Mental Health in Pregnancy Baby blues Affects approx 50% of women post delivery Brief episode of misery and tearfulness Usually after first baby PND Mild –severe non psychotic depressive illness During first post natal year Puerperal psychosis (PP) Acute onset of a manic/psychotic episode Patients usually have past hx of BPAD/vulnerability to childbirth related trigger Presents shortly after childbirth

Perinatal Mental Health Type of disorder Incidence (%) Mild/depressive/anxiety disorders Severe depressive illness Referral to psychiatric services 2.0 Admission to psychiatric unit 0.4 Puerperal psychosis 0.2

Maternal Mortality

Deaths from psychiatric cause = = =16

Suicide Majority of women died violently, 87% Over half from hanging or jumping

Puerperal Psychosis Psychotic illness arising in previously well woman after childbirth. First onset psychotic illness Previous psychotic illness but well in years preceding the pregnancy Incidence 2 per 1000 births Onset –Acute within days of delivery Recurrence after subsequent childbirth

Puerperal Psychosis Anger and agitation/Insomnia Confusion and perplexity (fluctuates with periods of orientation) Auditory hallucinations Paranoia/grandiose delusions Misrecognition of partner or mistaking others (such as male staff) for partner/father of the child. Mood disorder (manic and depressive in nature) Strange thoughts/statements Depersonalisation-loss of contact with reality with difficulty relating emotionally to child Thoughts of harming self or baby

Risk Factors Puerperal Psychosis Past Hx of puerperal psychosis (1 in 2) Family Hx of Bipolar illness or Puerperal psychosis (1 in3) History of serious affective disorder (bipolar illness and severe unipolar depression) Not strongly associated with psychosocial risk factors as non psychotic conditions

Marker Questions Have you ever been in hospital with you nerves? Has anyone in your direct family been in hospital with their nerves? Did your mother have postpartum psychosis/ “severe postnatal depression”?

SSRI in pregnancy are they “safe”?-yes Possible increase in congenital heart disease Possible Neonatal withdrawal Possible increase in PPHN (Best to avoid paroxitene and fluoxetine)

PPHN Persistence after birth of high pulmonary artery pressure R to L shunting across FO & DA Secondary to perinatal asphyxia, meconium aspiration, sepsis, diaphragmatic hernia Neonate cyanotic Needs O2, may need ventilation, NO, sildinafil, ECMO

PPHN primary studies Chambers, 2006 (used in safety update) After 20 weeks risk PPHN 1% –Case control study. 377 with confirmed PPHN. –14 on SSRI after 20/40, only 6 controls. OR 6.1 –Retrospective, 99% SSRIs no PPHN Wichman 2007 –808/25,000 on SSRI –16 had PPHN –none on SSRIs Kallen , cases PPHN OR 2 Risk of PPHN SSRI 1.5/1000 Andrade, 2009 –1104 on SSRIs in 3 rd trimester –Confounders –diabetes & asthma more in exposed group –5 PPHN (2 were on SSRI) –Risk not on SSRI 2.72/1000 –Risk on SSRI 2.14/1000

UK Tetrology Information Service

BUMPS

Signposting Non Drug RX Guided Self Help Psychological Therapies IAPT Support Groups

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