Promoting Maternal Mental Health During and After Pregnancy 2 3 4 5 6 Perinatal depression is the most common complication of pregnancy
http://www.acog.org/Womens-Health/Depression-and-Postpartum-Depression Perinatal depression is twice as common as gestational diabetes
Depression 10-15 in 100
Diabetes 3- 7 in 100
Gavin et al. Ob Gyn 2005, Vesga-Lopez et al. Arch Gen Psychiatry 2006. ACOG Practice Bulletin 2013. 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 2009. Cripe et al. Pedi &Perinatal Epid 2011. Forman et al. Dev & psych 2007 Two-thirds of perinatal depression begins before birth
Pregnancy 33%
Before pregnancy Postpartum 40% 27%
10 Wisner et al. JAMA Psychiatry 2013 Perinatal depression is under-diagnosed and under-treated
Treated Women
Untreated women
11 Byatt N, et al. Obstetrics and Gynecology. 2015. 855-Mom- Care Education MCPAP Coordination Telephone Consultation
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15 www.mcpapformoms.org Management of perinatal psychiatric disorders
Pregnancy Guiding principles Depression & Anxiety Bipolar & Psychosis Postpartum Think pregnancy for ALL reproductive aged women
Half of pregnancies are unplanned
Finer & Zolna Contraception 2011. 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 Risk depends on stage of pregnancy The U.S. FDA pregnancy risk categorization is limited Not consider risks of maternal illness Not consider Unclear benefits of categories medication
Does NOT inform decision making 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 Management of perinatal psychiatric disorders
Pregnancy Guiding Principles Depression & Anxiety Bipolar & Psychosis Postpartum 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 2006 . Yonkers et al, Epidemiology 2011. Past depression is the # 1 risk factor for perinatal depression
Reproductive Related RF General RF • Personal history of • Younger age postpartum depression • High neuroticism • Childhood trauma • Family history of • Sexual abuse postpartum depression • Psychosocial stress • Domestic violence • History of mood • Chronic medical condition changes related to hormonal changes • Race
Melville et al OBGYN 2010 ; Meltzer-Brody et al, Arch Women MH2013 Education about various treatment and support options is imperative Case of Ms. Y No decision is risk free
Vs.
SSRIs are among the best studied class of medications in pregnancy
Byatt et al. Acta Psych Scand 2013. 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 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. 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. 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. 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 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. 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 35 Management of perinatal psychiatric disorders
Preconception Pregnancy Depression & Anxiety Bipolar & Psychosis Breastfeeding Imperative to address bipolar disorder
Bipolar Disorder 23% Unipolar Depression Other 7% 69%
Wisner et al. JAMA Psychiatry 2013 During pregnancy medication discontinuation increase risk for recurrence of bipolar disorder
120 100% 100
80 62% 60
40
20
0 Abrupt Discontinuation > 14 day taper
Yonkers et al. AJP 2004 High risk of relapse for bipolar disorder after medication discontinuation postpartum
Viguera et al. AJP 2000 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 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
41 Wesseloo et al AJP 2016, Manic Depression Illness, Goodwin and Jamison, 2007 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 Risk of harm to baby when mother has thoughts of harming baby
OCD/anxiety/depression Postpartum Psychosis
• Good insight • Poor insight • Thoughts are intrusive • Psychotic symptoms and scary • Delusional beliefs or • No psychotic symptoms distorted reality present • Thoughts cause anxiety
Low risk High risk
43 Many mood stabilizers can be used during pregnancy
Lower Emerging Avoid risk reassuring data (if possible)
Typical Atypical Carbamazepine/ Antipsychotics Antipsychotics Oxcarbamazepine
Lamotrigine Lithium Valproic Acid 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 Pharmacokinetics of lithium (and most other meds) changes during pregnancy
Blood flow Respiratory ∆s ∆s
↑ cardiac ↓ albumin output
↑ plasma ∆ in drug ↑ GFR volume conc Monitor lithium levels closely during the perinatal period
Preconception 1st 2nd 3rd Birth Postpartum
Obtain Check level q3 weeks until Continue Li at onset of baseline week 34 labor level Check level weekly after week 34 ↓ dose to preconception level within 2-3 weeks Likely ↑ dose Check levels 1-2x/w after Twice daily dosing delivery *Maintain a narrow therapeutic index of 0.6-1.2mEq/L
Wesseloo et al. Br J Psych. 2017. Additional monitoring is necessary when using lithium during pregnancy
Patient needs high-risk Ob Fetal echocardiogram at 16-18 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 Use antipsychotics that work, while taking into account relative risks of medications
No single malformation consistently reported (some data suggests may 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 Second generation antipsychotics have an increasing role in treatment
FGA SGA Antipsychotics Antipsychotics
Small risk of transient Gestational diabetes & abnormal muscle movement obesity
Long-term data reassuring Limited data to 12 months though limited 2/2 indication somewhat reassuring
Vigood et al, BMJ 2015, Cohen et al, AJP, 2015, Huybrechts et al, JAMA Psychiatry 2016. Minimize stimulant use and optimize behavioral interventions during pregnancy Premature birth
Smaller size
Neonatal withdrawal symptoms
Postpartum hemorrhage Maternal hypertension Limited, but reassuring data on first trimester use
Limited, but reassuring long-term developmental data
Small amounts passed through to breastmilk
Freeman AJP, 2014 ; Huybrechts JAMA Psyc, 2017 Management of perinatal psychiatric disorders
Pregnancy Depression & Anxiety Bipolar & Psychosis
Postpartum Breastfeeding generally should not preclude treatment with antidepressants
SSRIs and most psychotropics are considered a reasonable option during breastfeeding Sertraline, paroxetine, nortriptyline & imipramine have lowest passage into milk of the antidepressants
Di Scalea & Wisner, Clin Ob & Gyn, 2009 Antipsychotic use should not preclude the possibility of breastfeeding
Quetiapine, olanzapine, risperidone < Typicals
*Use what has worked in the past, considering reproductive data. Breastfeeding
Safer Higher Risk
Antidepressants Carbamazepine Lithium Antipsychotics Valproic Acid Lamotrigine Among mood stabilizers, lithium requires most caution during breastfeeding
Medication AAP Carbamazepine Usually compatible with breastfeeding Valproic acid Usually compatible with breastfeeding Lamotrigine Unknown, but may be of concern Lithium Significant side effects, should be used with caution Infant monitoring is recommended during lactation for certain medications
Drug Infant Monitoring
Carbamazepine CBZ level, CBC, liver enzymes Valproic acid VPA level (free and total), liver enzymes, platelets Lamotrigine Rash, liver enzymes Lithium BUN, CRE, TSH, CBC, li
Typical Stiffness, CPK antipsychotics Atypical Weight, blood sugar antipsychotics In summary, psychiatric disorders affect mom, baby and family
Mom Fetus/Pregnancy Child/Family
• Suffering • Preterm birth • ↑ risk of • Poor self- • LBW depression care • HTN & • Child Preeclampsia • Suicide development • Marriage • Siblings
No decision is risk-free MCPAP for Moms aims to promote maternal and child health by building the capacity of front line providers to address perinatal mental illness 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 Acknowledgements MCPAP for Moms is funded by the Massachusetts Department of Mental Health MCPAP for Moms Consulting Leadership Psychiatrists
Nancy Byatt, DO, MS, MBA, FAPM Kara Brown, MD Brigham and Women’s Hospital / Medical Director, MCPAP for Moms Harvard Medical School UMass Memorial Medical Center / UMass Medical School Wendy Marsh, MD, MSc Leena Mittal, MD UMass Memorial Medical Center / Assoc. Medical Director, MCPAP for UMass Medical School Moms Brigham and Women’s Hospital / Harvard Medical School Valerie Sharpe, MD Baystate Medical Center
64 Please contact us www.mcpapformoms.org Call 855-Mom-MCPAP (855-666-6272)
Thank you!