1. Psychiatric Illness in Pregnancy and the Postnatal Year Dr Alison Wenzerul Consultant Perinatal Psychiatrist alison.wenzerul@dhft.nhs.uk

2. Objectives for Today  To learn about how severe mental illness impacts on women in the perinatal period.  Issues around physical treatments for pregnant women and those who are breast feeding.  Safeguarding Issues  The impact on the infant and family.  How individual management plans are developed for at risk women  Communication options between the maternity and mental health services

3. Mental Disorders During Pregnancy and the Postnatal Period  Severe mental illness  Schizophrenia  Bipolar Affective Disorder  Depression  Mild, Moderate, Severe  Anxiety disorders  Panic Disorder  OCD  GAD  PTSD  Eating Disorders

4. Parental Severe Mental Illness  25%+ of women with severe mental illness have dependant children  Same mental health needs as non mothers with SMI  Normal fertility but more:  Unwanted pregnancies  Pregnancies from sexual assault  Terminations  Sexual partners  Without current partner

5. The Effects of Severe Mental Illness on Foetus and Infant:  Babies small for dates  Preterm delivery  Low birth weight  Severity of maternal mental illness is a good predictor of obstetric complications and later outcome  Increased incidence of neurological abnormalities in the newborn baby  Developmental delay: emotional, social, motor, cognitive and intellectual  Failure to thrive and reduced growth

6. In Pregnancy and the Postnatal Period Women are more likely to:  Stop medication abruptly  Have a relapse or first episode of bipolar disorder  Need an urgent intervention  Have a more rapid onset of a psychotic postnatal disorder

7. Following Childbirth:  The risk of a women suffering from a serious mental illness is greater in the three months following childbirth than at any other time in her life.  Over 10% of mothers will suffer an episode of depressive illness. Approximately 3% will have a moderate to severe depressive illness  0.2% of mothers will suffer from a puerperal psychosis.  Suicide is a leading cause of maternal death in the postnatal period.  Mothers who suffer an episode of severe mental illness post partum have a 40% chance of a recurrence with any future pregnancy.

8. Why Mothers Die Saving Mothers’ Lives Key themes when mothers died:  Poor identification of past history (50%)  Poor identification of risk (50% of above)  Poor communication of both by psychiatric services, GPs, maternity  Misattribution of physical illness to psychiatric causes (32%)  All but 2 did not receive specialist care  Use of Illicit Substances

9. Risks to Children  Maternal mental ill health has significant consequences for children.  There are typically 750 – 800 homicides a year in England and Wales, of these, 25% are of children mainly by their parents.  Parental mental illness has been identified as a cause in a third of these case, 40% of these being schizophrenia. In addition to this,  Approximately one third of mental illness homicides are by women and 85% involve their children.  Every year approximately 20 children are killed by their mentally ill mothers – many of these are babies.

10. Prediction At first contact with maternity services, ask specific questions about:  Past or present severe mental illness  Previous treatment by psychiatrist/specialist mental health team  Family history of perinatal mental illness

11. The Whooley Questions  Can be used at first contact with primary care, at the booking visit and postnatally:  During the past month, have you often been bothered by feeling down, depressed or hopeless?  During the past month, have you been bothered by having little interest or pleasure in doing things?  If the answer is ‘yes’ to either of these questions, please ask;  Is this something you feel you need or want help with?

12. Management of depression Mild or moderate depression  Self-help strategies  Counselling (listening visits)  Brief cognitive behavioural therapy  Interpersonal psychotherapy  Antidepressants

13. Puerperal Psychosis and Bipolar Affective Disorder  Puerperal psychosis 0.5-1.0 per 1000 deliveries; risk rises to 1 in 7 if has had a past episode.  Link between Bipolar Affective Disorder and Postpartum Psychosis  Women with Bipolar Affective Disorder have a high risk of recurrence related to childbirth, with approx 70% experiencing an episode in the immediate postpartum period

14. PRE BIRTH PLANNING MEETINGS  To clarify the treatment package.  To flag up any areas that may be a potential concern either within the remainder of the pregnancy, during or following childbirth  To provide a multi - disciplinary seamless approach and improve communication.  To identify each professionals’ individual roles in the provision of care  To share relapse signatures  To produce an emergency plan and share contact details.

15. Physical Treatments in Pregnancy  A careful risk-benefit assessment  If possible use non pharmacological interventions  Avoid first trimester exposure when possible  Use the lowest effective dose for the shortest time  Avoid polypharmacy

16. Pregnancy Pharmacokinetics  Delayed gastric emptying and longer intestinal transit times: Increased absorption  Reduced blood flow to legs in late pregnancy: Reduced absorption of IM drugs  Increased plasma volume: Dilution effect on psychotropics  Increased body fat: Serum lipids may compete for protein-binding sites and alter unbound drug concentrations  Increased metabolism: lower serum levels of psychotropics  Increased CP450 and CYP3A4, reduced CYP1A2 activity  Increased constipation and lower blood pressure can potentiate side effects

17. Factors Affecting Drug Concentration in Breast Milk  Maternal plasma level  Drug half-life  Lipid solubility, breast milk is fatty and concentrates lipophilic drugs including psychotropics  Protein binding: free drugs transfer into breast milk  Time since delivery: in early post partum there are larger gaps between alveolar cells in the breast, increasing the amount of drug that passes from maternal blood. After 4 days this reduces  Fat content of milk: lipophilic drugs will show increased transfer in hind milk rather than fore milk

18. Factors Affecting Infant Plasma Drug Levels  Amount of drug ingested  Infant metabolism: neonates have a reduced capacity to metabolise drugs for at least the first 2 weeks, this could increase with a preterm or ill infant  Infant excretion: the neonatal kidney is less efficient than an adult and only reaches that level at 2-5 months  CNS exposure: the blood brain barrier of a neonate is immature

19. National Guidance to Improve Care Recommends a specialist multi-disciplinary service (MDT) within a managed clinical network for every maternity locality, which provides:  Direct services  Consultation and advice to maternity services, other mental health services and community services  Access to specialist expert advice on the risks and benefits of psychotropic medication during pregnancy and breastfeeding  Clear referral and management protocols for services across all levels of the existing stepped care frameworks for mental disorders to ensure effective transfer of information and continuity of care  Pathways of care for service users with defined roles and competencies for all professional groups involved

20. References  Henshaw C, Cox J & Barton J: Modern Management of Perinatal Psychiatric Disorders  Lewis G (2007) Saving Mother’s Lives  Lewis G & Drife J (2004) Why Mothers Die 2000-2002  McLennan J & Ganguli R (1999) Family Planning and Parenthood needs of Women with Severe Mental Illness  The National Teratology Information Service (NTIS) (http://www.nyrdtc.nhs.uk/Services/teratology/teratology.html)http://www.nyrdtc.nhs.uk/Services/teratology/teratology.html

21. The End