Antenatal mental health problems

Decisions about starting, continuing, and changing medication need to be individualised, and must carefully balance the risk to mother and baby of relapsing mental illness versus the risk to the fetus from the medications. Perinatal psychiatry advice should always be sought if there is uncertainty and especially for women with serious mental illness.

Generally avoid stopping medication suddenly on discovery of pregnancy since this does not necessarily remove risks of malformations and sudden discontinuation of medication may pose risks to the mother’s health. There is a different risk/benefit analysis to be made when continuing/changing pre-existing medication, compared with commencing a new treatment.¹

Psychiatric disorders during pregnancy and following delivery are common:²

• For the majority of women who develop mental health problems during pregnancy, this is usually a mild depressive illness, often combined with anxiety.

• Pregnancy protects against developing a serious mental illness (schizophrenia, bipolar disorder and severe depressive illness) but is not protective against relapses of pre-existing serious mental illness, especially where usual medication has been stopped at the outset of pregnancy.

• Women who have had a previous episode of a serious mental illness, either following childbirth or at other times, are at an increased risk of developing a postpartum onset illness even where they have been well during pregnancy and for many years previously.

• Pregnancy was thought to have a protective effect on maternal suicide rate but Confidential Enquiries into Maternal Deaths have shown that whilst suicide during pregnancy remains relatively uncommon, suicide is a leading cause of maternal death. The majority of suicides occur following childbirth.

Low social support shows significant associations with the risk of depression, anxiety, and self-harm during pregnancy.³

Ideally, women of reproductive age with pre-existing significant mental health problems should be encouraged to discuss pregnancy plans, enabling preconceptual counselling and medication reviews.

Treatment decisions can be challenging, as risks and benefits need to be considered in terms of the welfare of both mother and fetus.

General points

The National Institute for Health and Care Excellence (NICE) guidelines place emphasis on:⁴

• Person-centred care - taking account of individual needs and preferences.

• Good communication - with the patient, their family and carers and the provision of information that is accessible across any barriers such as language, culture or disability.

• Consent and capacity - due regard should be given to the prevailing legislation and guidelines on consent.⁵ This should include the Mental Health Act and the Mental Capacity Act.⁶ Treating adolescent patients can raise additional issues such as Fraser-Gillick competence, child protection concerns, and the Children Act.

• Early detection - enquiry regarding past psychiatric history and family history of perinatal mental illness at first contact with services in the antenatal period. Screening for depression at first contact in primary care and booking clinic. The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines further advise that at first booking appointment, women should be sensitively asked about history of intimate partner violence, sexual abuse/assault, use of illegal drugs, self-harm and lack of social support - women in this group are at risk of depressive illness and suicide during pregnancy.⁷

• Initial management - where a serious mental health illness is suspected or has been diagnosed:
  

  • Consult with/refer to specialist mental health colleagues. Specialist multidisciplinary perinatal teams should be available in all areas to provide direct services, consultation and advice to maternity services, other mental health services and community services.

  • Ask about mental health at all subsequent consultations.

  • Develop a written care plan in collaboration with the patient, her family, carers and specialist mental health services, which should deal with the management of the condition in pregnancy, delivery and the postnatal period. This should be recorded in all copies of the patient's notes (ie those held in primary and secondary care, and hand-held obstetric notes).

• Clear discussion regarding risks of treatment.

• Lower thresholds for access to psychological treatments - ideally, pregnant women should be seen for treatment within a month of initial assessment, and no longer than three months afterwards. This target reflects the changing risk-benefit ratio for psychotropic medication over this time.

Individual conditions⁴

Depression

See the separate article Depression in Pregnancy.

Generalised anxiety disorder and panic disorder

• For patients planning a pregnancy or presenting with an unplanned pregnancy, consider withdrawing existing medication and referring for cognitive behavioural therapy (CBT). Use a lower-risk drug if medication is required.

• Patients with a first attack of generalised anxiety disorder (GAD) during pregnancy should be offered CBT.

• Patients with a first attack of panic disorder in pregnancy should be offered CBT, self-help or computerised CBT (C-CBT) prior to considering drug treatment.

Obsessive-compulsive disorder

• For patients with obsessive-compulsive disorder (OCD) who are planning a pregnancy or are already pregnant, consider withdrawing medication and starting psychological therapy.

• For patients with OCD who are not already on medication, psychotherapy should be considered first-line.

Post-traumatic stress disorder (PTSD)⁸

For patients with PTSD planning a pregnancy or already pregnant, ideally withdraw medication - usually an antidepressant - and offer trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR) therapy.⁹

See also the separate article on Post-traumatic Stress Disorder.

Eating disorders¹⁰

• Anorexia: Follow the NICE guidance on eating disorders. This recommends assessment and psychological therapy in an outpatient setting wherever possible. In severe cases, inpatient treatment may be required for re-feeding.

• Binge eating: patients who are planning a pregnancy or already pregnant should be treated as per depression.

• Bulimia: for patients planning a pregnancy or already pregnant, consider withdrawing medication gradually.

Treatment decisions should generally be made by a specialist perinatal psychiatry team.

See also the articles on Anorexia Nervosa and Bulimia Nervosa.

Bipolar disorder¹¹

• Pregnant women with bipolar disorder are more likely to discontinue treatment, often in an unplanned and abrupt way. There is a high (23%) risk of relapse during pregnancy, with the risk of relapse or recurrence in the postpartum period as high as 50%.¹² Risk is increased if mood stabilising medication is stopped during pregnancy. All women with a history of bipolar disorder should be under the care of psychiatric services whilst pregnant and in the postpartum period, and a high level of vigilance and close monitoring is required.

• Studies suggest that bipolar disorder in pregnancy, whether treated or not, is associated with an increased risk of adverse pregnancy outcome.¹³

• Always seek specialist advice as needed.

See also the article on Bipolar Disorder.

Schizophrenia

• Schizophrenia is a major psychiatric disorder which affects about 1 in 100 people, and it usually first presents in the 20-30 age group.

• It should be treated in line with the NICE guidance on schizophrenia.¹⁴

See also the article on Schizophrenia.

Substance misuse

Mental health problems, such as depression, anxiety or personality disorders, frequently co-exist with alcohol or drug misuse.

Individuals with 'dual diagnosis', particularly in the context of a pregnancy, will need increased support and integrated services.

Substance misusers may be late bookers or erratic users of antenatal care. Screening and recognition of substance misuse are not uniform and many problems go undetected.

Alcohol
Alcohol is teratogenic and fetotoxic, causing fetal alcohol syndrome and other congenital abnormalities. Its use is associated with increased rates of miscarriage and preterm labour and intrauterine growth restriction, although there are important confounding factors. RCOG guidelines state:¹⁵

• The safest approach may be to avoid any alcohol intake during pregnancy, particularly during the first trimester, but there is no evidence of harm from low levels of alcohol consumption (≤1-2 units/week).

• Binge drinking appears particularly harmful.

• Better alcohol history taking is needed to identify the high-risk group of women with problem drinking. No biochemical test is recommended to provide an objective assessment of chronic alcohol use.

• Counselling and detoxification services should be easily accessible to women. As for heavy drinkers in general, motivational interviewing, CBT and brief interventions are thought to be effective. Very little evidence regarding alcohol detoxification in pregnant women is available but severe withdrawal symptoms are risky to both mother and fetus. Expert opinion suggests inpatient detoxification with IV benzodiazepine cover.

The risks of drugs to maintain abstinence (acamprosate, naltrexone, disulfiram) are not known in pregnancy so they are not currently recommended.

See also the articles on Alcoholism and Alcohol Misuse - Recognition and Assessment and Alcoholism and Alcohol Dependence (Management).

Opioids¹⁶
The prevalence of heroin use amongst pregnant women is thought to be 1-2% but may be much higher in some areas.

Opioid misuse is associated with a much increased risk of obstetric (eg, low birth weight, third trimester bleeding, malpresentation, fetal distress and meconium aspiration) and neonatal complications (eg, narcotic withdrawal, microcephaly, neurobehavioural problems, increased neonatal mortality and increased risk of sudden infant death syndrome).

• In pregnancy, goals of treatment are to prevent withdrawal syndrome and toxic opioid levels, both of which pose sizeable risk to the fetus, as well as reducing other potentially harmful behaviours (eg, risk of infection associated with injecting drugs) and increasing positive health behaviours (eg, attendance for antenatal care).

• Methadone maintenance programmes have been widely used in pregnancy and have been shown to result in improved maternal and fetal health. A Cochrane review found that methadone and buprenorphine may be similar in efficacy and safety for the treatment of opioid-dependent pregnant women and their babies. There was not enough evidence to make conclusions for the comparison between methadone and slow-release morphine. Overall, the body of evidence was too small to make firm conclusions about the equivalence of the treatments compared.¹⁷

• Detoxification or withdrawal, if undertaken, is usually preferred in the second trimester due to increased risk of miscarriage in the first trimester and risk of premature labour and fetal stress in the third trimester.

• Advance planning as regards pain relief in labour and delivery in a unit with adequate obstetric and neonatal facilities.

See also the articles on Opioid Misuse and Dependence and Substitute Prescribing for Opioid Dependence.

Other management issues⁴

Sleep problems

• Sleep disorders are common amongst healthy pregnant women, with decreasing duration of sleep, increased rates of snoring and restless legs syndrome associated with progression of pregnancy. Over half of women in the third trimester report poor sleep quality.¹⁸

• Women with mental health problems who have sleep disorders should be advised about sleep hygiene measures (eg, bedtime routines, avoiding caffeine, reduced activity before sleep).

Electroconvulsive therapy

This may be considered for pregnant women who have:

• Severe depression.

• Severe mixed affective states or mania in the context of bipolar disorder.

• Catatonia.

It may be considered for pregnant women whose physical health or that of the fetus is at serious risk. Evidence is limited but the risks to mother and fetus appear low.⁴

Rapid tranquilisation

There may be occasions when a woman with disturbed/violent behaviour needs to be restrained and rapidly tranquilised (eg, bipolar disorder, schizophrenia). The appropriate NICE guidance for the patient group needs to be followed but in addition:

• A restrained patient should not be secluded.

• Any restraint should be so adjusted as to not harm the fetus.

• An antipsychotic or benzodiazepine with a short half-life should be considered.

• Care should be planned with the involvement of an anaesthetist and a paediatrician.

Early postnatal care

The RCOG guidelines emphasise that:⁷

• Women who have been identified as having a high risk of puerperal psychosis should be closely monitored, and managed in accordance with a plan made during pregnancy in collaboration with appropriate specialist services.

• Infants of mothers on psychotropic medication during pregnancy should be carefully observed in the first few days of life for neonatal effects.

• There should be sharing of information with community midwives, health visitors and GPs.

Psychopharmacology in pregnancy^{4 19}

The risk/benefit ratio of medication needs careful consideration, ideally in advance of pregnancy. Stopping or switching medication may risk destabilisation or relapse.

Antidepressants

• Tricyclics. As a class, these carry the lowest known risk to the fetus, although they are more toxic in overdose than most other antidepressants.

• SSRIs. A warning was issued in 2005 advising that paroxetine should be avoided in the first trimester, as there were reports of congenital malformations, especially cardiac malformations, such as atrial and ventricular septal defects. NICE guidelines reflect this specific advice. However, more recently, the Medicines and Healthcare products Regulatory Agency (MHRA) has advised that similar risks of congenital cardiac malformations are also found with fluoxetine (which was previously considered the safest SSRI) in pregnancy.²⁰ The absolute risk remains small. (Background risk is 1 per 100 pregnancies; this becomes 2 per 100 with the use of fluoxetine.) A class effect cannot be discounted. The UK Teratology Information Service (UKTIS) states that "although a risk of cardiovascular malformations was initially reported with only paroxetine, more recent data have indicated that there may be risks associated with all four of the most commonly prescribed SSRIs (citalopram, fluoxetine, paroxetine, and sertraline) though data are conflicting. Since the published data are contradictory, the teratogenic potential of SSRIs remains unproven".²¹ Neonatal withdrawal effects may occur in up to 30% of cases.²²

• Monoamine-oxidase inhibitors (MAOIs). There is limited evidence of an increased risk of congenital malformation.

• Novel drugs.²¹ Some drugs such as mirtazapine are too new to have extensive data about safety. Venlafaxine is not recommended in pregnancy by the manufacturers. Data are inconclusive about the risk of congenital malformations, and exposure in utero may cause neonatal respiratory problems, convulsions and hypoglycaemia

• Neonatal complications. Pulmonary hypertension, jitteriness, crying and hypotonia have been reported in babies of women taking antidepressants - both SSRIs and tricyclics.

Anxiolytics and hypnotics

• Benzodiazepines. There is suggestion that exposure to benzodiazepines in the first trimester may be linked to congenital malformations (eg, cleft palate) although this is debatable. Exposure in later pregnancy can result in 'floppy baby syndrome' and withdrawal symptoms in the neonate. This class of drug should only be given for chronic severe symptoms, and prescribing limited to no longer than four weeks.

• 'Z' drugs (zopiclone, zolpidem and zaleplon). There are very little data on the fetotoxicity of these drugs, although studies on zopiclone have not shown any association with major malformations compared with controls. There have been reports of hypothermia and respiratory depression when taken in the third trimester. In view of the lack of data, the British National Formulary (BNF) recommends avoiding this class of drugs in pregnancy.²³

Antipsychotics

The general consensus is that most antipsychotics are not associated with malformations.

• Clozapine: this should not be routinely used in pregnancy because of the theoretical risk of agranulocytosis in the fetus, and the woman should be switched to another drug.

• Olanzapine: this can cause weight gain and gestational diabetes, so risk factors such as existing weight, ethnicity and family history need to be taken into account.

• Depot antipsychotics: these should be avoided, as there are insufficient safety data, and there have been reports of extrapyramidal effects in babies several months after maternal administration.

• Anticholinergic drugs: although frequently used as an adjunct to stave off extrapyramidal side-effects, they should be avoided in pregnancy. It is safer to alter the dosage and timings of the antipsychotic.

Mood stabilising drugs¹¹

The highest teratogenic risks are associated with the anticonvulsants valproate, carbamazepine and lamotrigine (with valproate having the highest risk). Lithium is also associated with teratogenicity, although the risk is lower than originally thought.

Lowest risks appear to be associated with the antipsychotics, although experience of the use of the newer antipsychotics in pregnancy is very limited and warrants caution.

• Valproate:⁴
  

  • In pregnancy, valproate is contraindicated and an alternative treatment should be decided on, with appropriate specialist consultation.

  • Medicines containing valproate taken in pregnancy can cause malformations in 11% of babies and developmental disorders in 30–40% of children after birth.

  • In the UK, the Valproate Pregnancy Prevention Programme aims to prevent valproate-exposed pregnancies.²⁴

• Carbamazepine and lamotrigine:

  • Avoid in pregnancy because of the risk of neural tube defects and other malformations.

  • A safer alternative, such as an antipsychotic should be substituted.

• Lithium:
  

  • Lithium should be avoided if possible, particularly in the first trimester (risk of teratogenicity, including cardiac abnormalities).²³

  • For a woman planning a pregnancy, lithium should be tailed off over four weeks.

  • If a woman is pregnant on lithium do not stop without consulting their psychiatrist or the specialist perinatal mental health service. Tapering of lithium during the first trimester should be weighed against the risks of relapse. Stopping lithium is associated with high rates of relapse, especially if this is done suddenly.²⁵

  • If the patient requires further treatment, an antipsychotic should be introduced.

  • If lithium is the only medication that controls symptoms and the patient is not going to breast-feed, it can be re-introduced in the second trimester.