Pregnancy and Psychiatry

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Reproduction events and processes have both physiological and psychological components.

Psychological states affect reproductive physiology and modulate reproductive processes and events.

Pregnancy

First is the absence of menses.
Others: breast engorgement and tenderness, changes in breast size, shape, nausea with or without vomiting, frequent urination, and fatigue, etc.

Stages of Pregnancy

First Trimester: A woman must adapt to the changes in her body - fatigue, nausea, vomiting, breast changes, and mood liability.
Second Trimester: This is the most rewarding.
- Return of energy
- End of morning sickness
- Looking pregnant
- Excitement of being pregnant
Third Trimester:
- Physical discomfort
- Multi-organ/systemic changes
- Weight gain, dyspnea, heartburn
- Need for assurance that the body will return to baseline.

Psychological changes occur:

The woman's attitude towards the pregnancy is a reflection of her belief towards reproduction and whether the pregnancy was planned and wanted.
The relationship with the partner.
Age of mother and her identity issues also affect her reaction to impending motherhood.

The prospective father also faces some psychological challenges.

May be a means of self-realization in psychologically healthy women.
Others may use it to decrease self-doubt about their femininity and their ability to function in the most basic way.
Others have a negative view and may fear childbirth and feel inadequate about mothering.
Psychological attachment to the fetus begins in utero by the beginning of the second trimester.
Mother may have a mental picture of her infant.
Mother may talk to their unborn baby, and this may help mother's effort to have a healthy pregnancy by adopting a healthy lifestyle.
Fathers are also affected by the pregnancy.
Impending parenthood creates issues on gender role, identity, separation, as well as sexuality issues in the father.
For some men, getting a woman pregnant is a proof of their potency.

Calls for a re-definition of roles as couples or individuals. Dealing with new responsibilities may create anxieties.
A husband may feel guilty about the wife's discomfort during pregnancy and delivery.
Some men may be jealous of the experience of pregnancy.

Attitude Towards Pregnant Women

Reflects several factors such as intelligence, temperament, culture, and myth of the society.

Married men's responses are generally positive.
- It may be pride in their ability to make a woman pregnant.
- Fear of increased responsibility and subsequent termination of pregnancy.
A woman's risk for abuse by partner is increased in pregnancy, particularly in the first trimester.

Some Psychiatric Disorders of Pregnancy

Pseudocyesis

Rare, false belief of pregnancy
Commoner in younger females

Develops amenorrhea, abdominal distention

Resolves quickly

May also appear in perimenopausal women.

Couvade Syndrome

Husband also experiences symptoms of pregnancy
It appears in early months
Has features of morning sickness as well as toothache in some. Resolves after a few weeks.
Has cramp-like abdominal pains at partner's labor which resolves after partner's delivery.
Thought to be as a result of anxiety about the pregnancy.

Hyperemesis Gravidarum

Nausea and vomiting are common in pregnancy, occurring in about 50% of pregnant women in the 1st trimester.
Severe condition called HG may have a psychological cause related to rejection of the pregnancy.

Risks from Untreated Psychiatric Disorders During Pregnancy

Decreased prenatal care
Insufficient weight gain
Increased use of addictive substances
Increased risk of being a victim of violence
Decision to abort due to depression
Suicide (although risk may be lower than in non-pregnant women)

Obstetric & Neonatal Complications of Psychiatric Disorders in Pregnancy

Fetal growth retardation
Pre-eclampsia
Premature labor
Placental abruption
Newborns more inconsolable (independently of addictive substance use, weight gain, length of labor, method of delivery, and Apgar scores)

Psychological Changes of Postpartum/Puerperium Period

Adjustments

Taking-In Phase:

Time of reflection regarding new role
May be passive or excited
Talks at length about birth experience on phone with family/friends recounting birth experience. Usually lasts 1-2 days.

Taking-Hold Phase:

Woman makes own decisions regarding self & infant care. Usually day 2 - 3. Occurs on day 1 especially if woman is multiparous. Can occur later, depends on recovery process or cultural beliefs.

Letting Go Phase:

Woman gives up fantasy image of baby and accepts real child.
Occurs within few weeks of getting home
Needs time to adjust to new experience.

Bonding:

Expressing maternal love & attachment toward new baby. Develops gradually.
Enface position: close eye contact with infant.
Healthy bonding - kissing, touching, counting fingers & toes, cooing, etc.

Factors Interfering with Bonding: difficult labor, separation @ birth (NICU)

Postpartum Mental Disorders

This can be divided into:

Maternity Blues
Depression of mild to moderate severity
Psychosis in puerperium

Obstacles to Recognition and Treatment of Perinatal Mood/Anxiety Disorders

High expectations of joy & happiness with new baby: cognitive dissonance if dysphoric symptoms arise.
Attribution of dysphoria to stress, not assessing hallmark symptoms.
Self-blame.
Lack of knowledge about mood and anxiety disorders.

Critical role of antenatal education.

Common Dysphoric Emotional Experiences in New Mothers

Mood lability - blues and euphoria.
Often unanticipated and sometimes overwhelming stress of newborn care: loss of control of one's time, feeling trapped, "Why did I do this?"
Heightened anxiety due to hypervigilance about the baby's welfare. Delayed feelings of love for the baby.

Ambiguous Symptoms

(often due to perinatal physiological changes, demands of newborn, not depression)

Changes in appetite or weight
Sleep disruption (however, persistent inability to sleep when the baby is asleep is a common symptom in depression).
Persistent fatigue.
Psychomotor retardation or agitation.
Diminished subjective perception of ability to think or concentrate.

Biological Risk Factors for Depression in Puerperium

History of depression in puerperium (up to 50% risk).
History of depression not associated with pregnancy (up to 25% risk).
Depressive symptoms during pregnancy.
Family history of depression.
History of premenstrual dysphoric disorder.
Maternity blues.

Psychosocial Risk Factors for Depression in Puerperium

Lack of social support.
Poor relationship with the father of the baby.
Stressful life events.
Primiparity.
Adolescence.

Anxiety Disorders in Puerperium: Clinical Characteristics

Panic Disorder:
- Intense fear of harm/harming baby.
- Palpitations, hyperventilation, sweating, etc.
- Difficulty caring for, leaving baby.
OCD (Obsessive-Compulsive Disorder):
- Intrusive thoughts/images of grievous harm to baby.
- Mother sometimes imagines herself inflicting harm.

Effects of Pregnancy on the Natural Course of Anxiety Disorders

Panic Disorder: Increased risk of recurrence or intensification postpartum.
Obsessive-Compulsive Disorder: Many women with OCD (perhaps around 40%) have initial onset of symptoms during pregnancy or the postpartum period.

Maternity Blues

Often viewed as "normal"
Affects 40 to 85% of new mothers
Peaks between postpartum days 3 and 5
Resolves within 24 to 72 hours
Subsides without treatment by postpartum day 14

Symptoms:

Anxiety, irritability, confusion
Uncontrollable tearfulness
Wide mood swings, tension
Occasional negative thoughts

Primary Treatment: Supportive care and reassurance about the condition

Depression in Puerperium

More severe form of sadness than "Maternity Blues"
Affects 10 to 15% of new mothers
Affects 26 to 32% of all adolescent new mothers
Symptoms are more intense and longer-lasting

Symptoms:

Must be present most of the day, nearly every day for more than 2 weeks postpartum
Anhedonia
Dysphoric mood
Difficulty concentrating or making decisions
Psychomotor agitation or retardation
Fatigue
Changes in appetite and/or sleep patterns
Recurrent thoughts of death or suicide
Feelings of worthlessness or guilt (especially focusing on failure at motherhood)
Excessive anxiety
Frequently focusing on the child's health

Who is at Risk?

Family History - especially a personal prior episode of depression
Mother experiencing poor marital relationship/abusive relationship
Lack of social support and/or child care stressors
Comorbidities of substance abuse, anxiety, or somatization disorders

Interventions:

Inpatient care. May be a psychiatric emergency.
Medication: For more severe symptoms, may need ECT.
Psychotherapy: Chronic psychosocial problems Incomplete response to meds Concurrent personality problems.
Combination of both

Consequences of Untreated Postpartum Depression

Disturbed mother-infant relationship (elevated cortisol found in both)
Psychiatric morbidity in children later (depression, conduct disorder, lower IQ)
Marital tension
Vulnerability to future depression
Suicide/homicide

Pharmacotherapy in Puerperium: Side Effect Concerns

Sedation
Insomnia
Weight gain
Decreased sexual desire
Effects on breastfeeding infant

Preventing Depression in Puerperium

Discuss family planning & reproduction
Identify women at risk during pregnancy

Psychosocial Prevention

Mood stabilizer prophylaxis for bipolar disorder
Antidepressant prophylaxis for depression
Estrogen prophylaxis (experimental)

Psychosis in Puerperium

Rare condition, affecting 1 to 2 out of 1000 women after childbirth
Presentation can be dramatic
Onset as early as 48 to 72 hours postpartum
Symptoms develop within the first 2 weeks after delivery

Early Symptoms:

Restlessness
Irritability
Sleep disturbance

Progressive Symptoms:

Depressed or elated mood
Disorganized behavior
Mood swings/instability
Delusions
Hallucinations

Psychological Complications in Puerperium

Mental health disorders in the postpartum period have implications for mother, newborn, and the entire family.
Interfere with attachment to newborn and family integration. May threaten safety and well-being of mother, newborn, and other children.

Depression without Psychotic Features

Moderate to severe depression: an intense and pervasive sadness with severe and labile mood swings.

Treatment options: Antidepressants, anxiolytic agents, and electroconvulsive therapy. Psychotherapy focuses fears and concerns of new responsibilities and roles, and monitoring for suicidal or homicidal thoughts.

Depression with Psychotic Features

Psychosis in puerperium: syndrome characterized by depression, delusions, and thoughts of harming either infant or herself.
Psychiatric emergency, and may require psychiatric hospitalization.

Treatments of choice: Antipsychotics and mood stabilizers.

Types of Psychosis in Puerperium:

Acute organic psychosis
Affective
Schizophrenia

Acute Organic Psychosis

Less frequent now due to the advent of antibiotics for treatment of puerperal sepsis

Affective Psychosis and Schizophrenia

Now most common is the affective syndromes
Affective features are probably more common in schizophrenic disorders in the puerperium
Disorientation and other organic functions are more common in both schizophrenia and affective disorders in puerperium

Assessment

Thorough history
Ascertain beliefs about the baby.
Assess for suicide and infanticide.
Thorough physical examination.

Treatment

This is according to the diagnosis.

It is a psychiatric emergency.
In care management.
Antipsychotics or antidepressants as indicated.
ECT (Electroconvulsive therapy).

Loss and Grief

Losses of what was hoped for, dreamed about, and/or planned
Any perception of loss of control during the birthing experience
Birth of a child with a handicap
Maternal death
Fetal or neonatal death

Conceptual Model of Parental Grief

Acute distress
Intense grief
Reorganization

Anticipatory Grief

Plan of Care and Implementation

Communicating and care techniques
Actualize the loss
Provide time to grieve
Interpret normal feelings
Allow for individual differences
Cultural and spiritual needs of parents
Physical comfort
Options for parents
Seeing and holding
Bathing and dressing
Privacy
Visitations: other family members or friends
Religious rituals/funeral arrangements
Special memories
Pictures

Maternal Death

Rare for a woman to die in childbirth
Families are at risk for developing complicated bereavement and altered parenting of surviving baby and other children in the family
Referral to therapist/social services can help combat potential problems before they develop

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