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Post Partum Depression

From Mediwikis

Postnatal psychiatric illness is both a major and important cause of maternal morbidity and mortality. Take care to ask about past psychiatric history when covering PMH in your history of a pregnant woman as it is often missed. These women should be cared for and referred to psychiatric services if necessary to optimize their care.

Bear in mind that women who experience these once are at an increased risk of them happening again in future pregnancies and postnatal depression is specifically associated with a ~70% risk of later developing depression.

There are four major brackets of postnatal psychiatric problems ranging from the least to the most severe as follows:

Third Day Blues

  • 50% of women
  • Emotional lability - temporary
  • Key management is reassurance and support

Postnatal Depression

  • 10% of women
  • Majority never present
  • Screening is needed but difficult (could try some of the standard questionnaires available)
  • Risk factors - isolated, PMH of depression, complicated pregnancy
  • Variable severity
  • Symptoms - fatigue, HAIG - hopelessness, anxiety, insomnia, guilt
  • Management - support, psychotherapy, antidepressants (see Depression)[1]
  • ΔΔ - postpartum thyroiditis

Antidepressants in Pregnancy[2]

  • Sick, premature or low birthweight babies should not be exposed to antidepressants via breast milk- seek specialist advice.
  • Otherwise:
    • TCAs except doxepin are safe
    • SSRIs except Citalopram and Fluoxetine are safe
  • MAOIs and other antidepressants are not recommended

Thoughts of self harm, suicide or harm to child

  • Most (but not all) women in this category have a PMH of psychiatric illness (especially bipolar affective disorder)
  • Women at high risk (due to previous or concurrent psychiatric illness) must have specialist support in pregnancy including seeing a psychiatrist prior to delivery and MDT postnatal care[3]
  • There are specialist "Mother and Baby" inpatient psychiatric units that can help to support mothers if needed

Puerperal Psychosis

  • 0.2% of women
  • Typically around the fourth day after birth there is an acute psychosis that can be extremely severe, women can be a real risk to both themselves and their children
  • Risk factors - first birth, FH
  • Management - specialist care, antipsychotics, tranquillisers, psychiatric admission
  • Usually full recovery
  • Future risk of mental illness increased, 10% risk of relapse following future births

Don't Forget

The key people in all of the above diagnoses are the mother and baby, but don't forget any other people that may be in their immediate circle (family, friends). Fathers can feel especially devastated when postnatal mental illness occurs, they may need extra support.

References

  1. http://www.nice.org.uk/guidance/cg192
  2. http://cks.nice.org.uk/depression-antenatal-and-postnatal#!scenario:2
  3. http://cks.nice.org.uk/depression-antenatal-and-postnatal#!scenario:2