Psychiatric Disorders

in

Pregnant & Lactating women

Dr\ Hosam Hassan

PR Director

National Mental Health Council

Agenda

1) Detection , Prediction, Prevention of

Mental Disorders Before & during

pregnancy .

2) Managements of Mental Disorders

during Pregnancy & Lactation .

3 ) Consent & Mental Capacity .

Introduction

PsychiatryObstetric & Gynecology

Already Diagnosed as a Psychiatric

Patient

Psychiatric Disorders Related To

Menstruation, Pregnancy & Labor

Detection

Prediction

Management

Prevention

Detection - Prediction

of Mental Disorder

Current Mental Disorder Potential Risk

Previous Treatments

Admission Consultations Medications

Past History of Mental illness

( previous deliveries ?)

Examination

Mental State( Thinking / Mood )

Psychological Tests

( EPDS )

Regular Check Up

Past Family History

( previous deliveries ?)

Screening Questions

Loss of interest

Feeling down

Need Help

Prevention

High Risk Mild

SymptomsPrevious Episodes

Psychosocial Intervention

Brief psychotherapy Social Support

Referral

Management

Treating Current Mental Disorder

Planning for pregnancy

PregnancyAfter

Delivery

Already

Diagnosed

Mental

Disorder

Developing

during any

Stage

Management of Psychiatric

DisorderInvestigation

Psychometry – Further Assessment

PsychotherapySupportive – CBT – Interpersonal

Psychopharmacotherapy

ECT( Electro – Convulsive Therapy )

Mild

Moderate

Severe

Overview of Psychiatric

Disorders

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

Overview of Psychiatric

Disorders

Eating DisordersAnorexia Nervosa

Bulimia Nervosa

Pica

Sleep Disorders

Insomnia Restless Leg Syndrome

Postpartum Psychiatric Illness

Characteristic SymptomsOnsetIncidence

Mood lability

Tearfulness

Insomnia

Anxiety

Within first

week

50 to 75%Postpartum

Blues

Depressed Mood

Excessive Anxiety

Insomnia

Usually

insidious, within

first two to

three months

10 to 15%Postpartum

Depression

Agitation and Irritability

Depressed Mood or

Euphoria

Delusions

Depersonalization

Disorganized Behavior

Usually within

first two to four

weeks

0.1 to

0.2%

Postpartum

Psychosis

Psychopharmacotherapy During

PregnancyGeneral Rules

Written Plan of Management

Informed Consent

Medications

Switch to The safest Drug Monotherapy Minimal Effective doseGradual withdrawal before

delivery (BDZ, SSRIs )

Try to Avoid Medications in 1st Trimester

Follow Up Psychotherapy

Discuss with the patient

Risks Benefits

ContinuationDiscontinuation

TeratogenicityRelapse

Psychopharmacotherapy During

LactationGeneral Rules

Medications

Switch to The safest Drug Monotherapy Minimal Effective doseSingle 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 Psychotherapy

Discuss with the patient

Risks Benefits

ContinuationDiscontinuation

Possible effects of drugs on babyRelapse

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

RisperidoneOlanzapineQuietiapineClozapine

Side Effects

Extra Pyramidal Dystonia

pseudo parkinsonism

NeurolepticMalignant 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

WhylactationWhypregnancy

If the baby has

hepatic impairment

Risk of

Agranulocytosis

ClozapineContra-indicated

Weight Gain (Mother)

Gestational

Diabetes

AtypicalBetter Avoid

Haloperidol

Chlorpromazine

Haloperidol

Chlorpromazine

Use but with

caution

Antidepressants

Types

TCAs - Tricyclic Antidepressants

AmitriptylineClomipramine

imipramine

SSRIs - Selective Serotonin

Reuptake Inhibitors Fluoxetine

paroxetine SertralineCipalopram

MAOIs –Monoamine

Oxidase Inhibitors

Hydrazines

Mode of Action

↑Serotonin↑Noradrenaline↑Dopamine↓Histamine↓Ach

↑Serotonin

↑Tyramine

Major Indications

Depression

Anxiety

Side Effects

Dry Mouth Blurring of Vision Urine retention

Cardiotoxic

NauseaVomiting

DiscontinuationSerotonin Syndrome

Hypertensive Crisis with Tyramine

Containing Food

Antidepressants

Generally Antidepressants are categorized as cluster C drugs

Except Nortriptyline (TCA ) & Paroxetine( SSRI ) D

It is better to prescribe TCAs rather than SSRIs during pregnancy:

◦ for SSRIs are newer & less studied regarding effect on pregnancy & lactation

◦ A study in 2006 showed that 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

Mood Stabilizers

Types

AnticonvulsantsValproate

carbamezapineLamotrigine

Lithium

Mode of Action

↑GABA

Modulate Cell membrane excitability

Major Indications

Epilepsy

Bipolar

Serious Side

Effects

Bone marrow depression

Skin Rashes

Toxicityrenal failure

hypothyroidism

Mood Stabilizers

Generally Mood Stabilizers are categorized ascluster D drugs

Except Lamotrigine 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 36th week 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 .

Mood Stabilizers

WhylactationWhypregnancy

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

Valproate•Oral cleft

9 in 1000

Lamotrigine

Anxiolytics

Mode of Action

↑GABA

Types

BenzodiazepinesAlprazolamLorazepamDiazepam

Non – BenzoBuspironeZolpidem

Major Indications

Anxiety

Insomnia

Seizures

Side Effects

Addiction

Paradoxical disinhibition

Anxiolytics

Generally Anxiolytics are categorized ascluster D drugs

Except : Flurazepam X / Zolpidem C / Buspirone B

Better Avoided during pregnancy :

◦ Fetus Cleft palate

◦ Neonate Floppy baby Syndrome ( Hypotonia , Hypothermia , Respiratory Depression )

If used :

◦ Short period .

◦ Minimal dose .

The organization of services

Clinical Network

MultiDisciplinary

Service

Clear Referral Protocol

Access to Specialized

Experts

References

NICE clinical guidelines for Antenatal & Postnatal Mental

Health .

National Institute for Health & Clinical Excellence

Oxford Handbook of Psychiatry . 2nd Edition .

David Semple & Roger Smyth

Management of Mood Disorders During Pregnancy .

Dr Magda Fahmy

Discussion