6.2 Disorders related to pregnancy and childbirth

The perinatal period

• Perinatal care covers pregnancy and the first postnatal year, with preconception planning for women with known illness.

• The excess risk of new or recurrent mood, anxiety and psychotic episodes after delivery lasts through roughly the first three months.

• Pregnancy carries a lower rate of death by suicide than in non-pregnant women of reproductive age, and this protection weakens after delivery.

• Maternal death enquiries highlight suicide, substance-related harm and social adversity, particularly beyond the first six postnatal weeks.

"Postnatal" describes timing, not a diagnosis, so assess the full syndrome.

Telling postnatal presentations apart

• Confusion or impaired attention needs urgent physical assessment even when postpartum psychosis seems likely, because medical and psychiatric causes can coexist.

Baby blues

• Baby blues affects more than half of women, up to about three-quarters depending on definition, far more than any postpartum disorder.

• Management is explanation, reassurance and review.

Postnatal depression

Features and course

• Postnatal depression is a depressive episode starting in the weeks after delivery; early waking and guilt about mothering are typical.

• Obsessional or anxious features centred on the baby within the episode are part of the depression, not a separate disorder.

• It affects roughly 10 to 15% of women after childbirth, about 10% in National Institute for Health and Care Excellence (NICE) figures, falling below 10% after about 12 weeks.

• Perinatal depression across pregnancy and the first postnatal year has a similar rate.

• Untreated postnatal depression is not reliably self-limiting: around 30% of women remain depressed a year after delivery.

• After one episode, around 38% of women have postnatal depression again after a later birth.

Risk factors

• Strong predictors are antenatal depression, previous postnatal depression, earlier depressive illness and bipolar disorder; a brief spell of baby blues predicts little by comparison.

• A poor or unsupportive partner relationship, as the woman herself perceives it, is an established risk factor, and a supportive, confiding partnership protects.

• Social isolation and domestic abuse also raise risk; ask about abuse privately.

• Older maternal age has no consistent association, unlike established factors in the relationship, demographic, obstetric history and substance use domains.

Depression in pregnancy

• Antenatal depression risk factors are psychosocial and psychiatric: personal or family history of depression, poor partner, family or social support, and ambivalence about or not wanting the pregnancy.

• Sociodemographic and obstetric characteristics do not predict antenatal depression.

• In recurrent major depressive disorder, about 40% of pregnancies are complicated by relapse.

• Women with recurrent depression who stop antidepressants around conception or in pregnancy relapse at about 70%, against about 25% in those who continue (psychiatric-setting cohorts).

• Relapse risk after stopping is set jointly by how recurrent and how severe the previous depression was.

Perinatal obsessions and trauma

• Perinatal obsessive-compulsive disorder (OCD) is recurrent, unwanted, egodystonic intrusive thoughts or images of harming the baby, held with insight and met with avoidance and reassurance seeking.

• Insight separates these thoughts from the delusions of postpartum psychosis, and their content separates them from re-experiencing of the delivery in post-traumatic stress disorder (PTSD).

• A traumatic delivery or frightening obstetric event can precipitate trauma-related illness.

• Ask directly and sensitively about thoughts of harming the infant, remembering that unwanted obsessions are not intent or delusional commands.

Assessing the mother and infant

• Assess mood, sleep, psychosis, cognition, intake, suicide and self-harm, ability to care safely for the infant, capacity and the legal basis for care.

• Observe feeding and interaction without judging parenting capacity from one encounter, and involve midwifery, obstetrics, health visiting, paediatrics and safeguarding as needed.

Rating scales

• The EPDS was built and validated for case detection after childbirth and leaves out somatic items, unlike most scales, which rate the severity of an established illness.

• EPDS item 10 asks about self-harm, so any positive answer, or a high total score, signals suicide risk needing assessment.

Postpartum psychosis

Epidemiology and presentation

• Postpartum psychosis follows about 1 to 2 of every 1,000 deliveries (1 in 500 to 1 in 1,000).

• It begins within the first two weeks after delivery, often in the first few days.

• It presents with sleeplessness, perplexity, rapidly shifting mood, agitation and a fixed delusion, often about the baby; hallucinations and disorganisation also occur.

Risk factors

• Bipolar disorder, above all bipolar I, is the pre-existing diagnosis most strongly linked to postpartum psychosis.

• A family history of affective psychosis, especially postpartum psychosis in a first-degree relative, is a genetic risk factor.

• A first delivery (primiparity) is the best-established obstetric risk factor.

• After one previous postpartum psychosis, 30 to 50% of women have another episode after a later birth.

• Recurrence approaches 50% with bipolar I or schizoaffective disorder plus a family history of postpartum psychosis or bipolar disorder.

• Sleep loss can trigger mania.

Management

• Suspected postpartum psychosis needs same-day specialist assessment, within four hours under NICE guidance, and usually admission because risk changes quickly.

• NICE guideline CG192 recommends mother and baby unit admission for any woman needing inpatient psychiatric care within 12 months of childbirth, with infant contact supervised according to risk.

• Exclude medical causes urgently, and treat with antipsychotic or mood-stabilising medication.

• Electroconvulsive therapy (ECT) is used for life-threatening illness, catatonia, poor intake or treatment failure, and pregnancy does not exclude it.

• Most women recover, but later affective and postpartum episodes remain possible.

Bipolar disorder and schizophrenia after childbirth

• In bipolar disorder the puerperium carries the highest relapse risk of any period.

• Depression is the commonest form of postpartum relapse, and mania or psychosis is the characteristic severe outcome of bipolar I.

Teratogenic risk: principles

• Major structural malformations follow exposure during organogenesis, the embryonic period in the first trimester.

• The background rate of major congenital malformation without drug exposure is 2 to 3%, so give absolute as well as relative risks.

• Miscarriage ends roughly 10 to 20% (about 15%) of clinically recognised pregnancies.

• Weigh drug exposure against relapse, suicide, self-neglect and poor antenatal care, because stopping abruptly carries its own hazards.

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Lithium

• First-trimester lithium is linked to Ebstein's anomaly: an apically displaced tricuspid valve with an atrialised right ventricle.

• The relative risk is raised, but the absolute risk is now thought well under 1 in 100, revised down from early register figures.

• Without lithium, Ebstein's anomaly occurs in roughly 1 in 20,000 births.

• In one large cohort, right ventricular outflow obstruction affected about 0.6% of exposed infants against 0.18% unexposed, a figure not limited to Ebstein's anomaly.

• The risk arises during cardiac organogenesis, peaking about 2 to 6 weeks after conception.

• Maternal benzodiazepine exposure in early pregnancy has also been associated with Ebstein's anomaly.

• After first-trimester exposure, the first detailed fetal ultrasound and echocardiogram is done at 11 to 14 weeks.

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Continuing or stopping

Monitoring and delivery

• Check levels every 4 weeks, weekly from 36 weeks, and within 24 hours of birth.

• Renal lithium clearance rises through pregnancy and falls back within days of birth.

• Withhold lithium in labour, or 24 to 48 hours before a planned delivery, and take a level 12 hours after the last dose.

• After birth, restart at a lower dose (800 mg daily) rather than stopping for weeks, keeping the late-pregnancy dose or raising it.

• A woman who plans to breastfeed should be offered an antipsychotic such as quetiapine or olanzapine as prophylaxis instead, because lithium passes into milk and accumulates in the infant.

Valproate and other anticonvulsants

Valproate

• Valproate carries the greatest teratogenic risk of the mood stabilisers and antipsychotics: about 10% major malformation with exposure throughout pregnancy.

• Its neural tube defect risk is about 1 to 2% (1 in 100), roughly thirteen times the background of about 0.1% and the highest of any psychotropic.

• In-utero exposure causes neurodevelopmental disorders in 30 to 40% of children, the highest of any antiepileptic: delay, lower intelligence quotient (IQ), autism and attention deficit hyperactivity disorder (ADHD).

• Valproate does not cause a seizure disorder in the child.

• Fetal valproate syndrome is autism, lowered verbal IQ and a facial pattern with a metopic ridge, flat nasal bridge and long smooth philtrum.

• Valproate is also a recognised cause of hypospadias.

• These harms are why valproate carries a pregnancy prevention programme.

• In bipolar disorder valproate has no permitted use or dose in pregnancy: withdraw it before a planned conception, and if a woman is found pregnant, stop it and give an antipsychotic as prophylaxis.

• Folic acid is offered alongside valproate even after the neural tube has closed, because it may help early neurodevelopment and carries little risk.

Other anticonvulsants

• Enzyme-inducing anticonvulsants such as carbamazepine lower the newborn's vitamin K-dependent clotting factors, so the baby is given vitamin K after delivery.

Antipsychotics and mania in pregnancy

• An antipsychotic with mood-stabilising action is preferred to the classic mood stabilisers for acute mania or a mixed state, and for prophylaxis in early pregnancy.

• The reason is that none of the mood stabilisers is clearly safe and some are strongly teratogenic.

• A woman with bipolar disorder who is stable on an antipsychotic and likely to relapse without it keeps taking it, with monitoring, rather than stopping or switching to valproate, lithium or lamotrigine.

• Quetiapine has overtaken olanzapine as the antipsychotic most often prescribed in pregnancy in the United Kingdom (UK), with a large safety dataset, relatively low placental passage and little effect on prolactin.

• A pregnant woman with schizophrenia who has relapsed off treatment is started on an antipsychotic with a large reproductive safety record, such as olanzapine, widely used by UK perinatal services.

• Monitor weight and gestational diabetes risk in women taking antipsychotics.

• ECT is the treatment for severe first-trimester mania, particularly when an antipsychotic has failed or physical health is at risk, because it works quickly without fetal drug exposure.

• Mild depressive symptoms in a pregnant woman with bipolar disorder who takes no medication are managed first with facilitated (guided) self-help.

Antidepressants in pregnancy

Choosing and continuing

• A woman with severe recurrent depression who is well on an effective antidepressant continues it unchanged, at the same dose, when she becomes pregnant.

• For a woman in stable remission from mild depression who is planning or starting a pregnancy, NICE advises considering gradual withdrawal, facilitated self-help and monitoring.

• This applies whether she takes a selective serotonin reuptake inhibitor (SSRI), a tricyclic or a serotonin and noradrenaline reuptake inhibitor.

• Sertraline is the preferred antidepressant to start for the first time in pregnancy, with the broadest reassuring data and the least placental exposure among well-studied agents.

• The safest choice is a widely used antidepressant with a large body of pregnancy data and no consistent link to malformations; alternatives carry specific teratogenic, cardiac, interaction or neonatal risks.

Risks to the baby

• Paroxetine has the strongest link with neonatal withdrawal, from its short half-life, lack of an active metabolite, self-inhibited cytochrome P450 2D6 metabolism and anticholinergic rebound.

• With its cardiac signal, this is why paroxetine is avoided as a first choice in pregnancy.

• Counsel about persistent pulmonary hypertension as a possible modest association, not proven harm.

• Neonatal adaptation can include respiratory difficulty, so assess symptoms rather than assume they are benign.

Benzodiazepines, hypnotics and substances

• Benzodiazepines are avoided in pregnancy and after birth except for short-term treatment of severe anxiety and agitation.

• Floppy infant syndrome follows late-pregnancy benzodiazepine exposure: hypotonia, sedation, poor suck, hypothermia and apnoea from birth.

• It occurs because diazepam and its active metabolite cross the placenta and clear slowly.

• First-trimester diazepam has a reported signal for orofacial clefts, whereas lithium and paroxetine are linked with cardiac defects.

• For persisting insomnia in pregnancy after non-drug measures, NICE suggests considering promethazine, a sedating antihistamine with long pregnancy experience.

• Neonatal abstinence syndrome after regular opioid exposure in the womb is a high-pitched cry, sneezing, yawning, sweating, tremor, raised tone, poor sleep, loose stools and poor feeding.

• Withdrawal from short-acting heroin begins within the first day, whereas methadone's long half-life delays onset to between the second and seventh day, usually 48 to 72 hours.

• Fetal alcohol syndrome, the severe end of fetal alcohol spectrum disorder, is short palpebral fissures, a smooth philtrum and a thin upper lip, with growth deficiency, a small head, and attention and learning problems.

• Regular maternal tobacco smoking in pregnancy is the best-supported prenatal exposure risk factor for ADHD in the offspring.

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Breastfeeding

Decisions depend on the drug, the infant's health, the exposure and monitoring, and the feeding plan is agreed before delivery where possible.

• Lamotrigine reaches the breastfed infant in high amounts, and rash is its signature infant adverse effect.

• Breastfeeding on lithium is not routine; if chosen in selected cases, it needs specialist advice and infant monitoring.

Planning ahead

• Agree a written antenatal plan covering medication through pregnancy and delivery, postpartum prophylaxis, protected sleep, infant care, early warning signs and emergency contacts.

• Review valproate before conception, and offer preconception advice before any further pregnancy.

Premenstrual and perimenopausal disorders

• Serotonergic dysfunction is implicated in premenstrual syndrome and premenstrual dysphoric disorder, from findings on luteal-phase blood serotonin, platelet transporter binding, tryptophan depletion and serotonergic challenge tests.

• ICD-11 premenstrual dysphoric disorder requires at least one affective symptom with additional somatic or cognitive symptoms and significant distress or impairment.

• Symptoms recur before menstruation in most cycles over the past year, improve within days of its onset and become minimal or absent within about a week. Confirm the pattern with a prospective diary over at least two symptomatic cycles when possible.

• Perimenopausal depression is new depressive symptoms in the menopausal transition, with irregular periods, vasomotor symptoms and sleep broken by night sweats.