Psychiatric disorders during pregnancy

Psychiatric Disorders
in
Pregnant & Lactating women
Dr Hosam Hassan
PR Director
National Mental Health Council
&
Ahmed Elbohoty MD, MRCOG
Assistant professor of obstetrics and gynecology
Ain Shams University

ILOs
• Understand the effect
of pregnancy on the
mood and mental
problems
• Understand the effect
of psychatric disorders
and medications on
pregnancy and fetus
• Develop an ability to
screen and predict
Mental during
pregnancy and
postpartum .
• Understand the
Managements of
different Mental
Disorders from the
precoceptional period,
Pregnancy & Lactation .
MRCOG courses 3/24/20

•Almost a quarter of maternal deaths occurring
between 6 weeks and 1 year after the end of
pregnancy were due to psychiatric causes.
3/24/20 MRCOG courses 4

•In almost a third of women with a prior history
of mental health problems who died by
suicide, there was evidence that significant
aspects of the woman’s past psychiatric history
were not communicated between primary care
and maternity services.
•The women who died by suicide frequently
used violent methods.
•Almost one in five women had expressed prior
thoughts of violent self-harm but the staff
caring for them had not appreciated the
significance of this.

Recommendations
•Good communication between primary care, mental health
and maternity services is critical to good quality care for
women with mental ill health, in particular:
• At booking there should be a routine enquiry about a
current or past history of mental health problems, which
should cover the full range of mental health issues and
not just depression.
•Maternity services should ensure that the general
practitioner (GP) is made aware of a woman’s pregnancy
and enquire of the GP about the woman’s past mental
health history.

•The following are ‘red flag’ signs for severe
maternal illness and require urgent senior
psychiatric assessment:
•recent significant change in mental state or
emergence of new symptoms,
•new thoughts or acts of violent self-harm,
•new and persistent expressions of
incompetency as a mother or estrangement
from the infant.

Effect of pregnancy on mental health & psychiatric
diseases
•Some changes in mental health state and functioning
(such as appetite, maternity blues) may mimic
psychiatric diseases.
•Anorexia nervosa and bulimia nervosa is lower in
pregnant women however binge eating disorder is
higher.
•Smoking and the use of illicit drugs and alcohol in
pregnancy are common with their complications
•Many mental health problems have a similar nature,
course and potential for relapse as at other times.

Effect of psychiatric diseases on pregnancy
•Risks of stopping medication taken for an
existing mental health problem
•There are risks associated with taking
psychotropic medication in pregnancy and
during breastfeeding.
•Postnatal depression & Psychosis are 2
conditions that can occur in high risk women
•Bipolar disorder shows an increased rate of
relapse and first presentation in the postnatal
period .3/24/20 MRCOG courses 11

Pre & Postpartum Prevalence of Psychiatric
Admissions among Women

Overview of Psychiatric Disorders
3/24/20 MRCOG courses
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
1st exclude a medical cause e.g. hyperthyroidism
13

Misattribution of physical illness
Actual diagnosis Psychiatric condition symptoms
attributed to
Aortic aneurysm and pulmonary embolus Anxiety and depression
Lymphoma Weight loss, cough and sweating
attributed to opiate abuse
Tachycardia/tachypnoea Anxiety
Tuberculosis Weight loss and loss of appetite –
anorexia nervosa
Encephalopathy, SLE Depression
Subarachnoid haemorrhage Depression
Eclampsia Anxiety
Pneumonia and sub-arachnoid
haemorrhage
Drug withdrawal

Other Psychiatric Disorders
Eating Disorders
Anorexia
Nervosa
Bulimia Nervosa Pica
Sleep Disorders
Insomnia Restless Leg Syndrome
15

Epidemiology
•Depression and anxiety are the most common mental
health problems during pregnancy
•12% of women experiencing depression
•13% experiencing anxiety
•Many women will experience both.
•Depression and anxiety also affect 15-20% of women in the
first year after childbirth.
•Anexity and depression are under-recognised throughout
pregnancy and the postnatal period.
•Between 3% and 5% of these women will be severely
affected and require the input of secondary care services or
specialist perinatal services.

Rates of perinatal psychiatric disorder per thousand maternities
Adjustment disorders and distress 150–300/1000
Mild-to-moderate depressive illness and anxiety
states
100–150/1000
Severe depressive illness 30/1000
Post-traumatic stress disorder 30/1000
Postpartum psychosis 2/1000
Chronic serious mental illness 2/1000

Presentation
Psychiatry
Obstetric &
Gynecology
Already Diagnosed as a Psychiatric Patient
Psychiatric Disorders Related To
Menstruation, Pregnancy & Labor
Detection
Prediction
Management
Prevention
18

The organization of services
Clinical
Network
Multi
Disciplinary
Service
Clear
Referral
Protocol
Access to
Specialized
Experts

Preconceptional counseling for who have a new,
existing or past mental health problem:

•the use of contraception and any plans for a
pregnancy
•how pregnancy and childbirth might affect a mental
health problem, including the risk of relapse
•how a mental health problem and its treatment
might affect the woman, the fetus and baby
•how a mental health problem and its treatment
might affect parenting.
•Do not offer valproate for acute or long-term
treatment of a mental health problem in women of
childbearing potential

Assessment

Red flags include:
• recent or rapidly changing significant alterations in mental state
• emergence of new symptoms, which can include psychotic symptoms (delusions,
hallucinations) or severe anxiety in relation to her infant's (and/or other
children's) welfare
• psychotic symptoms that involve the infant
• thoughts of violent self-harm or suicide
• acts of violent self-harm or suicide
• new/persistent/nonreassurable ideas and expression of these ideas, where the
woman believes she is incompetent/inadequate as a mother or feels estranged
from her infant
• pervasive guilt and hopelessness
• deterioration in function as a consequence of symptoms, e.g. self-care, care of
the infant, avoidance of the infant
• not eating
• severe insomnia
• psychomotor retardation

•Physical wellbeing (including weight, smoking, nutrition and
activity level) and history of any physical health problem
•Alcohol and drug misuse
•Domestic violence and abuse, sexual abuse, trauma or
childhood maltreatment
•If there is a risk of, or there are concerns about, suspected
child maltreatment, follow local safeguarding protocols.
•If there is a risk of self-harm or suicide:
•assess whether the woman has adequate social support
and is aware of sources of help
•arrange help appropriate to the level of risk
•inform all relevant healthcare professionals (including the
GP and those identified in the care plan
•advise the woman, and her partner, family or carer, to
seek further help if the situation deteriorates.

•Professionals in secondary mental health services,
including specialist perinatal mental health services,
should develop a written care plan in collaboration with
a woman who has or has had a severe mental illness. If
she agrees, her partner, family or carer should also be
involved. The plan should cover pregnancy, childbirth
and the postnatal period (including the potential impact
of the illness on the baby) and should include:
•a clear statement of jointly agreed treatment goals
and how outcomes will be routinely monitored
•increased contact with and referral to specialist
perinatal mental health services
•the names and contact details of key professionals.
•The care plan should be recorded in all versions of the
woman's notes

Detection

Screening for Mental Disorder
Current Mental Disorder
Previous Treatments
Admission Consultations Medications
Past History of Mental
illness
( previous deliveries ?)
Examination
Mental State
( Thinking / Mood )
Psychological
Tests
( EPDS )
Potential Risk
Regular Check Up
Past Family History
( previous deliveries ?)
Screening Questions
Loss of interest Feeling down Need Help

Screening for depression and anxiety
At a woman's first contact with primary care or
her booking visit, and during the early postnatal
period,
32

•Consider asking the following depression
identification questions :
•During the past month, have you often been
bothered by feeling down, depressed or hopeless?
•During the past month, have you often been
bothered by having little interest or pleasure in
doing things?
•Also consider asking about anxiety using the 2-item
Generalized Anxiety Disorder scale (GAD-2):
•During the past month, have you been feeling
nervous, anxious or on edge?
•During the past month have you not been able to
stop or control worrying?

•The EPDS has been validated across settings and has a
sensitivity range from 34% to 100%, and specificity from
44% to 100% in different studies.
•The most commonly used cut-off score of >12 has an overall
positive predictive value of 57% and negative predictive
value of 99%.
•The role of the EPDS is to identify women who require
further assessment; is not designed to diagnose depression.

Monitoring
• Symptoms can be monitored by using validated self-report questionnaires:
• the Edinburgh Postnatal Depression Scale [EPDS]
• Patient Health Questionnaire [PHQ-9]
• the 7-item Generalized Anxiety Disorder scale [GAD-7]

History taking
• past or present severe mental illness including schizophrenia, bipolar disorder, psychosis in
the postnatal period and severe depression
• previous treatment by a psychiatrist/specialist mental health team, including inpatient care
• a family history of perinatal mental illness.
• Other specific predictors, such as poor relationships with her partner, should not be used
for the routine prediction of the development of a mental disorder.

Referral
•To her GP (If there is a mild condition )
•Mental health professional preferably a specialist perinatal
mental health service for assessment and treatment
• woman with current illness where there are symptoms of
psychosis, severe anxiety, severe depression, suicidality, self-
neglect, harm to others or significant interference with daily
functioning. Such illnesses may include psychotic disorders,
severe anxiety or depression, obsessive–compulsive disorder and
eating disorders.
•woman with a history of bipolar disorder or schizophrenia.
•woman with previous serious postpartum mental illness
(puerperal psychosis).
•women on complex psychotropic medication regimens.

referral should be considered for:
• women with illness of moderate severity if developing in late pregnancy or the
early postpartum period.
• women with current illness of mild or moderate severity where there is a first-
degree relative with bipolar disorder or puerperal psychosis. In the absence of
current illness, such a family history indicates a raised, but low absolute, risk of
early postpartum serious mental illness. Where identified, information should be
shared with primary care and any evidence of mood disturbance during
pregnancy or in the postpartum period should lead to referral.

Perinatal mental healthcare service provision
•Women may need care from both obstetric
and psychiatric services. In the most severe
cases women will need admission to one of the
17 mother and baby units (MBUs) across the
UK

Prevention
High Risk
Mild
Symptoms
Previous
Episodes
Psychosocial Intervention
Brief psychotherapy Social Support
Referral
43

Management
Treating Current Mental Disorder
Planning for
pregnancy Pregnancy
After
Delivery
Already
Diagnosed
Mental
Disorder
Developing
during any
Stage
44

Management of Psychiatric Disorder
Investigation
( Psychometry – Further Assessment )
Psychotherapy
( Supportive – CBT – Interpersonal )
Psychopharmacotherapy
ECT
( Electro – Convulsive Therapy )
Mild
Moderate
Severe
45

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
46

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 Psychotherap
Discuss with the patient
Risks
Benefits
Continuation
Discontinuation
Possible effects of drugs on baby
Relapse
47

Electroconvulsive therapy
• Consider electroconvulsive therapy (ECT) for pregnant women with
• severe depression
• severe mixed affective states or mania, or catatonia, whose physical health or that of the
fetus is at serious risk.

Anxiety disorders
• Generalised anxiety disorder
• Characterised by anxiety that is generalised and persistent in any particular environment.
Women complain of persistent nervousness, trembling, muscular tensions, sweating,
lightheadedness, palpitations, dizziness and epigastric discomfort. Fears that the woman,
baby or a relative will become ill shortly or have an accident are often expressed
• Obsessive-compulsive disorder
• OCD is characterised by intrusive thoughts, images or ideas that the patient finds
distressing but difficult to resist. Obsessive ideas/thoughts/images are distinguishable from
psychotic delusions in that they belong to the patient and are identified as irrational (the
patient retains insight). Rituals or acts are carried out in an attempt to prevent an event
from happening, for example, someone coming to harm.
• Panic disorder
• Phobias (tocophobia, claustrophobia,…
• Post-traumatic stress disorder
• PTSD is characterised by flashbacks (repeated reliving of the trauma in intrusive
memories, dreams or nightmares), hyperarousal, avoidance and psychological distress.
• Social anxiety disorder

Tocophobia
• This is a morbid dread and fear of pregnancy and the birthing process.
• Some women with this phobia will avoid pregnancy and childbirth all together. It
can be classified as primary or secondary.
• Primary is a morbid fear of childbirth in a woman who has no previous
experience of pregnancy.
• Secondary is a morbid fear of childbirth developing after a traumatic obstetric
event in a previous pregnancy.
• Some women will be able to overcome the avoidance of pregnancy due to the
desire to become a mother. However, they still harbour a deep fear and this may
result in a decision to terminate the pregnancy or to seek an elective caesarean
section as their only alternative.
• A history of sexual assault may be associated with an aversion to routine
obstetric care associated with primary tocophobia.
• The trauma of a vaginal delivery may cause a resurgence of memories of
childhood sexual abuse and contribute to secondary tocophobia.

Presentation
• Excessive reassurance-seeking may be a presenting feature.
• Must identify any concurrent depression requiring treatment.
• Can be highly distressing and merit clinical attention, although evidence for an
adverse effect on fetal outcome remains conflicting.
• High antenatal anxiety is a predictor for postnatal depression.

Anxiolytics
Mode of
Action
↑GABA
Types
Benzodiazepines
Alprazolam
Lorazepam
Diazepam
Non – Benzo
Buspirone
Zolpidem
Major
Indications
Anxiety
Insomnia
Side
Effects
Addiction
Cleft palate
Floppy baby
Syndrome
Paradoxical
disinhibition

Preconceptional & antenatal care
• Do not offer benzodiazepines to women in pregnancy and the postnatal period
except for the short-term treatment of severe anxiety and agitation.
• Consider gradually stopping benzodiazepines in women who are planning a
pregnancy, pregnant or considering breastfeeding
• Psychological management (including cognitive-behavioural therapy (CBT)is
preferable to anxiolytics, but access within the timescale of pregnancy may be
limited.

Management of tokophobia
• Women with suspected tocophobia should be booked for consultant-
led care. Women need to feel safe to disclose their fears and to feel
that they are being listened to without being judged. A trusting
relationship needs to be built involving the midwifery, obstetric and
anaesthetic teams.
• It is important to develop a plan of care that documents information
provided to help support the team caring for these women, including
the extent of the woman's fear and ensuring that the woman is part of
the decision-making process. Women may wish to have a vaginal birth,
but may want minimal vaginal examinations because of a history of
sexual abuse; these requests can be built into the birth plan.

Anxiolytics
Generally Anxiolytics are categorized as
cluster D drugs
Except : Flurazepam à X / Zolpidem à C / Buspirone à B
• Better Avoided during pregnancy :
• Fetus à Cleft palate
• Neonate à Floppy baby Syndrome
( hypotonia , Hypothermia , Respirator Depression )
• If used :
• Short period .
• Minimal dose .

Type Onset Prevalence Symptoms
Baby Blues Postnatal blues typically
occurs between the fourth
and tenth days of the
puerperium
50- 80 percent of women
Equall in PG and MP,
Bottle and breast feeding
• Crying, weepiness
• Sadness
• Irritability
• Exaggerated sense of empathy
• Anxiety
• Mood lability (“ups” and
“downs”)
• Feeling overwhelmed
• Insomnia, trouble falling or
staying asleep;
fatigue/exhaustion
• Frustration
• A migrainous-type headache occurs
in about 30% of postnatal women
and is also associated with the
postnatal blues. 56
Postpartum Blues
The cause of postnatal blues is probably a
combination of psychosocial factors and
hormonal factors. There are huge individual
variations in hormone levels making a
correlation between mood changes and
hormone levels difficult.

Depression• low mood
• lack of energy or increased fatigability
• loss of enjoyment or interest in usual activities
• low self-esteem
• feelings of guilt, worthlessness, or hopelessness
• poor concentration
• change in appetite (leading to weight loss or gain)
• suicidal ideation.
• Associated with an increased risk of suicide.
• Can be effectively treated with pharmacological and psychological therapy.
Up to 30% of women affected still have depression beyond the first year
postpartum and up to 40% have a risk of relapse

Treatment of PP mood disorders
Psychotropics
Psychotherapy
Social Support
ECT
58

Antenatal
Prenatal depression During pregnancy 10 percent of pregnant
mothers
• Crying, weepiness
• Sleep problems
• Fatigue
• Appetite disturbance
• Anhedonia
• Anxiety
• Poor fetal attachment
• Irritability
59

Postpartum depression
Postpartum
depression
Usually insidious,
within first two to
three months post-
partum, though
onset can be
immediate after
delivery
(distinguishable
from “baby blues”
as it lasts beyond
two weeks post-
partum)
13%
3% severe
• Persistent sadness
• Frequent crying, even about little things
• Poor concentration
• Difficulty remembering things
• Feelings of worthlessness, inadequacy or guilt
• Irritability, crankiness
• Loss of interest in caring for oneself
• Not feeling up to doing everyday tasks
• Psychomotor agitation or retardation
• Fatigue, loss of energy
• Insomnia or hyperinsomnia
• Significant decrease or increase in appetite
• Anxiety manifested as bizarre thoughts and fears, such as
obsessive thoughts of harm to the baby
• Feeling overwhelmed
• Somatic symptoms (headaches, chest pains, heart
palpitations, numbness and hyperventilation)
• Poor bonding with the baby (no attachments), lack of
interest in the baby, family or activities
• Loss of pleasure or interest in doing things one used to
enjoy (including sex)
• Recurrent thoughts of death or suicide
60
The prognosis is good although there is a high risk of recurrence in future pregnancies
of approximately 1:2–1:3.

Antidepressants
Types
TCAs - Tricyclic
Antidepressants
Amitriptyline
Clomipramine
imipramine
SSRIs - Selective
Serotonin Reuptake
Inhibitors
Fluoxetine paroxetine
Sertraline Citalopram
MAOIs – Monoamine
Oxidase Inhibitors
Hydrazines
Mode of Action
↑Serotonin
↑Noradrenaline
↑Dopamine
↓Histamine
↓Ach
↑Serotonin
↑Tyramine
Major Indications
Depression
Side Effects
Dry Mouth
Blurring of Vision
Urine retention
Cardiotoxic
Nausea
Vomiting
Discontinuation
Serotonin Syndrome
persistent pulmonary
hypertension in neonates
Hypertensive Crisis with
Tyramine Containing Food

Side effects

Antidepressants
Generally Antidepressants are categorized as
cluster C drugs
Except Nortriptyline (TCA ) & Paroxetine( SSRI ) à D
• It is better to prescribe TCAs rather than SSRIs during pregnancy:
• for SSRIs are newer & less studied regarding effect on pregnancy & lactation
• 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 .

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

Bipolar affective disorder
• Affects 7% of women of childbearing age.
• Characterized by severe episodes of depression or mania (elevated mood,
excitability, irritability, overactivity) often associated with psychotic symptoms.
Can pose significant risk to mother and fetus.
• Associated with a 2-fold higher risk of admission postnatally than at other times.
• Decision to stop medication in existing patients when pregnancy is discovered
should be made only after a careful risk/benefi t review.
• Associated with a high suicide rate.

Mood Stabilizers
Types
Anticonvulsants
Valproate
carbamezapine
Lamotrigine
Lithium
Mode of
Action
↑GABA
Modulate Cell
membrane
excitability
Major
Indications
Epilepsy &
Mood stabilizer
Bipolar
Serious
Side
Effects
Bone marrow
depression
Skin Rashes
Toxicity
renal failure
hypothyroidism

Mood Stabilizers
Generally Mood Stabilizers are
categorized as
cluster D drugs
Except Lamotrigine à 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 à 36th
week à 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 .3/24/20 MRCOG courses 70

Mood Stabilizers
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
ValproateLamotrigine

Lithium
• If a woman continues taking lithium during pregnancy, serum lithium levels
should be checked every 4 weeks, then weekly from the 36th week, and less
than 24 hours after childbirth; the dose should be adjusted to keep serum levels
towards the lower end of the therapeutic range, and the woman should maintain
adequate fluid intake.
• Intrapartum monitoring should include fluid balance, because of the risk of
dehydration and lithium toxicity
• It is associated with neonatal hypotonia, poor feeding, cyanosis and
hypothyroidism
• Follow up: Requires monitoring of serum lithium concentrations every 3 months
and thyroid function tests every 6-12 months

Ebstien anomaly

• Carbamazepine and lamotrigine
• Carbamazepine or lamotrigine should not be routinely prescribed for women
who are pregnant because of the lack of evidence of efficacy and the risk of
neural tube defects in the fetus.
• Lamotrigine should not be routinely prescribed for women who are
breastfeeding because of the risk of dermatological problems in the infant, such
as Stevens–Johnson syndrome.

If a pregnant woman with bipolar disorder develops
mania while taking prophylactic medication
• check the dose of the prophylactic medication and adherence
• increase the dose if the prophylactic medication is an antipsychotic suggest
changing to an antipsychotic if she is taking another type of prophylactic
medication
• consider lithium if there is no response to an increase in dose or change of drug
and the woman has severe mania
• consider electroconvulsive therapy (ECT) if there has been no response to
lithium.

Schizophrenia• Clinical features vary, but include delusions hallucinations, and abnormalities of
affect, speech, and volition.
• Maintenance medication is usually required throughout pregnancy.
• Significant proportion of patients are unable to care for the child.
• The lifetime risk of schizophrenia for a child with one affected parent is in the
order of 10%.

Postpartum Psychosis
Characteristic SymptomsOnsetIncidence
Agitation and Irritability Depressed Mood or
Euphoria
Delusions
Depersonalization
Disorganized Behavior
The associated suicide rate is in the
order of 5% and the infanticide rate
is up to 4%.
Usually within first two to
four weeks
0.1 to 0.2%Postpartum Psychosis
A woman with bipolar affective disorder and a personal or family history
of puerperal psychosis has a 25 % risk of puerperal psychosis.
women with schizoaffective disorder have an increased risk of relapse and higher rates of
postpartum psychosis (25–50% risk of relapse).
Women with a history of bipolar disorder and a family history of postpartum psychosis in a first-
degree relative have a 74% chance of developing postpartum psychosis.
High-risk patients should be referred to specialist perinatal mental health services antenatally,
so an appropriate care plan can be developed and the use of prophylactic medication, following
delivery, may be considered.
Approximately 35–65% of women who suffer with an episode of postpartum psychosis will
develop bipolar disorder, and mood stabilisers are recommended for the long-term treatment of
bipolar disorder.
77

Management
• All women with a history of psychotic disorders should be under the care of a psychiatric
team ideally a perinatal mental health team. Women should be offered preconception
counseling with a specialist to discuss psychiatric care and make difficult decisions about
stopping, switching or continuing psychotropic medication in pregnancy, labour and the
postnatal period. A late-pregnancy planning meeting should take place. A number of
professionals form a multidisciplinary team where an individual's care is discussed.
• If a woman has sudden onset of symptoms suggesting postpartum psychosis, refer her to
a secondary mental health service (preferably a specialist perinatal mental health service)
for immediate assessment (within 4 hours of referral).
• They should be admitted, because of the risks to both mother and baby (neglect as well
as direct harm): ideally this will be to a specialist mother and baby unit, where the
maternal–infant relationship can be protected.
• Any decision to admit a baby to a mother and baby unit must be child centred, and
involve full consideration of the longer-term possibility of the baby remaining with the
mother if the mental health problems have been long-standing.
• Puerperal psychosis is treated according to diagnosis. This may involve:
• Antipsychotic medication.
• Mood stabilizers.
• Electroconvulsive therapy (ECT) .

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

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

Antipsychotics
Risk of Agranulocytosis
ClozapineContra-indicated
Weight Gain (Mother)
Gestational Diabetes
AtypicalBetter Avoid
Haloperidol
Chlorpromazine
Haloperidol
Chlorpromazine
Use but with caution

• Women taking antipsychotics who are planning a pregnancy should be told that
the raised prolactin levels associated with some antipsychotics (notably
amisulpride, risperidone and sulpiride) reduce the chances of conception.
• If prolactin levels are raised, an alternative drug should be considered.
• Depot antipsychotics should not be routinely prescribed to pregnant women:
extrapyramidal symptoms several months after administration of the depot.
These are usually self-limiting.

• Clozapine should not be routinely prescribed for women who are pregnant or
brestfeeding (risk of agranulocytosis in the fetus and infant)
• When deciding whether to prescribe olanzapine to a woman who is pregnant,
risk factors for gestational diabetes and weight gain

Eating disorders• Bulimia nervosa affects 1% of women of childbearing age and anorexia nervosa
0.2%.
• Characterized by disturbances in eating behaviour and abnormalities in body
image.
• Although anorexia nervosa is associated with reduced fertility and fecundity,
patients with sub-threshold symptoms can become pregnant and require careful
monitoring and management.
• possible effects on fetal outcome include IUGR, low birth weight, prematurity,
and a possible increase in congenital anomalies.

For a woman with an eating disorder in pregnancy
or the postnatal period:
• offer a psychological intervention in line with the guideline on eating
disorders
• monitor the woman's condition carefully throughout pregnancy and
the postnatal period
• assess the need for fetal growth scans

Sleep disorders
• Advise pregnant women who have a sleep problem about sleep
hygiene (including having a healthy bedtime routine, avoiding
caffeine and reducing activity before sleep). For women with a severe
or chronic sleep problem, consider promethazine

Discussion

Psychiatric disorders during pregnancy

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