Cases perin transcript — SMP305 lecture transcript

You want to put your hands up, I just want to see how many of you have seen. And these women whom you saw, how many of them were referred for mental health reasons? Or was that picked up during the consultation? It was. To pioneer's clinic. OK. Which hospital is this? Chesterfield. Chesterfield. OK. Oh, in the morning when I saw her. OK. So, she was specifically referred to that clinic? Yeah. OK. Um, the others, Who've seen, was it in a specific, was it in a mental health clinic or was it in general antenatal clinic? Was that picked up? I think my I think my one, yeah. OK. And did the woman ask for help or was it offered to her? How did that come up that she had mental health issue? Um, she sort of asked for help when, OK, and how were you feeling because it was sort of quite early on in her pregnancy and she was quite young and she's explaining what came on? OK, so that was initiated, yeah, and uh who if

anybody else is seen, how did that come up? The reason why I'm asking is, it's very. Commonly to just brush it under the carpet. So it is a big problem. And if not anything else from this lecture or from your placements that you've had, just remember that you have a duty to ask women to offer help, because it's still something that's not spoken about openly, but it is a big problem. Yeah. So, if you look at this picture, do you, Can you think of anything, anything, does anything strike out at all? They look like a happy mom and baby, if you saw this picture anyway, isn't it? But this was the reality. She's one amongst our fraternity, and this happened in the UK. OK, that's a sobering fact. So do you want to, I've just got a few questions. Do you want to work it out together or do you want to do it individually? I don't mind. What do you want to do, groups or individually? Your choice, or do you want me to pick?

OK, so then again, make it three groups like yesterday and just write down the um the answers. I don't think I. Copy of the questions now it's like a. I. OK. Unfortunately, I don't have it in my presentation. So, um, so perinatal mental health covers the period, you just shout out the answers, 6 weeks, 6 months. 12 months, 18 months? How many months or how many weeks? What's the time period that perinatal mental health covers? 6 weeks, 6 months, 12 months, 18 months? 6 weeks, how many of you say yes? 6 months? 12 months? 18 months? OK. Leading cause of mental mortality from 6 weeks after delivery up to 1 year after delivery, so these are the late deaths, OK? Heart disease, thrombosis, psychiatric causes, epilepsy. Psychiatric Psychiatric? How many say heart disease? Thrombosis? Epilepsy? Psychiatric causes? Mental health and cardiac causes account for similar mental mortality, true or false? True, false? Preferred place of admission for mothers requiring inpatient care. Adult psychiatry unit, intensive home-based team, tertiary psychiatric unit, mother baby unit. Adult psychiatry unit, tertiary psychiatric unit. Mother baby unit.

Intensive home-based incidence of anxiety in pregnancy, 5%, 13%, 23%, 30%, 5%, 13%, 23%. 30% pre-existing psychiatric condition with the highest risk of postpartum psychosis, bipolar disorder, schizophrenia, personality disorders, obsessive compulsive disorder, bipolar disorder, schizophrenia? Personality disorders? Obsessive compulsive disorder. management of anxiety in pregnancy, one or all or how many of you give me the choices, cognitive behavioural therapy, antidepressants, benzodiazepines, antipsychotics, so this is management of anxiety, yeah, antidepressants, cognitive behavioural therapy. Benzodiazepines, antipsychotics? Risk of ditrogenicity true or false lithium, diazepam, selective cytone reuptake inhibitors sodium valpyate. Effects of prenatal mental health and foetus again, yes or no, not significant preterm birth, behavioural difficulties later on in childhood, risk of thrombosis postnatal mood changes affects more than 50% of post. Postal women requires medical intervention? Yes or no? Not sure. Anxiety is a common presentation and risk of self-harm or harm to the baby. OK, let's find out, let's do this again at the end and let's see how we, how we fare. So have you heard of the Embrace? So this is a national programme that looks into maternal

deaths and neonatal deaths and infant deaths, and they work on the last 3 years, and they look at every single case and see what's gone well, what hasn't. Basically so that they can learn lessons and they published a report to say what has happened in the last three training. OK, the last one came out in September 25 and that looked at 21 to 23, so they divide the maternal deaths into direct and indirect causes. So direct uh causes which are directly related by or caused by pregnancy and related events and indirect art just could be coincidence. or indirectly contributing to the death, so there are again early and late deaths, so early is during pregnancy up to 6 weeks after delivery, and latest from 6 weeks up to a year, OK? Now, why do we pick 6 weeks? What do you know? What's the importance of 6 weeks postpartum? breastfeeding breastfeeding. OK. So what's that period called? 6 weeks postpartum, up to 6 weeks, what's that period called? What's the other word? Pureparian. Good. Why is it, what is the significance of that time

period? Is it when you have the highest risk of like post complications? I guess, yes, but so what is, is pregnancy a disease? Is it a pathological condition? No. No, it's a physiological adaptation. So every single organ in the body undergoes changes to accommodate the pregnancy changes, so it's immunity suppressed so it doesn't. This is like a foreign body because half the antigens are from the from from the father so graft versus host reaction could happen. So, so blood supply increases, heart rate increases, respiratory rate increases, renal function increases, gastric mobility changes, so every single organ in the body are those changes start up to cope with this pregnancy. All these physiological changes revert back to normal, revert back to pre-pregnancy state with over 6 weeks period. So at the end of 6 weeks, whatever changes were brought about the pregnancy have gone, have reversed. So until 6 weeks she's still an obstetric patient, obstetric remains under obstetric care, after 6 weeks, she's not related to pregnancy anymore, OK? So that's the importance of 6 weeks, and that's why they've classified the deaths up to 6 weeks as early, and 6 weeks onwards it's late, OK? Now, what's important here is in the late deaths. Both psychiatric and cardiovascular causes are almost similar, 11 versus

13. So if you think about the importance we ask about cardiac problems, if somebody's had cardiac surgery for a congenital abnormality in childhood, it's a big issue, whereas if she's got bipolar disorder pre-pregnancy, how many of you really. Knew that you have to take that significantly when the mortality is similar and of that late deaths, suicide and related psychiatric causes are 1/3. It's a huge number and even worse, it hasn't changed since whenever data has been collected. It hasn't. Changed psychiatric causes are still the leading cause of mental mortality in the late postpartum period. OK, so this is what the report was. So number 1 was thrombosis, 2 was heart disease. 3 was because it was between 21, 20, the COVID period. And fourth was mental health. So, let's look at a few scenarios and then see how we approach these women, OK? So, 28-year-old woman who's attending for her natal booking appointment, she's 12 weeks pregnant, yeah, she gives a history of depression since the age of 17, she was on sertraline since the age of 20, so for the last 8 years, she's in a stable. Relationship well supported full-time employment, non-smoker, and she's only been under the care of a GP she's not been referred to psychiatric services, no admission, nothing of the kind she

comes and asks, what do I do about my medication? So what category does sertraline come under? Is it an antipsychotic? Antidepressant, it's an SSR. It's an active serotonin reuptake inhibitor. So what would your advice be? So this woman has been on it for the last 8 years. Just stay on it. Just stay on it. Stay on it. Anybody else thinks otherwise? Would you ask, sorry, to evaluate her depression, see if she can take. So you ask her to see if she really needs it or she can do without it, OK? So you're asking her to titrate her dose depending on her symptoms or consider that, OK. Any other suggestions? Would you switch to paroxetine? Any particular reason why you want to switch? I heard that it's safe in pregnancy. Fluoxetine. No, paroxetine, paroxetine. OK, OK. We'll, we'll come to that in a minute. So we'll, we'll go back to the case and have a chat, yeah? So the incidence of depression or anxiety is 10 to 15%, OK? You are, you quoted it quite high at 25 and 30%, thankfully it's much lesser, and in the postnatal period, the combination of both again is around 15% psychosis is 1 to 2% per 0. much, much lesser, but the problem is only half of these are diagnosed, and fewer get proper care and treatment,

so we need to address these women in the preconception period. Why? What do you want to achieve by seeing them in the preconception period? It's the same as any condition in pregnancy, as in fact, any woman who's contemplating. Pregnancy has to have a preconception health check, because as we said, pregnancy is a challenge on the health of the mother, is a challenge on every system in her body, so unless she's at good physical, emotional health, to deal with the stress of pregnancy, she's going to struggle, yeah, if you think about people training to run a marathon, how many. Months they trained before, why? Because the marathon is going to put that person under so much of physical and emotional stress, so they train for it, whereas how many women trained to get pregnant? They don't even know what their health status is before they jumped into a pregnancy, so somebody who's got diabetes with poorly controlled blood sugars gets pregnant. Somebody who's got cardiac disease with poorly function. He gets pregnant. Somebody who's emotionally so labile with a pre-existing mental health condition gets pregnant, so that's the importance of preconception care with any condition, more so, or the same as during pregnancy. Now it's also important to support a woman through pregnancy because of the physical challenges, it also has an impact on her mental health, if she's not able to cope, she's not. Able to cope, yeah? So physical pain then translates into mental health as well and it's important to continue the care up to one year after delivery, the reason being, the late maternal mortality is counted up to one year after delivery, so these women need that support until one year after delivery, OK?

So how do we do that? Detailed history, and we do we. Questionnaires which is either the PHQ-9 or the GATD-7 and which is now being nice is now suggesting to move on to the Edinburgh postnatal questionnaire which is slowly coming into vogue it hasn't come but basically we use objective assessment with questionnaires OK so depression as you said 10 to 15% but the important thing is we need to look for that. Now a woman is extremely protective of her baby, which is what the maternal instinct is all about. So during pregnancy, she will not hurt herself for fear of harming the baby. She will not take any medication that she's not convinced about for fear of harming the baby. Yeah, however, if that feeling is not there. It is a red flag sign, so if she feels estranged from the baby, if she's still having hallucinations, if she feels that she's incompetent to care for the child, and she has self-harm or suicidal ideation, so that is a red flag sign that there's more that needs to

be done for her, OK? So whenever we see women during pregnancy, this is what we need to be focusing on. So as I said, we do the uh questionnaire and it's important to know her past history because recurrence of postnatal depression is 2 to 3 times. So this is the PHTN9 questionnaire. So how do we manage them? It's got to be an MDT approach, yeah, and the first line would be behavioural therapy with cognitive behavioural therapy, and then we move on to medication. Now, SSRI's on the whole, do not, are not associated with any significant teratogenic effects. There are some, uh, data saying paroxetine can be associated with persistent pulmonary hypertension or cardiac abnormalities, so between the SSRI's sertraline is the best choice, OK? And some of them babies can have withdrawal, so they might need monitoring, but majority of them are fine with breastfeeding, if they're on fluoxetine, we just have to warn them that it can be there in the babies's, uh, in the breast milk, therefore it can have high levels in the baby. So, the other important thing in terms of medication is

if somebody is on fluoxetine. for example, and they've been on it for the same scenario that we said, has been on it for the last 11 years, do we really want to change the medication in pregnancy? No, because pregnancy is a very emotionally labile period that you don't want to be trying new things then. If her mood is well controlled on a particular medication, just warn her, give her the information, let her make an informed choice, but then tell her it's fine to carry on, and that's why we have, we need the MDT, we need the. Prist on board, so are you aware of a subspecialty in psychiatry who take care of mental health in pregnancy? Do you know what that the subspecialty is called? Like adolescent, I'm sure you've heard of paediatric and adolescent, CAMHS, you've heard of that. So, the subspecialty in psychiatry is called perinatal mental health, so they take care of women during pregnancy and after delivery up to a year, yeah? so the same scenario, are you confident how you would approach her now? So we wouldn't want to swap her medication outright unless she wants to, yes, you've had that discussion with her, ask her if she wants to titrate her medication because she might say, no, I don't want to, so we are not here to force anybody, but give her the information, let her make the informed choice.

OK, the problem I have with women being referred to my clinic is GPs stop the medication, the minute she goes and tells them with a positive pregnancy test, they say, oh, you're on medication that you shouldn't be taking, it's a psychiatric medication, stop it now. So by the time, and the medication take at least 4 to 6 weeks to kick in to for them to see the benefit as well as to completely get withdrawn from the system for them to see the. When the response of stopping the medication, so by the time they come to see me at 12 weeks, it's been 6 weeks, so they've been all right uh because the medication is still there in the system, and by the time they come to see me 6 to 8 weeks later, that's when their mood just goes down, OK? So let's move on to the second scenario now, any questions on the first one? So this is an 18-year-old girl who's already in her 3rd pregnancy. Who's had two previous social terminations of pregnancy, this is a new partner, she's well known to camps, she's been with them for a long time, she's a smoker. She gives a history of cocaine and alcohol use in the past, but she says she's not using them now, and she was on propranolol for anxiety for two years, but she's now stopped the medication because she says she

feels well. How are you going to manage? Are you, are you confident this woman is in a good position? There are a lot of alarm bells ringing here, isn't it? So, one social issues because of her age, she's obviously not in a stable relationship, so what is the kind of support that she's getting? She's had two social terminations before, this is with a new partner, she smokes, she was. Drinking alcohol and was using cocaine in the past, she says she stopped, we've got to take her word for it, we do not know what her employment status is, what her housing situation is, we do not know if she's in an abusive relationship, none of them we know what's the support she has from her family, so there's a lot of social factors that are involved here as well, so this is more to highlight compared to the previous case where it was just purely. Depression, but everything else seems safe, OK? So here we definitely want to get more support from our colleagues, we don't want to be managing her on

her own. So let's talk about anxiety now, again, similar to depression, 10 to 15%. Now what's the characteristic of anxiety when do you say this is anxiety, this is OK. If you were going to do some adventure sport, say bungee jumping, I would never be able to push myself to do it. I don't know how many of you here are happy to try it. So if you're going to do it, what would be your anxiety state? I'd be concerned if somebody said, that doesn't bother me. You would be anxious to a certain extent, isn't it? That's expected. That's normal, whereas if somebody's excessively anxious, which is not situation related at all, that is a concern, yeah, so that's how we identify anxiety, somebody refusing to leave the house and step out of the house because she's going to be hit by a car. That's not normal. So, again, we use the um objective scoring system called GAD-7 to assess anxiety, so that that's the scale. So what are the common anxiety disorders? It could just be general anxiety, it could be post-traumatic stress, which could be anything. It could be because she went to hospital as a child. and they did a blood test on her at the age of 7, she's traumatised by that experience, so she

doesn't want to come back to the hospital again. She's seen her sister go through labour and saw everything that was appeared scary, so she's scared that she's going to go through the same thing again. She's getting flashbacks from the. That experience, she's been abused before, and now that she's pregnant, it's all coming back, she herself has had a labour before and found that experience so traumatic, so that is called tocophobia, it's a morbid fear of childbirth, so toko is labour and phobia is fear. So it could be any of these. So how do we manage these women? Again, make sure we get enough support from our colleagues, always MDT again, we try the behavioural therapy first, and the next line would be antidepressants, so for anxiety as well, we use antidepressants, because it just relaxes them a bit more. And we try to avoid benzodiazepines, which are the anxiolytics, so the, the reason why we avoid is because they can be associated with cleft palate, neonatal withdrawal, and floppy baby, OK? If at all we have to do it, then we try and avoid in the third trimester and give it for a short duration of time. So, similar to depression, we've got to take care of them at every stage in pregnancy.

Because they can have an impact on the baby too, so any adverse effect on pregnancy has an impact on the course of pregnancy, so preterm delivery, growth restriction, low birth weight, and behavioural effects on the baby too so coming back to this case, would you be more happy to manage her now? to get the MDT approach, make sure she's safe, get social services to check on her as well, and give her the support if she wants medication or counselling, all right? Happy with that scenario? So then moving on to the more rarer but most severe forms of mental health, which has the. Psychotic disorders, bipolar and schizophrenia. Now, why do we worry so much about these? Because of the risk of psychotic illnesses, because of the risk of pupil psychosis, OK? This cohort of women need to be under the care of perinatal psychiatrist. They have a birth plan meeting at 2 weeks with a 14 day care plan for up to 14 days after. Delivery they might need elect to mother baby unit admission

because they might end up with an emergency admission there, so they need to be closely monitored so similar, uh, both bipolar and schizoaffective disorders are affecting 1-2% of the population, but the concern is the mean age is the age that they commonly come to us with pregnancy. But then look at the risk of psychosis in this cohort, 25-50% so it's both psychological and pharmacological management, it's important that the medication is not stopped, OK? In terms of schizophrenia, again, similar kind of presentation, yeah that's positive, negative. And manic and depressive episodes, that's similar kind of flare-ups, again, peripheral psychosis is the big bug here medic management is similar, OK? Now, one important thing, um, with mood stabilisers are lithium and sodium valprobate, which are both teratogenic, and we would want to avoid them in pregnancy, so if somebody comes with being on lithium, we've got to have a close. Involvement with the psychiatrist and discussion with the women. Having said that, I've had 3 women in the last 15 years who've been on lithium and who've said, please do not stop lithium, I cannot cope, so we've managed them through pregnancy being on lithium because it was their choice, it was an informed decision.

Yeah, so what is the teratogenic effect of sodium chloate? The system does it affect? Any guesses? Causes neural tube tube defects. OK. What about lithium? Which system does that affect? Cardiac, OK? So let's move on to the third scenario. So she's a 40-year-old executive director, works in high flying career. She has a past history of bipolar disorder. She was on antipsychotics, and her mood has been fine. Previous pregnancy, she stopped the medication and then said. I coped all right. She had postnatal depression, but then she said I was fine. How would you want to manage her? So the principles of care are the same, whichever cohort you saw. So I just want you guys to shout out now. I'm not going to tell. About how she coped without the medication? Absolutely. What kind of support she had, what really happened? Excellent. And then I guess if she was struggling I would talk about offering antipsychotic medications, preferably the least risky one would it be to her I guess. Yeah. Find out what she was on, what worked well for her, and when did she stop it? Did she stop it in her last pregnancy too? Because she might say I didn't take it in my last pregnancy, I was fine, but. And also what you want to find out is what is her situation now compared to the last one, we don't know how old her last child was, it might have been in her twenties, she might have been in a different relationship, she might have been in different social environment, so find out what her situation is now, this can be completely different, so the importance here. I reassess the woman as if from the beginning, OK?

And then find out what her needs are and cater the treatment accordingly yeah? Would you want to get the psychiatrist involved in this woman? Absolutely. Bipolar, stopped medication, says she had postnatal depression before, but said she's coping. I'm not an expert in assessing her mental health, yeah? So, moving on to the common postnatal changes, so have you heard of the phrase baby blues? Every pregnant woman is told, oh baby blues after delivery, so it affects almost 3 out of 4 women. It starts in the first week, peaks at day 5. It's usually self-limiting. Why do you think it's so common? Yes, what else? Yes, sleep deprivation. What else? She's gone through the most stressful time of her life. labour is a big event, yeah, so she's gone through the challenges, emotional challenge, the physical. Challenge of labour. We do not know what the course of labour was in our eyes. It might have been straightforward. She came, she went through a smooth labour, delivered within 6 hours. Small episotomy, sutured, needed a little bit of lift out with the forceps. Went home well, didn't bleed, no infection, no thrombosis. Fine, but for her.

She didn't deliver herself. She needed somebody to help her with the forceps. She's had a tear. She's had a cut. She's in pain, and she's got this new baby who's crying all the time. She doesn't know what the baby's crying for, and it's up to her to deal with that crying baby. It's her responsibility, so it's a. Lot to take, plus she might have 3 other children who need feeding, who need to be put to sleep as well. All she needs is a bit of TLC rather than just saying, oh, baby blues, oh, she's crying. Come on, yeah, so all the biological and the psychological factors come into play. And with good support and good um emotional and physical stamina, the woman is going to deal with it. End of the day, she's a strong woman. Yeah, so this is the biggest concern in the postpartum, which is pupil psychosis. Thankfully, it's only 1 in 2 in 1000, but the problem is, it's very. Predictable now we know the risk factors we know these conditions, especially bipolar disorder, has a 50% up to 50% chance of risk of psychosis. We also know it's a 50% risk of recurrence in subsequent pregnancies, and if there's a family history, all the

more concerning, so they can be very vague to start off it could. Just be like, exhaustion, upset, depression, but the problem is, it's rapidly changing, OK? It's a psychiatric emergency. The men are still dying from this, so when we said 1/3 of the mortality after 6 weeks to a year is because of this, it is a big number. They need to be intervened and they die by violent deaths. They jump off the bridge, alight themselves, hang in. So it's really important that we identify these women and get a safety net around them to support them and prevent it from happening, so. Units are, there are only 19 in the country. The reason why they are specifically to whom both mother and baby is to support bonding, OK? So let me see if this works. Babies this young are extremely responsive to the emotions and the reactivity and the social interaction that they get from the world around them. This is something that we started studying 34 years ago when people didn't think that infants could engage in social

interaction. The still face experiment that the mother did was she sits down and she's playing with her baby who's about a year of age. 00. And she gives a greeting to the baby. The baby gives a greeting back to, This baby starts pointing at different places in the world, and then the mother's trying to engage her and play with her. Working to coordinate their emotions and their intentions, what they want to do in the world, and that's really what the baby is used to, and then we ask the mother to not respond to the baby. The baby very quickly picks up on this, and then she uses all of her abilities. To try and get the mother back, she smiles at the mother. She points because she's used to the mother looking where she points. The baby puts both hands up in front of her and says, what's happening here? She makes that screechy sound. Like, come on, why aren't we doing this? Even in those two minutes when they don't get the normal reaction, they react with negative emotions, they turn away, they feel the stress of it. They actually they lose control of their posture because of the stress that they're.

for what reason. It's a little like the good, the bad and the ugly. The good is that normal stuff that goes on that we all do with our kids. The bad is when something bad happens, but the infant can overcome it. After all, when we stop the still face, the mother and the baby start to play again. The elderly is when. You don't give the child any chance to get back to the good. There's no reparation, and they're stuck in a really ugly situations. 2 minutes of interaction says a lot. So if this child is exposed to a depressed mother who is just not engaging, so that is how the child is going to develop. That's why we've got at the mother's help. And remember it's not just this baby that we are dealing with. She's got the entire family in the background. She's got other children if she may. It's a partner, so it's the whole circle that's affected, OK? So, that's the importance and that's what your take home message is it's remembering to ask because why do women fear asking for help? Why do you think the men don't say they're not able to cope? Absolutely. The first thing they think is if they are being incompetent as a mom, then the child is going to be taken away from them, so they rather put up

and struggle in the hope that it will just go away. It's really important that we tell them that unless they are in good health, the baby is not going to be in good health. It's going to be behavioural factors, changes, adaptation problems, mental health issues in the baby, and it's going to carry on with the different generations, so that's why it's important that we really tell them help is out there, just shout for help. So it takes at least 7 times, asking a woman before she shouts. And ask for help. So every opportunity, every person that asks her, she realises that maybe I can tell, maybe it's not going to be an issue. Everybody seems to be asking me about it. Maybe I can say I need help. So even if you think you're not contributing in whatever specialty you work, or even as a medical student in the rest of your career, if you just ask, you'll be another person who's. Given that woman that there is hope out there, yeah, so, to summarise, perinatal mental health is common, and there

are huge impact with poorly treated perinatal mental health, it's important to get a good outcome, remember it's an MDT approach, and it's got to be empathetic and non-judgmental so be proactive. Ask them, signpost them to, you, you may not know the answers to every question, but just signpost them in the right direction, be positive, and again reassure them that not all medications are theratogenic, OK? Any questions? So would you answer the questions differently now if we went through them again? So perinatal mental health covers the postnatal period up to? What's the duration? 1 year. Leading cause of maternal mortality from 6 weeks after delivery up to 1 year after delivery. What's the what's the problem? What's the condition? You're talking about the late maternal deaths. What's the reading cost? Come on. Psychiatric. There's got to be some benefit of me standing here and talking for 45 minutes. Mental health and cardiac disease account for similar mental mortality, true or false. I expect to hear a few. More voices, come on guys, please. Preferred place of admission for mothers requiring inpatient care? Incidence of anxiety in pregnancy?

10 or 15 or 1510 to 15. Depression? Similar pre-existing psychiatric. A condition with the highest risk of postpartum psychosis? Bipolar disorder. Management of anxiety in pregnancy. How would you go about? what all would you offer them? CBT SSRS counselling. If they need medication, what's your first choice? It would be sexually anti antidepressants first. If that doesn't work, then you go to anxiolytics. So which are the two drugs that you would definitely avoid in pregnancy? Lithium. Postnatal mood changes affect what percentage of women. More than 50 to 80%, yeah? And they just, it's usually self-limiting and you just need to give them reassurance, OK? Any questions? All right. N I It I see Yeah, I used to be a girl. At the moment there is. with And. All Yeah. this morning. Oh, OK. What was that? I. I. I. I. I. I.