Mental health problems in pregnancy or postpartum 🤰

🤰 Mental health problems during pregnancy and postpartum are common, affecting ~1 in 5 women. They range from mild anxiety or depression to severe psychiatric emergencies (e.g., postpartum psychosis). ⚠️ Always consider risk to mother and baby, and involve perinatal mental health teams early.

📊 Background

• Pregnancy and the perinatal period are times of major hormonal, psychological, and social change.
• Risk factors: personal/family psychiatric history, poor social support, trauma, substance use, domestic violence.
• Unmanaged mental illness can → maternal suicide (leading cause of maternal death in UK up to 1 year post-birth), poor bonding, impaired infant development.

🧬 Physiology & Pathophysiology

• Hormonal changes (oestrogen, progesterone, prolactin, cortisol) can influence mood and stress responses.
• Sleep disruption, physical stress of labour, and social stressors increase vulnerability.
• Breastfeeding may alter psychotropic drug metabolism and influence treatment choice.

🔍 Common Conditions

🧪 Assessment

• 📚 History: Past psychiatric illness, current symptoms, medication adherence, support network.
• 👶 Impact on baby: Bonding, feeding, safeguarding concerns.
• ⚠️ Risk assessment: Suicide, infanticide, neglect, domestic violence.
• 🧠 Use validated tools: EPDS for depression, GAD-7 for anxiety.

🛠️ Management Principles

• 👩‍⚕️ Multidisciplinary approach: Involve perinatal psychiatry, obstetrics, midwifery, health visitors, social workers.
• 💊 Medication:
  • SSRIs (e.g. sertraline) are first-line for depression/anxiety; relatively safe in pregnancy & breastfeeding.
  • Avoid valproate in women of childbearing age (teratogenic).
  • Antipsychotics (e.g., olanzapine, quetiapine) may be used with specialist input.
• 🗣️ Psychological therapies: CBT, interpersonal therapy, family interventions.
• 🏥 Hospitalisation: Urgent admission (ideally mother & baby unit) for postpartum psychosis or high-risk cases.
• 📚 Prevention: Pre-pregnancy counselling for women with psychiatric history; clear relapse prevention plan.

🚩 Red Flags in the Perinatal Period

• Acute onset of postpartum psychosis (usually within 2 weeks of delivery).
• Any suicidal ideation with intent or plans.
• Thoughts of harming the baby or violent intrusive obsessions.
• Severe anxiety, panic, or OCD symptoms with loss of function.
• Failure to bond with the infant or neglect of basic care needs.

🧑‍⚕️ Clinical Scenarios

• Case 1 (Postnatal blues): A 28-year-old woman, five days after delivery, reports tearfulness, mood swings, and heightened anxiety about caring for her baby. She remains functional and continues to feed and bond with her infant. This presentation is most consistent with postnatal “blues,” a self-limiting condition that typically resolves within two weeks, requiring only reassurance, supportive care, and monitoring to ensure symptoms do not progress.
• Case 2 (Postnatal depression): A 32-year-old woman with a past history of depression presents six weeks postpartum with persistent low mood, guilt, and difficulty bonding with her baby, alongside poor sleep and loss of enjoyment. The picture is suggestive of postnatal depression, which affects up to 15% of new mothers. Management involves a thorough risk assessment for suicidality, referral for CBT or other psychological therapy, and initiation of an SSRI such as sertraline if symptoms are moderate to severe, with ongoing support from community perinatal services.
• Case 3 (Postpartum psychosis): A 24-year-old woman, one week after giving birth, becomes acutely agitated and sleepless, expressing hallucinations that her baby is “possessed” and showing disorganised behaviour. This constitutes a psychiatric emergency: postpartum psychosis. She requires urgent admission to a specialist mother and baby unit for antipsychotic and possibly mood stabiliser therapy under close psychiatric supervision, as well as safeguarding measures for both her and the infant.

📚 References

• NICE CG192: Antenatal and Postnatal Mental Health
• MBRRACE-UK: Reports on maternal mental health-related mortality