Perinatal Psychiatry

Mother	Baby
❏ Suicide	❏ Low birth weight, smaller head circumferences, premature delivery, etc.
❏ Unhealthy practices e.g. smoking	❏ Poor mother-infant attachment, delayed cognitive and linguistic skills, impaired emotional development, and behavioral issues
❏ Poor nutrition	❏ Emotional instability and conduct disorders, attempts at suicide, and require mental health services
❏ Less compliant with prenatal care
❏ Increased pain, nausea, stomach pain, SOB, GI symptoms, etc.

Depression in Pregnant Women

10% to 16% of pregnant women fulfill the diagnostic criteria for MDD, and even more women experience subsyndromal depressive symptoms.
Many of depressive symptoms overlap with the physical and mental changes experienced during pregnancy.

Several meta-analyses of SSRIs: NO increase in risk of congenital malformation with the exception of ?paroxetine.
Antidepressants reduce risk for preterm birth and cesarean delivery compared with depressed women untreated BUT has more neonatal complications, including low Apgar score (? Withdrawal syndrome), but benign and self-limited.
NO association between TCA use in pregnancy and structural malformations.
Fluoxetine and TCA are not behavioral teratogens and do not have a significant effect on cognitive development, language or behavior.
Presumed associations between antidepressants and malformations may be complicated by confounders e.g., depression itself, poly-drug interactions.

Bupropion, ? venlafaxine, duloxetine, nefazodone, and mirtazepine: NO statistically significant difference or higher than expected rate of congenital anomalies.
ECT has long been regarded as a safe and effective treatment for severe depression, life-threatening depression, or failure to respond to antidepressant drugs.
Psychotherapy: is considered to be an evidence-based treatment of mood disorders.
Mild depression: interpersonal psychotherapy (IPT) or cognitive behavioral therapy (CBT), both having solid evidence-based outcomes data for the treatment of depression.
Couples counseling.

Typical antipsychotics, especially high potent, considered as relatively safe compared to other medications.
Atypical antipsychotics: no major malformations were found. However, limited data so far, Metabolic syndrome is more with olanzapine and clozapine.
Lithium is considered first-line mood stabilizer during pregnancy despite rare cardiac anomaly.
Lamotrigine is the safest anticonvulsants mood stabilizers.
Avoid valproate & carbamazepine in childbearing women and pregnancy.

Neural tube defects secondary to interference with folate metabolism with first trimester exposure

– Risk = 7-16%

Craniofacial defects:
Mid-face hypoplasia, short nose with anteverted nostrils, and long upper lip
Hypoglycemia, hepatic dysfunction, fingernail hypoplasia, cardiac defects, cleft palate, hypospadias, polydactyly
Neonatal toxicity possible
Significantly lower mean IQ and verbal IQ

SSRIs are medications prescribed most commonly but other agents should be considered.
More positive response to SSRIs and Venlafaxine, than to TCAs.
Pharmacotherapy should continue for at least 6 months to prevent a relapse of symptoms.
The nutritional, immunologic, and psychological benefits of breastfeeding have been well documented.
Breastfeeding: All antidepressants are secreted to some degree into the breast milk!
Recommend sertraline or Paroxetine: Infant serum levels are low to undetectable.

Antidepressants, especially SSRIs, in general are considered to be relatively safe for use during breastfeeding when clinically warranted.
Research on long-term effects of SSRI and TCA exposure through breast milk on children shows NO alteration in IQ, language development, or behavior.
IPT and CBT are effective.

Rare: 1 in 500-1000 deliveries.
Typically presents within 2 weeks of delivery.
Often is a manifestation of bipolar disorder (BP).
S/S:
Severe insomnia
Rapid mood swings
Anxiety
Psychomotor restlessness
Delusions (childbirth themes)
Hallucinations
Cognitive disturbance, neglecting infant.
Assess for suicidal, homicidal/ infanticidal ideations.
Treatment: similar to Tx of bipolar disorder, consider ECT.
Majority fully recover, some may recur only postpartum, few will end up as BD.
For women with bipolar disorder, breastfeeding may be challenging!
On-demand breastfeeding disrupts the mother’s sleep and thus increases relapse during the acute postpartum period.
Toxicity was reported in breastfed infants exposed to mood stabilizers, including lithium and carbamazepine.
Antipsychotics except clozapine are mostly compatible with breastfeeding.