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Patient is Not (PIC)turing Pregnancy - Mental Health

Background

  • Scope: Women in reproductive age are more likely to have mental health issues such as depression and anxiety (26%) and other mental health issues (35%). Other conditions may include: Anxiety disorders, attention deficit hyperactivity disorder (ADHD), bipolar disorder. Borderline personality disorder, eating disorder and schizophrenia.

  • Preconception Significance: Psychiatric disorder in pregnancy can lead to poor obstetric outcomes, postpartum psychiatric disease, increased substance abuse, low prenatal care, and adverse infant outcomes that may cause more trauma to patient and child.

Reproductive Life plans are essential for women with comorbid mental illnesses. These plans should focus on contraception while conditions stabilize.

Medication regimens for mental illness can pose threats to maternal and fetal well-being and must be discussed with patient before stopping contraception and beginning conception.

Decisions about treatments during pregnancy should be made as risk to the mother and baby from the disorder outweighs risk of treatment.

  • Risk Identification:

Screening:

  • Family history of mental illness

  • Personal history of mood disorders, depression

  • History of postpartum depression, psychosis

  • History of military service (for military sexual trauma or exposure to combat, both associated with mental health illness)

Clinician Guide

  • Mental health screenings should be a part of routine primary care, screening for:

    • Alcohol/substance abuse

    • Psychosocial stress (abuse/intimate partner violence, financial issues, lack of social support)

    • History of personal or familial mental illness

    • Other current illnesses

    • Current medications

    • History of mental illness during previous pregnancies

    • Illness instability

    • Served in the military, Ask:

      • Did you experience unwanted sexual attention (touching, pressure, harassment)?

      • Were you ever forced or threatened with force to have sexual contact against your will?

      • “Yes” to these questions requires a psychiatric evaluation.

  • Woman should NOT discontinue medications without medical guidance first

Depression

Prevalence: 26% of women have depression or anxiety. More than 60 percent of women experience depression during pregnancy.

  • Providers must routinely screen for depression and anxiety for all women of childbearing age.

  • Note for depression in previous pregnancy as an indication for postpartum depression as depression could lead to preterm birth, low birth weight and other adverse effects.

  • Note for anxiety disorders during pregnancy can also lead to poor birth outcomes, complications during pregnancy, child behavioral issues socially and with mother.

  • Women at risk for unintended pregnancy should actively create and follow a reproductive life plan to minimize chance of pregnancy with poor birth outcomes.

Medication:

  • 68 percent of women who stop using antidepressants will relapse into depression.

  • When selecting medicine to minimize the risk of illness:

    • Efficacy

    • Woman’ personal response

    • Available and reliable pregnancy safety information

  • SSRIs are the usual treatments for depression in most patients, pregnant or not. However, note, paroxetine in first trimester is associated with increased cardiac malformations so do not prescriber for women who are risk for pregnancy.

  • Woman should NOT discontinue medications without medical guidance first.

  • Stress that she should see her provider immediately if she suspects or is pregnant.

Family Planning and Contraception:

  • Stress a highly effective LARC given the woman’s desires to become pregnant and to consider preconception care in her reproductive life plan.

Bipolar Disorder

Prevalence: About 2.6 percent of the U.S. population older than 18 years old (median age: 25)

  • Bipolar is a mood disorder with episodes of mania, hypomania and depression.

  • Onset usually begins during reproductive years.

  • Screen for familial patterns as 10 percent of first degree relatives are usually affected:

    • Ask of familial history of mood disorders and personal history of depression or mania.

    • If the patient screens positive, refer for a psychiatric assessment.

Medication:

  • There can be a high relapse risk if medications are discontinued.

  • Choose drug therapies during preconception/prenatal period by:

    • Response to previous medications

    • Severity of illness

    • Euthymia during medication use

    • Relapse time after discontinuation of medication

    • Recovery time after reintroduction of medication

    • Fetal safety of drug

  • First trimester exposure to lithium increases risk of cardiac malformation by 10-20 times more than the general population (Absolute risk 0.05-0.1%).

  • Anticonvulsants for bipolar disorder increases risk of neural tube disorder (1-7%).

  • Also, discuss medication choices with the woman’s psychiatric provider for more coordinated care.

  • Woman should NOT discontinue medications without medical guidance first.

Family Planning and Contraception:

  • Note that unplanned pregnancies are common with bipolar disorders as manic episodes can involve high risk sexual behavior.

  • Stress a highly effective LARC and to consider reproductive life plan.

  • Encourage woman to contact your office if reproductive life plans on pregnancy changes or she wishes to stop contraception.

Schizophrenia

Prevalence: About 1 percent of the U.S. population, average onset for women is 25-25 years old.

  • Screen for family history of psychotic disorders and personal history of psychosis.

  • Women with schizophrenia have a higher prevalence of cigarette smoking, alcohol use, illicit drug use, low socioeconomic status and all should be assessed by provider.

  • Some of the antipsychotic medications for treatment have an increased risk for causing Type 2 diabetes mellitus and thus women on this drug should be monitored accordingly.

Medication:

  • There is a high risk for relapse if medications are discontinued

  • Deviations from medication regimens should be coordinated with woman’s mental health provider.

  • Woman should NOT discontinue medications without medical guidance first.

Family Planning and Contraception:

  • Stress a highly effective LARC given the woman’s desires to become pregnant and to consider preconception care in reproductive life plan.

  • Encourage woman to contact your office if reproductive life plans on pregnancy changes or she wishes to stop contraception.

 

Page Updated: 8/14/2017