Neonatal withdrawal syndrome
Cognitive/neurobehavioural problems
Breastfeeding risks
Stress on fetus
Poor obstetric outcome
Low birth weight
Intrauterine growth restriction
Poor mother–infant bonding
Severe depression warrants a combination of antidepressant plus CBT and referral to a specialist perinatal psychiatry service if one exists locally. Where risk of suicide or harm to the pregnancy becomes an issue, hospitalization may be needed.
Psychosis in pregnancy
Clinical features
Psychotic symptoms in pregnancy, such as those of schizophrenia and severe bipolar disorder, do not differ from other times in a woman’s life.
Hallucinations in any modality can occur. Most commonly these will be auditory, with the woman complaining of ‘hearing voices’. She may also see things when nothing is there (visual hallucinations) or feel things on her skin (tactile hallucinations).
Delusions (fixed false beliefs) that are held with absolute conviction are the other main psychotic symptom, and persecutory delusions are the most common. Other types of delusions that may be evident include grandiose, nihilistic, jealous, hypochondriacal or bizarre.
In chronic schizophrenia, ‘negative’ symptoms such as affective blunting, poverty of speech (alogia), loss of drive (avolition) and social withdrawal (asociality) may be predominant and disabling.
Bipolar disorder that is unstable presents with hypomania/mania or depression. Hypomania/mania is characterized by elevated mood, overactivity, racing thoughts, grandiose thinking, pressured speech, disinhibition and decreased need for sleep. Depressive symptoms include pervasive low mood, loss of interest and enjoyment (anhedonia), poor concentration, sleep disturbance, negative thinking and hopelessness.
Treatment
Management of pregnant women with psychosis is complex and requires an integrated multidisciplinary approach including psychiatry, obstetrics, paediatrics and social services. The aim is to maximize the mental and physical health of the mother while minimizing any risks to the child. Success hinges on forward planning, joint working and good communication between disciplines.
As a general guide, women with psychosis who become pregnant while on antipsychotic medication will, in the majority of cases, need to continue on it as maintenance therapy. However, it is advisable that the lowest effective dose be used in pregnancy. Abrupt discontinuation of antipsychotic and mood-stabilizing medication (e.g. lithium) should be avoided without discussion with a psychiatrist. Polypharmacy is also best avoided in pregnancy.
As with antidepressant prescribing, any decision to start a new antipsychotic in pregnancy should be made after a full discussion of the risks and benefits of the medication with the pregnant woman. A multidisciplinary pre-birth planning meeting around 30 weeks of gestation is essential in all cases of psychosis and for women at particularly high risk of postpartum psychosis (e.g. women with bipolar disorder).
A prophylactic management plan for prevention of postpartum psychosis needs to be made for all bipolar women, even in cases where the condition has been stable for many years. A recommended strategy is to start such women on a low-dose atypical antipsychotic (e.g. olanzapine) immediately after delivery, and to continue this for at least 3 months into the postnatal period.
General principles of prescribing psychotropic medication in pregnancy are summarized in Table 10.2. Current evidence on the safety profile of psychotropic medication in pregnancy is summarized in Table 10.3.
Careful risk–benefit assessment
If mild to moderate severity, use non-pharmacological intervention
Avoid first-trimester exposure if possible
Choose drugs with lower risk profiles for mother/fetus/infant
Start at the lowest effective dose and increase slowly
Avoid abrupt discontinuation of maintenance mood-stabilizing/antipsychotic medication without discussion with psychiatrist
Avoid polypharmacy if possible
Postnatal psychiatric disorders
Postpartum blues
Incidence
Affects 50–80% of women.
Onset
Typically starts on second or third postnatal day.
Prognosis
Transient, self-limiting. Symptoms should start to remit by second week. However, women who experience severe postpartum blues may be up to three times more likely to develop postnatal depression, according to research.
Treatment
No specific treatment other than reassurance and support is required.
Postnatal depression
Incidence
Affects 10–15% of women at any time in the first 6 months following childbirth.
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