Dr Cressida Manning

Perinatal Mental Health
Dr Cressida Manning
Consultant Perinatal Psychiatrist
Florence House Mother and
Baby Unit
Contents of Presentation
 Confidential Enquiry into maternal deaths.
 Risks of untreated illness.
 Risk factors for postnatal depression and psychosis.
 Discussions around treatment.
 Medication.
Recent Case Study
 Felicia Boots. 35
 Mother of 2 ( 14 months and 10 weeks).
 Manslaughter on grounds of diminished responsibility.
 Stopped medication as breastfeeding.
Confidential Enquiry
 Centre for Maternal and Child Enquiries (CMACE)
 Most recent report ‘Saving Mothers Lives’ (2011) 2006-2008
 29 suicides 1st 6 months
 19 past psychiatric history
 9 identified of which 4 had care plan
Saving Mothers Lives
 38% Psychosis
 21% Severe Depressive Illness
Recommendations - Back to Basics 1
Saving Mothers Lives
Anxiety or depression
 Review in 2 weeks
 Consider psych referral if symptoms persist
 Refer urgently where:
Suicidal ideation, uncharacteristic
symptoms/marked change from normal
functioning, morbid fears, profound low mood,
personal or family history of serious affective
disorder, mental health deterioration, morbid
fears, panic attacks and intrusive obsessional
Effects of Untreated Illness
 Increased morbidity.
 Increased risks towards self and others.
 Links between maternal anxiety and fetal behaviour and heart rate
 Stress/anxiety during pregnancy can have long term effects on child
 Associated with an increased incidence of:
 Emotional problems - Anxiety/depression
 Behavioural problems – ADHD, conduct disorder
 Impaired cognitive development, esp language
 Sleep problems in infants
Sensitive early mothering important as what happens in utero for child
Effects of antenatal and
postnatal depression
 Children of mothers depressed in perinatal period compared to
children of well mothers:
 Lower IQ scores
 12x more likely to have a statement of special needs
 elevated risk of violence at 11 and 16 years
 More likely to suffer separation anxiety at 11 and a diagnosis of depression
at 16
 Majority of deaths secondary to postpartum psychosis
or very severe depressive illness
 Oates (2008) Suicide rate for ppp 2/1000
 Common profile; white, older, 2nd or subsequent
pregnancy, married, comfortable circumstances
 Likely to die violently
 Similar profile
 1/3rd mental illness
 Death extended suicide or occasionally altruistic
based on delusional belief
 Highest concern if delusion involves child e.g baby
changed, not hers, possessed, evil.
Postpartum Psychosis
1st few weeks highest risk
 Heron et al (2007) Greater than 80% 1st
 Link with BPAD
Bipolar Disorder
 52% relapse in 1st 40 weeks after stopping treatment
 If pregnant and stable on antipsychotic and likely to
relapse without medication continue
 Up to 70% relapse if untreated in postnatal period
 50% psychotic symptoms day 1 - 3
Postpartum Psychosis – Risk
 1st Baby
 Single
 C- Section
 Older
 Fertility Problems
 Previous episode – 1 in 7
 Sleep Loss
Warning Signs
 Early signs often non specific
 Insomnia, agitation/anxious, perplexed and odd
behaviour. Risk overlooked
Can lead to rapid deterioration to Psychotic symptoms
Postnatal Depression
 10 -15%
 Severe 3%
 1/3 to ½ continuation of antenatal anxiety and
 Onset few days to 6 months
 Increased risk in subsequent pregnancies – approx 25
– 50%
Postnatal Depression – Risk
 Antenatal anxiety or depression
 Past history of psychiatric illness
 Life events
 Lack of or perceived lack of support
 Low income
 Domestic violence
 FH of psychiatric illness
 Childhood abuse
Risk Factors cont…
 Obstetric factors
 Sleep deprivation
 Infant factors –irritability
 Personality factors – control, interpersonal sensitivity,
 Biological factors – inconsistent results
Early Detection
 1st contact;
Past or present mental illness
Previous psychiatric input,
including admissions
Family history of severe
mental illness
Treatment of pregnant and breast
feeding women- NICE guidelines
 Importance of balancing risks and benefits
 Cautious
 Women requiring psychological treatment should be seen for
treatment within 1 month of assessment and no longer than 3
 Discussion should include:
 Risk of relapse and not treating disorder
 Woman’s ability to cope with untreated symptoms
 Severity of previous episodes and response to treatment
 Woman’s preference
 Possibility that stopping drug with teratogenic risk once pregnancy
confirmed may not remove risk
 Risks of stopping medication abruptly
 Need for prompt treatment due to impact of illness on foetus/child
 Increased risk of harm of specific drug treatments
 Treatment option that would allow mother to breastfeed
 Prescribing:
 Drugs with lowest risk profile
 Lowest effective dose
 Monotherapy
 Risks lower threshold for psychological treatment
Important to put risks from drug treatment in context of the individual
woman’s illness
 Paroxetine in 1st trimester increase in cardiac
malformations (VSD) – planning pregnancy or
unplanned advise to stop. Other SSRIs now
 SSRI’s taken after 20 weeks may be associated
with an increased risk of persistent pulmonary
hypertension of the new born
Neonatal withdrawal- normally mild and
self limiting
Symptoms include;
Difficulties feeding
 Tricyclics have lower known risks during pregnancy than other
 Have higher fatal toxicity index
 CHD with clomipramine
 Withdrawal symptoms
 No effects on long term neurodevelopmental outcomes
 Imipramine
Other antidepressants
 Venlafaxine – Conflicting results for congenital malformations – data
too limited to say safe. Possible increased neonatal withdrawal and
increased risk of high blood pressure at higher doses. Theoretical risk
 Mirtazapine – Possible association with increased rate of spontaneous
abortion. No evidence to link to congenital malformations but data
too limited to say safe.
 JAMA 13 – Metaanalysis – preterm birth 3 days
- Apgar <0.5
- Weight 75g
- Spontaneous abortion not significant.
 Benzodiazepines
 Raised risk of oral cleft (7 in 1000; x10)
 Withdrawal syndrome – jitteriness, autonomic dysregulation, seizure,
floppy baby syndrome
 Consider gradually stopping in women who are pregnant
 Short term use only for severe agitation and anxiety
 Lithium – Ebsteins anomoly (1 in 1000) General population 1 in 20000
 Overall risk CHD 0.9-12% vs 0.5-1% general population.
 Floppy baby syndrome, thyroid dysfunction, nephrogenic diabetes
 High quantities in breast milk.
NTD 100 to 200 in 10000
Facial dysmorphias
Low IQ
Do not routinely prescribe to women of child
bearing age.
If no option adequate contraception
Discontinue if pregnant
 Carbamazepinne
 Increased risk congenital malformations -6.7% v 2.3%
 Craniofacial, GIT, cardiac, urinary tract and digit anomalies
 Advice as valproate
 Lamotrigine
 Cleft palate 8.9/1000
Atypical Antipsychotics
 Olanzapine and Quetiapine
 Limited data to base assessment of safety in pregnancy,
but available data does not suggest a substantially
increased risk of congenital malformations or
spontaneous abortions
 No pattern of malformations observed.
 Withdrawal symptoms
 Olanzapine – increased birth weight
What Clinicians need to do
 Do not assume it is always better to stop medication
 Provide prompt and Effective treatment of mental illness in
pregnancy and postnatal period
 Understand, consider and communicate known risks (and how these
will be managed) of medication
 Complete risk benefit analysis for individual patient.

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