© Springer India 2016
Alpesh Gandhi, Narendra Malhotra, Jaideep Malhotra, Nidhi Gupta and Neharika Malhotra Bora (eds.)Principles of Critical Care in Obstetrics10.1007/978-81-322-2686-4_2929. Acute Psychiatric Crisis in Obstetrics
(1)
Department of Obstetrics and Gynecology, DMIMS(DU), Wardha, India
Introduction and Etiopathology
Although pregnancy has typically been considered a time of emotional well-being, recent studies suggest that up to 20 % of women suffer from mood or anxiety disorders during pregnancy. It is not rare to present women with the first onset of psychiatric illness while pregnant.
It is likely that biological, psychological, and social factors interact to trigger an episode of a major psychiatric disorder in pregnant and postpartum women.
Estrogen has effects on neurotransmitter systems and has been implicated in major depressive disorder. Studies that support this theory have shown that postpartum estrogen supplementation, which slows the postpartum decline in estrogen levels, leads to resolution of depressive symptoms. Hormones and neurotransmitter systems and neurotransmitters implicated in major depressive disorder such as monoamine oxidases (MAOs), i.e., MAO-A and MAO-B, serotonin, and norepinephrine have been specifically studied in perinatal populations. According to hypothalamo-pituitary-cortico axis theory, the placenta independently produces a number of hormones (e.g., CRH, ACTH, and cortisol) that are regulated in a feed-forward manner, which leads to downregulation of autoreceptors in the hypothalamus and anterior pituitary. This process of receptor downregulation and the transition to a nonpregnant hormonal state has been hypothesized by some to constitute a period of vulnerability for mood disorders.
Immune theory states that pro-inflammatory cytokines produced in peripartum period due to pain in physical exertion and tissue injury are also linked to hypothalamic-pituitary-adrenal axis activity and have been associated with mood disorders in nonpregnant individuals.
Types of Psychiatric Disorders during Pregnancy
1.
Major depression
2.
Bipolar disorders
3.
Anxiety disorder
4.
Psychosis
Antidepressants and Pregnancy
Rates of major and minor depression during pregnancy are as high as approximating 10 %. About one third of depressed pregnant women experience the first episode of major depression. Pregnant women may have many clinical signs and symptoms like sleep and appetite disturbance and low energy, feelings of guilt and hopelessness, and suicidal thoughts. Of all the antidepressants, fluoxetine (Prozac) is the best studied antidepressant. Data collected from over 2500 cases indicate no increase in risk of major congenital malformation in fluoxetine-exposed infants.
Anxiolytic Therapy during Pregnancy
Pregnancy appears to be a protective period for some anxiety disorders, including panic, while it may precipitate to obsessive compulsive disorder. Some studies, however, have shown an increase in both panic disorder and OCD in pregnant women. Women with anxiety related to pregnancy may be at a greater risk for postnatal depression. Hence, recognition and management of anxiety disorders in pregnant women is important. For these cases, fluoxetine or a TCA is a reasonable treatment option. In patients who do not respond to these antidepressants, benzodiazepine use may be considered. Patients with moderate to severe OCD require maintenance therapy.
Bipolar Disorder During Pregnancy
Bipolar disorder or manic-depressive disorder affects between 3.9 and 6.4 % of women. Bipolar disorder should always be considered in the differential diagnosis of depression; one quarter of those presenting with depression prove to have bipolar disorder. Women who experience relapse appear to be more likely to have relapse into an episode of depression or mixed mood disorder that is characterized by both manic and depressive symptoms. Rates of postpartum relapse range from 32 to 67 %. Almost 33 % of women with bipolar disorder will experience an episode during pregnancy. Use of lithium in pregnancy may be associated with a small increase in congenital cardiac malformations particularly Ebstein’s anomaly, neonatal cardiac arrhythmias, hypoglycemia, nephrogenic diabetes insipidus function, premature delivery, and floppy infant syndrome. Symptoms of neonatal lithium toxicity include flaccidity, lethargy, and poor suck reflexes, which may persist for a week.
Guidelines for Treatment of Women with Bipolar Illness
Guidelines for women treated with lithium and plan to conceive are as follows:
1.
In women who experience mild and infrequent episodes of illness, treatment with lithium should be gradually tapered before conception.
2.
In women who have more severe episodes but are only at moderate risk for relapse in short-term, treatment with lithium should be tapered before conception but reinstituted after organogenesis.
3.
In women who have especially severe and frequent episodes of illness, treatment with lithium should be continued throughout gestation and the patient counseled regarding reproductive risks.
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