Psychiatric aspect of obstetrics and gynecology
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Psychiatric aspect of obstetrics and gynecology
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Psychiatric aspect of obstetrics and gynecology
- 1. Psychiatric aspect of obstetrics and gynecology K. Kavindya M. Fernando JMJ 1
- 2. Psychiatric disorders during Pregnancy • More common in 1st and 3rd trimester • In 1st trimester –unwanted pregnancies • Anxiety • Depression • In 3rd trimester • Fear about impending delivery • Doubts about the normality of the fetus • Psychiatric disorders common in • Previous Hx of psychiatric disorder + • But for some, disorders improve during pregnancy JMJ 2
- 3. During Pregnancy • Unwanted pregnancy (common • Hyperemisis gravidarum (unusual) • Pseudocyesis (rare) • Couvade Syndrome (rare) JMJ 3
- 4. Hyperemisiis gravidarum • Severe and repeated vomiting • Much worse than the usual “morning sickness” • Appears to have a primary physiological cause • But, psychological reaction may exacerbate • Severity • Duration of symptoms JMJ 4
- 5. Pseudocyesis • A condition, which woman believes, • She is pregnant, when she is not • And develops • Amenorrhea • Abdominal distension • Other changes resembling early pregnancy • Usually resolved quickly following diagnosis • May be recurrent JMJ 5
- 6. Couvade Syndrome • A condition in which, • The husband or partner of a pregnant woman, • Experiences some of the symptoms of pregnancy, • Including • minor weight gain, • Morning nausea • Disturbed sleep JMJ 6
- 7. Post partum Mental Disorders Maternity ‘Blues’ Puerperal psychosis Other depressive disorders of moderate severity JMJ 7
- 8. Why is it important? • Pregnancy is a stress and stresses bring about psychological consequences • It is not just a stress, it is a stress that is taken granted for, • Hence the psychological issues could be taken as granted as well, • Specially if the symptoms are mild JMJ 8
- 9. Why is it important? • The awareness of psychological issues may be low among lay people/medical personal • The outcome could be devastating • Bonding/ attachment issues, suicide, infanticides, homicide, violence, divorce etc • It could be prevented or intensity could be reduced JMJ 9
- 10. Maternity ‘Blues’ • Occur in ½ & 2/3rd of woman • Up to 85% of woman experiences • Symptoms are • Irritability • Muddled thinking • Tearfulness • Lability of mood • Common in primigravida JMJ 10
- 11. Maternity ‘Blues’ • Onset during the 1st 48 hours resolves in a few days • Reach peak on 3-4th postpartum day • Common & short lived • No specific treatment needed JMJ 11
- 13. Puerperal psychosis • Begins typically 2-3 days after delivery • Nearly always in the 1st 1-2 postpartum weeks JMJ 13 Puerperal Psychosis Affective syndrome Schizophreniform syndrome Delirium
- 14. Puerperal psychosis • Affective syndromes • Most common in high income nation • Schizophreniform Syndrome • Delirium • Common before antibiotics were introduced to treat puerperal sepsis JMJ 14
- 15. Puerperal psychosis • Occur in about 1 in 500 births • (Handout – 1:1000 births) • Common in • Primiparous woman • Those with previous hx of serious psychiatric disorder • Those who have family history of psychiatric disorder • Puerperal psychosis is not more common after complicated deliveries JMJ 15
- 16. Puerperal psychosis • Assessment • Take the history • Examination – Mental State Examination • It is essential to ascertain the mother’s ideas concerning the baby • Severely depressed mothers may think • Their baby is malformed • Try to kill them to spare it from future suffering • Assess suicidal ideations JMJ 16
- 17. Puerperal psychosis - Tx • For depressive disorders of marked or moderate severity • ECT is often the best treatment • ECT • Rapid effect JMJ 17
- 18. Prognosis • Most recover fully from a puerperal psychosis • But few remain chronically ill (most with schizophrenic psychosis) • At a subsequent birth, • the recurrence rate for puerperal affective disorder is • much higher than in those without previous puerperal affective disorder JMJ 18
- 19. Treatment during subsequent pregnancies • Woman with previous hx • Should be monitored very closely in the hours and days after delivery • For patients with previous history of bipolar disorder • May require lithium prophylaxis • Avoid in 1st trimester • Stop for the short period after delivery JMJ 19
- 21. Other Puerperal Depressive Disorder • Mild or moderate severity depression • More common than puerperal psychosis • 10-15% recently delivered mothers + • Symptoms • Tiredness • Irritability • Anxiety • Above may more prominent than depressive mood • May have prominent phobic symptoms JMJ 21
- 22. Other Puerperal Depressive Disorder • Peak falls 6 months after partus • The majority presents with atypical features of depression whilst a minority as per the ICD 10 • Risk factors • Younger age • Previous psych history • Early post partum blues • Poor support/mariatal relationship • poverty JMJ 22
- 23. Other Puerperal Depressive Disorder • Caused mainly by • Psychological adjustment required after childbirth • By loss of sleep • By hard work involved in the care for the baby • This adversely affect on • Mother – infant relationship • Cognitive & emotional development of the infant • Assessment • Edinburgh Postnatal Depression Scale JMJ 23
- 24. Other Puerperal Depressive Disorder • Assessment • Edinburgh Postnatal Depression Scale • Management • Advise about childcare • Help with childcare • Advice on sexual relationships • More general marital guidance JMJ 24
- 25. Aetiology of abnormal psychology in puerperium • Not known for certain • Hormonal theory • Body cannot cope with the sudden reduction of hormones • Increased CRH in mid pregnancy • Generic predisposition/ social class/ ethnicity • Life events • Complicated or unwanted preganncies JMJ 25
- 26. Management • Immediate physical management • Short term • Long term management JMJ 26
- 27. Immediate physical management • Where she is manage? • Depends on the current problem in/out patient • What is the care of her baby? • How? • Exclude (or attend) physical problems • Sedation • Butyrophenones • Thioxanthines • Benzodiazepines JMJ 27
- 28. Short Term • ECT • Antipsychotics • Antidepressnets • Anxiolytics • REMEMBER • Lactation JMJ 28
- 29. Long term management • Consider the current recovery • Continue the current medication – months 6? 12? • Prevention of relapse • General prophylaxis • Specific therapy – LiCO3 • Look for side effects • Family involvement JMJ 29
- 30. Short and long term psychological intervention • Supportive psychotherapy • To patient and spouse • Share the knowledge with relations • Specific psychological interventions • CBT • Social management • Social case work • Liaison work JMJ 30
- 32. Premenstrual syndrome • Psychological symptoms • Anxiety, irritability and depression • Physical symptoms • Breast tenderness • Abdominal discomfort • Feeling of distension • Psychological problems may exacerbate the symptoms • Treat with - SSRI / TCA and CBT JMJ 32
- 33. Menopause • Psychological symptoms • Anxiety and depression • Hormone replacement therapy (HRT) is not a treatment for this JMJ 33