Summary of psychiatric disorders during pregnancy & lactation
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Overview of Mental Disorders during pregnancy & lactation & their management
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Summary of psychiatric disorders during pregnancy & lactation
- 1. Psychiatric Disorders in Pregnant & Lactating women Dr Hosam Hassan PR Director National Mental Health Council
- 2. Agenda 1) Detection , Prediction, Prevention of Mental Disorders Before & during pregnancy . 2) Managements of Mental Disorders during Pregnancy & Lactation . 3 ) Consent & Mental Capacity .
- 3. Introduction Psychiatry Obstetric & Gynecology Already Diagnosed as a Psychiatric Patient Psychiatric Disorders Related To Menstruation, Pregnancy & Labor Detection Prediction Management Prevention
- 4. Detection - Prediction of Mental Disorder Current Mental Disorder Potential Risk Previous Treatments Admission Consultations Medications Past History of Mental illness ( previous deliveries ?) Examination Mental State ( Thinking / Mood ) Psychological Tests ( EPDS ) Regular Check Up Past Family History ( previous deliveries ?) Screening Questions Loss of interest Feeling down Need Help
- 5. Prevention High Risk Mild Symptoms Previous Episodes Psychosocial Intervention Brief psychotherapy Social Support Referral
- 6. Management Treating Current Mental Disorder Planning for pregnancy Pregnancy After Delivery Already Diagnosed Mental Disorder Developing during any Stage
- 7. Management of Psychiatric Disorder Investigation Psychometry – Further Assessment Psychotherapy Supportive – CBT – Interpersonal Psychopharmacotherapy ECT ( Electro – Convulsive Therapy ) Mild Moderate Severe
- 8. Overview of Psychiatric Disorders Neurotic Disorders GAD PD OCD PTSD Phobia Mood Disorders Depression Mania Bipolar Psychotic Disorders Delusions + Hallucinations Schizophrenia Brief Psychotic Episode Substance Abuse Benzodiazepine Opiates Cannabis Nicotine Alcohol
- 9. Overview of Psychiatric Disorders Eating Disorders Anorexia Nervosa Bulimia Nervosa Pica Sleep Disorders Insomnia Restless Leg Syndrome
- 10. Postpartum Psychiatric Illness Characteristic SymptomsOnsetIncidence Mood lability Tearfulness Insomnia Anxiety Within first week 50 to 75%Postpartum Blues Depressed Mood Excessive Anxiety Insomnia Usually insidious, within first two to three months 10 to 15%Postpartum Depression Agitation and Irritability Depressed Mood or Euphoria Delusions Depersonalization Disorganized Behavior Usually within first two to four weeks 0.1 to 0.2% Postpartum Psychosis
- 11. Psychopharmacotherapy During Pregnancy General Rules Written Plan of Management Informed Consent Medications Switch to The safest Drug Monotherapy Minimal Effective dose Gradual withdrawal before delivery (BDZ, SSRIs ) Try to Avoid Medications in 1st Trimester Follow Up Psychotherapy Discuss with the patient Risks Benefits Continuation Discontinuation Teratogenicity Relapse
- 12. Psychopharmacotherapy During Lactation General Rules Medications Switch to The safest Drug Monotherapy Minimal Effective dose Single dose before infant longest sleep period You shouldn’t discourage breast feeding Schedule Feedings according to half life of the drug & its serum levels Try to use non pharmacological interventions Follow Up Psychotherapy Discuss with the patient Risks Benefits Continuation Discontinuation Possible effects of drugs on baby Relapse
- 13. Antipsychotics ( Neuroleptics / Major Tranquilizers ) Mode of Action ↓Dopamine Major Indications Psychosis Bipolar Mood Disorder Agitation Types Typical 1st Generation Conventional Chlorpromazine Haloperidol Pimozide Atypical 2nd Generation Risperidone Olanzapine Quietiapine Clozapine Side Effects Extra Pyramidal Dystonia pseudo parkinsonism Neuroleptic Malignant Syndrome Hyperprolactinemia Metabolic Syndrome
- 14. Antipsychotics Generally Antipsychotics are categorized as cluster C drugs Except Clozapine is Cluster B Better Avoid : Depot injections for ◦ possible extra pyramidal effect on the baby ◦ may produce severe withdrawal symptoms after delivery Anti - cholinergic : ◦ Possible side effects on the baby ◦ Better adjust dose of antipsychotics
- 15. Antipsychotics WhylactationWhypregnancy If the baby has hepatic impairment Risk of Agranulocytosis ClozapineContra-indicated Weight Gain (Mother) Gestational Diabetes AtypicalBetter Avoid Haloperidol Chlorpromazine Haloperidol Chlorpromazine Use but with caution
- 16. Antidepressants Types TCAs - Tricyclic Antidepressants Amitriptyline Clomipramine imipramine SSRIs - Selective Serotonin Reuptake Inhibitors Fluoxetine paroxetine Sertraline Cipalopram MAOIs – Monoamine Oxidase Inhibitors Hydrazines Mode of Action ↑Serotonin ↑Noradrenaline ↑Dopamine ↓Histamine ↓Ach ↑Serotonin ↑Tyramine Major Indications Depression Anxiety Side Effects Dry Mouth Blurring of Vision Urine retention Cardiotoxic Nausea Vomiting Discontinuation Serotonin Syndrome Hypertensive Crisis with Tyramine Containing Food
- 17. Antidepressants Generally Antidepressants are categorized as cluster C drugs Except Nortriptyline (TCA ) & Paroxetine( SSRI ) D It is better to prescribe TCAs rather than SSRIs during pregnancy: ◦ for SSRIs are newer & less studied regarding effect on pregnancy & lactation ◦ A study in 2006 showed that using SSRIs after 20 week gestation increase risk of persistent pulmonary hypertension in neonates . Neonates may show Discontinuation symptoms ( neonatal toxicity ) of antidepressants taken in pregnancy : Feeding Difficulties, irritability , Rigidity , Respiratory Distress ( for SSRIs) , Diarrhea , Jitterness , Muscle weakness ( for TCAs ) usually mild & self limiting ( 1-2 weeks ) , Less frequent signs of excessive crying , Sleep disturbance , Seizures could occur , the infant should be monitored .
- 18. Antidepressants WhylactationWhypregnancy Present in breast milk at relatively high levels Citalopram Fluoxetine Congenital Cardiac Malformations ParoxetineBetter Avoid HypertentionVenlafaxine Present in breast milk at relatively low levels Imipramine Setraline Imipramine Fluoxetine Use but with caution
- 19. Mood Stabilizers Types Anticonvulsants Valproate carbamezapine Lamotrigine Lithium Mode of Action ↑GABA Modulate Cell membrane excitability Major Indications Epilepsy Bipolar Serious Side Effects Bone marrow depression Skin Rashes Toxicity renal failure hypothyroidism
- 20. Mood Stabilizers Generally Mood Stabilizers are categorized as cluster D drugs Except Lamotrigine C Careful Choice of drug should be considered for any female in her child bearing period . Try switching gradually to antipsychotics Should the patient continue taking mood stabilizers , special care should be offered : ◦ Generally : offer appropriate screening & counseling regarding continuation of pregnancy , the need for additional monitoring & risks to the fetus . full pediatric assessment of the newborn infant , & monitor for the 1st few weeks . ◦ lithium : Monitor serum level every 4 weeks 36th week weekly . Adequate fluid intake . Hospital delivery with monitoring specially fluid balance ◦ Valproate : Max dose 1 gm daily in divided dose & slow release form . Add Folic Acid 5 mg/day .
- 21. Mood Stabilizers WhylactationWhypregnancy Present in breast milk at high levels Hypotonia - lethargy Lithium•Fetal Heart defects 60 in 1000 •Ebstein anomaly 10 in 20,000 LithiumBetter Avoid Steven-johnson syndrome in the infant Lamotrigine• Neural tube defect (spina bifida) 100 – 200 in 10,000 Valproate Single dose /day Carbamezapine•Neural tube defect 20 – 50 in 10,000 CarbamezapineUse but with caution Valproate•Oral cleft 9 in 1000 Lamotrigine
- 22. Anxiolytics Mode of Action ↑GABA Types Benzodiazepines Alprazolam Lorazepam Diazepam Non – Benzo Buspirone Zolpidem Major Indications Anxiety Insomnia Seizures Side Effects Addiction Paradoxical disinhibition
- 23. Anxiolytics Generally Anxiolytics are categorized as cluster D drugs Except : Flurazepam X / Zolpidem C / Buspirone B Better Avoided during pregnancy : ◦ Fetus Cleft palate ◦ Neonate Floppy baby Syndrome ( Hypotonia , Hypothermia , Respiratory Depression ) If used : ◦ Short period . ◦ Minimal dose .
- 24. The organization of services Clinical Network Multi Disciplinary Service Clear Referral Protocol Access to Specialized Experts
- 25. References NICE clinical guidelines for Antenatal & Postnatal Mental Health . National Institute for Health & Clinical Excellence Oxford Handbook of Psychiatry . 2nd Edition . David Semple & Roger Smyth Management of Mood Disorders During Pregnancy . Dr Magda Fahmy
- 26. Discussion