How to recognize, assess, and manage mental health problems in pregnancy as an obstetrician in regard to recent RCOG guidelines.

1. By
Dr./ Sarah Mohamed Hamed Aboelsoud
Senior Registrar OB/GYNE
Damietta General Hospital

2.  Pre-existing sever and enduring mental
health issue.
 Mental health concerns in current pregnancy
 The risk of having antenatal or postnatal
depression.
 Family history of mental problems.

3.  Always be nonjudgmental and
compassionate.
 Explore expectations, ideas and concerns of
the woman.
 Explore social history and support system of
the patient.
 Provide health education and necessary
information about mental health problems in
pregnancy.

4.  History of rapid changes in mental state.
 History of mental illness or current
medications.
 Developing new symptoms such as
hallucinations, delusions or uncontrolled
anxiety.
 Thoughts of self harm or suicide.
 Sever lack of sleep.
 Sense of hopelessness, guilt or lack of self-
care.
 Thoughts or attempts of harming her baby.
 Feeling estranged from her baby.

5.  Ask if in the last 2 weeks :
Has she ever felt nervous, anxious or on the
edge?
Has she not been able to stop or control
worrying?
The Score ( +0= not at all, +1= several days, +2= more
than half the days, +3= nearly everyday).
 In cases of patients with history of sever
mental illness, they should be followed up by
consultant obstetrician and mental health
specialist.

6.  At booking visit:
Women identified as at high risk of postpartum major mental disorders
should be referred to specialized perinatal mental health services
where available, or otherwise to general psychiatric services.
 Antenatal care visits:
Using of GAD-2 scale to identify vulnerable patients and manage
accordingly:
1. For women who develop mild/moderate depression or anxiety during
pregnancy, self-help strategies (guided self-help, computerized
cognitive behavioral therapy or exercise) should be considered.
2. Local protocols should be in place to assist maternity services to
refer vulnerable women to their GP for further assessment.
3. Referral should be made to specialist where available, for women
suffering from serious illness with symptoms of psychosis, suicidal
ideation, self-neglect, evidence of harm to others or significant
interference with daily functioning.

7.  During labor:
There should be an agreed care plan in place describing the roles of different
care workers: midwives (one-to-one care), obstetrician, anesthetist and
neonatologist/pediatrician.
The plan should clearly state advice on whether women can continue to take
their prescribed psychotropic medicines during labor and the anesthetist and
neonatologist should be made aware of it.
 During postpartum period:
There should be a care plan which has been devised in collaboration with
psychiatric specialist.
Infants of mothers who have been taking psychotropic medication in
pregnancy should be observed for signs of neonatal adaptation syndrome.
While usually mild and self-limiting, if they occur the infant should receive
neonatal assessment.

8.  Haloperidol (antipsychotic):
It may cause limb reduction syndrome and patients taking it should have mid-
trimester anomaly scan.
 Clonazepam ( atypical antipsychotic):
It may cause agranulocytosis and myocarditis of neonates, so it should be
avoided if possible.
 Tricyclic antidepressants:
it carries the risk of neonatal withdrawal and it is very toxic and can cause
death in overdose. There should be a neonatal alert.
 Clomipramine (SSRI):
Should be avoided in the first trimester if possible and if used, the patient
should have mid-trimester anomaly scan.
 Citalopram ( SSRI of choice during pregnancy):
It is risk lies in higher concentrations of the drug excreted in breast milk. So
should be replaced by Sertraline during breast feeding.

9.  Benzodiazepine:
It causes facial clefts, floppy baby syndrome and neonatal withdrawal
symptoms. So you should only be used in acute agitation and sever anxiety
cases.
 Carbamazepine :
It is a mood stabilizer which can cause NTDs, cardiac defects, and GIT
anomalies.
It should be avoided if possible, but if taken the woman should have
5mg folic acid daily and a mid-trimester anomaly scan.

10.  Treat all women with the highest standard of care.
 Give women as much sense of safety, control, and
respect as possible by :
1. Asking her choice of name, do not use endearments as love or dear,
and don’t ask her intrusive questions about her past.
2. Obtain history before asking her to remove any clothing.
3. Always explain the relevance of any inquiries.
4. Ensure her privacy, and offer a cover for modesty.
5. Ensure that she understands that she can ask you to stop or slow
down if she is uncomfortable.
6. Be aware of her body language of any discomfort.
7. Always take clear informed consent before doing any procedure or
examination.

11. Thank you