This chapter deals primarily with APGO Educational Topic Areas:
TOPIC 17 MEDICAL AND SURGICAL COMPLICATIONS OF PREGNANCY
TOPIC 29 ANXIETY AND DEPRESSION
Students should be able to identify how pregnancy affects the natural history of various neurologic and mood disorders and how a preexisting neurologic and mood disorder affects maternal and fetal health. They should be able to outline a basic approach to evaluation and management of neurologic and mood disorders in pregnancy.
Clinical Case
You are seeing a new patient who is at 14 weeks of gestation with her first pregnancy. She informs you that she has had significant depression for some years. When she has tried stopping her antidepressant medications, her symptoms became severe and on two occasions required hospital admission. Her psychiatrist discussed continued use of a selective serotonin reuptake inhibitor in pregnancy, and together they decided she should remain on such medications. In discussing general obstetric care, you counsel her on depression and management during pregnancy.
Headaches are common during pregnancy, particularly in the first trimester. Depression and anxiety are seen quite frequently in the pregnant population, as they are in all populations. Postpartum depression (PPD) is an important entity that must be appreciated by anyone caring for patients during and after delivery. Other specific neurologic and psychiatric disorders are infrequently seen, but they pose challenges for those providing obstetric care to patients with these conditions.
NEUROLOGIC DISORDERS
Headaches
Hormonal changes are thought to influence headaches in women in pregnancy, the postpartum period, and at other reproductive system changes throughout life. Headaches are especially common in pregnancy, particularly in the first trimester.
Patients who report the new onset of significant headaches in pregnancy, or describe acute worsening of symptoms, should undergo evaluation, including imaging. Computed tomography and magnetic resonance imaging scans, and lumbar puncture, are considered safe.
Tension Headaches
Tension headaches are the most common type of headache experienced; symptoms include painful pressure or “tightness” all around the head, originating over the forehead or frontalis muscle, radiating over the crown of the head down to the posterior neck; the severity varies. Initial treatment is usually with acetaminophen, being careful not to exceed the manufacturer’s recommendation for total consumption per day; nonsteroidal anti-inflammatory drugs are best avoided in pregnancy. Combination medications, some including narcotics, may be necessary short-term. Alternative therapies for short-term use include combinations of acetaminophen, butalbital, and caffeine.
Migraine Headaches
Migraine headaches occur more often in women than in men, and they are thought to be related to hormonal fluctuations more than are tension headaches. The prevalence is highest during the childbearing years. Overall, the majority of patients experience an improvement in the frequency and severity of migraines during pregnancy, with the most improvement described in the third trimester. Return to the prepregnant pattern of migraines often occurs during the puerperium. Again, initial treatment is generally with acetaminophen, alone or in combination with codeine or other agents. Prolonged use of narcotics is to be avoided, if at all possible. Ergotamines should be avoided. Treatment for symptoms of nausea and vomiting associated with migraine headaches is individualized. Ondansetron and metoclopramide are sometimes used for severe gastrointestinal symptoms. Prophylaxis with b-blockers, oral magnesium, and other agents may be needed. Collaboration with a neurologist is appropriate and encouraged in patients with ongoing symptoms despite standard therapies.
Epilepsy
Despite the fact that most women with epilepsy have successful pregnancies, optimal management may prove challenging. Pharmaceutical agents used to treat epilepsy appear to increase the risk of both major and minor congenital anomalies. However, the risk of obstetric complications appears to be less than previously thought. Adequate data concerning pregnancy loss rates are lacking.
Management
Preconception counseling is strongly recommended for patients contemplating pregnancy. At that time, drug choices and adjustments in doses can be reviewed, along with a discussion of risks and overall pregnant management. Folate supplementation (usually at a dose of 4 mg/day) should begin several months before conception is attempted and continued at least through the first trimester of pregnancy.
The frequency of seizure activity does not change during pregnancy for most patients.
Besides the risks noted below, fetal injury (e.g., placental abruption) or oxygen deprivation from a prolonged maternal seizure is possible. Offspring of patients with epilepsy are at increased risk for being diagnosed with epilepsy in later life.
All of the commonly used anti-epileptic drugs appear to increase the risk of congenital abnormalities by a factor of roughly two—from 2%–3% to 4%–6%. Valproate carries the highest risk of malformations, specifically with neural tube defects, and it should be avoided unless absolutely necessary for seizure control. The other agents commonly used in pregnancy (e.g., phenytoin, carbamazepine, and phenobarbital) appear to have similar risk profiles, so there are no specific recommendations as to choice of drug. The lowest dose that prevents seizure activity is preferred, of course. If patients have been seizure free for several years, some neurologists recommend discontinuation of anti-epileptic medications prior to conception, to see if ongoing medications are indeed necessary.
In addition to anti-seizure medications, pregnancy management for patients with epilepsy include frequent visits, with folate supplementation, monitoring of free folate levels, and dose adjustments of anti-seizure medicines as needed secondary to changes in maternal weight and plasma volume; screening for fetal congenital anomalies; possibly, maternal vitamin K supplementation in the third trimester; and preparation for treatment of an epileptic seizure during labor, delivery, or in the first day postpartum.
Postpartum, medication dose adjustments to prepregnancy dosing should be coordinated with the patient’s neurologist. Unless epileptic treatment includes sedatives, breastfeeding may be recommended, but data remain limited.
Multiple Sclerosis
Multiple sclerosis (MS) is also more common in women, with diagnosis most commonly around age 30 years. In general, pregnant patients report fewer, and less severe, relapses during pregnancy, though postpartum relapse occurs. Lower infant birth weights and a higher cesarean delivery rate have been noted in patients with MS. Medical management during pregnancy and the puerperium (if breastfeeding) must take into account the perinatal effects of the agents used. Anesthesia for delivery should be based on obstetric circumstances.
Carpal Tunnel Syndrome
carpal tunnel syndrome is quite common in pregnancy. Although it can occur anytime during pregnancy, it is more common as pregnancy advances. Fluid retention is thought to be causative; compression of the median nerve within the carpal tunnel causes symptoms of pain, tingling, and numbness. Wrist splints widely available may offer significant relief. Symptoms subside postpartum but not immediately.
Bell’s Palsy
For reasons that are unknown, paralysis of the facial nerve (Bell’s palsy) more commonly occurs during pregnancy. Overall, the outcome with complete facial nerve paralysis during pregnancy is somewhat worse than when the palsy occurs in the nonpregnant state. Steroids remain the mainstay of therapy.
PSYCHIATRIC DISORDERS
Depression and Anxiety
Pregnancy and the puerperium are periods of life that can be very emotional. Although excitement and joy often exist, depression and anxiety may arise or recur, especially in the postpartum speriod.Pregnancy can present many stresses for patients and their families. Hormonal influences are thought to play a role but are not the only responsible factor. Depression is the most common mood disorder seen in pregnancy, affecting roughly 10% of women.Depression, in general, is twice as common in women than in men. Both genetic and environmental factors are thought to be involved.
Awareness of the possibility of these disorders, and the screening and recognition of them, is important. Published screening tools are available.
Risk Factors
Risk factors include a personal or family history of depression, abuse (sexual, verbal, and physical), and drug use (including smoking, alcohol, and illicit drugs), along with a history of personality disorder.
A history of mental illness is important in optimizing care during pregnancy and beyond. The association of depression during and after previous pregnancies is also helpful in formulating care.
Management
Patients with inadequate treatment of depression and anxiety often will fail to care for themselves (and their fetuses) during pregnancy. With depression, poor diet and nutrition, substance abuse, and other suboptimal care may be involved in the increased prevalence of low birth weight infants seen in women with depression. Anxiety alone does not seem to alter perinatal outcome.
Management of depression and anxiety involves counseling and, at times, medications. Prompt referral for psychiatric care is sometimes needed. Involvement of a patient’s partner and/or other family members can be beneficial.
A variety of antidepressant medications are available, including selective serotonin reuptake inhibitors, which are more commonly used; tricyclic antidepressants; and others (e.g., bupropion). All appear to cross the placenta. Teratogenicity and fetal/neonatal effects are concerns, although the absolute risk of major congenital abnormalities appears to be quite low. Available studies offer varying levels of risk. For the fetus exposed to these medications in the third trimester, neonatal behavior may be altered, with a range of sequelae, such as tremors, to, rarely, persistent pulmonary hypertension.
When medications are to be considered part of the management of pregnant patients with depression and anxiety, a current search for new reports is wise, insofar as new data are commonly added to our information regarding the perinatal effects of such drugs. Careful counseling regarding benefits, risks, and alternatives should be thoroughly discussed with the patient prior to prescribing them.
Postpartum Depression
Depression in varying degrees is common in the postpartum period. There is a wide spectrum of response to pregnancy and delivery, ranging from mild postpartum blues to severe PPD (see Table 11.2). Approximately 70% to 80% of women report feeling sad, anxious, or angry beginning 2 to 4 days after birth. These postpartum blues may come and go throughout the day, are usually mild, and abate within 1 to 2 weeks. Supportive care and reassurance are helpful in ensuring that symptoms are self-limited. Approximately 10% to 15% of new mothers experience PPD, which is a more serious disorder and usually requires medication and counseling. PPD differs from postpartum blues in the severity and duration of symptoms. Women with PPD have pronounced feelings of sadness, anxiety, and despair that interfere with activities of daily living, including infant care. These symptoms do not abate but, instead, worsen over several weeks. Counseling and medical treatment are indicated. Although the exact cause of PPD is unknown, several associated factors have been identified. The normal hormonal fluctuations that occur following birth may trigger depression in some women. Women who have a personal or family history of depression or anxiety may be more likely to develop PPD. Acute stressors, including those specific to motherhood (childcare), or other stressors (e.g., death of a family member) may contribute to the development of PPD. Having a child with a difficult temperament or health issues may lead the mother to doubt her ability to care for her newborn, which can lead to depression. The age of the mother may influence susceptibility to PPD, with younger women more likely to experience depression than older women. Toxins, poor diet, crowded living conditions, low socioeconomic status, and low social support may also play a role. A strong predictor of PPD is depression during pregnancy. It is estimated that half of all cases of PPD may begin during pregnancy. PPD may also be a continuation of a depressive disorder that existed prior to pregnancy, rather than a new disorder.
Treatment
Treatment must be tailored to the patient’s individual situation. Postpartum blues do not require treatment other than support and reassurance. Women with PPD should receive mental health counseling and medication, if warranted. Effective therapies for the treatment of PPD include cognitive–behavioral and interpersonal therapies.
Anxiety Disorders
Phobias, obsessive–compulsive disorders, and generalized anxiety disorders are among a number of anxiety disorders. Counseling and medications are sometimes necessary. Little is known about the effects of anxiety disorders on pregnancy, but potential risks seem to be small. Patients with anxiety disorders during pregnancy are prone to PPD.
Bipolar Disorders
Approximately 1% of the population is affected with bipolar disorder. Because its onset often occurs in early adulthood, pregnancy can be an important consideration in therapy. Preconceptional treatment planning is wise. There is a strong genetic component to bipolar illness. Manifestations include depression, mania, and psychosis. Teratogenic concerns exist for medications such as sodium valproate and carbamazepine; previous concern for lithium may have been exaggerated. Careful collaboration with mental health professionals is important in optimizing outcome.
Postpartum Psychosis
Postpartum psychosis is the most severe form of mental derangement and is most common in women with preexisting disorders, such as bipolar illness or schizophrenia. This condition should be considered a medical emergency, and the patient should be referred for immediate, often inpatient, treatment.
Schizophrenia
Schizophrenia is a serious condition that also affects approximately 1% of the population and manifests symptoms in young adulthood. It, too, has a strong genetic component. The offspring of a couple, one of whom has schizophrenia, has a 5% to 10% risk of having the disorder. Outcome with treatment is variable.
Clinical Follow-Up
In your initial discussion with your G1 at 14 weeks of gestation, you review the potential adverse effects of antidepressants in pregnancy. Given her history of severe relapses when off medications, you concur with her decision to remain on a selective serotonin reuptake inhibitor (SSRI). You also discuss postpartum depression, which is quite common in patients without a history of depression. She continues through pregnancy, delivers uneventfully at term, and continues her SSRI therapy through and after delivery.
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