dr.

Herdy Munayang, MA


Department of Psychiatry
Faculty of Medicine
Sam Ratulangi University

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Introduction
Mental disorders during pregnancy and the postnatal
period can have serious consequences for the health and
wellbeing of a mother and her baby, as well as her
partner and other family members, if not identified and
treated.

Women with an existing mental disorder often stop taking
their medication when they become pregnant, without the
benefit of an informed discussion. Stopping medication in
this way can precipitate or worsen an episode.
Epidemiology
The UK Confidential Enquiry into Maternal Deaths
(CEMD) reports that psychiatric disorders contributed to
12% of all maternal deaths (10% of which were due to
suicide).
As many as 1 in 7 women experience a mental health
disorder during pregnancy or in the postnatal period.
PSYCHIATRIC DISORDERS IN THE
THIRD MONTH OF PREGNANCY
N = 1066
Anxiety increased,
including panic
Multiparity doubled the
likelihood of having a
mood d/o
Low socioeconomic
status and multiparity
associated with excess
mood d/o
Low educational level
associated with excess
anxiety d/o
% with current
prevalence
ANXIETY 21.7
MOOD 8.8
MDD 3.0
ALCOHOL 0.2
ANOREXIA 0.2

Borri,: J Clin Psych 69:10, October 2008
Postpartum Depression (PPD)
Many women affective symptoms: 4-6 weeks fol.
Delivery
Baby blues: mood lability, sadness, dysphoria, subjective
confusion, and tearfulness.
If the symptoms persist > 2 weeks evaluate for PPD.
PPD: depressed mood, excessive anxiety, insomnia, &
weight change. The onset is generally within 12 weeks after
delivery.
A syndrome described in fathers: mood changes during
their wifes pregnancies or after the babies are born.
These fathers are affected by several factors:
added responsibility, diminished sexual outlet, decreased
attention from his wife, & the belief that the child is a
binding force in an unsatisfactory marriage
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This recommendation lists some of the key drugs used in
treating depression, and associated risks
The risks of taking tricyclic antidepressants during
pregnancy and when breastfeeding are better established
than those of newer drugs, although the issues of
tolerability and risk in overdose remain
Most antidepressants appear in some concentration in
breast milk although the effects on the infant are not well
understood


Management of depression
Prescribing Antidepressant
Medication
Tricyclics (TCAs)
have lower known risks during
pregnancy than other
antidepressants. May be more
dangerous if taken in overdose

SSRI serotonin selective
reuptake inhibitor is taken after 20 weeks
gestation may be associated with
an increased
risk of persistent pulmonary
hypertension in the neonate

Venlafaxine may be associated
with increased risk of high blood
pressure at high doses, higher
toxicity in overdose and
increased difficulty in withdrawal
Most antidepressants pass into
breast milk.

Fluoxetine has fewer known risks
during pregnancy than other SSRIs
Paroxetine taken in the first
trimester may be associated with
fetal heart defects

All antidepressants carry the risk
of withdrawal or toxicity
symptoms in neonates
Postpartum Psychosis (PPP)
Alternative name: puerperal psychosis.
Characterized by: mothers depression, delusions, and
thoughts of harming either herself or her infant.
Such ideation of suicide or infanticide must be
carefully monitored.
Correlation between PPP & bipolar disorder and major
depressive disorder.
Symptoms of PPP often begin within days of delivery,
although the mean time to onset is within 2-3 weeks
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WALES STUDY OF INFANT
HOMICIDE
112 perpetrators convicted from 1996-2001
Men accounted for 66%, women for 34%
Median age of perpetrator was 24
Of the infants murdered in the first year of life, 44%
were killed in first 3 months of life
Mothers were more likely to kill in the first month of
life (12 vs. 4 deaths)
Women committed neonaticide (within 24 hrs of
birth) for 7 of 8 victims.
Women more likely to have psych dx, men more
likely to have SUD
One third of perpetrators had a lifetime Hx of mental
illness.


Flynn: J Clin Psychiatry 2007
Psychotropic Medications in Pregnancy
No definitive answers for safest psychotropic meds.
In patients with worsening psychiatric illness
during pregnancy Outpatient psychotherap,
hospitalization, and milieu therapy (terapi
lingkungan/sosio terapi) should be attempted
before routine use of psychotropic meds.
Risks & Benefits of treatment with psychotropics
Versus maternal psychiatric illness must be
carefully evaluated on an individual basis.
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Teratogens
Infections such as: varicella, toxoplasmosis, &
herpes simplex can interfere with normal
development
Smoking is related to premature births, and
congenital defects.
Alcohol abuse is associated with fetal alcohol
syndrome
Other drugs of abuse, such as cocaine and heroin
produce drug-dependent newborns.
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Premenstrual Dysphoric Disorder (PMDD)
PMDD is a somatopsychic illnes triggered by
changing levels of sex steroids that accompany an
ovulatory menstrual cycle.
It occurs about 1 week before the onset of menses
and is characterized by irritability, emotional
lability, headache, anxiety, & depression.
Somatic symptoms include: edema, weight gain,
breast pain, syncope, and paresthesias.
Treatments: analgesics for pain, and sedatives for
anxiety and insomnia. Diuretics to relieve fluid
retention.
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Other Issues
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Sexually Transmitted Diseases
Sexual monogamy and abstinence, which will
prevent most STDs, are advocated as public health
measures.
Libidinal impulses, however, can be difficult to
control and restrict.
The risks of sexual intercourse may be forgotten or
seem minimal in comparison to the need for
affection or escape.
Persons with low self-esteem or under stress may
view sex as a means of bolstering their self-image
or escaping their stresses.
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Pelvic Pain
Pelvic pain can have many causes: Endometriosis, Pelvic
adhesions, Ovarian or Adnexal masses, hernias, and bowel
or rectal disease.
Pelvic pain can also be secondary to psychogenic causes
such as guilt, fertility, or fears of infertility, and the
emotional disturbances associated with ongoing or past
incest or sexual abuse.
It should not be attributed to psychogenic causes unless a
thorough evaluation has excluded organic causes.
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Pseudocyesis
False pregnancy: is the development of the classic
symptoms of pregnancyamenorhea, nausea, breast
enlargement and pigmentation, abdominal distention,
and labor painsin a nonpregnant woman.
Pseudocyesis demonstrates the ability of the psyche
to dominate the soma.
Predisposing psychological processes: a pathological
wish for, and fear of, pregnancy; ambivalence or
conflict regarding gender, sexuality, or childbearing;
and a grief reaction to loss following a miscarriage,
tubal litigation, or hysterectomy.
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Pseudocyesis (cont.)
The patient may have a true somatic delusion that
is not subject to reality testing, but often a negative
pregnancy test result or pelvic ultrasound scan
leads to resolution.
Psychotherapy is recommended during or after a
presentation of pseudocyesis to evaluate and treat
the underlying psychological dysfunction.
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Hyperemesis Gravidarum
Although the cause is unknown, a psychological
component may exist.
Women with histories of anorexia nervosa or
bulimia nervosa may be at risk.
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Pica
Pica is the repeated ingestion of nonnutritive
substances, such as dirt, clay, starch, sand, and
feces.
This eating disorder is most often seen in young
children, but is common in pregnant women in
some subcultures, most notably among African
American women in the rural South, who may eat
clay or starch.
The cause of pica is unknown, but it may be
related to nutritional deficiencies in the mother.
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Thank You

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