Pre-existing mental health disorders and pregnancy

Mental health disorders are independent risk factors for adverse perinatal and neonatal outcomes. It is estimated that 20% of women may experience symptoms of mental health disorders during or following pregnancy. It is important that obstetricians recognize the presentation of these symptoms and follow pathways for managing these conditions. This article utilizes case vignettes to describe the epidemiology, role of the multi-disciplinary team, clinical presentation, and management of common perinatal mental health disorders both from the obstetric and psychiatric view point. Indications and duration of psychotropic medications including side effects are also discussed as well as safety in pregnancy and lactation.     

An obstetrician's guide to perinatal psychiatry

Between 15 and 20% of pregnant women will have mental health difficulties so obstetricians need to be familiar with these conditions. Using case vignettes to illustrate specific examples, this article will review the epidemiology, the obstetrician's role, the psychiatrist's role and the basics of managing serious mental illnesses in pregnancy and post-partum including post-partum psychosis. Common psychotropic medications used in pregnancy and their indications will be considered, as well as the Mental Health Act and the Mental Capacity Act.     

Early pregnancy complications

The early pregnancy period can be complicated by a range of symptoms varying from nausea, vomiting, vaginal spotting and pelvic pain, to more severe conditions such as hyperemesis gravidarum, early embryonic demise, mental health problems and either molar or ectopic pregnancies. Some of these conditions require hospital admission and multidisciplinary team management, whilst others can be managed in an outpatient setting after the appropriate investigations. Complications early on in the pregnancy can be distressing, therefore women who experience such symptoms require close monitoring, reassurance and information on how to access help. Early pregnancy units have been specifically designed to serve patients with complications in early pregnancy and the health professionals are trained to support women during their treatment, whilst helping these patients make informed decisions about their care. This review summarises the key presentations, investigations and management of the most common complications that can arise in early pregnancy.     

Psychiatric disorders in pregnancy

Psychiatric disorders are common in pregnancy and can be associated with a range of adverse outcomes, including maternal death. Early identification and, where appropriate, referral to a specialist mental health service, is the key to successful management. Women with more severe psychiatric disorders, such as bipolar affective disorder, schizophrenia and moderate to severe depression, benefit from a shared management approach involving obstetric, primary care and specialist mental health services, formalized within a written perinatal care plan. Large numbers of women take psychotropic medication during pregnancy, but when it represents an appropriate alternative to medication, timely psychological treatment is the preferred approach for a range of psychiatric disorders. When medication is used, it should be based on a risk/benefit analysis that takes appropriate notice of the dangers of stopping or avoiding medication as well as any risk to the exposed fetus. All decisions about the management of a psychiatric disorder should involve the pregnant women as a fully informed partner in a shared decision-making approach. This review summarizes general guidance on management for the obstetrician and issues arising in relation to a number of specific psychiatric disorders and specific psychiatric treatments.     

Neurological disease in pregnancy

Neurological disease encompasses a broad spectrum of conditions which may be affected by pregnancy, present de novo in pregnancy, or are caused by the pregnancy itself. In the UK, 9.8 women in 100,000 died during pregnancy or up to 42 days after delivery (Mothers and Babies Reducing Risk through Confidential Enquiry (MBRRACE) report 2018). Neurological diseases, including epilepsy and stroke, continues to be the second leading indirect cause of maternal mortality and the numbers have not changed since reporting began in 1985, despite the availability of easily accessible Green-top Guidelines on the management of epilepsy through the Royal College of Obstetricians and Gynaecologists (RCOG). It is important than any women of child-bearing age with a neurological condition receive appropriate pre-pregnancy counselling and that during pregnancy they are managed by an experienced multi-disciplinary team including a neurologist, specialist nurse or midwife, maternal medicine obstetrician or obstetric physician and obstetric anaesthetist. Additional benefits in care will come with improving awareness in the general public and community doctors so that appropriate support is provided to enable the safest possible pregnancy.     

Consultation préconceptionnelle et psychopathologie

Women with mental health conditions/psychic vulnerability such as depression, bipolar disorder and schizophrenia prior to pregnancy should all benefit of a complete preconceptional management plan. Ideally, this should be done by a medical doctor experienced in preconception care; a gynaecologist, or a general practitioner. Specific management of pharmacologic treatment should be managed together by the psychiatrist and the preconception specialist. Popularization and dissemination of healthy behaviors will benefit to all women and especially to those who carry preconception health risks. Specific tools may increase the impact of preconception health among young adults. Individually, it implies to discuss pre-pregnancy rapidly after the diagnosis. At community level, it implies to augment the exposition of the preconceptional concept to school, family planning consultations and media.     

Neurological disease in pregnancy

Neurological disease encompasses a broad spectrum of conditions which may be affected by pregnancy, present de novo in pregnancy, or are caused by the pregnancy itself. In the Confidential Enquiry into Maternal Deaths Report 2006–08, 36 women died from diseases of the central nervous system, and 11 of these women were deemed to have had major substandard care. The overall number of deaths is similar to that of previous years, and the proportion with epilepsy was unchanged. Pre-pregnancy counselling should be offered to patients in order to optimise their condition, as well as to make appropriate changes to medication. A thorough history and physical examination should be performed, and specialist advice sought early when looking after these women in their pregnancies. Women should be managed by a multidisciplinary team, ideally including a neurologist, specialist nurse or midwife, obstetrician with an interest in maternal medicine, obstetric physician and an obstetric anaesthetist.     

Pelvic girdle pain during pregnancy and puerperium

Pelvic girdle pain (PGP) is a term used specifically to pregnancy-related pain in the lumbosacral, sacroiliac and symphysis pubis joints. Pregnancy-induced hormonal and physical changes increase the risk of musculoskeletal problems in pregnancy. The severity of these conditions varies from mild self-limiting pain to a severe disabling condition. PGP is common in pregnancy and while most can be managed as outpatients, a few patients require inpatient admission for further investigations and management. Prompt identification of these conditions is essential to avoid serious disability. Lack of awareness and failure of recognition not only results in women feeling isolated, but may also result in long-term morbidity. In this review, we explore the aetiology, presentation, risk factors, risk of recurrence, differential diagnosis and multidisciplinary management of these conditions. We also enclose obstetric guidelines to increase the awareness of the health professionals.     

Aims of obstetric critical care management

The aims of critical care management are broad. Critical illness in pregnancy is especially pertinent as the patient is usually young and previously fit, and management decisions must also consider the fetus. Assessment must consider the normal physiological changes of pregnancy, which may complicate diagnosis of disease and scoring levels of severity. Pregnant women may present with any medical or surgical problem, as well as specific pathologies unique to pregnancy that may be life threatening, including pre-eclampsia and hypertension, thromboembolic disease and massive obstetric haemorrhage. There are also increasing numbers of pregnancies in those with high-risk medical conditions such as cardiac disease. As numbers are small and clinical trials in pregnancy are not practical, management in most cases relies on general intensive care principles extrapolated from the non-pregnant population. This chapter will outline the aims of management in an organ-system-based approach, focusing on important general principles of critical care management with considerations for the pregnant and puerperal patient.     

Effiziente Schwangerenvorsorge durch korrekte Diagnose von „Befundrisiken”

The concept of prenatal care has been part of the obstetrician’s job for over 100 years. Much of the focus was originally the reduction of maternal mortality. Now the emphasis has shifted more toward improving fetal outcome and preventing maternal complications. Healthcare services use a risk system to identify women with “high-” and “low-risk” pregnancies. Risk factors do not appear however to be good indicators of which pregnancies will have complications. All pregnancies should be regarded as at risk of developing complications and managed with utmost care. The focus of obstetric care should be shifted from predicting complications by identification of risk factors to correctly detecting signs and symptoms of actual problems. Their significance should be considered for each pregnancy and childbirth on an individual basis. Evidence-based pregnancy care must become the standard for obstetric and perinatal health care professionals. Prenatal care is not useful as a screening tool but should only serve for detecting problems and keeping normal pregnancies normal.     

Assessing mental health during pregnancy: An exploratory qualitative study of midwives’ perceptions

BackgroundMental health disorders are estimated to affect between 10% and 20% of women who access maternity services and can be defined as a public health issue due to the potential consequences for women, children and families. Detecting problems early in pregnancy can significantly improve outcomes for women and their families. However, mental health problems are not being consistently identified in routine midwifery practice and little is known from current literature about midwives’ practice in relation to current national guidelines or the impact models of care have on assessing maternal mental health.ObjectiveTo identify midwives’ views about barriers and facilitators to screening for mental health in pregnancy using current UK guidelines.DesignNine community midwives from a single district general hospital in the south of England were recruited to take part in focus groups. Thematic analysis was used to extract key themes from the data.FindingsThree key themes were identified from the focus groups and included system factors, social factors and trust. Barriers and facilitators to screening maternal mental health were associated with the initial ‘booking’ appointment’ and differences in models of care. Barriers to screening were defined as high workload, poor continuity, and a lack of trust between women and midwives.ConclusionsThis study highlights key barriers and facilitators associated with mental health screening during pregnancy, including issues of trust and uncertainty about women's willingness to disclose mental health conditions. Further research is required to evaluate the relationship between women and midwives in contemporary practice and the influence this may have on maternal mental health.     

The findings of the MBRRACE-UK confidential enquiry into Maternal Deaths and Morbidity

Reports from the UK Confidential Enquiries into Maternal Deaths and Morbidity are now published annually. In 2013–15, the maternal mortality rate was 8.8 per 100,000 maternities. Over two thirds of women died from medical and mental health causes and less than one third from obstetric causes. Cardiac disease remained the leading cause of maternal death in the UK. With the majority of women dying from pre-existing conditions, there remain multiple opportunities to reduce women's risk of complications in pregnancy through early and forward planning of the care of women with known pre-existing medical and mental health problems. Provision of appropriate advice and optimisation of medication prior to pregnancy, referral early in pregnancy for the appropriate specialist advice and planning of antenatal, intrapartum and postnatal care and effective postnatal provision of advice concerning risks and planning for future pregnancies are the key improvements needed to prevent women dying in the future.     

Pregnancy and pulmonary arterial hypertension: A clinical conundrum

Pulmonary arterial hypertension (PAH) is a rare and devastating disease characterized by progressive increases in pulmonary arterial pressure and pulmonary vascular resistance which eventually leads to right ventricular failure and death. PAH inflicts most commonly women, majority of who are of childbearing age. Pregnancy in the setting of PAH is absolutely contraindicated due to high maternal fetal morbidity and guidelines do not exist for the management of such cases. A MEDLINE/PubMed search was performed identifying all relevant articles with “pulmonary arterial hypertension” and “pregnancy” in the title. Six case series were reviewed as well as our own center’s experience outlined. Though there exists generalized treatment measures that are followed in such cases, management varies among different national centers as well an on an international level. At our center patients are managed using a multidisciplinary approach at a high risk obstetric center with preference for intravenous prostacyclin therapy. Women of child bearing age with possible signs and symptoms of PAH must be promptly diagnosed and managed expectantly with an emphasis on maternal–fetal safety.     

Pregnancy in women with renal disease. Part I: general principles

The purpose of this review is to improve the basis upon which advice on pregnancy is given to women with renal disease and to address issues of obstetric management by drawing upon the accumulated world experience. To ensure the proper rapport between the respect for patient's autonomy and the ethical principle of beneficence, the review attempts to impart up-to-date, evidence-based information on the predictable outcomes and hazards of pregnancy in women with chronic renal disease. The physiology of pregnancy from the perspective of the affected kidney will be discussed as well as the principal predictors of maternal and fetal outcomes and general recommendations of management. The available evidence supports the implication that the degree of renal function impairment is the major determinant for pregnancy outcome. In addition, the presence of hypertension further compounds the risks. On the contrary, the degree of proteinuria does not demonstrate a linear correlation with obstetric outcomes. Management and outcome of pregnancies occurring in women on dialysis and after renal transplant are also discussed. Although the outcome of pregnancies under chronic dialysis has markedly improved in the past decade, the chances of achieving a viable pregnancy are much higher after transplantation. But even in renal transplant recipients, the rate of maternal and fetal complications remains high, in addition to concerns regarding possible adverse effects of immunosuppressive drugs on the developing embryo and fetus.     

Mental health of perinatal women

Pregnancy and childbirth are major stressors for some women. They can be followed by deterioration in mental health status and cause mental illnesses during perinatal period. Undetected and untreated perinatal mental illnesses can have negative unexpected impacts on parenting skills of the women and children's development. Mentally ill mothers may not effectively attend their children's needs in a timely manner and may experience an unfavourable mother-child attachment affecting the child's language, social, emotional and cognitive development. The rate of pregnancy and postnatal health complications and interventions is higher among mentally ill women with some certain risk factors. The mentally ill mothers along with their partners need comprehensive support and counselling to be able to care for their infants and establish strong parent-child bond and attachment. Mental health campaigns across the world have endeavoured to increase the knowledge and awareness of the public towards perinatal mental health illnesses. To this aim, a routine screening is recommended in order to identify the women who are at risk of mood or anxiety disorder during perinatal period. The development of knowledge on perinatal mental illnesses among public and the health professionals has resulted in timely recognition and treatment of perinatal mental illnesses. Although great volumes of research show high prevalence of perinatal mental illnesses and their impacts on parenting confidence and competence as well as child's developmental process, there is still lack of research on various aspects of perinatal mental illnesses. To enable early prevention, diagnosis and intervention, it is crucial to identify families who are at an increased risk of perinatal mental illnesses and provide support and intervention to minimise the adverse outcomes. The children's needs may not be met by providing treatment to parental mental illnesses alone. It is also important to understand the impact of specific parenting behaviours on child outcomes which is modified by the quality of parenting.     

Management of HIV in pregnancy

A cohesive multidisciplinary team approach is key in the management of HIV in pregnancy. The primary aim is to prevent transmission to the neonate but also to support the mother in any issues arising from her pre-existing, or new, diagnosis of HIV. Specialist advice should be sought, wherever possible.Key areas discussed in this review include antenatal management of the mother (particularly pharmacological management), obstetric management, pharmacological treatment for the neonate and infant feeding. Due to progress made in both in HIV testing, and in the way all patients with HIV in the UK are managed over the last few decades, most women who present with HIV in pregnancy are aware of their diagnosis and on treatment. However, it is not entirely uncommon for women to be diagnosed in pregnancy and it is these cases that present the greater challenge. The cases in this review cover the most common scenarios encountered.     

Hypothyroidism during pregnancy: Controversy over screening and intervention

Thyroid hormones are critical for foetal neurological development and maternal health. Maternal hypothyroidism during pregnancy is associated with adverse impact on health of the mother as well as the progeny. Reduced thyroid hormone levels predispose the child to develop mental retardation and cognitive delay in early life. In the mother, hypothyroidism during pregnancy is associated with spontaneous abortion, placental abruption, preterm delivery and hypertensive disorders. Therefore, screening and therapeutic intervention is justified to prevent foetal as well as maternal co-morbidities. In view of impact of such a large-scale screening and intervention program on limited healthcare resources, it is debatable if a targeted rather than universal screening program will result in comparable outcomes. In addition, there is an ongoing debate regarding best evidence-based practice for the management of isolated hypothyroxinaemia, subclinical hypothyroidism and euthyroid women with autoimmune hypothyroidism. We have carried out a review of the literature; firstly, to determine whether universal screening for asymptomatic women in early pregnancy would be cost-effective. Secondly, we have retrospectively reviewed the literature to analyse the evidence regarding the impact of therapeutic intervention in women with subclinical hypothyroidism.     

Clinical approach to mental health issues among obstetrician-gynecologists: a review

In recent years, obstetrician-gynecologists have taken on a greater role in the provision of primary care. Mental health has been a topic worthy of further exploration as a result of the high prevalence rates of women presenting in gynecologic settings with depressive, anxiety, or eating-disordered symptoms. The detrimental effects of psychopathology have been well documented in the literature, especially if present during pregnancy. This article provides a review of the literature in the area of clinical practice related to mental health among obstetrician-gynecologists based on searches of the Psyc Info and MEDLINE databases. Lack of recognition and underdiagnosis are common problems that need to be addressed by focused educational initiatives. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to recall the importance of screening for various types of mental disease during an ob/gyn visit; describe the detrimental effects of psychopathology, especially during pregnancy; and explain the importance of educational initiatives in detecting and treating mental disorders.     

Thyroid disorders and other endocrinological disorders in pregnancy

Endocrine disorders are commonly encountered in pregnancy. To optimize pregnancy outcome, it is essential to understand the physiology underlying these conditions. Clinicians should be aware of which investigations are required for diagnosis and monitoring during pregnancy as well as current guidance on which treatments are safe to use. The most common endocrine disorder encountered in pregnancy is diabetes, followed by hypo and hyperthyroidism. Rarer endocrine disorders including pituitary dysfunction, adrenal and parathyroid disease are as important to be aware of due to the potential for significant maternal and fetal morbidity or mortality if not diagnosed or managed appropriately. Over recent years awareness of the potential adverse effects of vitamin D deficiency has driven the guidance for vitamin D supplementation for pregnant and lactating women. This review focuses on the physiology and current management of thyroid dysfunction and the rarer endocrine disorders in pregnancy, and includes current guidance on vitamin D supplementation.