Abstract
Psychiatric disorders occur commonly during pregnancy and can have significant effects on the mother, child, and family, and important economic costs to society. Suicide is a major cause of maternal mortality. Women have higher rates than men of many psychiatric disorders, such as anxiety, feeding and eating disorders, and depression; the reproductive years coincide with the greatest period of risk. Management can be difficult and may be complicated by variable presentation of symptoms, social stigmas, confusion with normal symptoms of pregnancy, and inconsistent published treatment recommendations. Further, pregnant women with psychiatric disorders may resist drug treatment because of their desire to avoid fetal harm. Psychiatric disorders during pregnancy may be associated with other aspects of poor maternal health and deficient prenatal care, which may affect anesthesia care. Women with a history of previous psychiatric hospitalization or an identified mental illness are at increased risk for cesarean delivery.
Keywords
Pregnancy, Postpartum, Psychiatric disorder, Anxiety, Depression
Chapter Outline
Classification, 1207
Epidemiology, 1207
Mood Disorders, 1208
Major Depressive Disorder, 1208
Bipolar (Manic-Depressive) Disorder, 1208
Postpartum Depression, 1208
Postpartum Psychosis, 1208
Anxiety Disorders, 1208
Feeding and Eating Disorders, 1209
Schizophrenia Spectrum and Other Psychotic Disorders, 1209
Other Disorders, 1209
Management of Psychiatric Disorders in Pregnancy, 1210
General Considerations, 1210
Psychological and Psychosocial Therapies, 1210
Psychotropic Drugs, 1210
Drug Interactions, 1212
Electroconvulsive Therapy, 1212
Psychiatric disorders occur commonly during pregnancy and can have significant effects on the mother, child, and family, and important economic costs to society. Suicide is a major cause of maternal mortality. Women have higher rates than men of many psychiatric disorders, such as anxiety, feeding and eating disorders, and depression; the reproductive years coincide with the greatest period of risk. Management can be difficult and may be complicated by variable presentation of symptoms, social stigmas, confusion with normal symptoms of pregnancy, and inconsistent published treatment recommendations. Further, pregnant women with psychiatric disorders may resist drug treatment because of their desire to avoid fetal harm. Psychiatric disorders during pregnancy may be associated with other aspects of poor maternal health and deficient prenatal care, which may affect anesthesia care. Women with a history of previous psychiatric hospitalization or an identified mental illness are at increased risk for cesarean delivery.
Classification
Internationally, psychiatric disorders are most commonly classified according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10) a
a http://apps.who.int.easyaccess2.lib.cuhk.edu.hk/classifications/icd10/browse/2010/en
produced by the World Health Organization. In the United States, a clinical modification of ICD is used (ICD-10-CM). bb https://www.cdc.gov/nchs/icd/icd10cm.htm
Although in the United States ICD is the official diagnostic system for mental disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association (APA), is widely used. These classification systems provide standardized language and criteria for diagnosis and classification of mental disorders; however, definitions may not have precise boundaries and there may be considerable overlap between “mental” and “physical” disorders.Epidemiology
It has been estimated that more than 500,000 pregnancies each year in the United States involve women who have a psychiatric illness that either predates or emerges during pregnancy. Psychiatric illness occurs in approximately 15% of pregnant women, and 10% to 13% of fetuses are exposed to psychotropic drugs. The World Health Organization has reclassified maternal suicide as a direct cause of maternal death, and the Confidential Enquiries into Maternal Deaths in the United Kingdom has identified suicide as an important cause of maternal mortality and the leading cause of direct maternal deaths occurring within 1 year after the end of pregnancy.
Pregnancy is widely considered a time of increased vulnerability to psychiatric disorders. However, studies suggest that the prevalence is similar between pregnant and nonpregnant women. A conspicuous exception is the risk for major depressive disorder, which is increased during the postpartum period. Identified risk factors for developing psychiatric disorders during pregnancy include younger age, unmarried status, exposure to traumatic or stressful life events, pregnancy complications, and poor overall health. Treatment rates among pregnant women with psychiatric disorders are often low.
Mood Disorders
Mood disorders include depressive disorders and bipolar disorders (“manic-depressive disorders”).
Major Depressive Disorder
The DSM-5 has defined criteria for major depressive disorder that are based on the presence, within the same 2-week period, of specific symptoms that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; these symptoms should not be the result of the physiologic effects of a substance. Although depression is recognized as being relatively common during pregnancy, many of its symptoms (e.g., weight gain, appetite changes, sleep disturbances, fatigue) must be differentiated from symptoms that may occur during normal pregnancy. Risk factors for depression during pregnancy include a history of depression or bipolar disorder, childhood mistreatment, being a single mother or having more than three children, marital problems, unwanted pregnancy, smoking, low income, age younger than 20 years, poor social support, and domestic violence. The risk for major depressive illness is increased in women who have a miscarriage (i.e., early pregnancy loss); this most frequently occurs in the first month after miscarriage and is more likely to occur in women who are childless or who have a prior history of major depressive disorder. Depression during pregnancy is associated with an increased risk for poor obstetric outcomes such as miscarriage, preterm birth, and low birth weight.
Bipolar (Manic-Depressive) Disorder
Patients with bipolar disorder (BPD) have episodes of major depression with other distinct periods of mania or hypomania. A strong familial association exists. DSM-5 diagnostic criteria for mania specify a distinct period when there is abnormally and persistently elevated, expansive, or irritable mood and persistently increased goal-directed activity or energy, which lasts at least 1 week and is present most of nearly every day or requires hospitalization. Specific symptoms are listed, which should be severe enough to cause marked impairment in occupational functioning, social activities, and interpersonal relationships and necessitate hospitalization or have psychotic features; symptoms should not meet criteria for a mixed episode and should not be caused by substance abuse or general medical conditions (e.g., hyperthyroidism). BPD in pregnancy is particularly important because there is a strong link between discontinuation of medication and relapse of BPD and a relatively high suicide rate among patients. Treatment of BPD typically consists of mood stabilizer and antipsychotic medication, with psychotherapy as an adjunct. Electroconvulsive therapy (ECT) is very effective for patients with BPD and severe depression.
Postpartum Depression
Postpartum depression describes a major depressive episode that occurs in the first 4 to 6 weeks after birth. Symptoms do not differ from those of depression occurring at other times. There may be accompanying psychotic features, which are thought to be more common in nulliparous women, and there is a high risk for recurrence in subsequent pregnancies. It is important to differentiate postpartum depression from the “baby blues,” which affects up to 70% of women in the first 10 days after delivery and is transient without functional impairment. It is also important to differentiate postpartum depression from delirium that arises from physical causes. In a systematic review, Robertson et al. showed that the strongest predictors of postpartum depression were (1) depression, anxiety, or stressful life events occurring during pregnancy or the early puerperium; (2) low levels of social support; and (3) previous history of depression. Biologic effects such as hormonal changes and psychological and social role changes that occur with childbirth may increase the risk for postpartum depression. In a retrospective study, Ding et al. showed an association between use of labor epidural analgesia and a decreased risk for postpartum depression; further research is required to confirm these findings.
Postpartum Psychosis
Postpartum psychosis occurs within 2 weeks of approximately 1 to 2 per 1000 live births; a relatively high risk continues for the first 3 months postpartum. The risk is higher in patients with a history of BPD or a history of previous postpartum psychosis, as well as in women with major depression and schizophrenia. Typical features include prominence of cognitive symptoms such as disorganization, confusion, impaired sensorium, disorientation, and distractibility. Infanticide is rare and may be associated with command hallucinations to kill the infant or delusions that the infant is possessed.
Anxiety Disorders
Anxiety disorders affect women twice as often as men and are the most common psychiatric disorders during pregnancy and the postpartum period. There is a wide range of anxiety disorders, including panic disorder, separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, agoraphobia, generalized anxiety disorder, substance/medication-induced anxiety disorder, anxiety disorder due to another medical condition, other specified anxiety disorder, and unspecified anxiety disorder. Closely related to anxiety disorders are trauma- and stressor-related disorders, which includes posttraumatic stress disorder and obsessive-compulsive disorder. Clinical features of anxiety disorders in pregnant women are similar to those in nonpregnant women, but concern about the pregnancy and the fetus may be the predominant feature.
Panic Disorder
Panic disorder is characterized by the occurrence of recurrent, unexpected panic attacks. Affected women experience discrete episodes of intense fear or discomfort in the absence of a true danger; these episodes are accompanied by somatic or cognitive symptoms such as palpitations, sweating, shaking, dyspnea, choking, chest pain, nausea, paresthesias, chills, and/or flushes. Typically there is a rapid onset and peak of symptoms that may be accompanied by an urge to escape. It is important to be aware of the possibility that panic attacks may occur during preparation of a patient for cesarean delivery. Panic attacks with hyperventilation may mimic local anesthetic systemic toxicity. Patients with panic disorder often have comorbid major depression.
Posttraumatic Stress Disorder
Posttraumatic stress disorder (PTSD) occurs after the experience of a traumatic event that evokes intense fear or helplessness and has been estimated to occur in 4% to 6% of women in pregnancy or postpartum. PTSD may arise during the perinatal period, or preexisting PTSD can be exacerbated during pregnancy. Symptoms of PTSD are more common after emergency cesarean delivery than after other modes of delivery, and PTSD has resulted from (1) awareness during general anesthesia, (2) inadequate neuraxial anesthesia for cesarean delivery, and (3) inadequate pain control during vaginal delivery. The risk for PTSD may be increased if the pregnancy has resulted from rape or if memories of sexual trauma are triggered. It has been suggested that the childbirth experience itself can precipitate PTSD with a resulting fear of pregnancy termed tocophobia. Fear of vaginal delivery may be a factor that contributes to maternal request for cesarean delivery.
Obsessive-Compulsive Disorder
Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions (intrusive thoughts or images) and compulsions (repetitive or ritualistic behaviors or thought patterns). OCD is more common in pregnant and postpartum women than in the general population. Obsessions most frequently center around contamination or aggression toward the child and may lead to compulsive cleaning, checking, or avoidance of the child. Care should be taken to identify infanticidal ideation.
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