1. Consultant Perinatal Psychiatrist
Perinatal Psychiatry
City CCG PLT
18th & 25th September 2018
Dr Zena Schofield
Consultant Perinatal Psychiatrist

2. Show of hand please GPs- partners or salaried GPVTS Practice Nurses
Non-medical prescribers
FY1 and FY2
Who has done a perinatal psychiatry post?

3. Objectives
Update your knowledge on prescribing in pregnancy and lactation in perinatal mental illnesses
Reminder of why perinatal psychiatry is important
Case Vignettes to apply knowledge

4. Presentation Quiz Medication in pregnancy & lactation Vignettes
Nottinghamshire Perinatal Psychiatry Service including who to refer

5. Phone calls from GPs to our team
Topic
% of total GP calls about topic
Anti-depressants in pregnancy
54%
Anti-depressants postpartum
24%
Other or multiple medications in pregnancy
14%
Refer or not? 5%
Urgent referral 3%

6. Quiz Most common mental health problem post-partum & incidence rate?
Adjustment reaction 15-30%
Incidence rates of:
Mild-mod depression
10%
Severe Depression
2-3%

7. Quiz
% women with bipolar who have been well for 2(+) years who will relapse after delivery?
50%

8. Quiz Postpartum Psychosis: % of total cases onset by days 7, 16, 90
Incidence rate
2 in 1000
Recurrence rate for next pregnancy
1 in 2

9. Medication-Pregnancy
Risk: benefit analysis
Documentation
British Association of Psychopharmacology perinatal guidelines 2017
NICE guidelines 2014

10. Anti-depressants in pregnancy
Longer duration evidence base TCAs
TCAs- most studies have not found statistically significant ↑ risk of congenital anomalies
SSRIs- most recent data including meta-analyses has not demonstrated ↑ risk of congenital anomalies once confounders were removed (age, diabetes, obesity, alcohol use, illicit drug use)
Paroxetine- small ↑ risk of cardiac defects
BJOG antidepressants in late pregnancy ↑risk of PPH (aRR 1.5)
SSRI use and ASD risk: case control study showed double risk of ASD but nested case control study showed increased risk with untreated maternal depression, mat. Dep & SSRI increased risk for ASD without ID. Also heritage component of ASD not controlled for in studies.

11. SSRIs in pregnancy neonatal outcomes
Persistent Pulmonary Hypertension in neonate
JAMA much lower risk than originally thought, OR=1.1 (not stat signif) when confounders removed
Peds 2016 NNH=285
↑ risk of admission to NICU which ↑ with antidepressant use in late pregnancy (aOR=1.6 CI= ) Peds 2016 (740,000 infants ‘06-’12)

12. SSRIs in pregnancy and ASD in offspring
Autistic Spectrum Disorder
Mixed evidence
Meta-analysis in 2015 shows modest ↑ risk but many confounders
Association, causality not demonstrated
Swedish study (BMJ 2013) modest ↑ risk but not able to control for effects of maternal depression
BMJ 2017 Rai et al- no pregnant woman took antidepressants then it might prevent 2% of all cases of ASD. Response from Dr Schendel

13. Antidepressants in pregnancy and offspring outcomes
ADHD and Antidepressants- BMJ May 2017 Man et al- probably at least confounding factor, effect size smaller than previously estimated
2017 JAMA Sujan et al- antidepressants in 1st trimester- small ↑ risk of preterm birth but no increased risk of ASD or ADHD in offspring

14. SSRIs in pregnancy- long term outcomes
Long term impact:
2015 BJOG-Danish pop. Cohort study- independent of maternal illness, prenatal antidepressant exposure is not associated with an increased risk of behavioural problems in children at 7 years of age (49,178 dyads)
2016 JClinPsych- language and behavioural differences but not cognitive (178 dyads)

15. Anti-depressants in pregnancy
Venlafaxine (SNRI) and Duloxetine
Far smaller evidence base than SSRIs
Probably not teratogenic but not sure
Poor Neonatal adaptation syndrome- SNRIs > SSRIs
If can change to SSRI or TCA then do so
Mirtazapine-limited data
Buproprion-possible risk of cardiac defects but data is conflicting and limited

16. Antidepressants in pregnancy summary
Tricyclics are generally OK unless OD risk
Sertraline, fluoxetine and citalopram ok
Limited data on other antidepressants so discuss with perinatal team and be cautious
Stick with what works for the patient
May be an opportunity to reduce and stop medication if she has been in recovery for awhile

17. Anti-psychotics in pregnancy
Risks of relapse of psychotic illness if stopped
GTT at 28/40
First generation anti-psychotics (FGA)
Haloperidol, Trifluoperazine, Chlorpromazine
Relatively safe in pregnancy
No difference in development of children at 5 years
Second generation anti-psychotics (SGA)
Gestational diabetes

18. Anti-psychotics in pregnancy
2017 BMJ Grigoriadis- no significant ↑ risk of congenital anomalies with antipsychotics (SGA >9000, FGA 700 of 1.3 million births)
2015 O&G- meta-analysis of case controlled or cohort studies of antipsychotic use in pregnancy- ↑ risk of adverse obstetric and neonatal outcomes, inc small ↑ risk of congenital anomalies . No difference between FGA & SGA.

19. Anti-psychotics in pregnancy
Aripiprazole-?? ↑ risk of miscarriage (2017)
Clozapine-
Very limited evidence
Gestational diabetes rates x2
Monitor clozapine levels due to changes in pharmacodynamics in pregnancy
Babies-floppy, ↓ pulse, seizures, ?agranulocytosis
Crosses placenta, in breast milk, accumulates in baby

20. Mood Stabilisers in Pregnancy
Valproate:
AVOID in women of reproductive age- NICE Dec 2014
8-10% major congenital abnormalities particularly neural tube defects
Up to 30% learning difficulties in 1 study
Long term developmental delays continue
Valproate syndrome
Linked to autistic spectrum disorder

21. Mood stabilisers in pregnancy
Lithium
Increased risk of cardiac defects
Epstein’s anomaly-1-2/1000 (gen. pop. 1/20,000)
Floppy baby syndrome
Careful monitoring of lithium levels in pregnancy
No impact on child development at age 5
Carbamazepine- avoid due to neural tube defects

22. Mood stabilisers in pregnancy
Lamotrigine
Small ↑ risk of cleft lip & palate
Safest of AEDs used as mood stabilisers
Use of antipsychotics as mood stabilisers in pregnancy, especially first generation

23. Medications to avoid in pregnancy
Valproate
Lithium
Carbamazepine
Diazepam (?cleft lip & palate)
Procyclidine
Paroxetine

24. Psychotropic medications in lactation
Antidepressants in low levels in breast milk:
Tricyclic antidepressants e.g. imipramine
Sertraline & paroxetine
Antipsychotics:
First generation antipsychotics e.g. haloperidol
Starting to use some 2nd generation antipsychotics in breast feeding WITH CAUTION- specialist team

25. Medications in Lactation
High levels in breast milk so DO NOT use:
Lithium
Benzos
Lamotrigine-risk of SJ syndrome in baby
Avoid meds with long half lives
Avoid fluoxetine
Insufficient data on other meds so avoid

26. M-BRRACE- UK Saving Lives, Improving Mothers’ Care
The UK Confidential Enquiry into Maternal Deaths (CEMD) has represented a gold standard internationally for detailed investigation and improvement in maternity care for over 60 years.
Reviewed maternal deaths in UK from
Death rate reduced from 11/100,000 ( ) to 10/100,000
68% of deaths due to medical and mental health problems
Key messages:
Think sepsis
Prevent influenza
Mental health matters

27. ‘Red Flags’ Recent significant change in mental state,
new thoughts or acts of violent self-harm,
new and persistent expressions of incompetency as a mother or estrangement from the infant

28. Classification of care received by women who died as a result of psychiatric causes and for whom case notes were available for a detailed review, UK and Ireland
Care Classification
Suicide n=93 (%)
Substance misuse n=29 (%)
Good Care
17 (18)
9 (32)
Improvements to care were noted which would
not have made a difference to outcome
10 (36)
have made a difference to outcome
48 (51)
6 (21)
Insufficient data to classify
12 (13)
3 (11)

29. Vignettes How would you manage this case?
Would you refer to perinatal psychiatry?

30. Vignette 1
31, partner for 5 years, degree in biology, works as a commissioner for CCG, 2 previous admissions to hospital, 2 episodes with CRHT, on Quetiapine 300mg BD, wants to get pregnant, is currently using contraception but comes to you to discuss stopping it
What would you advise her?

31. Vignette 2
27 female, G3 P1, 8/40
On citalopram 20mg daily for depressive episode, in recovery for 4 months
No previous episodes
Trigger- redundancy and loss of home

32. Vignette 3 Just moved into your area
3 older children not in her care, removed by social services
Pregnant 34/40
She was fleeing DV but has allowed partner to know her new address
Social care involved- she didn’t tell you
No medication currently
She is feeling a bit anxious

33. Notts Perinatal Team Whole county
1.7 WTE Consultants for MBU and community
1 WTE band 7 nurse- team leader
8 WTE band 6 CPNs
Specialty Doctor, Mother-infant therapist (0.4), psychologist (0.8), OT, 2 nursery nurses, peer support workers
8 bed MBU- new, purpose built
CT3 +/- ST
OPCs throughout the county

34. Notts Perinatal Team 1,400 referrals per year, offer Ax to 700+
For serious SMI, 5% of live births=680
Birth rate 13,500 per year in Notts

35. Who to refer
Serious mental illness-whether well or ill especially with an affective component
PHx severe depression- esp post-partum
Current symptoms of mod depression or mod-severe anxiety disorder
Pre-conceptual counselling
From 13/40 to max 12/12pp

36. Summary Anti-depressants in pregnancy- TCAs and SSRIs
Anti-depressants in breast feeding- preference for SERTRALINE or Imipramine
Anti-psychotics in pregnancy- get secondary MH services involved
Active management of serious perinatal mental illnesses by our specialist team
Milder perinatal MH difficulties are managed in primary care

37. Summary Good prognosis for perinatal illnesses
Ask Perinatal Psychiatrists for advice
Expansion in perinatal services
‘Red Flags’
Recent significant change in mental state,
new thoughts or acts of violent self-harm,
new and persistent expressions of incompetency as a mother or estrangement from the infant

38. Any Questions?