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Unipolar and bipolar spectrum mood disorders typically emerge in the late teens to early twenties, which coincide with peak fertility years. There has been much work exploring the link between hormones and mood disorders with a strong focus on attempting to understand the postpartum mood state. Estimates on the incidence of postpartum mood disorders, ranging from mild and self-limited depressions (sometimes called “the baby blues") to severe depressions or manias or psychoses range from 10% to 80%. The prevalence of mood disorders during pregnancy is less clear given these conditions are still poorly recognized in the community and the psychosocial stigma associated with psychiatric conditions in general tends to keep reporting low. The incidence of depression in the general population ranges from 2% to 10% and estimates of perinatal depression have been as high as 20% to 25% in a high-risk pregnancy population.
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The obstetrician or perinatologist must assess for depression as part of the regular evaluation process. Depression is often a condition intensified by psychosocial or emotional distress, thus it is not difficult to imagine that women with high-risk pregnancies will be at higher risk for developing this condition. Screening can start with as simple a question as “How has your mood been lately?” For a more formal process, the Edinburgh Postpartum Depression Scale (EPDS) is a commonly used tool,8 although a number of screening tools are available (and can easily be implemented into an office or hospital-based perinatal practice).
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The impact of depression is far reaching. Depression can result in muted emotional responses, diminished self-care, apathy, impaired compliance, substance misuse, and suicidality. Social, cultural, and even financial issues impact how depression is identified and addressed. Depression can, for many women, imply a sense of inadequacy or incompetence as a future mother; shame readily accompanies depression and only serves to more firmly anchor this disease and make for even more resistance and difficulty in seeking out appropriate treatment.
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By far, the most important tool available to the clinician is awareness. Table 21-12 describes common risk factors for perinatal depression.
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Depression can present in a variety of ways. Being able to engage with the patient to gather data and offer support enhances the therapeutic relationship. This should include establishing a connection with the birth-partner and other family members/supports. These contacts can provide a wealth of information as well as allow for the further strengthening of support and comfort to the high-risk OB patient.
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The presence of mania does not always signal the presence of bipolar disorder (BD). Substance-induced mania is not uncommon and is typically associated with the misuse of illicit substances such as cocaine or methamphetamine. It has also been reported in cases of overuse of prescribed stimulants such as methylphenidate and dextroamphetamine. In the absence of such illicit drug use, manic eruption is then diagnostic for BD.
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Mania refers to an escalated mood state and is characterized by an elated, expansive, or irritable mood, a diminished need for sleep, heightened impulsivity and recklessness, feelings of grandiosity, racing thoughts and rapid, hyperverbal, or pressured speech. Manic episodes can emerge spontaneously or in the face of heightened emotional distress. Psychotic symptoms can co-occur with mania (as well as with depression) and can lead to serious complications including violence and other dangerous behavior. Common management strategies when faced with a manic pregnant patient include assurance of safety and well-being to the mother and fetus and prompt initiation of psychiatric care. Gather collaborative data paying attention to the current medication regimen (if known) as well as previous history of violence or other unsafe acting out behaviors.
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While a common response to the occurrence of a pregnancy in women on antidepressant medication is to immediately discontinue the medication, this has been associated with poorer outcomes including exacerbations of the mood disorder. In a paper by Einarson (2001), over 70% of women abruptly discontinued use of antidepressants either because of fear of teratogenicity or on the advice of their physician.9 Nearly 30% of these women experienced a worsening of their mood disorder resulting in suicidal ideation with 10% requiring psychiatric hospitalization. The consideration to use medications to treat a mood disorder, especially during pregnancy, is a complex one that has implications to maternal and fetal well-being. Initiation of any psychotropic agent should never be done in unilaterally and proper informed consent must occur. This discussion includes an explanation of known potential side effects, the FDA pregnancy category rating, any known teratogenic issues (such as the incidence of facial clefts) as well as any special precautions related to pregnancy (monitoring of lithium levels especially around the time of parturition).
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Antidepressant medications are commonly used to treat unipolar depression. The selective serotonin reuptake inhibitors (SSRIs) are typically well tolerated and have high efficacy rates, thus having become the preferred first-line agent for many clinicians working with patients with depression. There are numerous anecdotal reports of medications of this class being used to treat depression during pregnancy. Recent reports suggest that the SSRI paroxetine may be associated with higher rates of ventricular septal defects in infants with first trimester in utero exposure while other reports fail to find a similar association.10,11 The decision to treat a pregnant woman with any psychotropic agent must take into account the potential adverse effects of in utero exposure weighed against the potential for psychiatric suffering (and its associated ill effects including the heightened potential for suicide and neonaticide). Thorough and repeated discussions with the pregnant patient and her pregnancy partner (including family if indicated), which includes accurate documentation of these meetings should be a standard part of any such intervention. Consultation with a psychiatrist familiar with and skilled at working with the gravid patient is preferred, but often such clinicians are not available in the community or the patient (or family) declines such encounters.
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Side effects of the antidepressants can include nausea/gastrointestinal (GI) distress, headache, dizziness, tremulousness, diminished appetite, insomnia or hypersomnia, and sexual dysfunction. The serotonin syndrome is a rare clinical entity that can be seen with the use of serotonergic antidepressants. It can occur in patients who, unbeknownst to the clinician, are concomitantly on other serotonergic agents (ie, St. John’s wort or even meperidine). The clinical presentation can range from very mild to quite severe and typically includes fever, skin flushing, agitation/restlessness or alterations in mental status, diaphoresis, GI cramping with diarrhea, hyperreflexia, rigors, autonomic instability, seizures, and gait disturbances. Supportive care is the treatment of choice.
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Electroconvulsive therapy is a viable alternative particularly in cases that involve significant melancholia with poor self-care or refusal to eat or drink. It may also prove useful with patients who are actively suicidal or psychotic. Special considerations for the administration of this modality are described in Table 21-13. Anderson (2009) reported on a review of 339 cases of electroconvulsive therapy (ECT) in pregnancy.12,13 In the 339 cases reviewed, there were 25 adverse fetal events and 20 adverse maternal events. Of the 25 fetal events, 11 (3.2%) were thought to be related to ECT. The most common was transient fetal bradycardia or deceleration, which occurred in 8 (2.7%) of cases. The other fetal events included one fetal death following an episode of status epilepticus, one first trimester miscarriage 24 hours after ECT, and one case of multiple brain infarcts after multiple ECT courses. Of the maternal adverse events, 18 (5.3%) were thought to be related to ECT. Uterine contraction or preterm contraction was the most common event and occurred in 12 (3.5%) of cases. Other complications thought to be related to ECT included status epilepticus, hematuria, miscarriage, vaginal bleeding, abdominal pain, and placental abruption. Where efficacy data were available, the results were similar to ECT in the nonpregnant patient with at least partial response reported in 84% of those treated for depression and in 61% of those treated for schizophrenia. Additionally, the response to ECT occurred more rapidly compared to antidepressant medication.
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The anticonvulsant mood stabilizer medications (valproic acid, carbamazepine, oxcarbazepine, lamotrigine, etc) are commonly used by psychiatrists to treat bipolar spectrum mood disorders.14,15 While generally very effective, their use in pregnancy has now been studied very closely (in both epileptic and bipolar patients where it is felt, by the physician, patient, and her supports, necessary for use of one of these medications during pregnancy) to watch for teratogenic effects. Valproic acid and carbamazepine, for example, have been associated with facial cleft anomalies and neural tube defects and other features (Table 21-14). The risk of neural tube defects is even higher when valproate is used in combination with other anticonvulsant agents. Additional folic acid supplementation to women taking such medications given the known link between these medications in folic acid metabolic pathways has been recommended. However, the specific folic acid dose is still undetermined with recommendations from various experts ranging from 1 to 4 mg daily. Vitamin K supplementation of 20 mg daily (at 36 weeks’ gestation) has also been suggested by some clinicians for patients on carbamazepine. To date, lamotrigine has been shown to have the lowest incidence of anomalies to babies exposed in utero. When it is decided to embark on the use of an antiepileptic drug to treat a bipolar spectrum mood disorder, striving for the lowest effective dose with a single agent is still the preferred approach. The North American Pregnancy AED Registry has compiled this data in an attempt to monitor the safety of these medications in pregnancy.
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Lithium use has historically been avoided during pregnancy due to its link with Ebstein anomaly. Lithium, a well-respected mood stabilizer, has been shown to provide mood stabilization, alleviation of depressive symptomatology, and reduction of suicidality. Although not typically used in the acute or emergent situation, lithium is the only agent shown to reduce suicidality in bipolar patients and should receive appropriate consideration for its use.16 Further observation has shown that this fear may be overstated especially if the exposure occurs after the first trimester. The risk ranges from 1:1000 to 1:20,000. Lithium, however, is not completely innocuous. Given the everchanging fluid balance states of the pregnant woman, serum lithium levels can fluctuate rapidly, especially around the time of delivery. Other factors associated with lithium toxicity are listed in Table 21-15.
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Lithium can also be associated with neonatal complications (Table 21-16). The maternal and neonatal complications of lithium therapy can be reduced by avoiding those factors associated with lithium toxicity, monitoring serum levels during the pregnancy (ideally a 12-hour trough level), discontinuing the medication at delivery (or 48 hours in advance of a scheduled delivery), and reinstitution of the medication at a lower dose after delivery. Table 21-17 outlines a basic guideline for management of the pregnant patient taking lithium.
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