Difference between revisions of "Peripartum Psychiatry"

Revision as of 21:04, 13 May 2016

Introduction

This article is a brief overview of an important topic in psychiatry. Residents and fellows receive very little, if any, exposure to peripartum psychiatric disorders in training.

Prevalence

• 20% of pregnant women experience postpartum mood and anxiety symptoms. This is more common than gestational diabetes (10%) but does not get the same attention or routine screening.

• "Baby blues" are mood changes that occur within days of delivery; "baby blues" often subsides in 2-3 weeks; 50-80% of women experience this and it is not considered a disorder.

Postpartum psychosis is a psychiatric emergency; may signify preexisting bipolar disorder (4% have involved infanticide).

Peripartum OCD, occurs in 3-5% of mothers and is ego-dystonic; mothers often have intrusive fears of harming the baby.

Screening

Edinburgh Postnatal Depression Scale - quick self report.

Pharamacology

General principles

• Most medications should be used at lowest effective dose;
• Most medications may need to be increased during 3rd trimester, and adjusted carefully after delivery due to significant shifts in body fluid distribution.

Current FDA labeling of medications' pregnancy risk is misleading. Labeling of pregnancy risk has been changed for new medications coming to market.

• • The new rule replaces the product letter categories – A, B, C, D and X – with three detailed subsections that describe risks within the real-world context of caring for pregnant women.[1]
• Most medications should be continued during breastfeeding.

Antidepressants

SSRIs and SNRIs are not causally associated with birth defects; Paxil is somewhat more suspect, not first choice, but should be continued. There is risk of pre-term birth (4-9% vs >20%); there is a small increase in risk of a miscarriage, particularly in first term. The largest study of association of SSRIs with autism, found an increase in risk; however it had a number of importnatn shortcomings: it did not capture parental age, smoking, siblings with autism. Medications for depression should be continued; risk of relapse is very high.

Lamotrigine is an option; plssible unestablished risk of cleft palate.

Lithium - increases risk of Epstein Anamoly in first trimester, from 1/20000 to 1/1000, still a low absolute risk. Can be used with caution risk assessment and education. Potentially can cause "floppy baby syndrome." Check levels, particularly at delivery.

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