Part B: Perinatal psychiatric conditions W ha t is perinatal psychiatric disorde r ? Includes pre-existing disorders such as schizophrenia, bipolar illness and depression Care on effects of the illness itself and of its treatment on the developing fetus and infant psychiatric disorder in pregnancy and the postpartum period has been a leading cause of maternal mortality,

. It is essential that all midwives have education and training to be familiar with normal emotional changes, adjustment reactions as well as the signs and symptoms of more serious psychiatric illnesses. Types of psychiatric disorder ‘mental health problem’ is used to describe all types of emotional difficulties from transient to severe and uncommon mental illness. describe learning difficulties, substance misuse problems and difficulties coping with the stresses and strains of life.

Psychiatric disorders are categorized into: Serious mental illnesses schizophrenia,, bipolar illness and severe depressive illness. Previously, these conditions were called psychotic disorders.

Mild to moderate psychiatric disorders These were previously known as ‘neurotic disorders’. mild to moderate depressive illness mixed anxiety Depression anxiety disorders including phobic anxiety, panic disorder, obsessive–compulsive disorder and post- traumatic stress disorder

Adjustment reactions distressing reactions to life events, including death and adversity. Substance misuse who misuse or who are dependent upon alcohol and other drugs of dependency, including both prescription and legal/illegal drugs. Personality disorders people who have persistent severe problems in dealing with the stresses and strains of normal life, maintaining satisfactory relationships, controlling their behavior.

Learning disability have intellectual and cognitive impairment, developmental delay and consequent learning disabilities. N.B: The majority of these disorders are managed in primary care. Mild to moderate depressive illness and anxiety states respond to psychological treatments.

Psychiatric disorder in pregnancy The prevalence of psychiatric disorder in young women means that at least 20% of women will have current or previous psychiatric disorder in early pregnancy, many of whom will be taking psychiatric medication at the time of conception. Pregnancy is not protective against psychiatric disorder, increased risk of a recurrence of that illness following birth.

Mild–moderate conditions mild depressive illness mixed anxiety depression anxiety states. These disorders present most commonly in the early weeks of pregnancy, becoming less common as the pregnancy progresses. Women may also be vulnerable at this time because of:

previous fertility problems previous obstetric loss anxieties about the viability of their pregnancy social and relationship problems ambivalence towards the pregnancy other reasons for personal unhappiness

In the past, hyper emesis gravidarum (severe vomiting) was a psychosomatic manifestation of personal unhappiness and psychological disturbance. . Psychological factors, anxiety and cognitive remain a significant factor in some women.

Prognosis and management Most of the conditions are likely to improve as the pregnancy progresses. Psychological treatments and psychosocial interventions are effective for these conditions and caution needs to be exercised before pharmacological interventions are initiated during pregnancy, although medication may be necessary for the more severe illnesses. those who develop a psychiatric illness in the later stages of pregnancy, their condition is likely to continue and worsen in the postpartum period.

Serious conditions This term refers to Schizophrenia bipolar illness (manic depressive illness) severe depressive illness. Incidence Women are at a lower risk of developing a serious mental illness for the first time during pregnancy than at other times in their lives.

these conditions are uncommon, they require urgent and expert treatment, as an acute psychosis in pregnancy can pose a risk to the mother and developing fetus such an illness can interfere with proper antenatal care. Prevalence ; It is important to realize that these women may range from women who are well and stable, leading normal lives through to those who are disabled, chronically symptomatic and on medication.

Group 1 previous episode of bipolar illness or a psychotic episode earlier in their lives. They are usually well, stable not on medication and may not be in contact with psychiatric services. If illness was disappear more than 2 years ago, may not be at an increased risk of a recurrence of their condition during pregnancy

Group 2 those who have had a previous and/or recent episode of a serious mental illness who are relatively well and stable but whose health is being maintained by taking medication. This may be antipsychotic medication or in the case of bipolar illness, a mood stabilizer (lithium or an anticonvulsant).

These women are at risk of a relapse of their condition during pregnancy. This risk is particularly high if they stop their medication at the diagnosis of pregnancy. some of these medications may have an adverse effect on the development of the fetus

Group 3 women who are chronically mentally ill with complex social needs, persisting symptoms and on medication. These women will usually be in contact with psychiatric services. They should be able to discuss the risk to their mental health of becoming pregnant and becoming a parent as well as the risks to the developing fetus of continuing with their usual medication and perhaps the need to change it.

Psychiatric disorder after birth affective (mood) disorders. the ‘blues’ puerperal (postpartum) psychosis postnatal depression. The ‘blues’ is a common self-limiting state, occurring in the first week postpartum

Puerperal (postpartum) psychosis puerperal psychosis, the most severe form of postpartum affective (mood) disorder mostly in the first few weeks postpartum. rare condition Risk factors ; previously well without obvious risk factors illness comes as a shock to them and their families biological factors (neuroendocrine and genetic) are the most important aetiological factors for this condition.

Clinical features Puerperal psychosis is an acute early onset majority of cases present in the first 14 days postpartum. develop suddenly between day 3 and day 7, at a time when most women will be experiencing the ‘blues’. Differential diagnosis between the earliest phase of a developing psychosis and the ‘blues’ can be difficult. deteriorates over the following 48 hours while the ‘blues’ tends to resolve spontaneously.

The earliest signs are commonly of perplexityالحيرة , fear – even terror – and restless agitation associated with insomnia. Other signs include: purposeless activity uncharacteristic behaviour disinhibition irritation and anger, resistive behaviour and sometimes incontinence.

A woman may have fears for her own and her baby's health and safety, or even about its identity. elation and grandiosity, suspiciousness, depression or unspeakable ideas of horror رعب . symptoms of schizophrenia (delusions and hallucinations) may occur. A mood of perplexity and terror is often found, as are delusions about the passage of time and other bizarre delusions.

believe that they are still pregnant or that more than one child has been born or that the baby is older than it is. Women often seem confused and disorientated. In the very common mixed affective pressure of speech and flight of ideas, there is often a mixture of grandiosity, elation

alternating with states of fearful tearfulness, guilt The sufferers are usually restless and agitated, resistive, and difficult to reassure. they are usually calmer in the presence of familiar relatives.

The woman may be unable to attend to her own personal hygiene and nutrition and unable to care for her baby. Her concentration is impaired and she is unable to initiate and complete tasks. Over the next few days her condition deteriorates and the symptoms usually become more clearly those of an acute affective psychosis. Most women will have symptoms and signs suggestive of a depressive psychosis, with a mixture of both – a mixed affective psychosis.

Relationship with the baby they do not seem to be aware of their recently born baby. Others are preoccupied with the baby, reluctant to let it out of their sight and forever checking on its presence and condition. delusional ideas frequently involve the baby and there may be delusional ideas of infant ill health or changed identity,

rare for women with puerperal psychosis to be hostile to their baby. The risk to their baby lies more from an inability to organize and complete tasks, and to inappropriate handling and tasks being impaired by their mental state. These problems, directly attributable to the maternal psychosis, tend to resolve as the mother recovers.

Management require admission to hospital, which should be to a specialist mother and baby unit, This ensures that the physical and emotional needs of both mother and baby are met and the developing relationship with the baby promoted.

Prognosis they resolve relatively over 2–4 weeks. initial recovery is often fragile and relapses are common in the first few weeks. it is common for women to pass through a phase of depression and anxiety and preoccupation with their past experiences and the implications of these memories for their future mental health and their role as a mother.

Sensitive and expert help is required to assist women through this phase, to help them understand what has happened completely recovered by 3–6 months postpartum. However, they face at least a 50% risk of a recurrence