Associated medical illness can lead to adverse perinatal outcome. So proper management and early identification is very important in antenatal period.

1. EPILEPSY, ASTHMA &
PSYCHIATRIC DISORDER IN
PREGNANCY
PRESENTED BY
LIPI MONDAL
M.SC NURSING 2ND YEAR

2. EPILEPSY IN PREGNANCY

3. EFFECTS OF EPILEPSY IN PREGNANCY
◦Cleft lip/palate
◦Mental retardation
◦Cardiac abnormalities
◦Limb defects & hypoplasia of the terminal phalanges
◦Sodium valporate is associated with neural tube defects
◦Chance of neonatal hemorrhage
◦The risk of developing epilepsy to the offspring of an
epileptic mother is 5 to 8%.

4. PRECONCEPTIONAL COUNSELLING
◦To initiate monotherapy replacing polytherapy.
◦To administer folic acid 4mg daily.
◦Importance of prenatal diagnosis is to be discussed.

5. MANAGEMENT
◦ The dose of the chosen drug should be kept as low as possible. Valporate &
phenytoin are found to be most teratogenic.
◦ The commonly used drugs are: carbamazepine 0.8 – 1.2mg daily in divided doses,
phenytoin 150-300 mg daily in two divided doses. Lamotrigine 300-500mg/day is
given & it is not an enzyme inducer. Newer drug used with safety is : Levitriacetum
1-3 gm/day .
◦ Serum levels may be measured in patients with frequent seizures to assess
therapeutic levels & compliance.
◦ Fits are controlled by IV Phenytoin with a slow loading dose of 15-20mg/kg. It is
highly effective, has long duration of action & side effects are less.
◦ Otherwise Benzodiazepine 10-20 mg slow IV may be given .
◦ Folic acid 4mg daily is to be started before pregnancy & to be continued throughout.
Supplementation with Vitamin D3 is to be done as vitamin D deficiency is common.

6. CONTD…
◦ Prenatal diagnosis with serum alpha- FP at 16 weeks & detailed fetal anomaly scan
at 18 weeks with real time ultrasonography including fetal echocardiography is
done.
◦ There is decrease in free level of most of the anticonvulsants in pregnancy. The
reasons are: delayed gastric emptying, nausea, vomiting, increase in plasma volume,
increase in hepatic metabolism & renal clearance. Vitamin K 10 mg a day orally is to
be given to mother in last two weeks.
◦ There is no contra-indications for breastfeeding. Infant is given injection Vitamin K 1
mg IM at birth to prevent neonatal hemorrhage due to decreased vitamin-K
dependent clotting factors. The infant may be drowsy. Readjustment of the
anticonvulsant dosage is necessary & to bring down the dose to the pre-pregnant
level by 3-4 weeks postpartum.
◦ Steroidal contraceptives are better to be avoided due to hepatic microsomal enzyme
induction. The risk of having epilepsy of an infant born to a mother with seizure
disorder is four times higher compared to a normal one.

7. ASTHMA IN PREGNANCY

8. EFFECT OF PREGNANCY ON ASTHMA
◦The course of the disease is very much unpredictable.
In about 20%, the condition improves, in 30%, it
detoriates & in 50% , it remains unchanged.
Bronchodialator influences are due to progesterone &
cortisol & Bronchoconstrictor influences are due to
reduced residual volume. Asthma increases maternal
morbidity.

9. EFFECT OF ASTHMA ON PREGNANCY
◦There is increased incidence of Pre-term labor , PROM,
Pre-eclampsia, FGR or LBW & Neonatal hypoxia.
Maternal risk increases with status asthmaticus. Life-
threatening complications include Pneumothorax,
Cor-pulmonale, Cardiac arrhythmias & Respiratory
failure.

10. MANAGEMENT
◦ Preconception counseling
◦ Step therapy of asthma during pregnancy
Mild intermittent Inhaled beta-agonist (albuterol) as needed
Mild persistent Low dose inhaled corticosteroid (budesonide) or LTRA
Moderate
persistent
Low dose or medium dose inhaled corticosteroids &
LABA(Salmetrol)
Severe persistent High dose inhaled corticosteroid & LABA±OCS

11. CONTD…
◦ Management of acute attacks of asthma in pregnancy:
◦ Avoidance of asthma triggers (allergens, irritant) to minimize airway inflammation
& hyper-responsiveness.
◦ Oxygen inhalation with mask to maintain oxygen saturation.
◦ High dose albuterol by nebulization every 20 mins & inhaled ipratropium bromide &
systemic cortico-steroids. Repeat assessment of symptom, physical examination &
oxygen saturation is to be done.
◦ Corticosteroids 200mg stat intravenously & to be repeated after 4 hours. Because of
long onset of action, cortico-steroids should be given with beta -2 agonists.
◦ Forced expired volume in one second or peak expiratory flow rate necessitates
intubation & mechanical ventilation with 100% oxygen in ICU.
◦ Mechanical ventilation is needed for status asthmaticus to avoid hypoxemia &
carbon dioxide retention.

12. CONTD…
◦ Labor:
◦ Opiate analgesics should be avoided as they are bronchoconstrictor & respiratory
depressant. Maternal oxygenation should be adequately maintained. Labetalol
should be avoided.
◦ Hydrocortisone 100mg IV 8 hoursly during labor & 24 hours postpartum is to be
given if the patient had steroids within the previous 4 weeks. Inhaled corticosteroids
prevent bronchial hyper-responsiveness to allergens.
◦ Syntocinon is better than ergometrine because of bronchoconstrictor effect of the
latter.
◦ Epidural anesthesia is preferable to general anesthesia because of risk of atelectasis
& subsequent chest infection following the latter. Halothene is better in GA. However,
it produces uterine atony.
◦ Ketamine is used for induction of GA as it prevents bronchospasm.
◦ Oxygen saturation is assessed with Pulse oxymeter or ABG.

13. PSYCHIATRIC DISEASE IN
PREGNANCY

14. TREATMENT OF OBSESSIVE COMPULSIVE
DISORDER
◦ During pregnancy treatment includes Cognitive behavioral
therapy (treatment of choice) and SSRIs. Selective serotonin
reuptake inhibitors (SSRIs) are the most commonly prescribed
treatment of OCD or OCD with co morbid disorders such as
major depression. Atypical antipsychotic medication is added
for refractory cases. With the exception of fluoxetine, all SSRIs
were found at low levels in breast milk and are not expected to
cause adverse effects in breastfeeding infants.

15. TREATMENT OF PANIC DISORDER
◦ Cognitive behavioral therapy remains the treatment of choice
for panic disorder during pregnancy. The most commonly used
medications for panic disorder are the benzodiazepines
(lorazepam, clonazepam) and the antidepressants, including
the SSRIs (Selective Serotonin Reuptake Inhibitors) and the
SNRIs (Serotonin and Norepinephrine Reuptake Inhibitors)
that also have a positive effect on anxiety .

16. DEPRESSION
◦ The study reports that intimate partner violence emerged as one of
the strongest independent predictors of antenatal major depression.
One third of pregnant women report major depression first time
during pregnancy. Factors associated with depression during
pregnancy include marital problems, lack of psychological and social
support, unplanned pregnancy, traumatic life events and lower socio-
economic status. It has also been reported that multigravidas,
women with current and past obstetric complications and history of
previous abortions can also attribute to depression.

17. TREATMENT OF SCHIZOPHRENIA
◦It should not be discontinued in a woman already on
treatment since there is high risk of relapse in
pregnancy. Atypical antipsychotics, especially
haloperidol, remain the drug of choice; possibly low
doses should be given to avoid anti cholinergic side
effects .

18. PREVENTION OF PSYCHIATRIC DISORDER
◦ Women with mental instability can feel insecure at various levels. Right from
planning a baby to carrying a pregnancy and the postpartum period, a woman
needs security and support from the partner and the family. Emotional support can
be a great help in reducing the recurrence of any mental disorder during this time.
◦ Pre-conceptional counselling plays a crucial role. The importance of mutual love,
positive relationships, dietary importance, and continuation of drugs during
pregnancy and post-partum should be emphasized. Chances of relapse and
worsening of symptoms during pregnancy should be explained.
◦ The importance of healthy, balanced diet should be explained. Need to reduce
alcohol intake, smoking ,tobacco and other addictive substance should be explained
The possible consequences of substance abuse such as preterm births leading to
delivery of preterm and low birth weight babies further adds to the impairment of
maternal and child health.

19. JOURNAL ARTICLE
TITLE: Psychiatric Disorders during Pregnancy and Postpartum
-Pallavi Sharma, Nilanchali Singh, Anjali Tempe and Mahima Malhotra
◦ Pregnancy is the most beautiful and memorable time in a woman’s life. Apart from
medical and obstetrical challenges it involves a of lot emotional, psychological and
social aspects too. Although women having medical and obstetrical disorders
commonly seek treatment, psychological problems are often not addressed. A female
may continue to live in a state of emotional turmoil and may attribute these changes
to the hormonal changes in the body due to pregnancy. Psychiatric disorders which
remain untreated can disrupt the social life and can have undesirable effects on fetal
and neonatal development, so it becomes important to identify women at risk for
developing psychiatric disorders during pregnancy and postpartum and initiate
timely management. Although the American College of Obstetrics and Gynaecology
recommended strongly considering screening pregnant women for depression in
2006, it is not done as a routine.

20. THANK YOU!!!