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An update on

Perinatal Psychiatry

Dr Azlan Luk
Consultant Psychiatrist
Guildford CMHRS

Disclosures
I am not a perinatal psychiatrist.
I am a General Adult Psychiatrist
Attended BAP, Maudsley Simulation day
Read NICE, Confidential enquiry into maternal
deaths etc

Structure
Psychiatric disorders
Brief epidemiology

Confidential enquiry into Maternal Deaths


Postpartum Psychosis
General Prescribing Advice
Preconception
Pregnancy

Specific prescribing
Antidepressants
Antipsychotics
Mood stabilisers
Anxiolytics / Hypnotics

How many women are affected?


Obsessive Compulsive disorder

2.5 9 % vs 1.1%
(gen pop)

Current moderate to severe depression in


pregnancy

3-5%

Moderate / severe depression after


delivery

3 - 5%

All major depression

10 15%

Postpartum Psychosis

1in 1000 (0.1%)

Psychiatric outpatient referrals after


delivery

2%

Key messages from the report


2015

Working to deliver excellence in mental health simulation as part of South London and Maudsley NHS Foundation Trust

Confidential Enquiry into Maternal


Deaths

Suicide profile of childbearing women differs


from that of other women.
The women who died were:

White, older women

Married and living in comfortable circumstances

Baby <3 months old

Currently being treated

Used more violent methods

Working to deliver excellence in mental health simulation as part of South London and Maudsley NHS Foundation Trust

Domestic violence in pregnancy


1 in 4 women experience domestic abuse at some
point in their lives
30% of cases start in pregnancy
Existing domestic violence worsens in pregnancy or
after birth
Domestic abuse puts unborn and new born babies at
risk
Toxic Trio of domestic violence, substance misuse
and mental health issues increases risk to pregnant
women and their families.

Domestic Violence
Systematic review: high prevalence and increased odds (2-3)
among pregnant women across all diagnoses
19% experienced domestic violence in pregnancy (CRIS SLAM)
Identification of domestic violence by clinicians occurs in 1030% of cases
(Feder et al 2011; Howard et al 2010, 2013)

Shah and Shah J Womens Hlth 2010

Postpartum Psychosis
Psychiatric emergency
1 in every 1000 births
30 50% of women with BPAD, schizoaffective
disorder, psychotic depression, previous post
partum psychosis or schizophrenia develop it
> 60 % of BPAD with FHx / PHx of post partum
psychosis
Onset greatest in first 30 days (50 60% by day
14)
Approx. 50% are first episodes
60% will have future psychotic episode
30 50% risk of future postpartum psychosis

Postpartum psychosis -features


Clinical features
Sudden onset
Mood disturbance
Restless / agitated
Disorganised / bizarre behaviour
Perplexity and confusion
Psychotic symptoms

Incipient symptoms often missed


Stressed and tired
Fluctuating symptoms
The blues
Concealment of symptoms

If suspected, mental health team to assess within 4 hours


(NICE 2014)

Women of childbearing potential


(NICE 2014)

1st trimester pregnancy and on psychotropics


(NICE 2014)

Confirm the pregnancy as soon as possible


Explain that stopping or switching the medication after
pregnancy is confirmed may not remove the risk of fetal
abnormalities.
Offer screening for fetal abnormalities and counselling
about continuing the pregnancy
Explain the need for additional monitoring and the risks to
the fetus if she continues to take the medication
Seek advice from a specialist if there is uncertainty about
the risks associated with specific drugs

Uncertainty
Evidence is uncertain about
benefits, risks and harm of
treatments
Balance the risks of harm to
mother and fetus / baby
Likely benefits of treatment
Previous history
Risks to mother and fetus of treating
Potential effect of untreated mental
illness
Risks or harms to mother and fetus /
baby associated with stopping or
changing treatment

Significant confounding factors

Prescribing in pregnancy
Identify risk factors
Optimise non-pharmacological treatments
Talking therapy provide within one month of assessment
(NICE)

Postnatal stress reduction


Liaise with obstetric services
No risk free management options
Discuss risks / benefits
Avoid drugs
with higher teratogenic risk
with the least safety data
polypharmacy
Higher doses (but do not undertreat)

Breastfeeding
All psychotropic drugs transferred into breast
milk
Exposure less than pregnancy
Few data for most psychotropics
Most psychotropics are well below 10% RID
(relative infant dose) but some exceptions
Half life of drugs should be considered
Lowest effective dose
Avoid polypharmacy
Time dose to avoid peak levels

Antidepressants - outcomes
All commonly used SSRIs implicated (with malformations) but residual
confounding factors (including depression itself) not controlled for
Persistent pulmonary Hypertension - OR 1.1 2.1
Premature delivery 0.45 weeks earlier
Birthweight 74 grams lower (though not significant if compared to
women with depression)
Apgar scores - significant outcome 0.37 1min and 0.16 at 5 min
Postnatal Adaptation syndrome OR 5.07
Respiratory distress OR 2.2
Tremors OR 7.89
ASD unclear

Antidepressants
Pregnancy
Commonly used 10% in USA
Relapse rates are high with stopping antidepressants in
women with a history of depression (68% vs 26%)
Absolute risk low
Most evidence with Amitriptyline, Imipramine ( both
constipation, withdrawals), Sertraline (low infant exposure),
Fluoxetine (earlier delivery, reduced birth weight)
Paroxetine ?less safe - 1.5 2 x risk cardiac defects

Breastfeeding
Differences between antidepressants are small
Sertraline (low infant serum levels)

Antipsychotics
Current evidence antipsychotics not major teratogens
Small increase in major congenital anomalies mostly
cardiovascular could be due to confounding factors
Small increase pre-term birth and small for gestational
age
Possibly small increase in still births
Uncertain association with gestational diabetes
No indication of significant long term
neurodevelopmental effect
Most experience with chlorpromazine,
trifluoperazine, haloperidol, olanzapine,
quetiapine and clozapine

Antipsychotics - Breastfeeding
Olanzapine (Maudsley)
Not seem to be affected by prolactin raising
antipsychotics
Avoid clozapine (agranulocytosis)
Avoid depots

Mood stabilisers
Valproate 3 fold increase in major congenital malformations
Spina bifida OR 12.7
Associated with hypospadias, cleft palate, atrial septal defects,
polydactyly, craniosynostosis
Cognitive development IQ difference 8 points
Effect of folate effect at best is uncertain
No safe time and no known safe dose

Carbamazepine spina bifida OR 2.6


Do not offer in pregnancy or planning pregnancy (NICE)

Lamotrigine inconsistent reports


Use only if there is clear evidence that drug was highly effective
Monitor levels

Pregabalin little data

Lithium
Conflicted data potentially a small increase (2
fold) in major congenital malformations
Ebstein Anomaly currently no evidence for
increased risk but low number of events.
Cases of maternal lithium toxicity at delivery
Case reports of

cardiac arrhythmias, hypoglycaemia, DI,


polyhydramnios, thyroid dysfunction, goitre, floppiness, lethargy,
hepatic anomalies and respiratory difficulties

Neurobehavioural no adverse effects in 5 year study

Lithium - considerations
Only continue in preconception and 1 st trimester if switch means
high risk of occurrence
Replace lithium with antipsychotic agent until 2 nd trimester or until
after delivery
Adjust lithium dose
Structural ultrasound and fetal echocardiogram
Delivery in hospital, obstetrician-led care
Stop lithium when labour starts
Breast feeding
dont offer lithium (serum levels 10 50%) - NICE
Dont offer valproate or carbamazepine (NICE)

Anxiolytics and hypnotics


Benzodiazepines
Probably not teratogenic floppy baby
Do not offer unless for short term treatment of
severe anxiety and agitation
Consider gradually stopping benzodiazepines
Breast feeding avoid diazepam (accumulates in breast milk)

Z- drugs
Not teratogenic
Zolpidem possibly some increase risk preterm birth,
small for
gestational age, low birthweight
Use short term avoid Zolpidem

Anxiolytics and hypnotics 2


Trazodone, promazine, promethazine, pregabalin
Little data Avoid
NICE promethazine for women with a severe or chronic
sleep
problem
Low dose quetiapine as a possible alternative
Breastfeeding
dont use pregabalin, promazine
Trazodone compatible if dose <100mg

Structure
Psychiatric disorders
Brief epidemiology

Confidential enquiry into Maternal Deaths


Postpartum Psychosis
General Prescribing Advice
Preconception
Pregnancy

Specific prescribing
Antidepressants
Antipsychotics
Mood stabilisers
Anxiolytics / Hypnotics

Remember - Uncertainty

Information
Patients
UK teratology information service
www.uktis.org
Bumps best use of medicines in pregnancy
www.medicinesinpreganancy.org
Professionals
TOXBASE 0344 892 0111 www.toxbase.org
The Maudsley Pharmacy - Specialist Prescriber Advice
020 3228 2317

Questions

References
Confidential Enquiry into Maternal Death, MBRRACE-UK Report 2015 https://www.npeu.ox.ac.uk/mbrrace-uk
Antenatal and postnatal mental health: Clinical management and service guidance, NICE
guidelines (CG192) 2014
The Maudsley Prescribing Guidelines in Psychiatry 13 th Edition 2015: Taylor, Paton,
Kapur Wiley Blackwell
Course material British Association for Psychopharmacology Perinatal Masterclass 28 th
April 2016
Course material Maudsley Perinatal Mental Health Simulation Day 11th February 2016
Presentation implications of the Barker Hypothesis (what can we do about modifiable
in utero risk factors L Howard - http://www.rcpsych.ac.uk/pdf/IC14%20S32%20Howard
%20Louise.pdf

The Maudsley Prescribing Guidelines in Psychiatry 12th


Edition (2015)
Pregnancy

The Maudsley Prescribing Guidelines in Psychiatry 12th


Edition (2015)
Breastfeeding