Obstetric and Gynaecological Conditions Associated with Psychiatric Disorder
Ian Brockington
Introduction
This chapter covers the psychiatry of menstruation, various manifestations of the desire for children (such as surrogate pregnancy and pseudocyesis), pregnancy and mental health, the psychopathology of parturition, infant loss, postpartum psychiatric disorders, the mother–infant relationship and infanticide.
The psychiatry of menstruation
It has long been realized that menstruation and mental illness are linked. As early as 1827 menstrual mood disorder was used as a defence in filicide.(1) In the 1850s, Brière de Boismont(2) and Schlager(3) carried out the first surveys showing that 20–30 per cent of women suffered a mood disorder before or during the menses— usually irritability or depression, occasionally euphoria. There are descriptions of a wide variety of deviant behaviours, including nymphomania, food cravings, binge drinking, pathological lying, shoplifting, and fire-setting, as well as suicide, violence, homicide, and morbid jealousy. There are other nervous diseases associated with menstruation, including epilepsy, migraine, and hypersomnia.
Recently, there has been much research into the biological basis and treatment of ‘premenstrual tension’ (or its synonyms). A number of daily rating schedules have been published, but self-devised rating scales, tailored to an individual patient’s symptoms, can be used, provided that they are carefully completed every day. Scientific studies are bedevilled by difficulties in defining the disorders.(4) It is not known whether this is one syndrome or many. Irritability is striking, but otherwise the symptoms are common to many other disorders.
Although little is known about the aetiology, progress has been made in treatment. There may be a response to serotonin-reuptakeinhibiting antidepressants (e.g. fluoxetine, chlomipramine). In so far as a luteal-phase defect may be a factor, ovulation-promoting drugs such as clomiphene can be tried. The synthetic steroid danazol, and the gonadorelin agonists (which suppress menstruation), are draconian treatments for severe cases. All interventions should be prescribed in the context of a long-term study using daily ratings.
Rarely, menstruation is linked to a psychosis with acute onset, brief duration, and full recovery. Premenstrual, catamenial, paramenstrual, mid-cycle, and ‘epochal’ variants have been described.(5) Menstrual psychosis is rare, but perhaps not excessively so. There is a clustering of episodes around puberty and after childbirth, although only a small proportion of menstrual cycles are involved. There are sufficient case reports from Japan, India, and Islamic countries to suggest a worldwide disorder. This is not a specific entity, and most typical examples manifest non-menstrual bipolar disorder at another stage of life. Clinically, it resembles puerperal psychosis. The close relationship between these two psychoses is emphasized by women who develop puerperal and menstrual psychosis at different times.(6) A Japanese investigation showed an association with anovulatory cycles.(7) Pregnancy has a beneficial effect, and there are claims of successful treatment with oral contraceptives, progesterone, clomiphene, danazol, and gonadorelins. The basis for intervention is a long-term study, with a good baseline and exact timing of events in relation to the menstrual cycle.
Infertility
Motherhood is among the strongest and most universal of motivations. For many infertile women, childlessness is the most upsetting experience of their lives, and the yearning for children dominates everything. Infertility is stigmatizing, especially in some cultures. Infertile couples often suffer from self-reproach over sexual indiscretions, abortions, or contraception. They envy fertile couples, and contacts with other people’s children, family celebrations, and friends’ pregnancies are problematic. The security of the marriage may be threatened by the fear that the spouse will desert to a fertile partner; nevertheless, the marriages themselves are often happy.
Infertility differs from other stresses in its duration. The psychological reaction unfolds over years. When treatment begins, there is a cycle of optimism and hope, with a build-up of tension towards the end of the cycle, followed by disappointment and despair. Sexual functioning comes under strain during the investigation, and the discovery of azoospermia is especially stressful. There is some evidence that stress affects conception, though more prospective studies are needed.
Assisted reproduction
Artificial insemination (using the husband’s or partner’s semen) has been available from the late eighteenth century, and donor insemination since 1884. Its psychological effects on marriage seem minimal; husbands or partners rarely react with jealousy to the
baby, any more than to an adopted child. The proof that the experience is acceptable is that it is often repeated. One of the principles is privacy, ensuring that donor and couple never meet and remain ignorant of each other’s identity. It is felt that violating anonymity might compromise the marriage, since donor and mother are too deeply involved in procreation to regard their relationship with detachment; but times may be changing. The interests of the children have to be considered; donor insemination obscures the genetic lineage, and the child cannot benefit from advances in genetics.
baby, any more than to an adopted child. The proof that the experience is acceptable is that it is often repeated. One of the principles is privacy, ensuring that donor and couple never meet and remain ignorant of each other’s identity. It is felt that violating anonymity might compromise the marriage, since donor and mother are too deeply involved in procreation to regard their relationship with detachment; but times may be changing. The interests of the children have to be considered; donor insemination obscures the genetic lineage, and the child cannot benefit from advances in genetics.
In vitro fertilization (IVF) was first performed in 1978, and was achieved with a donated oocyte in 1984; it is now widely used—in Holland, 1/60 babies are born by IVF. The procedure is harrowing, and counselling is mandatory. There is an increase in multiple births, which are more stressful. But the quality of parenting may be superior to that of families with naturally conceived children.
Surrogate motherhood
This has two meanings:
A woman is inseminated (artificially or naturally) with the husband’s or partner’s semen, and surrenders the child to the genetic father and adoptive mother. The surrogate provides oocyte and womb, and is a substitute spouse.
The wife donates a fertilized oocyte to the surrogate gestational mother. This method, involving in vitro fertilization and embryo transfer, is the only way a woman without a uterus can have a child that is genetically her own.
A considerable number of women apply to become surrogate mothers, for motives of financial gain, altruism, pleasure in being pregnant, or atonement.(8) A child can now have 3 mothers— genetic, gestational, and rearing.
Surrogate pregnancy has stirred up an ethical debate. Apart from religious objections, there is concern about the physical and psychological consequences for the gestational mother, and there are endless opportunities for custody disputes and other legal complications. It has been found that the gestational mother does not bond strongly to the foetus, and most surrogate and commissioning mothers do not suffer from psychological problems.
Pseudocyesis
When a woman believes herself to be pregnant and develops symptoms and signs of pregnancy, this is called pseudocyesis. In a classic monograph, Bivin and Klinger(9) collected 444 cases from the literature. Many sufferers were parous, including women with as many as 10 children, and as many as six episodes of pseudocyesis.
The differential diagnosis includes delusions of pregnancy, in which there are no somatic changes. This is a common delusion and can also occur in men. There is also pregnancy simulated for social, mercenary, or legal purposes (e.g. to escape the death penalty).
The clinical features include:
a firm belief in the pregnancy, usually lasting until the onset of a false labour at 9 months, after which the disorder usually resolves
amenorrhoea
morning sickness and/or pica
enlargement of the breasts and nipples, and even a discharge of colostrum
abdominal enlargement, caused by muscular contraction, tympanites, fat, or pathological lesions, but without effacement of the navel
an illusion of foetal movements
enlargement of the uterus to the size of a 6-week pregnancy.
Modern diagnostic tests have greatly reduced the frequency. The diagnosis should be made on ultrasound examination. Where radiology or ultrasound are unavailable, an examination under anaesthetic is recommended—in the presence of a family member to avoid accusations of abortion.
The psychological basis is usually an intense desire for children, especially in older childless women. In some cases, however, a guilty fear of pregnancy has been the background; this has occasionally led to dangerous attempts at abortion by non-pregnant women. Pseudocyesis is a demonstration of the influence of psyche over soma, mediated by hormonal secretion. It occurs in dogs, cattle, and rodents. Persistence of the corpus luteum would explain breast changes, moderate uterine enlargement, and secretory endometrium; but it is not the only basis: hormonal measurements have been made in at least 30 patients, some of whom had chronic anovulatory states, hyperprolactinaemia, or androgen excess.
These women require psychotherapy. Simply revealing the diagnosis is unsatisfactory because the patient may consult another doctor with the same symptoms, or develop a recurrence. The underlying conflicts must be explored, helping the patient to accept that she is not pregnant.
Sterilization
Women can be prevented from bearing children by various operations on the uterus and Fallopian tubes, indications for which are contraceptive, medical, eugenic, or psychiatric. Sterilization is the most effective and widespread contraceptive method. A large number of studies have looked at its effect on mental health, but many had methodological weaknesses. Ekblad, however, published two thorough studies in 1950s—a general study of 225 women, of whom 99 per cent were interviewed 5 to 6 years later, and a unique study of 60 sterilized women with no living children.(10)
There have been two modern prospective studies. Cooper and colleagues in Oxford(11) interviewed 201 women 4 weeks before non-puerperal tubal sterilization for contraceptive reasons; 190 were re-interviewed 6 months later, and 193 at 18 months after sterilization: the number with psychiatric illness fell from 21 before the operation to 9 at 6 months, and rose to 18 at 18 months. Not surprisingly, the presence of psychiatric disorder before the operation was a predictor of its continued presence; only two who were in good psychological health before the operation developed psychiatric illness 6 months later. A WHO collaborative study, involving five countries (India, Colombia, Nigeria, Philippines, and England), compared 926 sterilized women with 924 who used other methods of contraception: those who chose sterilization had more preoperative psychiatric disorder. The results from the Nottingham field centre(12) were published separately, and found that 9/138 sterilized women had psychiatric disorder before the operation; after surgery there were only three new cases at 6 weeks, and four more at 6 months, less than the control group.
A small minority of sterilized women are troubled by frigidity or severe regret. The most concrete evidence is a request for reversal, several studies of which have been published. Regret is more common in the following groups of women:
Younger women or those with fewer children: Ekblad(10) found that none of his 60 childless women required hospitalization for depression, but 16 were seriously distressed and 29 expressed a longing for children of their own.
Those in whom sterilization was the condition for a termination —a barbaric and punitive practice that used to be the rule in some countries.
Those sterilized at a time of crisis—after parturition, or during a psychiatric illness—when it is difficult to make a balanced judgement.
Those under external pressure.
Those with learning difficulties: the issue of sterilization, which has from time to time been practised in various countries, is becoming more important. With a policy of community care and a greater tolerance of sexual activity, there is an increased risk of pregnancy in women with severe learning difficulties, with the spectre of inherited disorders and problems in mothering. Yet these women greatly desire children, and do not have the same resources to compensate for their lack.
Those sterilized for medical reasons such as inherited disorders, for which medical advances have later provided alternative solutions (e.g. amniocentesis).
Those who seek sterilization in a context of marital disharmony: after the marriage has failed, the wife may remarry and change her mind about further children.
Those with religious scruples.
Hysterectomy
This is one of the commonest operations, and is performed in about 10 per cent of women. There have been claims that it leads to ‘post-hysterectomy depression’. But this idea has been thoroughly and systematically refuted. Several prospective investigations have shown that mental health improves after hysterectomy. Three comparable Oxford studies, conducted between 1975 and 1990, have addressed this problem: all showed that psychiatric morbidity fell below its preoperative level, or remained low.(13) The ranks of women with ‘post-hysterectomy’ depression are swollen by those seeking a surgical remedy for psychosomatic complaints.
In younger women, infertility can be a source of discontent. It would not be surprising if the loss of the womb affected feminine identity and libido; but this is probably also a myth. Prospective studies from Oxford,(13) St Louis,(14) and Aberdeen showed an increase in the frequency of intercourse, and of enjoyment. Concomitant oöphorectomy does not adversely affect psychiatric well-being.(15)
The psychiatry of pregnancy
Pregnancy adjustment
The psychopathology of pregnancy needs to be understood in terms of the adjustment all women must make when they conceive. Pregnancy is not only a biological event, but also an adaptive process.(16) A pregnant woman must carry the baby safely through to delivery, and adjust to the sacrifices that motherhood demands. She must ensure the acceptance of the child by the family, develop an attachment to the baby within, and prepare for the birth. She must adjust to the alteration in her physical appearance, and develop a somewhat different relationship with the child’s father.
Many pregnancies are unplanned and not initially welcomed. Many women react to conception with grief and anger. A random sample of English mothers showed that 44 per cent of pregnancies were unintentional, including 17 per cent that ended by legal abortion. In married women aged 25 to 29 years with one child, 80 to 84 per cent of pregnancies were planned, compared with 26 per cent in the unmarried.(17) The planning of pregnancy and its acceptance are two different things. The fact of planning does not guarantee acceptance; 6 to 12 per cent of those who plan their pregnancies subsequently regret them. Most unplanned pregnancies are immediately accepted; even if the initial response is negative, gradual acceptance usually follows. In a small proportion of cases, rejection continues to the end of the pregnancy.
Pregnancy has a profound effect on the relationship with the child’s father. At every stage this relationship is of the highest importance. A pregnant woman needs increased attention and care and is sensitive to perceived rejection. Pregnancy alters other relationships as well—with the wider family and friends. Many women become closer to their families-of-origin and in-laws.
The change in appearance and shape is sometimes distressing. Some take pride and pleasure in these changes, enjoy the extra attention, and feel an enhanced sense of womanliness. Others are concerned about their loss of figure and facial bloom, weight gain, and stretch marks. Dysmorphophobia, with ideas of reference and social avoidance can ensue.
Pregnancy may be accompanied by medical disorders, and in all there is an interaction between physical and psychological factors. Pica is common, especially geophagia (eating earth or clay), which can lead to iron deficiency anaemia, bowel obstruction, and roundworm infection; other forms of pica can lead to lead poisoning or hypokalaemia. Rarely, hyperemesis can cause Wernicke’s encephalopathy, and delirium can complicate chorea gravidarum.(18)
Denial of pregnancy
In women who do not realize they are pregnant, one must distinguish between three different phenomena: unnoticed pregnancy, deliberate concealment, and dissociative denial. A German survey of 29 000 births found 62 women who failed to recognize pregnancy until the 20th week (1/475 births); 12 were not diagnosed until they were in labour with a viable infant (1/2455).(19) A Welsh study obtained similar figures.(20)
The late discovery of an unwelcome pregnancy carries a small risk of suicide. The mother is also at risk of all those complications of delivery that, with modern antenatal care, have become rare. For the child there are increased hazards, including prematurity and neonaticide.
Prenatal attachment
The mother ‘bonds’ or ‘affiliates’ to the unborn child in a way analogous to the formation of the mother–infant relationship after birth. Prepartum bonding is catalysed by quickening and probably by ultrasound examination. The mother begins to have fantasies
about the baby and talks affectionately to it. She may engage the husband or partner and other children in ‘playing’ with the baby. At the same time she prepares for the birth and motherhood (‘nesting behaviour’).
about the baby and talks affectionately to it. She may engage the husband or partner and other children in ‘playing’ with the baby. At the same time she prepares for the birth and motherhood (‘nesting behaviour’).
There is a pathology of the affiliative stage. In some mothers there is minimal attachment even at term. The foetus is viewed as an intrusion, whose movements annoy the mother and disturb her sleep. A poor mother–foetus relationship is one of the predictors of impaired mother–infant bonding. When the mother’s attitude to the pregnancy is obstinately rejecting, therapists can direct her attention to the relationship with the child within. Stroking the abdomen and identifying foetal body parts, or telling stories about the baby’s future life, have been suggested.
Foetal abuse
When a mother deeply resents her pregnancy, she may try to harm the foetus. This occurs, with determined intent, in self-induced abortion. It may also occur as a manifestation of rage against the baby;(21) a pregnant woman may pound on her abdomen, even to the point of causing bruising.
It is not only the mother who may ‘batter’ the foetus. Domestic violence is common and may increase during pregnancy, when kicks and blows are directed at the abdomen, rather than the face. The main factors are sexual frustration, substance abuse, jealousy, the mother’s irritability, and unreadiness for fatherhood.
The foetus is cushioned from external violence by the amniotic fluid, but can still be damaged by severe abdominal or pelvic injuries. Domestic violence can lead to miscarriage, foetal death, and premature birth. Infants can be damaged by penetrating wounds, and there are over 100 instances of gunshot wounds to the gravid uterus—the result of murderous assaults, attempts to induce a late abortion, or suicide attempts.
Mental illness during pregnancy
(a) Anxiety
For many mothers, pregnancy is a time of considerable anxiety. The first trimester may involve an anguished decision whether to continue or terminate the pregnancy. Those who have previously suffered from prolonged infertility, multiple miscarriages or foetal loss are especially prone to prepartum anxiety. In the third trimester anxiety is centred on three main themes: fears of parturition (tocophobia), of foetal abnormality, and of failure to cope with motherhood.
These anxieties will usually be managed by ventilation and support, but anxiolytic medication can be used cautiously. Of the anxiolytic agents, phenothiazines are relatively safe. Benzodiazepines are contraindicated in the last stages of pregnancy because of foetal intoxication (‘the floppy infant syndrome’). Propranolol is best avoided, because of reports of intrauterine growth retardation, and neonatal cardiac and respiratory symptoms.
(b) Depression
Although prepartum depression has not aroused the same interest as postpartum depression, it is no less common. Depression is common in all women in the reproductive age group, and pregnancy is not protective. Depression can be recurrent, and there is an association with puerperal mania.
The frequency of suicide is a vexed question. There are problems about the accuracy of the data since not all suicides are reported to the coroner, not all have necropsies, and not all necropsies include an examination of the uterus. In addition, both suicide and pregnancy are often concealed. One must therefore treat with scepticism those enquiries which do not scrutinize the primary records. Nevertheless, there is evidence that the suicide rate has declined throughout this century; in the first quarter, about 13 per cent of women who committed suicide were pregnant—a rather high figure, suggesting that pregnancy was a risk factor at a time when illegitimate pregnancy was stigmatized. This was confirmed by the thorough mid-twentieth century study of Weir.(22) More recent studies show rates below those in the general population.
Severe prepartum depression is sometimes left untreated, because of fears about the effect of drugs on the foetus. These fears have been exaggerated. No antidepressive drug is known to have teratogenic effects. Most have no effect on the foetus, though fluoxetine may reduce uterine blood flow and paroxetine may cause neonatal pulmonary hypertension. There are reports of toxic effects or withdrawal symptoms in neonates, so that medication is more to be avoided during the last trimester. Electroconvulsive therapy is safe, provided that the mother is competently oxygenated during anaesthesia; pregnant women should be screened for rare syndromes of pseudocholinesterase deficiency before receiving this treatment.
(c) Alcoholism
Pregnancy has a beneficial effect on alcohol addiction, but, if heavy abuse continues, there are severe effects on the foetus. The main effect is retardation of intrauterine growth(23); although ethanol shortens gestation, the low birth weight is not explained by prematurity, rather the infants are small for gestational age. The infant becomes addicted and may suffer neonatal withdrawal symptoms. Ethanol is also teratogenic, causing ‘the foetal alcohol syndrome’ (or ‘spectrum disorder’), first described in France in 1968.(24) The features include facial dysmorphism due to maxillary hypoplasia, and brain damage, resulting in long-term cognitive impairment and behavioural disorders (see also Chapters 9.2.7 and 10.4). In the detection of these severe complications, systematic prenatal screening for alcohol abuse is useful.
(d) Other addictions
Cannabis is commonly abused by pregnant women; it affects foetal growth, and may lead to long-term neurobehavioural and cognitive deficits. Lysergic acid diethylamide may have teratogenic or mutagenic effects. Phencyclidine addiction leads to withdrawal symptoms.
Narcotic addicts, like alcoholics, have multiple emotional and social problems, and many do not seek antenatal care. The infants may be affected by maternal malnutrition and infections such as venereal disease, hepatitis, endocarditis, and AIDS. Narcotics are not teratogenic, but a high proportion of the infants are of low birth weight, partly explained by prematurity, and partly by intrauterine growth retardation. A withdrawal syndrome develops in most babies. The perinatal mortality rate and frequency of sudden infant death, are increased. There is an increased incidence of microcephaly, and there may be impaired mental development, although other factors in the maternal life style may account for this. Methadone maintenance reduces the effect on birth weight; but it may depress respiration in the newborn, and lead to a more severe and prolonged withdrawal syndrome, with a greater frequency of seizures. Buprenorphine may be a more suitable maintenance therapy, with milder withdrawal effects. If it is decided to withdraw heroin, this should be done in the second trimester,
replacing it by methadone. Naloxone, which can be given by implant, has been used, although there are concerns about foetal abstinence syndromes. After birth, the infants should be kept in hospital for at least 14 days. Respiratory depression can be treated by naloxone, and seizures and withdrawal symptoms by sedatives such as diazepam, or by tincture of opium.
replacing it by methadone. Naloxone, which can be given by implant, has been used, although there are concerns about foetal abstinence syndromes. After birth, the infants should be kept in hospital for at least 14 days. Respiratory depression can be treated by naloxone, and seizures and withdrawal symptoms by sedatives such as diazepam, or by tincture of opium.
Cocaine may be teratogenic, causing genitourinary and cardiac abnormalities, but the evidence is conflicting. Its main effects are cardiovascular: it causes uterine vasoconstriction, and this can lead to placental abruption. The infants may suffer cerebral infarction. There is intrauterine growth reduction and an increased incidence of microcephaly. Premature labour is common. There is a withdrawal syndrome, but this is less severe than with narcotics. There is some evidence of an increased risk of sudden infant death. Long-term effects on language development and behaviour are controversial, and may be due to confounding factors such as maternal depression, other drugs, and the environment.
All these mothers should receive close psychiatric supervision and social casework. Hair and meconium analysis improves the diagnosis of opiate and cocaine abuse in mothers who present unexpectedly in labour.
(e) Eating disorders
There are psychological and somatic reasons for an antagonism between pregnancy and anorexia nervosa; nonetheless, most anorexic women recover, and menstruate when their weight reaches about 80 per cent of the standard weight. Ovulation can be induced by clomiphene or menopausal gonadotrophin in those who fail to menstruate. There are numerous case reports and several long-term studies showing that many women with a history of anorexia nervosa give birth to children in the normal way. The overall effect on fertility has been quantified by a 12-year Danish study; the average number of children (0.6) was about one-third the usual figure.(25) The desire for children is shown by the frequency of infertility treatment, planned pregnancy, and breast feeding.
A minority become pregnant while in the throes of the disease. Anorexic amenorrhoea may delay the diagnosis. Pregnancy usually has a beneficial effect; but if the mother continues to restrict her diet, the foetus may suffer from malnutrition. Occasionally it has been necessary to rescue the infant by elective Caesarean section. There is a tendency to relapse in the puerperium. When mothers are actively anorexic, there is often conflict at mealtimes; occasionally children may become involved in their mother’s asceticism, and suffer stunted growth.
Bulimia nervosa is often improved by pregnancy. The pressure of the enlarging uterus on the stomach makes bingeing more difficult. About half relapse after delivery.(26) Pregnancy is not much affected by bulimia, but low birth weight has been reported. Bulimic mothers sometimes show deviant mothering, ignoring or excluding their children while overeating or vomiting, or restricting food supplies.
(f) Obstetric factitious disorder
Self-induced illness behaviour can extend into the obstetric domain.(27) Women may induce bleeding to simulate threatened miscarriage, placenta praevia, or postpartum haemorrhage. They may stimulate rupture of the membranes to precipitate an early delivery. Others have been caught manipulating instruments, for example an external tachodynamometer. Two patients even attempted to simulate hydatidiform mole, by adding human chorionic gonadotrophin to blood samples.
(g) Psychosis
Numerous asylum surveys have testified to the lower frequency of psychosis during pregnancy than after delivery. This was confirmed by Kendell and colleagues, in their linkage of Edinburgh obstetric and psychiatric case registers(28): in a study of 54 087 births, they found rates of 2.1 per month before conception and 2.0 per month during pregnancy, much lower than after childbirth (51 in the first month).
Pregnancy probably has no effect on chronic delusional states, but it does have a beneficial effect on menstrual, bipolar, and possibly cycloid (acute polymorphic) psychoses.(29) Nonetheless, acute manic and cycloid episodes occur during pregnancy, and some seem remarkably similar to puerperal psychosis. They would be regarded as sporadic or random, except that they have been observed in women with a history of puerperal psychosis (at least 13 in the literature).(30) There is an association with multiparity, with the postpartum episode occurring first.
Neuroleptic agents appear to be safe during pregnancy. Phenothiazines and butyrophenones are not teratogenic. The main (but infrequent) hazard is sedation and extrapyramidal symptoms in the newborn. Lithium is relatively dangerous; at least 12 cases of the rare Ebstein’s anomaly have been reported. As delivery approaches, reduced renal clearance can result in toxicity with normal doses; eight cases of alarming blood levels (up to 5 mmol/l) have been reported, with coma and convulsions in the mother. Even at normal blood levels, babies exposed to lithium have suffered lethargy, hypotonicity, and other effects. Carbamazepine has been associated with rather high rates of congenital abnormality, and sodium valproate is particularly dangerous, with major abnormalities especially spina bifida, and a foetal valproate syndrome.
(h) Obstetric liaison services
In view of the complexity of the psychological response to pregnancy, and the frequency of anxiety, depression, and other psychiatric disorders, there should be good liaison between obstetric and psychiatric services. In addition to the need to diagnose and treat prepartum psychiatric disorders, the high level of supervision in the antenatal clinics offers an opportunity for preventive psychiatry, by screening for vulnerable women, including those with unwanted pregnancies, severe social problems, or a history of psychosis, addictions, or depression.
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