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POSTPARTUM DEPRESSION
Adriano Lercara | João Augusto Ribeiro | João Sousa Soares
CU Gynecology and Obstetrics, 4th year
NO...
POSTPARTUM DEPRESSION
Postpartum depression
Blues
Postpartum psychosis
≠
≠
POSTPARTUM DEPRESSION
1. Biological Factors
2. Obstetric Factors
3. Clinical and Pshychological Factors
4. Socials and Psycho-Social Factors
POS...
1. Biological Factors
Hormonal variations during pregnancy and puerperium
2. Obstetric Factors
C-section
Unplanned pregnan...
3. Clinical and Psychological Factors
History of previous depression
Prenatal anxiety and/or depression
POSTPARTUM DEPRESS...
Stress pré-
natal
Falta de
suporte
social
Falta de
suporte
conjugal
Expectativa/Reali
dade de ser mãe
Exigências
do cuidad...
Sintomas
• Perda de prazer, energia e motivação
• Ansiedade
• Irritabilidade, agitação
• Alteração dos hábitos alimentares...
Trying to mitigate the serious adverse outcomes of PPD already mentioned → EARLY DETECTION!
Screening: at 1st postnatal ob...
PPD frequently missed by the primary care team (clinical signs not apparent unless screened for)
DSM-IV Criteria for MDE (...
Treatment
1st line therapy: non-pharmacological therapy!
Psychotherapy → IPT (Interpersonal Therapy) and CBT (Cognitive Be...
1. Postpartum blues: generally self-limited and resolve between 2 weeks and
3 months. Supportive reassurance is sufficient...
• IPT (InterPersonal Therapy): time-limited (12-20 weeks) treatment based on
addressing connection between interpersonal p...
• Doses and time are similar to the ones for major depression.
• Must be continued for 6 to 12 months after childbirth.
• ...
• SSRI (Selective Serotonin Recaption Inhibitors): I choice
• Sertraline
• Paroxetine
• Fluoxetine (Prozac®)
• TCA (Tricyc...
• Transdermal Estrogen
• neural growth
• neurotransmitters activity
• oxidative stress
• Must be avoided if risk of tro...
• Few studies on the effects on infants of exposure to antidepressants
through breast milk.
• Adverse effects include: sle...
• Diet
•  Ω3 fatty acids (3-4 g/die): depletion during pregnancy to build the fetus’s CNS
•  Proteins
•  vit. B6
•  ca...
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Pospartum depression

  1. 1. POSTPARTUM DEPRESSION Adriano Lercara | João Augusto Ribeiro | João Sousa Soares CU Gynecology and Obstetrics, 4th year NOVA Medical School
  2. 2. POSTPARTUM DEPRESSION
  3. 3. Postpartum depression Blues Postpartum psychosis ≠ ≠ POSTPARTUM DEPRESSION
  4. 4. 1. Biological Factors 2. Obstetric Factors 3. Clinical and Pshychological Factors 4. Socials and Psycho-Social Factors POSTPARTUM DEPRESSION RISK FACTORS
  5. 5. 1. Biological Factors Hormonal variations during pregnancy and puerperium 2. Obstetric Factors C-section Unplanned pregnancies POSTPARTUM DEPRESSION RISK FACTORS
  6. 6. 3. Clinical and Psychological Factors History of previous depression Prenatal anxiety and/or depression POSTPARTUM DEPRESSION RISK FACTORS
  7. 7. Stress pré- natal Falta de suporte social Falta de suporte conjugal Expectativa/Reali dade de ser mãe Exigências do cuidado do bebé Temperamento do bebé POSTPARTUM DEPRESSION RISK FACTORS – SOCIAL AND PSYCHO-SOCIAL FACTORS POSTPARTUM DEPRESSION RISK FACTORS – SOCIAL AND PSYCHO-SOCIAL FACTORS
  8. 8. Sintomas • Perda de prazer, energia e motivação • Ansiedade • Irritabilidade, agitação • Alteração dos hábitos alimentares e de sono • Medo de não ser uma boa mãe – culpa • Pensamentos em magoar o bebé ou a si própria
  9. 9. Trying to mitigate the serious adverse outcomes of PPD already mentioned → EARLY DETECTION! Screening: at 1st postnatal obstetrical visit (usually 4-6 weeks after delivery), FP or pediatric setting Most common: EPDS (Edinburgh Postnatal Depression Scale) (Sensitivity 80-82%, Specificity 78-82%) Other: PDSS (Postpartum Depression Screening Scale) and PHQ-9 (9-item Physician’s Health Questionnaire) Antepartum: APQ (Antepartum Questionnaire) (Sensitivity 80-82%, Specificity 78-82%) POSTPARTUM DEPRESSION SCREENING
  10. 10. PPD frequently missed by the primary care team (clinical signs not apparent unless screened for) DSM-IV Criteria for MDE (Major Depressive Episode) ↔ PPD Antepartum education on PPD! Postpartum onset of MDE → 4 weeks after delivery … but… 3 months? ≥1 year? Differential psychiatric diagnosis: Postpartum Blues (up to 75% of mothers in the 10 days following delivery) Differential psychiatric diagnosis: Postpartum Psychosis (psychiatric emergency requiring hospitalization) Differential non-psychiatric diagnosis: Transient hypothyroidism, hyperthyroidism, anemia, infection POSTPARTUM DEPRESSION DIAGNOSIS
  11. 11. Treatment 1st line therapy: non-pharmacological therapy! Psychotherapy → IPT (Interpersonal Therapy) and CBT (Cognitive Behavioral Therapy) IPT – time-limited interpersonally-oriented psychotherapy (depression as a medical illness occurring in a social context) Effectiveness supported by several studies (O’Hara and colleagues, Clark et al) CBT – well studied and effective treatment for MDE (modification of distorted patterns of negative thinking and making behavioral changes that enhance coping and reduce distress) Several trials assessing CBT alone or with other interventions for the treatment of PPD → support CBT interventions as helpful in the treatment of PPD (Appleby et al, Misri et al)
  12. 12. 1. Postpartum blues: generally self-limited and resolve between 2 weeks and 3 months. Supportive reassurance is sufficient. 2. Postpartum depression: • psychotherapy • pharmacotherapy • diet 3. Postpartum Psychosis, add: • electroconvulsive therapy • hospitalization POSTPARTUM DEPRESSION TREATMENT OPTIONS
  13. 13. • IPT (InterPersonal Therapy): time-limited (12-20 weeks) treatment based on addressing connection between interpersonal problems and mood. • CBT (Cognitive Behavior Therapy): to help the depressed patient to modify negative thinking and to make behavioral changes in order to reduce distress. • Non-Directive Counseling: with a health visitor to empathically and nonjudgementally listen and support. • Peer and Partner Support: practical and emotional support from partner and friends are essential to recovery for most women. POSTPARTUM DEPRESSION PSYCHOTHERAPY – 1ST LINE TREATMENT
  14. 14. • Doses and time are similar to the ones for major depression. • Must be continued for 6 to 12 months after childbirth. • If the mother had responded to a specific psychodrug in the past, that medication must be the first one to consider. POSTPARTUM DEPRESSION PHARMACOTHERAPY – 2ND LINE TREATMENT
  15. 15. • SSRI (Selective Serotonin Recaption Inhibitors): I choice • Sertraline • Paroxetine • Fluoxetine (Prozac®) • TCA (Tricyclic Antidepressant): II choice - Nortriptyline - Imipramine POSTPARTUM DEPRESSION PHARMACOTHERAPY – ANTIDEPRESSANTS
  16. 16. • Transdermal Estrogen • neural growth • neurotransmitters activity • oxidative stress • Must be avoided if risk of tromboembolism is present • Progesterone (norethisterone nitrate) • Very few studies • No role for synthetic progesterone in treatment • Increases risk of depression After childbirth, we assist to a dramatic drop of maternal levels of estrogen and progesterone that could be the trigger to PPD. POSTPARTUM DEPRESSION PHARMACOTHERAPY – HORMONAL THERAPY
  17. 17. • Few studies on the effects on infants of exposure to antidepressants through breast milk. • Adverse effects include: sleep changes, gastrointestinal problems, respiratory problems, seizure. • Mostly resolved by interruption of treatment or breastfeeding • SSRI (sertraline, fluoxetine) and TCA (nortriptyilne) have the most data supporting safety during breastfeeding POSTPARTUM DEPRESSION PHARMACOTHERAPY – BREASTFEEDING CONSIDERATIONS
  18. 18. • Diet •  Ω3 fatty acids (3-4 g/die): depletion during pregnancy to build the fetus’s CNS •  Proteins •  vit. B6 •  carbohydrates, caffeine, sugar • Electroconvulsant therapy (ECT) - psychotic symptoms - for non-respondent to antidepressants women • Hospitalization - suicide risk POSTPARTUM DEPRESSION OTHER TREATMENTS
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    Jul. 20, 2019
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