Pregnancy and Mental Health
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Introduction
Issues can come up with high risk pregnancies, with bleeding or repeated bouts of false labour, can cuase chronic anxiety. There can also be serious trauma, mimicing PTSD. The mother's experience can be very different from the facts of the case, and psychological trauma can result without health care providers knowing.
Pregnancy does not protect against mental illness. Rates are 10-12%
pregnancy loss, trauma.
During pregnancy, there are many changes in the body, in cluding with hormones. The degree of changes in physiology is tremendously substantial.
"Hormone-sensitive neurochemistry"
Progesterone can be anxiolytic mid-pregnancy, but stress can ramp up as delivery comes closer.
Body image can be difficult, as can a mother identity and the lifestyle changes that no one is fully prepared for.
A changing view of self vs other can be new and different, especially in an unplanned pregnancy.
Postpartum Mental Health
Baby blues
Occurs in 50-80% of women; it is normal and peaks at days 3-5; resolved by two weeks. Sleep deprivation, anxiety about being a new mom, hormonal shift.
It is not associated with stress or past psychiatric history
usually begins 3-5d post-partum. Doesn't last, and usually over by 3-4 weeks.
superficialy, sudden changes in mood; teariness, irritability, brief anxiety.
Not present all the time.
Post-Partum Depression
The symptoms of depression and pregnancy overlap.
People are reluctant to seek help.
Onset is within 3-6 months or even later;
10% of pregnant women are depressed, the same as other women of their age.
10-15% of women develop postpartum depression, 60-70% with no prior history
Postpartum is an important time of adapting to motherhood and developing attachment. There can be struggles with family of origin. There can be real difficulties if babies are in critical condition. Problems with the partner...
50% of pregancies are unplanned and are as such not always welcome. Prior issues of self-esteem can be magnified with motherhood.
Postpartum depression has a prevalence of 10-15% - slightly higher than the average rate of 10%. Postpartum is the highest risk of new MDD.
Biological: estrogen, progesterone, endorphins, thyroid, etc
Psychosocial:
- change from wife to mother
- change in marital relationship
- renegotion of instrumental tasks
- role of work
- child care - if you can afford it
- available supports
- reduced socializing
mood- sad, depressed, tearful, irritable
anhedonia
energy
weight/appetitie: low, or eating for comfort
change in sleep
fatigue/agitation
guilt bad mother
poor concentration
suicide and homicide
obsessive thoughts (am I a good parent? will I harm the baby?)
"Some ladies feel worried about their parenting. Do you every fear you'll hurt the baby by mistake? Do you ever think you might intentially hurt the baby?"
Bipolar and psychosis functional inquiries.
Ask about atttitudes towards the baby..
Edinburough postpartum depression scale: who is at risk?
Labs: CBC, TSH, free T4, drug screen
Treatments
Support - partner, family, friends, RN, MSW, MD, prenatal classes, exercise program.
Motherrisk offer advice regarding pharmacotherapy
Exposure through placenta, amniotic fluid, and lactation
Medications
SSRIs show no increase in miscarriage and no teratogenicity; no adverse effects on cognition, language, or temperament up to 2006. Possible low birth weight and moderate premature delivery.
20-30% of newborns exposed during the 3rd trimester develop neonatal adaptation syndrome - transient, mild, increa:sed crying and feeding problems).
JAMA 2006 - persistent pumonary hypertension of the newborn. Risk increases from 1-2 to 6-12/1000; 99.5% of children are ok.
CVS abnormality with paroxetine: risk increases from 1:100 to 1:50.
Pros and cons; treat in warranted.
Other medications include: TCAs (desipramine, nortryptiline), venlafaxine, bupoprion; avoid MAOIs.
ECT can safely be used as lifesaving treatment during pregnancy.
Recognize and ask
Involve partner as ally/support/monitor
responds well to therapy
can refer to a post-partum depression unit
individual psychotherapy: IPT, CBT
marital therapy
partner therapy
contraception
Psychosis is an emergency and requires immediate intervention.
Medications
are they breastfeeding?
sertraline is currently (2009) the safest SSRI. Avoid paroxetine
Clomipramine is best if OCD is present.
MotherRisk is a valuable resource for clincians and parents.
Course and Prognosis
Risks associated with untreated depression in pregnancy
- poor prenatal care
- inadequate weifht
Consequences of no treatment
- disturbed mother/infant relationship
- stress in marital/extended family relationship
- psychiatric morbidity in children: depression, conduct disorder, IQ, behaviour
- suicide and infanticide
- negative parenting - yelling, hitting, shaking
Risk of recurrence
Subsequent pregnancies: 30-50%
post
Postpartum psychosis
Postpartum psychosis has a prevalence of 1:1000, and can come on quite rapidly. It presents most often 3-14 days postpartum.
Rates of suicide or infanticide are the highest around.
There can be a delirious quality, with initial euphoria and mood lability. Insomnia can be an initial sign, with a worsening excited agitated state.
It can also be a bipolar disorder, unmasked.
Peaks within 3 weeks of delivery up to 3 months.
Rate of 1-2/1000 deliveries across cultures
Not a diagnosis in itself, but rather a symptom
Causes and Risk Factors
Post-partum depression
Drugs
Risk factors
- past history of affective disorders
- etc
Signs, Symptoms, and Diagnosis
- extreme restlessness
- confusion and disorientation
- insomnia
- delusional thinking
- hallucinations
Often identified by partner or family for increasingly bizarre behaviour.
"she's listening to something else that you're not hearing" Dr Patty Pierce
CBC, B12, TSH
Treatments
Hospitalize for safety
No breastfeeding
Antipsychotics, +/- mood stabilizer
involve partner and offer marital therapy
With supervision, gradually increase visitations with baby
contraception
Consequences and Course
Untreated psychosis has a suicide/infanticide risk of ~4%
Resources and References
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