnancy known)
‒ High resolution USS and echo at 6/52 and
18/52
BPAD - treatment
• Lithium (continued)
‒ Crosses placenta, avoid if possible
‒ Consider gradual discontinuation before
conception but  70% relapse post-partum
‒ Be aware of 3rd trimester pharmacokinetics
  total body water, so  dose required
 But on delivery, dose required 
immediately
 Monthly serum lithium levels throughout
 Delivery in hospital
‒ goitre, hypotonia, lethargy and arrhythmias can
occur
BPAD - treatment
• Carbamazapine and valproate
‒ Associated with neonatal malformations
‒ Spina bifida:
 Valproate 1-2%,
 Carbamazepine 0.5-1%
 (baseline 0.1%)
‒ Total malformations:
 Valproate 7.2%
 Carbamazepine 2.3%
‒ Dose-related, so lowest dose possible if
essential
‒ Folate prescription pre-conception
BPAD - treatment
• Lamotrigine
‒ Low risk of malformations
‒  cleft palate
‒ Not recommended by NICE
BPAD - treatment
• Recommendations
1. If long period without relapse, consider switch
or stop for at least 1st trimester
2. Abrupt discontinuation  risk of relapse
3. Severe illness/high relpase risk, continue
medication after discussion of risks
4. No mood stabiliser is safe but avoid valproate
and combination therapy
5. NICE recommends considering atypical
antipsychotic
6. Acute mania, use atypical antipsychotic or
ECT
7. Acute depression: CBT if moderate, SSRI if
severe
Anxiety and insomnia
Anxiety and insomnia
• Anxiety disorders use CBT, insomnia use
sleep hygiene advice where possible
• Benzodiazepines:
‒ 1st trimester use  oral clefts, pylorostenosis
‒ 3rd trimester use  floppy baby syndrome
‒ Associated with low birth weight
• Promethazine:
‒ Doesn’t appear teratogenic
• NICE recommends low dose
chlorpromazine or amitriptyline
Breastfeeding and medication
Breast feeding – drug choice
• Benefits of breast feeding vs exposure
• Little data on long term effects
• Premature babies may be more vulnerable
due to renal/hepatic/cardiac impairment
• Close monitoring of baby for side effects,
feeding, growth and development
• Prioritise treatment of maternal illness
• Low dose, monotherapy, timing of
feeds/expressing
Breastfeeding - antidepressants
• Paroxetine excreted in milk but
low/undetectable levels in newborn
• Sertraline also excreted in milk but low
levels, no known adverse effects
Breastfeeding - antipsychotics
• Sulpiride: low excretion in breast milk, may
increase lactation, no adverse effects
• Olanzapine: low-undetectable levels in
breast milk
• Avoid clozapine if possible (neutropenia
and seizures)
Breastfeeding – mood stabilisers
• Antipsychotic e.g. Olanzapine
• Valproate if contraception used
• Not carbamazepine (hepatic problems),
lamotrigine (rashes) or lithium (levels in
newborn)
Breastfeeding - sedatives
• Benzodiazepines
‒ Anxiety: lorazepam (short t1/2). Avoid long t1/2
due to CNS depression/apnoea in newborn
‒ Insomnia: zolpidem
Summary
1. Expect relapses in those with history and
plan accordingly
2. Use lowest effective doses of low
teratogenicity medications in pregnancy if
relapse risk outweighs potential harm to
the foetus
3. If breast feeding, consider effects on
newborn of medication vs relapse risk
4. If in doubt, consult your local perinatal
psychiatry lead
(In CPFT this is Dr Fiona Blake)
Learning objectives - recap
• To be able to describe the most
important perinatal psychiatric conditions
• To list treatment principles during
pregnancy and breastfeeding
• To be able to state malformation rates
for commonly used psychotropics
• To state the recommended medications
during pregnancy and breast-feeding for
psychosis, depression, BPAD, anxiety
and insomnia