Mental Health in Pregnancy

Jane.panikkar@sath.nhs.uk

Baby bluesAffects approx 50% of women post delivery

Brief episode of misery and tearfulnessUsually after first baby

PNDMild –severe non psychotic depressive illness

During first post natal year

Puerperal psychosis (PP)Acute onset of a manic/psychotic episode

Patients usually have past hx of BPAD/vulnerability to childbirth related trigger

Presents shortly after childbirth

Perinatal Mental Health

Type of disorder Incidence (%)• Mild/depressive/anxiety disorders 15.0-20.0• Severe depressive illness 3.0-5.0• Referral to psychiatric services 2.0• Admission to psychiatric unit 0.4• Puerperal psychosis 0.2

Maternal Mortality

Deaths from psychiatric cause2006-8=13 2009-11=13 2010-2012=16

Suicide

• Majority of women died violently, 87%

• Over half from hanging or jumping

Puerperal Psychosis

• Psychotic illness arising in previously well woman after childbirth.

• First onset psychotic illness

• Previous psychotic illness but well in years preceding the pregnancy

• Incidence 2 per 1000 births

• Onset –Acute within days of delivery

• Recurrence after subsequent childbirth

Puerperal Psychosis

• Anger and agitation/Insomnia• Confusion and perplexity (fluctuates with periods of

orientation)• Auditory hallucinations• Paranoia/grandiose delusions• Misrecognition of partner or mistaking others (such as male

staff) for partner/father of the child.• Mood disorder (manic and depressive in nature)• Strange thoughts/statements• Depersonalisation-loss of contact with reality with difficulty

relating emotionally to child• Thoughts of harming self or baby

Risk Factors Puerperal Psychosis

• Past Hx of puerperal psychosis (1 in 2)

• Family Hx of Bipolar illness or Puerperal psychosis (1 in3)

• History of serious affective disorder (bipolar illness and severe unipolar depression)

• Not strongly associated with psychosocial risk factors as non psychotic conditions

Marker Questions

• Have you ever been in hospital with you nerves?

• Has anyone in your direct family been in hospital with their nerves?

• Did your mother have postpartum psychosis/ “severe postnatal depression”?

SSRI in pregnancyare they “safe”?-yes

• Possible increase in congenital heart disease

• Possible Neonatal withdrawal

• Possible increase in PPHN

• (Best to avoid paroxitene and fluoxetine)

PPHN• Persistence after birth

of high pulmonary artery pressure

• R to L shunting across FO & DA

• Secondary to perinatal asphyxia, meconium aspiration, sepsis, diaphragmatic hernia

• Neonate cyanotic• Needs O2, may need

ventilation, NO, sildinafil, ECMO

PPHN primary studies• Chambers, 2006 (used in safety update) • After 20 weeks risk PPHN 1%

– Case control study. 377 with confirmed PPHN.– 14 on SSRI after 20/40, only 6 controls. OR 6.1– Retrospective, 99% SSRIs no PPHN

• Wichman 2007 – 808/25,000 on SSRI– 16 had PPHN –none on SSRIs

• Kallen 2008• 831,324 506 cases PPHN• OR 2 • Risk of PPHN SSRI 1.5/1000

• Andrade, 2009– 1104 on SSRIs in 3rd trimester– Confounders –diabetes & asthma more in exposed group– 5 PPHN (2 were on SSRI)– Risk not on SSRI 2.72/1000 – Risk on SSRI 2.14/1000

UK Tetrology Information Service

BUMPS

Signposting Non Drug RX

• Guided Self Help

• Psychological Therapies IAPT

• Support Groups

THANKS

• www.uktis.org• www.medicinesinpregnancy.org

• www.pandasfoundation.org.uk

• www.livinglifetothefulll.com• www.mind.org.uk• www.mindfulness4mothers.com• www.mindfulmotherhood.org