Mental Health In

Pregnancy
Liaison Psychiatry

Introduction
Most women go through pregnancy with
no complications.
Mental health is dependent on
Type of mental illness experienced;
If the lady is on treatment if a mental illness
is present;
Recent stressful events in life;
How the lady feels about her pregnancy
Increased emotional liability;
Fears regarding inability to cope with pregnancy;
Fear of childbirth, changes in relationships or
roles;
Lack of support and being alone.

Introduction
Risk factors: Women with pre-existing mental health
problem;
Severe mental illnesses developing
much more quickly and more seriously;
Women who stop taking their
medications when they are pregnant.

Depression and anxiety are the

most common mental health
problems in pregnancy.

How to Recognise?
Pregnancy is a duration of great
adjustments
Emotional, social, financial and physical
demands are harder to manage.

No specific routine assessment tools.

Beck Depression Inventory

Assessment on
The severity of mental illness;
Adaptation to pregnancy, infant care, bonding
and pregnancy;
Necessity of referral to mental health service.

When to Refer a Patient?

Serious mental illness
Schizophrenia, bipolar disorder, severe
depression and schizoaffective disorder.

On treatment from mental health

services;
History of
Postpartum psychosis or severe postnatal
depression;
Severe anxiety disorder like OCD;
Eating disorder like anorexia or bulimia.

General
Non-Management
Pharmacological

Pharmacological

Pre-natal Counseling
Discuss and plan the
pregnancy;
Ways of maintaining mental
well-being during pregnancy.

Nutritional
recommendation
Folic acid or vitamin
supplements.

Improved social support

Psychotherapy;
Patient education.

Maternal care
Maternity services;
Assess and promote maternalinfant attachment.

Do not stop previous

mental health
medications without
discussing with a
doctor.
Need to be cautious.

Depression
Antenatal
depression is
overlooked.
1 in 10 women with
recurrent risk of
50%.
Causes
Physical
Physical changes in
pregnancy.
Hormonal changes.

Emotional and social

Lack of emotional
and social support.

Symptoms
Chronic anxiety;
Sense of
hopelessness;
Suicidal ideations;
Lack of energy.

Management
Mood diary;
Meditate and positive
thinking;
Fluoxetine is
considered safe.

Anxiety
Risk Factors
Younger age;
Previous history;
Previous stillbirth or
miscarriage;
Other life events.

Symptoms
Panic attacks;
Persistent worries;
Feeling on the edge

Generalised Anxiety
Disorder
Panic Disorders or
phobias.

Obsessive Compulsive
Disorder
Increased risk of
exacerbation or onset.

Post Traumatic Stress

Disorder
Previous complications
in pregnancy.

Bipolar Disorder
Usually a preexisting condition.
Most likely on
maintenance
therapy
Mood stabilisers
have teratogenic
risks.
Need to plan a
pregnancy and the
care.

Greatest risk for

Management
Combination of
mood stabilisers
Psychological
therapy;
Lifestyle advise.

Schizophrenia
Generally have less
children.
Usually a preexisting condition.
Increased risk of
Pregnancy
complications;
Birth complications;
Low birthweight;
Congenital
cardiovascular
anomalies.

Usually on
maintenance
antipsychotic
medication.
Relapse rate is high;
Needs to continue
medication unless
contraindicated;
Haloperidol or
trifluoperazine is
preferable.

Psychotropic Drugs
in pregnancy

Prescribing in pregnancy
Clear indication for drug and absence of effective
alternative treatment
Lowest effective dose for shortest time necessary
Drugs with better evidence base on absence of
harm
Individual assessments of benefits and risks
Avoid prescribing in first trimester if possible
Avoid polypharmacy
risk of synergistic teratogenicity

Reduced drug efficacy

Physiological changes alters pharmacokinetics

Increased volume of distribution and renal clearance

Reduced compliance
50% of pregnant women fear harming the fetus and
do not comply with prescription

Engage in early discussions weighing risks of fetal

exposure against risks of discontinuation

Antidepressants
Types

Effects

Conclusion

TCA & SSRI

Small increased risk of minor Relatively safe

anomalies, prematurity
Discontinue close to EDD to
avoid neonatal withdrawal

MAOI

Teratogenic in animals

AVOID

Antipsychotics
Types

Effects

Conclusion

1st generation

0.04% increased risk of

congenital anomalies

Use in drug-nave pregnant

patients
Taper in 3rd trimester

2nd generation

Elevated rates of GDM

Large-for-dates babies

Taper in 3rd trimester

Depot

Prematurity and small-fordates babies

Avoid if possible
Continue if risk of
discontinuation in
schizophrenic is highly
significant

Mood stabilisers
Types
Lithium

Effects
Conclusion
10% risk of congenital
Fetal echo at 16-20 weeks if
abnormality
prescribed in first trimester
Higher risk in later trimesters

Sodium valproate

Neural tube defects

22% risk of impaired
cognition

Avoid if possible in women of

childbearing age
Folate 5mg/day 12 weeks
prior to conception

Lamotrigine

Increased risk of oral cleft

Slow reduction in dosage

over last month with
reinstatement after delivery

Anxiolytics
Types

Effects

Conclusion

Benzodiazepines Increased risk of oral cleft Avoid if possible in first

trimester

ECT
Effective and relatively safe
Both normal and high-risk pregnancies
Careful attention to obstetric and anaesthetic factors
Low rate of ECT-related complications and no cases
of premature labour

Preparation
Intravenous hydration
Elevation of patients right hip
External fetal cardiac monitoring

Breastfeeding
Pros
General benefits of breastfeeding
Reduced fetal withdrawal symptoms if
psychotropes taken antenatally

Cons
Less disturbed sleep
Increased practical support from others
Avoidance of transmitted drugs
All psychotropic medication passes into breast
milk at 1% of maternal serum level

Clinical issues in breastfeeding

Avoid drugs or breastfeeding if baby is vulnerable

Premature
Renal/hepatic/cardiac/neurological impairment

Close monitoring of babys behaviour

Avoid sedating medications
Time feeds to avoid peak levels