Pharmacological treatment

2. Pharmacological treatment In general, psychiatric illnesses occurring during the perinatal period respond to the same treatments as at other times. There are no specific treatments for perinatal psychiatric disorder.

3. Moderate to severe depressive illnesses respond to antidepressants, psychotic illnesses to antipsychotics and mood stabilizers • the possibility of adverse consequences on the embryo and developing fetus and via breastmilk on the infant makes the choice and dose of the drug important.

4. All psychotropic medication passes across the placenta and into the breastmilk. • an alternative, non-pharmacological treatment • the clinician must endeavour to balance the risk of not treating the mother on both mother and baby against the risk to the fetus or infant of treating the mother.

5. The risks to both mother and baby of a serious maternal mental illness are greater than the risks of medication. Fetal and infant elimination of psychotropic medication is slower and less than adults and their central nervous systems more sensitive to the effects of these drugs.

6. Adverse of medication on the fetus and infant are dose-related. If medication is used it should be used in the lowest effective dose and given in divided dosage throughout the day. • The exposure of the baby to psychotropic medication in breastmilk will depend on the volume of milk, the frequency of feeding, weight and age.

7. Antidepressants Tricyclic antidepressants Pregnancy Tricyclic antidepressants (e.g. imipramine, lofepramine, amitriptyline and dosulepin). Tricyclic antidepressants are not associated with an increased risk of fetal abnormality, early pregnancy loss or growth restriction when used in later pregnancy. clomipramine (Anaframil) has been linked to cardiac abnormalities. Newborn babies of mothers who were receiving a therapeutic dose of tricyclic antidepressants at the point of birth are at risk of suffering from withdrawal effects (jiferiness, poor feeding and on occasion fits). Consideration should be given to a gradual reduction of the dose prior to birth.

8. Breastfeeding The excretion of tricyclic antidepressants in breastmilk is very low. doxepin cause sedation in babies. Minimized side effect by dividing the dose, e.g. 50 mg of imipramine

9. Selective serotonin reuptake inhibitorsPregnancy (SSRIs) (e.g. fluoxetine, paroxetine, citalopram) There may be an increased risk of miscarriage an increased risk of cardiac abnormalities related to first trimester ventricular septal defects (VSD) use of paroxetine in pregnancy.

10. fluoxetine (Prozac) and sertraline (Lustral)better tricyclic antidepressants or sertraline should be the treatment of choice if antidepressants are required during pregnancy. Continued use of SSRI medication during pregnancy has been associated with pre- term birth, reduced crown–rump measurement and lower birth weight. Babies born to mothers receiving SSRI medication at the point of birth are likely to experience withdrawal effects,

11. babies who are preterm. SSRIs, also associated with a serotonergic syndrome in the newborn (jiferiness, poor feeding, hypoglycaemia and sleeplessness).

12. Breastfeeding avoided when breastfeeding the newborn. Tricyclic antidepressants or sertraline should be the antidepressants of choice in breastfeeding.

13. Antipsychotics Typical :,haloperidol, chlorpromazine)  Pregnancy no evidence that their use in early pregnancy is associated with an increased risk of fetal abnormality antipsychotic medication freely passes to the developing fetus and its brain and the dose should be reduced to that which is the minimum for clinical effectiveness. Babies experience a withdrawal syndrome and extrapyramidal symptoms (muscle stiffness, rigidity, jiferiness and poor feeding). a reduction of the dose before birth and a Decrease dose may be associated with a risk of a relapse of the maternal condition.

14. Atypical antipsychotics • The use of olanzapine in pregnancy increased risk of gestational diabetes. • Clozapine should not be used in pregnancy and breastfeeding because of the risk of blood dyscrasias in the infant.

15. Mood stabilizers used to treat the manic component of bipolar illness mood stabilizers arelithium carbonate (Priadel) and various anti-epileptic drugs, commonly sodium valproate and carbamazepine

16. Pregnancy Lithium carbonate in pregnancy is associated with a cardiac condition The continued use of lithium throughout pregnancy is associated with an increased risk of fetal hypothyroidism, diabetes insipidus, fetal macrosomia and the ‘floppy baby’ syndrome (neonatal cyanosis and hypotonia). woman will require increasing doses of lithium in later pregnancy to maintain a therapeutic serum level because of the increased maternal clearance of lithium.

17. During labour and immediately following birth, physiological diuresis can result in toxic levels of maternal lithium. • frequent estimations of her serum lithium throughout labour and in the early postpartum days.

18. BreastfeedingLithium should not be used in breastfeeding result in infant lithium toxicity, hypothyroidism and ‘floppy baby’ syndrome.

19. Anticonvulsants • used as mood stabilizers • Carbamazepine was first used • sodium valproate is now the mood stabilizer of choice

20. Pregnancy • Continued use of anticonvulsants throughout pregnancy is associated with an increased risk of neuro-developmental problems in the child. • They should also take folic acid.

21. Breastfeeding the infant should be monitored for excessive drowsiness and, in the case of sodium valproate, rashes.

22. Prevention and prophylaxis • all recommend that women should be screened at early pregnancy assessment for a previous or family history of serious mental illness, particularly bipolar illness, because they face at least a 50% risk of recurrence of that condition following birth.

23. Prophylaxis • previous history of bipolar illness or puerperal psychosis, consideration should be given to starting medication on day one postnatally. • antidepressants taken prophylactically may prevent the onset of a depressive psychosis • .

24. Hormones no evidence that progesterone, natural or synthetic, prevents or treats postnatal depression or puerperal psychosis. transdermal oestrogens are effective in treating postnatal depression, A specialist community perinatal psychiatric nurse together with the midwife should visit on a daily basis for the first two weeks and remain in close contact for the first six.

25. psychiatric causes of maternal death • suicide and other psychiatric causes of death are a leading cause (indirect) of maternal death. • Suicide in pregnancy is less common. The majority of suicides took place in the year following birth, most in the first 3 months. • The majority of suicides were older, married and relatively socially advantaged and seriously ill.

26. The f our main catogeries o f psy chiatric death saving mothers lives • Suicide • Overdose of drugs abuse • Medical conditions caused by or mistaken for psychiatric disorder • Violence and accidents related to psychiatric disorders