Chapter 12 – Perinatal Psychiatry




Abstract




Ms Angela Russo is a 29-year-old woman with a background of bipolar affective disorder. She has been referred to the perinatal psychiatry team by her GP for advice regarding lithium use in pregnancy.





Chapter 12 Perinatal Psychiatry



Elizabeth Tyrrell Bunge


Practice Stations




  • Station 12.1: Lithium in Pregnancy



  • Station 12.2: Methadone in Pregnancy



  • Station 12.3: Postnatal Depression



  • Station 12.4: Postpartum Psychosis



Station 12.1 (4 Minutes)



Candidate Instructions


Ms Angela Russo is a 29-year-old woman with a background of bipolar affective disorder. She has been referred to the perinatal psychiatry team by her GP for advice regarding lithium use in pregnancy.


Ms Russo had a tumultuous time in her late teens and early 20s after developing bipolar. During this time, she was trialled on several different antipsychotic medications. Despite compliance with the medication, she experienced three relapses necessitating two formal admissions to the hospital for treatment of manic episodes. The relapses were traumatic and disruptive, and she is keen to avoid this happening again.


Since commencing lithium five years ago, Ms Russo has not suffered any manic relapses and her mental state has remained generally stable (except for a short depressive episode last year). She has been tolerating the medication well and has not experienced any adverse side effects.


Ms Russo has recently decided to start trying for a baby and would like to know whether she can continue to take lithium safely.


Please address Ms Russo’s concerns, answer any questions she may have, and discuss an appropriate management plan.



Actor Instructions


You are Angela Russo, a 29-year-old junior executive at a publishing firm. You suffer from bipolar affective disorder and have been very unwell in the past; however, since starting lithium five years ago, you have remained well.


You and your long-term partner, Raymond, have recently decided that you want to start a family together. You are still using contraception, as you first want to discuss how your diagnosis of bipolar affective disorder and prescribed medication may impact a pregnancy.


You vaguely remember your psychiatrist mentioning something about lithium use during pregnancy when you were initially prescribed it. Consequently, you have been searching for information on the internet. To your dismay, you have discovered that lithium can affect a baby’s heart.


You have some specific questions you’d like answered:




  • Can lithium harm the baby during pregnancy?



  • Will lithium affect my fertility?



  • Can I continue to take lithium throughout the pregnancy?



  • Can I breastfeed when taking lithium?



  • What are the alternative options if I decide I want to stop taking lithium?



Feedback Domains



Knowledge

The candidate is able to confidently explain the risks of lithium therapy during pregnancy:1




  • General risks to baby – There is insufficient evidence to determine whether lithium increases the risk of miscarriage, premature birth, and low birth weight. However, there is some evidence to suggest that exposure to lithium is associated with the baby experiencing transient sedation, difficulty feeding, and reduced muscle tone after birth.



  • Birth defects – Some studies have found an association between lithium use and a small increase in the risk of birth defects; however, other studies have found no such risk. Historically, there has been a specific concern about an increased risk of a rare, but potentially serious, heart problem known as Ebstein’s anomaly. This condition occurs in approximately one in 20,000 babies who were not exposed to lithium during pregnancy, and it increases to one in 1,000 babies if the mother has taken lithium during pregnancy. However, recent studies have failed to demonstrate this increased risk.



Management

The candidate outlines the management options available to the patient, highlighting the risks associated with each.2


If a patient’s mental state has been stable for a significant period of time, it may be possible to consider swapping them onto a safer mood-stabilising medication in pregnancy (e.g. an antipsychotic). Alternatively, a patient who has been well for some time may contemplate discontinuing all medication before conception and throughout at least the first trimester (the riskiest period of the pregnancy). The patient would need to be aware of the high risk of relapse during pregnancy and the postnatal period if medication is stopped (even higher if medication is stopped abruptly). Therefore, this decision should always be made in collaboration with a psychiatrist (ideally a perinatal psychiatrist) and the obstetric team.


If the patient’s bipolar affective disorder is severe or they have suffered relapses in the past after stopping or changing medication, they should be advised to continue lithium during the pregnancy. They should be informed of the risks of lithium in pregnancy as described above and counselled on how lithium is prescribed during pregnancy:




  • As you progress through your pregnancy, your body naturally undergoes physiological changes. Some of these changes can affect the levels of lithium in your body (e.g. increases in body fluid volumes and increased kidney function).



  • The levels of lithium in your body tend to decrease as the pregnancy progresses, and your dose may need to be increased to keep the levels within a therapeutic range. Toward the end of a pregnancy, and after birth, lithium levels start to increase again. If your levels decrease too much, you risk a relapse in your mental health, whereas if your levels rise too high, you risk lithium toxicity.



  • In order to monitor the levels and adjust your lithium dose accordingly, you will have blood tests every four weeks, increasing to weekly after 36 weeks’ gestation.


The candidate reassures the patient that lithium is not known to have any effect on a woman’s ability to conceive naturally. They are also aware that breastfeeding is not recommended if a patient is prescribed lithium. This is because lithium passes from the mother’s circulation into her breastmilk and can cause high levels in the baby’s blood.


The risk of relapse remains significant in each of the three management options discussed above. Consequently, a safety plan should always be discussed and agreed with the patient and their family that focuses on identifying warning signs of relapse early and ensuring prompt treatment is provided, which in severe cases may include treatment in a specialist perinatal psychiatric ward.



Communication

The candidate provides information clearly, using layman’s terms. It is a good idea to stop and check the patient’s understanding at various points throughout the station. The candidate clearly informs the patient that it is ultimately their choice and that necessary support will be provided for whatever option they choose. The candidate remembers to offer information leaflets about lithium use in pregnancy and suggests seeing the patient again to re-discuss any issues.



Author’s Note


No mood stabiliser is 100% safe in pregnancy. However, some of the traditional concerns about lithium are being re-evaluated in light of new research. The relatively small risks of lithium, which can be mitigated by close monitoring, must be weighed against the significant risks of relapse during or immediately after pregnancy for patients who chose to discontinue mood-stabilising medication. A pre- or postpartum relapse poses risks not only to the mother (e.g. self-harm, neglecting self-care, disengaging from obstetric services), but also to the foetus or newborn baby (e.g. malnutrition, neglect, and, in extreme cases, infanticide).



Station 12.2 (4 Minutes)



Candidate Instructions


You are working with a perinatal psychiatry team, and you have been referred 31-year-old Ms Claire Young for a specialist opinion.


Ms Young has been using methadone for the last four years after successfully giving up heroin. Her records indicate that prior to stabilising on methadone, she used to inject heroin on a daily basis. She is currently prescribed 30 mg methadone daily, which she collects from the pharmacist. She does not require supervised administration.


Other than methadone, Ms Young is not prescribed any regular medications and is not presently using any illicit substances.


Ms Young is not known to have a history of major mental illness other than a depressive episode in her early 20s. She does not currently suffer from any physical health conditions; however, her GP records indicate that she has previously tested positive for hepatitis C.


Ms Young has recently discovered that she is eight weeks pregnant. She is currently in a stable relationship, and although the pregnancy was unplanned, she is happy with the news and is looking forward to being a mother.


Since learning about the pregnancy, Ms Young has stopped smoking cigarettes and is avoiding alcohol. She is keen to do the ‘right thing’ for her unborn baby and has consequently been worrying about the effect methadone may have on the pregnancy. She would ideally like to stop taking any medication; however, she is worried about withdrawal symptoms and the risk of relapse into heroin use.


Discuss management options with Ms Young and answer any questions she may have.



Actor Instructions


You are 31-year-old Claire Young. You present as relaxed and amiable. You have attended today’s appointment as you have recently found out you are pregnant and want to discuss whether it is safe to continue taking methadone.


You are currently prescribed a 30 mg daily dose of methadone, which you have been taking since you ‘kicked’ your heroin habit four years ago. You are very proud of this achievement and hope never again to return to drug misuse. You do not use any other illicit drugs and do not take heroin or prescription opioids on top of your methadone prescription.


You have visited your GP, who has estimated you are eight weeks into the pregnancy. You have a booking visit with a midwife next week. This is your first pregnancy and it was unplanned; however, you are happy with the news and have no intention of terminating the pregnancy. You feel your life has been much more stable in recent years after giving up heroin and meeting Barry, your current partner and father of your unborn baby.



If asked, you were previously diagnosed with hepatitis C; however, you received treatment and have successfully cleared the virus. You have no other physical health issues.

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Jun 20, 2021 | Posted by in PSYCHIATRY | Comments Off on Chapter 12 – Perinatal Psychiatry

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