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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

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notes	336
EMQ	1502
SBA	2115

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ESSAY 205 - PSYCHIATRY

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		Posted by Kishor S. Tue Aug 8, 2006 07:18 am
Psychological disorders are rare in pregnancy as compared to postpartum period. Schizophrenia is a major psychosis characterized by delusions, hallucinations, incoherence and inappropriate affect. Changes during pregnancy in endocrine functions such as thyroid, weight gain can influence the course of the disease in the form of exacerbations. Psychotic symptoms have been associated with fetal abuse, impaired self-care and adverse outcomes like prematurity and low birth weight. Continued hospitalization is necessary for an effective prenatal care and multidisciplinary approach involving psychiatrist, obstetrician and support group should be adopted. Termination of pregnancy is not indicated as there is greater risk of post-termination psychological reactions. Detailed history should be obtained from the record with regard to onset and duration of the illness, drug treatment, sexual abuse and sexual/marital relation. Recent onset such as during the present pregnancy is likely to have a better prognosis than a chronic patient. She is likely to have antecedent history of schizophrenia with remissions in between and family history of psychosis as there is an association of genetic predisposition and higher chance of having an affected child. Conventional antipsychotic drugs such as haloperidol and trifluperazine are relatively safe during pregnancy and should be continued as per requirement. Another commonly used drug, olanzapine is also not associated with adverse pregnancy outcome as compared to normal population. However, use of lithium is associated with cardiac anomalies. Electroconvulsive therapy is effective and safe during pregnancy though there is phase of deceleration. At this visit, complete examination should be done along with a dating ultrasound to confirm the gestation. In view of her age she should be offered the standard screening of Down?s syndrome; and also NTDs (sometimes she may not be capable to give consent). Anomaly scan is to be done at 20 weeks. Fetal monitoring should be closely done both clinically and by USS as she is likely to have growth retardation. It is also associated with increased risk of preterm labour. Some studies have shown increased risk of placental abruption. The mode of delivery is not affected by the disease but postpartum exacerbation is more likely with caesarean delivery. Such postpartum psychosis is a psychiatric emergency due to potential danger to the baby (of violence or neglect or mishandling). Antipsychotic drugs/electroconculsive therapy are indicated as appropriate to the symptoms. Psychotherapy may be of supportive help and requires expert care. Breast feeding needs to be stopped during acute phase. Lastly contraceptive is to be discussed. During the first month of use of OCP there may be an increase of psychiatric symptoms but there is no good evidence that oral pills can exacerbate psychosis. In view of likely to be non-compliant about daily intake of pills, IUCD or injectables will be a better option.
		Posted by neera B. Tue Aug 8, 2006 04:41 pm
The latest confidential enquiries reveal psychiatric disorders to be the commonest indirect cause of maternal death. Detailed history and review of her notes regarding duration and severity of psychiatric disease, current and past treatment is important . In case of family history of psychiatric disease,the baby is at risk of inheriting the same. Ascertain if pregnancy is wanted or not. History of sexual abuse , domestic violence, drug abuse, alcoholism and smoking should be sought as these could be the the underlying causes of voluntary admisssion. Her level of understanding and ability to care for her child should be assessed. Family and partner support should be ascertained. BMI , BP and pallor should be assessed,as poor nutrition can cause anemia. Dating scan should be done to confirm maturity. She should be booked under consultants care. If pregnancy is unwanted termination should be discusssed, though chances of exacerbation of disease after termination must be conveyed. Cofidentiality should be ensured.She should be reassured that despite risks of IUGR and postnatal depression outcome is good with regular follow up and compliance with treatment. A multidisciplinary meeting with senior obstetrician, psychiarist, partner or support person, experiences midwfe and social worker should be held and plan of management for the rest of the pregnancy , labor, and postparum made and attached to her hand held notes.Tricyclic antidepressants haloperidol, and SSRI like fluoxitine are safe during pregnancy, though not licensed for use in pregnancy. If she has taken lithium there is risk of cardiac anomalies hence detailed anomaly scan at 18-20 and fetal ECHO at 22 wks should be arranged. If the disease is severe Electroconvulsive therapy is safe during pregnancy.Cognitive behavioral therapy and psychotherapy should be considered in consultation with psychiatrist. Two weekly growth scans after 24 wks; effect of her illness on family members assessed and treatment offered to them. After discharge, GP, social worker, and community midwife should be involved so that home visits can be provided as these women are often poor attendees. Patient should be involved in decision making. Vaginal delivery in hospital in specialist unit is encouraged. Cesaerian is indicated only for obstetric reasons. Due to increased risk of postnatal depression, admission to specialist mother and baby units shoul be considered after delivery. Fluoxetine and haloperidol are safe during breast feeding. Contraceptive advice should be rendered. Follow up for one year is essential due to risk of late maternal deaths. Twentyfive percent women have recurrence during next pregnancy so preconceptional counselling is important.
		Posted by Radha P. Tue Aug 8, 2006 09:46 pm
This woman needs comprehensive planned care in accordance with written protocol providing maternity services for women with serious mental disorders. Management plan is agreed and discussed with the specialist mental health team and the woman herself. In the first visit, inquires about previous psychiatric history, its severity, care received and clinical presentation made in a systematic and sensitive way. Social history especially to rule out domestic violence, substance abuse taken and referral to concerned services provided as early as possible. Inquiry about her expectations in this pregnancy .Whether pregnancy is planned, stable family relationship and occupational potential, general health. Confidentiality always maintained during discussion and use of the term ?schizophrenic? will be avoided. The important issues discussed with the woman are her ability to cope with pregnancy, stress of pregnancy, the risk of child inheriting the disorder (10%-12%), Her ability to meet the needs of the child, balance between harm and benefits of medication, risk of relapse in pregnancy and postpartum period, antenatal and peripartum management plan agreed by the woman, maternity team, specialist mental health team and her GP is followed throughout. It is placed in her hand held records also. Detailed information about medication, its affect on the pregnancy, breast feeding issues is given to the woman. Verbal discussion is backed up with detailed written information (preferably in her own language). Informed consent should be taken from the patient. Use of interpreter is also justified. Early dating scan needed as she may not be aware of her dates. Medications can cause health problems like DM, obesity, CVS complications. So screening for these problems is done as early as possible and early referral provided. Regarding medication, if not on medication, regular assessment of her mental health by psychiatric consultants arranged. If she is on medication, gradually the drug dosage is adjusted to the lowest effective dose. If she is on clozapine, it is better to other drugs as it causes granulocytosis in the newborn. As far as possible oral medications is advised. If she is on depot preparations she can continue with that. Detailed anomaly scan, fetal echocardiography Advised and discussion with neonatologist arranged as the risk of congenital anomalies from the medications are more. Rapid tranquilisation, if needed anaesthetic advice taken as there is a risk of cardio-respiratory complications. Restrain procedures carried out without harm to baby. Avoid Benzodiazepene as it causes floppy baby syndrome. ECT if needed is safe is pregnancy. Family involvement, cognitive behavioral therapy arranged with the woman?s consent. Delivery planned in consultant led unit. Aim is for vaginal delivery, continous fetal monitoring needed, pain management discussed with anaesthetist . The unit should have close liaison with perinatal psychiatric team and should have mother and baby unit facilities. Postnatal period is the most vulnerable time for the woman as the relapse rate is high. Adequate monitoring of mother?s mental health is mandatory. Breast feeding encouraged with special input from mid wives. Before discharge, I will make sure there id adequate help from community mental health team, family involvement and social assistance and parenting help. Recurrence rate is high in subsequent pregnancies, so adequate contraception recommended. From Dr.Radha Palappetty
		Posted by Srivas P. Wed Aug 9, 2006 06:31 am
Women with schizophrenia have high rates of unplanned pregnancies and psychotic disorders have been reported to worsen during pregnancy. History of psychosis increases the risk for postpartum psychosis and mental illnesses contribute to 12% of maternal deaths according to latest CEMD. Her care needs to be multidisciplinary involving psychiatrists, a senior obstetrician, social worker, GPs and health visitor with active participation from her family and partner. She may present with symptoms of withdrawal, under activity, lack of conversation or interests, odd ideas or behaviour, neglect of appearance, depression, and mood disturbance like anxiety, irritability or euphoria. Her and her partner?s version can help assess the severity of her complains and duration, prior episodes, drugs taken so far and if she stopped drugs due to concerns about the baby. Since she is 14 weeks pregnant, the teratogenic effect of drugs already taken cannot be prevented. Some drugs like lithium are teratogenic even after 1st trimester and should be avoided unless her symptoms are severe. But the couple should be told the importance of the drugs to control maternal symptoms even if it has some potential side effects and she should be asked not to stop medication as relapses may occur. Safer and well known drugs should be prescribed. The couple should be told that schizophrenia runs in families and her child has 10% chance of getting schizophrenia. The drugs like Lithium can cause major structural and heart anamolies and if she has taken them she should have detailed USG screening at 18-20 wks and an echocardiography done and she should be offered termination if major anamolies are detected. Valproate and carbamazepine can cause NTD?s which can be detected on ultrasound scan. Maternal schizophrenia is associated with higher rates of prenatal substance abuse, obstetrical complications like stillbirth, preterm delivery and small-for-gestational-age and infant death. Highly potent antipsychotics like haloperidol is agent of choice. Phenothiazines like chlorpromazine should be avoided as it can cause cleft palate while valproate and carbamazepine can cause NTD?s. TCA?s like Amitriptyline, clomipramine, Imipramine, and nortriptyline are safer in pregnancy. Drugs dosage should be minimized or stopped 2-4 weeks before delivery to reduce neonatal symptoms. Post delivery the drugs should be taken as single dosage preferably before baby?s longest sleeping hour. TCA and SSRI?s are safe in breast feeding woman. Paroxetine is preferred due to decreased levels in milk. Lithium is best avoided. She is likely to get post partum psychosis and depression and should be closely monitored. later she may show aberrant parenting styles that may impair child?s development. A social worker should keep regular visits and she may need psychotherapy, counseling and cognitive behavioral therapy. She should be given contraceptive advice and her next pregnancy should be planned with prenatal counseling , optimum drug intake and folic acid.
		Posted by Freha Z. Wed Aug 9, 2006 04:39 pm
Women\'s attitude towards pregnancy should be explored whether the pregnancy was planned and how is she coping. She needs to be seen with partener or carer because there may be delusional denial of pregnancy or pregnancy incorporated into established delusional system. Depending on her mental/physical state termination of pregnancy can be offered although there is risk of post termination exacerbation. Her pregnancy care needs to be planned with obstetrician,social worker, psychiatric nurse, community midwife and her family. Plan of management should incorporate maintaining healthy life style, choice of healthy diet, exercise and avoidance of alcohol and smoking. Dating scan should be done to confirm gestation. Counselling should be done regarding risk of offspring inheriting (15%) the disease. Chlorpromazine and Lithium should be avoided because of risk of congenital anomalies and 18-20 week anomaly scan should be performed. Depot antipsychotics can cause extrapyramidal symptoms in newborn therefore they should not be used. Regular psychiatric consultations should be made to maintain the drug dosage to minimum effective level and detect early signs of psychotic relapse followed by prompt admission preferably to mother and baby unit. She should be offered continuous psychosocial support and social worker should be involved to encorage her to uptake prenatal care. Regular growth scans are to be performed because of the risk of growth retardation. During pregnancy assessment of women\'s capability to care for baby should begin. She should be booked for hospital delivery. Aim is vaginal delivery with continuous fetal monitering and pain management discussed with anaesthetist. After delivery she should be kept in mother and baby unit with additional psychosocial support and vigilance of relapse of acute phase. Breast feeding is allowed carefully monitering the withdrawl effects of drugs in infant. Effective contraception should be given and follow up appointment should be made. GP and social worker should be informed about the discharge.
		Posted by Balakrishnan V. Thu Aug 10, 2006 01:58 am
Maternal schizophrenia is associated with high maternal and perinatal morbidity and mortality due to antipsychotic medications, obstetrical complications and postpartum pshchosis. A multidisciplinary team of obstetrician, psychiatrist, peadiatrician, general practitionar, community midwife and social worker should take care of her during antenatal, intrapartum and post natal period. The goal of treatment is to maximize maternal and infant well being while minimizing risks of exposure to medication, medical illness and environmental toxins. In her booking visit details of duration of illness, medication and their efficacy are enquired about. If she is stable on medication risk of relapse if treatment stopped has to be weighed against risk of adverse effect on fetus. Although old antipsychotic like haloperidol has known to have no teratogenic effect, change of medication is not adviced as maternal condition can become unstable and fetus has been already exposed to the drug. Dose may need to be adjusted as pregnancy advances. She should be ensured that risk of continuing to take medicine is less than untreated maternal mental illness on fetal development to make her compliance better. Her capacity to consent should be established. Usually these patients are not voluntary so possibility of underlying domestic or social problem should be enquired by direct questions. Schizophrenic patients also have drug abuse, smoking and drinking problems. Blood should be taken for screening of Hep B, C and HIV. She may need appointment with smoking sesassion or drug counsellor. Her attitude towards the pregnancy and plans of labour should be discussed. The gestation is confirmed by dating scan and booking should be made for detailed anomally scan. Fetus is at risk of low birth weight, prematurity and intrauterine death. Serial growth scan from 30 weeks should be done fortnightly. If she is discharged home community midwife, general physician and social worker should give her home visits and take care of her well being as well as making sure she attends antnatal clinics. Hospital delivery is adviced as any labour complication can be delt with efficiently. She may need higher doses of analgesia. Paediatrician should be present at delivery to observe the neonate for signs of neuroleptic malignant syndrome and extra pyramidal side effects. Breast feeding is not contraindicated it also help the infant against acute withdrawal. She should be given proper contraception. If baby\'s safety is at risk, social worker has to be informed. Post natal followup with health visitor is very important to assess her risk of developing depression. Edinburgh Postnatal Depression Scale is used to assess the risk and refer for appropriate intervention.
		Posted by Ismatara B. Thu Aug 10, 2006 03:37 am
Psychiatric disorder is the commonest indirect cause of maternal death reported in the last triennium (CEMACH 2000-02). A thorough history should be obtained from the record with regard to onset, duration and severity of the disease, drug treatment (current and past) is important. If there is any family history of psychiatric illness, the risk of inheriting the baby (10-12%) should be discussed. Social history of domestic violence, sexual abuse, substance abuse (drug, alcohol), and smoking should be sought and referral to the proper services is ensured. She is single or living with her partner or other family member should be enquired. Enquiry about her present pregnancy is planned or not. Her level of understanding and ability to care for her child should be assessed. Confidentiality should be maintained and the term ?schizophrenia? should be avoided. At this visit a complete examination including BP and pallor should be assessed, if any problem should be treated. Dating scan should be arranged to confirm maturity, as she may not aware about the pregnancy. A multidisciplinary team with psychiatrist, senior obstetrician, experiences midwife, GP, partner or support person, the women, and social worker should be involved. Management plan for her antenatal, intra and postparum care should be made. It is placed in her hand held notes. Consultant led care should be ensured. If pregnancy is unwanted, termination should be the option and chances of exacerbation of disease after termination should be discussed. If she wishes to continue, Home visits should be ensured, as these women are often poor attendees. There is chance of IUGR, premature labour and postnatal depression. She should be reassured that the outcome is good with regular follow up and compliance with treatment. If at present she is not on any medication, regular assessment with psychiatric consultant is enough. If she is on haloperidol or SSRI like fluoxetine, she should be ensured that they are safe during pregnancy, though not licensed for use in pregnancy. Trycyclic antidepressant like Amitryptaline, nortryptaline etc are safer in pregnancy. Phenothiazine like clorpromazine can cause cleft plate, so should be avoided. If she is on clozapine, it is better to switch over to other safer drugs as it causes granulocytosis to the newborn. Sodium valproate and carbamazepine should be avoided as these can cause NTDs. If she has taken Lithium there is risk of cardiac anomalies. Hence detailed anomaly scan at 18-20wks and fetal echocardiography at 22 wks and two weekly growth scans after 24 wks. should be arranged. Cognitive behavioral therapy and psychotherapy should be considered in consultation with psychiatrist. If the disease is severe Electroconvulsive therapy may be considered as it is safe during pregnancy. Vaginal delivery in hospital in specialist unit under consultant care is encouraged. Continuous fetal monitoring should be done and pain management should be discussed with anaesthesist. Paediatrician should be present at delivery to observe any signs of neuroleptic syndrome or other extra pyramidal side effects. Caesarian is indicated only for obstetric reasons. Patient should be involved in decision making. As postnatal period is most vulnerable and relapse rate is high, admission to specialist care mother and baby units with additional psychological help should be considered after delivery. Before discharge, GP, social worker, and community mental health team should be involved with regular visit. Family involvement and parenting help should be ensured if needed. Fluoxetine and haloperidol are safe during breast feeding. Lithium should be avoided. Follow up for one year is essential due to risk of late maternal deaths. As recurrence rate is high, contraceptive advice should be given and next pregnancy should be planned with preconceptional counselling (optimal drug and folic acid intake).
		Posted by afroz S. Mon Aug 14, 2006 06:08 am
Confidential enquiries into the maternal deaths have revealed that psychiatric illness is a most cause of maternal mortality.Large number of mortalities are due to suicides. The most important factor responsible for this was failure to recognize this problem and to deal with it appropriately.This patient comes in high risk group. Planning of care for her both in the hospital and in the community during pregnancy and after delivery is required. Multidisciplinary approach including obstetrician, psychiatrist, GP, social worker, community midwife, psychiatric nurse play a very important role. Her severity of schizophrenia symptoms is taken into account in the management. The aggravating factors of her disease includes pregnancy itself which is a stressful event, low socio economic status, domestic violence, unsupported or single parent, rejection from family or society and unwanted pregnancy. Counselling about the positive aspects of pregnancy is done. There is increased incidence of smoking, alcoholism and drug abuse among these patients. There is increased risk of STDs which require screening. General advice about stopping smoking & reduced alcohol intake is given.The importance of regular antenatal follow up is stressed. Fetal growth and wellbeing is monitored through out the pregnancy. Avoid stressful situations and support at home by partner and caregivers is important. It is important to weigh the consequences of untreated psychiatric illness against risks of prenatal exposure to drugs.Little is known about the effects of psychotropic drugs on fetus. Electroconvulsive therapy is generally considered safe. During pregnancy a higher dosage of drug is required due to increased GFR and hepatic metabolism. Labour is a stressful situation and adequate analgesia and supportive care is required. Paediatrician should be present at the time of delivery.There may be problems with the informed consent which should be dealt appropriately. Post partum exacerbation of symptoms may occur. Suicides are more common in postpartum.Treatment with psychotropic drugs should be continued. Patient may be admitted to dedicated mother and baby units. Breast feeding is continued as it has a positive impact on the mental status of mother. The drugs are excreted in milk but the child gets relatively small doses. Mothers taking lithium should not breast feed.Contraceptive advice is given. Follow up and surveillance of the woman is required even after discharge. The safety of the child is taken into account before discharge and even at home with the help of social worker. Any remediable social factors are attended to include help from partner,family members, emotional support ,rest & care of the baby. The contact numbers of local & national support groups are provided.