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Patient is undecided about 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.

  • Educate woman on the impact of pregnancy on mental health and subsequent birth outcomes

  • Discuss the importance of the reproductive life plan and pregnancy with women with mental illnesses. However, encourage women that they can still have healthy pregnancies and babies but they must manage disease carefully with safe medications

  • Woman should NOT discontinue medications without medical guidance first

Depression

Prevalence: 26 percent 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.

  • Coordination between maternity provider, mental health provider, and primary care provider in woman with mental health and preconception care plans is essential.

  • A single medication with higher does is preferred to multiple medications

  •  When selecting medicine to minimize the risk of illness:

    • Efficacy

    • Woman’s personal response

    • Available and reliable pregnancy safety information

  • If patient decides to continue antidepressants after discussing with provider, always choose the most effective in treating patient in the past.

  • 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.

  • Consider suggesting therapies such as psychotherapy, cognitive behavioral therapy, interpersonal therapy to women who want to avoid antidepressant medication.

  • Woman should NOT discontinue medications without medical guidance first.

Family Planning and Contraception:

  • Stress a highly effective LARC and to consider 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 screens positive, refer for a psychiatric assessment.

  • During pregnancy and postpartum, a woman is at high risk for relapsing into bipolar disorder (10-20 percent prevalence of postpartum psychosis). NOTE: this puts women at high risk for suicide and infanticide.

  • Bipolar women are at risk for unintended pregnancies and risky sexual behavior especially during manic periods. Provider should stress a reproductive life plan to minimize risk of poor birth outcomes.

Medication:

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

  • 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%). Must weigh risks and benefits before conceiving.

  • Anticonvulsants for bipolar disorder increases risk of neural tube disorder (1-7%). For those on these medications, high dosage of folic acid is recommended starting one month before attempt at conception and throughout the first trimester.

  • 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:

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

  • Encourage woman to contact your office if reproductive life plans on pregnancy changes.

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 are associated with poor birth outcomes.

  • 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

  • Teratogenicity from antipsychotics use on schizophrenia have not been confirmed.

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

  • If benefits of medication treatment during preconception/prenatal period are better than risk of relapse, then continue treatment.

Family Planning and Contraception:

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

  • Encourage woman to contact your office if reproductive life plans on pregnancy changes.

Page Updated: 8/14/2017