Promoting Maternal Mental Health During and After Pregnancy

Transcription

1 Promoting Maternal Mental Health During and After Pregnancy Leena Mittal, MD, FAPM Associate Medical Director, MCPAP for Moms Director, Reproductive Psychiatry Consultation, Brigham and Women s Hospital Instructor, Harvard Medical School

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6 Perinatal depression is the most common complication of pregnancy

7 Perinatal depression is twice as common as gestational diabetes Depression in 100 Diabetes 3-7 in 100 Gavin et al. Ob Gyn 2005, Vesga-Lopez et al. Arch Gen Psychiatry ACOG Practice Bulletin 2013.

8 Perinatal depression affects mom, child & family Poor health care Substance abuse Preeclampsia Maternal suicide Low birth weight Preterm delivery Cognitive delays Behavioral problems Bodnar et al. J Clin Psych Cripe et al. Pedi &Perinatal Epid Forman et al. Dev & psych 2007

9 Two-thirds of perinatal depression begins before birth Pregnancy 33% Before pregnancy 27% Postpartu m 40% Wisner et al. JAMA Psychiatry

10 Perinatal depression is under-diagnosed and under-treated Treated Women Untreated women Byatt N, et al. Obstetrics and Gynecology

11 Management of perinatal psychiatric disorders Pregnancy Guiding principles Depression & Anxiety Bipolar & Psychosis Postpartum

12 Think pregnancy for ALL reproductive aged women Half of pregnancies are unplanned Finer & Zolna Contraception 2011.

13 Document preconception discussion Document contraception Discuss risks of teratogenic medication Avoid valproic acid Note interaction between hormonal contraception and mood stabilizers - Birth Control Pill can decrease lamotrigine levels - Oxcarbazepine can decrease BCP efficacy

14 Risk Depends on Stage of Pregnancy

15 The U.S. FDA pregnancy risk categorization is limited Unclear categories Not consider risks of maternal illness Does NOT inform decision making Not consider benefits of medication

16 No choice is completely free of risk Need to balance and discuss the risks and benefits of medication treatment and risks of untreated mental illness

17 Management of perinatal psychiatric disorders Pregnancy Guiding Principles Depression & Anxiety Bipolar & Psychosis Postpartum

18 High risk of relapse during pregnancy in woman discontinuing antidepressants preconception Continue Discontinue *If tapering medication prior to conception, continue to follow women during pregnancy. Cohen et al. JAMA Yonkers et al, Epidemiology 2011.

19 Past depression is the # 1 risk factor for perinatal depression Reproductive Related RF Personal history of postpartum depression Family history of postpartum depression History of mood changes related to hormonal changes General RF Younger age High neuroticism Childhood trauma Sexual abuse Psychosocial stress Domestic violence Chronic medical condition Race Melville et al OBGYN 2010 ; Meltzer-Brody et al, Arch Women MH2013

20 Education about various treatment and support options is imperative

21 Case of Ms. Y

22 No decision is risk free Vs. SSRIs are among the best studied class of medications in pregnancy Byatt et al. Acta Psych Scand 2013.

23 Same prescribing principles for preconception, pregnancy and breastfeeding Use what has previously worked (considering available reproductive safety information) Use lowest EFFECTIVE dose Minimize switching Monotherapy preferable Be aware of need to adjust dose with advancing pregnancy Discourage stopping SSRIs prior to delivery

24 Most data does not support increased risk of birth defects Data is inconsistent, paroxetine has been most controversial Byatt et al. Acta Psych Scand 2013.

25 Possible transient neonatal symptoms with exposure to antidepressants Transient and self-limited syndrome that may occur in up to 30% of neonates Data does not support taper in third trimester Moses-Kolko et al JAMA 2005, Warburton et al. Acta Psychiatr Scand 2010.

26 Absolute risk of persistent pulmonary hypertension (PPHN) appears small Baseline rate of 1-2 per 1000 births, may increase to 3-4 in 1000 births Chambers et al. NEJM 2006, Kallen et al. Pharmacoepidemiol Drug Saf 2008, Andrade et al. Pharm Drug Saf 2009.

27 Possible association with preterm labor & low birth weight Depression also a risk factor for preterm labor & low birth weight Huybrechts, N Engl J Med. 2014; Ross JAMA Psychiatry 2013

28 Limited studies do not suggest long-term neurobehavioral effects on children Postpartum depression is associated with negative neurobehavioral effects on children Nulman et al. AJP 2012, Croen et al. AGP 2011, Rai et al BMJ 2013.

29 When possible, slowly taper benzodiazepines, with goal to be on lowest possible dose Possible risks Cleft lip/palate Preterm birth Low birth weight Neonatal withdrawal syndrome/rare risk of floppy infant Guidelines Monotherapy preferable to polypharmacy, so optimize SSRI first Fewer/no active metabolites (lorazepam) may be safer Try to avoid longer-acting benzos, e.g. diazepam 29

30 Management of perinatal psychiatric disorders Preconception Pregnancy Depression & Anxiety Bipolar & Psychosis Breastfeeding

31 Imperative to address bipolar disorder Bipolar Disorder 23% Other 7% Unipolar Depression 69% Wisner et al. JAMA Psychiatry 2013

32 During pregnancy medication discontinuation increase risk for recurrence of bipolar disorder % % Abrupt Discontinuation > 14 day taper Yonkers et al. AJP 2004

33 High risk of relapse for bipolar disorder after medication discontinuation postpartum Viguera et al. AJP 2000

34 Bipolar Disorder in pregnancy is associated with negative outcomes Pregnancy does not protect against mood episodes Bipolar (like depression) is associated with - low birth weight, - preterm <37wks - small for gestational age Increased rate of C-section Mood elevation can lead to behaviors with known perinatal risk (eg Substance use, high risk driving, hypersexuality) Mei-Dan et al, AM J OB Gyn 2015, Boden Et al, BMJ 2012

35 Bipolar disorder increases risk of postpartum psychosis 1-2/1000 women >70% bipolar disorder 24 hrs 3 weeks postpartum Mood symptoms, psychotic symptoms & disorientation R/o medical causes of delirium Psychiatric emergency 4% risk of infanticide with postpartum psychosis Wesseloo et al AJP 2016, Manic Depression Illness, Goodwin and Jamison,

36 Preventing decompensation among women with bipolar disorder is critical Prophylaxis with mood stabilizer A birth plan Close monitoring Collaboration with newborn medicine Plan for infant feeding Support adequate sleep Limit stress Support maternal-infant bonding wesselloo 2015

37 Risk of harm to baby when mother has thoughts of harming baby OCD/anxiety/depressio n Good insight Thoughts are intrusive and scary No psychotic symptoms Thoughts cause anxiety Postpartum Psychosis Poor insight Psychotic symptoms Delusional beliefs or distorted reality present Low risk High risk 37

38 Many mood stabilizers can be used during pregnancy Lower risk Emerging reassuring data Avoid (if possible) Typical Antipsychotics Atypical Antipsychotics Carbamazepine/ Oxcarbamazepine Lamotrigine Lithium Valproic Acid

39 Lithium use in pregnancy as been associated with risks to mother and baby Preterm labor Large for gestational age Polyhydramnios Cardiac defects (Epstein s anomaly) Polyuria/polydipsia Neural tube defects (possible small) Lithium toxicity Neonatal adaption/floppy baby Long-term developmental issues? Wesselloo BJP, 2017

40 Pharmacokinetics of lithium (and most other meds) changes during pregnancy Blood flow s Respiratory s cardiac output albumin plasma volume in drug conc GFR

41 Monitor lithium levels closely during the perinatal period Preconception 1 st 2 nd 3 rd Birth Postpartum Obtain baseline level Check level q3 weeks until week 34 Check level weekly after week 34 Likely dose Twice daily dosing *Maintain a narrow therapeutic index of mEq/L Continue Li at onset of labor dose to preconception level within 2-3 weeks Check levels 1-2x/w after delivery Wesseloo et al. Br J Psych

42 Additional monitoring is necessary when using lithium during pregnancy Patient needs high-risk Ob Fetal echocardiogram at wks GA Monitor: Infants lithium serum levels, TSH, renal function Monitor for interactions: Increase Li levels NSAIDS, diuretics (HCTZ), ARBs ACE-I Decrease Li levels Caffeine and theophylline Galbally et al, Aus NZ J Psychiatry 2010, Wesseloo et al. Br J Psych. 2017

43 Psychosis and schizophrenia in pregnancy pose risks to mother and baby Less prenatal care Smoking Prematurity Poor maternal-fetal attachment Postpartum psychosis Suicide Infanticide Matevosyan NR; Arch GynObstet2011

44 Use antipsychotics that work, while taking into account relative risks of medications No single malformation consistently reported (some data suggests may é ASDs/VSDs) Preterm labor Low and high birth weight Increased risk of postnatal adaptation symptoms Increase risk of NICU stays Coughlin et al, OB GYN 2015; Tosato et al J Clin Psyc 2017, Ennis et al, Basic Clin Pharmacol Toxicol. 2015; Huybrechts et al, JAMA Pscy 2016; Cohen et al AJP2016, Vigod et al, BMJ 2015

45 Second generation antipsychotics have an increasing role in treatment FGA Antipsychotics SGA Antipsychotics Small risk of transient abnormal muscle movement Long-term data reassuring though limited 2/2 indication Gestational diabetes & obesity Limited data to 12 months somewhat reassuring Vigood et al, BMJ 2015

46 Electroconvulsive Therapy (ECT) is effective and can be safe in pregnancy Indications Mood DO Psychotic DO Risks Fetal bradyarrhythmia Uterine ctx/rare PTL Aspiration Monitoring FHR, tocometry Third trimester positioning Setting When to consider: Severe depression (suicidal/sib) Catatonia/NMS Medication resistant illness, Psychosis (agitation, dangerous) Malnutrition or dehydration Anderson et al Psychosomatics 2009; LeiknesArch WMH 2015

47 Management of perinatal psychiatric disorders Pregnancy Depression & Anxiety Bipolar & Psychosis Postpartum

48 Breastfeeding generally should not preclude treatment with antidepressants SSRIs and most psychotropics are considered a reasonable option during breastfeeding

49 Sertraline, paroxetine, nortriptyline & imipramine have lowest passage into milk of the antidepressants Di Scalea & Wisner, Clin Ob & Gyn, 2009

50 Antipsychotic use should not preclude the possibility of breastfeeding Quetiapine, olanzapine, risperidone < Typicals *Use what has worked in the past, considering reproductive data.

51 Breastfeeding Safer Higher Risk Antidepressants Carbamazepine Lithium Antipsychotics Valproic Acid Lamotrigine

52 Among mood stabilizers, lithium requires most caution during breastfeeding Medication AAP Carbamazepine Valproic acid Lamotrigine Lithium Usually compatible with breastfeeding Usually compatible with breastfeeding Unknown, but may be of concern Significant side effects, should be used with caution

53 Infant monitoring is recommended during lactation for certain medications Drug Carbamazepine Valproic acid Lamotrigine Lithium Typical antipsychotics Atypical antipsychotics Infant Monitoring CBZ level, CBC, liver enzymes VPA level (free and total), liver enzymes, platelets Rash, liver enzymes BUN, CRE, TSH, CBC, li Stiffness, CPK Weight, blood sugar

54 In summary, psychiatric disorders affect mom, baby and family Mom Suffering Poor selfcare Suicide Fetus/Pregnancy Preterm birth LBW HTN & Preeclampsia Child/Family risk of depression Child development Marriage Siblings No decision is risk-free

55 Resources MCPAP for Moms Mcpapformoms.org MGH Center for Women s Mental Health Womensmentalhealth.org Reprotox Reprotox.org Postpartum Support International Postpartum.net Lactmed toxnet.nlm.nih.gov/newtoxnet/lactmed.htm

56 Trainings Educational Materials 855-Mom- MCPAP