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 associated with 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-11)
produced by the WHO. In the United States, a clinical modification of ICD is used (ICD-10-CM) . Although ICD is the official diagnostic system for mental disorders in the United States, 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 Centers for Disease Control and Prevention determined that between 2017 and 2019, mental health conditions were the leading cause (22.7%) of maternal deaths. Similarly, the Confidential Enquiries into Maternal Deaths in the United Kingdom and Ireland found that psychiatric and cardiovascular disorders are the leading causes of maternal death, with each contributing to about 15% of maternal deaths; maternal suicide was the leading direct cause of death during that period.
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 and affects one in seven women. 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 (BPDs) (“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 BPD, 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 an early pregnancy loss (miscarriage); this most frequently occurs in the first month after early pregnancy loss 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 early pregnancy loss, preterm birth, and low birth weight. To ensure timely diagnosis and treatment, the American College of Obstetricians and Gynecologists (ACOG) recommends three separate screenings for depression: at the initial prenatal visit, later in pregnancy, and postpartum.
Bipolar (Manic-Depressive) Disorder
Patients with 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.
Perinatal Depression
Perinatal depression is a mood disorder that affects patients during pregnancy and after childbirth. Perinatal depression includes depression that begins during pregnancy (“prenatal depression”) and depression that begins after the baby is born (“postpartum depression”). There may be accompanying psychotic features 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, environmental, and psychosocial effects such as hormonal changes and psychological and social role changes that occur with childbirth may increase the risk for postpartum depression. Although some studies have observed associations between labor analgesia and reduced risks for postpartum depression, others have not. One study demonstrated a harmful effect for women who planned to avoid, but ended up using labor epidural analgesia. These conflicting results reflect that the relationships between pain, emotion, and cognition are complex and are influenced by factors outside of physical health and interventions alone (e.g., culture, expectations, and quality of social support networks).
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 include posttraumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD) . 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
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
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.
EATING DISORDERS
There are conflicting data on the effect of pregnancy in patients with feeding and eating disorders, which include anorexia nervosa and bulimia nervosa as well as pica, rumination disorder, avoidant/restrictive food intake disorder, binge-eating disorder, other specified feeding or eating disorder, and unspecified feeding or eating disorder . Improvement in symptoms during pregnancy has been described, but conversely, pregnancy may result in body image preoccupations and unfavorable eating habits that may develop into a frank eating disorder. Although fertility is reduced in patients with anorexia nervosa, patients may still conceive. Patients with eating disorders have a higher risk for psychiatric comorbidity, including anxiety and postpartum depression, and are at greater risk for fetal growth restriction and cesarean delivery.
SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS
These disorders include schizophrenia, other psychotic disorders, and schizotypal (personality) disorder. Defining features include abnormalities in one or more of the following areas: hallucinations, disorganized thinking, grossly disorganized or abnormal motor behavior, and negative symptoms. In schizophrenia , the disorder lasts for at least 6 months, with at least 1 month of active symptoms.
Limited data are available on the course of psychotic disorders in pregnancy; both deterioration and improvement have been reported. The postpartum period is thought to be a high-risk period for relapse. Compared with women without psychotic disorders, pregnant women who have psychotic disorders often receive less prenatal care; have poorer nutrition; exhibit greater use of tobacco, alcohol, and illicit drugs; and have higher rates of obstetric interventions and obstetric complications. Fear of loss of child custody may result in underreporting of symptoms.
OTHER DISORDERS
Personality Disorders
Personality disorders have high prevalence rates of approximately 10% in the general population and up to 40% among psychiatric patients. The DSM-5 lists 10 specific personality disorders that are grouped into three clusters based on descriptive similarities. Patients in cluster A (paranoid, schizoid, schizotypal) appear odd or eccentric; patients in cluster B (antisocial, borderline, histrionic, narcissistic) appear dramatic, emotional, or erratic; and patients in cluster C (avoidant, dependent, obsessive-compulsive) appear anxious and fearful. There is also one further category, personality disorder not otherwise specified . The DSM-5 also provides an alternative dimensional model for personality disorders based on both personality functioning and pathologic personality traits that takes the perspective that personality disorders represent maladaptive variants of personality traits that merge into normality and into one another. This accounts for the observation that patients who meet criteria for a specific personality disorder frequently also meet criteria for other personality disorders.
Pseudocyesis
Pseudocyesis is a clinical syndrome in which a woman firmly believes that she is pregnant in the absence of a true gestation. Patients may develop convincing signs and symptoms suggestive of pregnancy, including abdominal enlargement and menstrual disturbance. Diagnosis can be made using a pregnancy test and ultrasonography. Physical diagnoses should be excluded. For example, tumors such as bronchogenic carcinoma may produce hormones (e.g., human chorionic gonadotrophin) that can cause secondary amenorrhea, which may be confused with pregnancy.
Denial of Pregnancy
In contrast to pseudocyesis, denial of pregnancy is more common, with an estimated incidence of 1 in 400 to 516 pregnancies. It may be associated with adverse outcomes, including psychological stress, unassisted delivery, and infanticide. Patients who are identified should be referred for psychiatric assessment.
Substance Abuse
Substance use during pregnancy is discussed in Chapter 52 .
MANAGEMENT OF PSYCHIATRIC DISORDERS IN PREGNANCY
General Considerations
Guidelines for the management of pregnant women with psychiatric disorders have been published by the ACOG and the APA, and guidelines are also available from the United Kingdom and Australia.
Screening for anxiety and depression during pregnancy and the postpartum period is essential and recommended by the ACOG and APA for diagnosing perinatal mental health problems. Screening can be achieved through face-to-face screening or online. Pregnant women should also be screened for substance abuse and domestic violence. Positive screens require referral for support services. Patients voicing thoughts of self-harm, in any care context, must be referred for immediate support and evaluation.
Treatment options for different psychiatric disorders overlap and include nonpharmacologic and pharmacologic therapies. Data are limited on pregnancy-specific efficacy of treatments, but in general, response in pregnant patients is thought to be similar to that in nonpregnant patients. A family-centered approach is recommended, and cultural and social context should be taken into account. Nonpharmacologic therapies are important because of maternal preferences and concerns about potential effects of drugs on the fetus, infant, or breast milk transfer. Although there are theoretical concerns about potential harmful effects of psychotropic drugs during pregnancy and lactation, psychotropic drugs prescribed in pregnancy should be chosen for their track records of safety. The significant risks for exacerbation of illness and serious harm associated with cessation or withholding of psychotropic drugs must be balanced against these other risks.
Because diabetes, obesity, smoking, and substance abuse are more common in people with psychiatric disorders, it can be difficult to separate the effects of psychiatric drugs on the fetus from the effects of these other factors. Further, some of the risks associated with psychiatric drugs may be attributable to the fact that women who take medication for psychiatric disorders are likely to have a more severe disease than women not on medication (i.e., confounding by indication).
Readers are referred to published guidelines from the ACOG for the screening and diagnosis of mental health conditions during pregnancy. In summary: (1) all pregnant patients should be screened for depression, anxiety, and BPD using validated instruments; (2) the screening for anxiety and depression should occur at the initial prenatal visit, later in pregnancy, and postpartum; (3) screening for BPD should occur before initiating pharmacotherapy for anxiety or depression if not already done; (4) because BPD is associated with suicide and infanticide, a mental health professional should be consulted if screening is positive for BPD; and (5) systems should be in place for effective treatment, monitoring, and follow-up of any patient who screens positive for any of the above.
A multidisciplinary approach is essential in the management of pregnant patients with psychiatric disorders, especially because many anesthesia providers may not be familiar with management of these patients. Patients who are noncooperative or violent may be challenging and require patience, compassion, and emotional support. Flexibility in management is important. For example, general anesthesia may sometimes be required if neuraxial anesthesia is considered impractical or unsafe.
Psychological and Psychosocial Therapies
Psychological and psychosocial interventions include cognitive behavioral therapy, interpersonal therapy, nondirective counseling, and peer support; these strategies are particularly effective for management of anxiety disorders and depression. Promising interventions for postpartum depression include professionally based postpartum home visits, lay- or peer-based postpartum telephone support, and interpersonal psychotherapy.
Psychotropic Drugs
There is often concern about potential harmful fetal/neonatal effects of psychotropic drugs given during pregnancy and lactation. However, because of the difficulties of performing experimental studies in this area, much of the available evidence is based on observational studies that are unable to differentiate between association and causation. The decision to initiate or continue a psychotropic medication during pregnancy requires the physician and patient to carefully weigh the possible risks associated with medications versus the serious potential consequences of inadequately treated disease. Psychiatric medications should generally be continued in pregnant women presenting for anesthesia and surgery.
Box 49.1 outlines principles for the use of psychiatric medications during pregnancy. The use of nonanesthetic drugs during pregnancy and lactation is discussed in Chapter 16 .
Box 49.1
General Principles Related to the Use of Psychotropic Drugs in Pregnancy
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Use nonpharmacologic therapy when possible, but do not assume that it is always better to avoid psychotropic drugs.
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Be aware that discontinuing medication exchanges the fetal and neonatal risks of drug exposure for the risks of untreated maternal illness.
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Be aware that all psychotropic drugs cross the placenta and pass into breast milk, and that the major risk for teratogenesis occurs during embryogenesis (i.e., 3–8 weeks’ gestation).
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Use drugs with largest up-to-date evidence of safety for the mother and fetus.
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Prescribe the smallest number of drugs possible, preferring monotherapy to multiple medications.
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Use the lowest effective doses and minimize changing drug regimens.
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Prefer medications with fewer metabolites, higher protein binding, and fewer drug interactions.
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Monitor mental state and adjust doses as pregnancy progresses because of alteration in pharmacokinetics.
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Involve the mother and partner/family in decisions, and document decisions.
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