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Critical Issues in Perinatal Psychiatric Emergency Care

Critical Issues in Perinatal Psychiatric Emergency Care

Over the past decade, there has been increasing attention to the identification and management of mood and anxiety disorders related to childbearing. Emergency physicians, including psychiatrists, primary care providers, obstetricians, gynecologists, and pediatricians, encounter women who are struggling with mental health issues in the context of reproductive events, such as pregnancy, pregnancy loss, and the postpartum adjustment period.

In some cases, the reproductive event may precipitate a mental health crisis. In others, it may exacerbate an underlying mental health condition that, in turn, may need to be managed differently because of issues related to pregnancy or breast-feeding.

This article reviews the common mental health conditions encountered in emergency care settings as these conditions relate to childbearing, including special considerations in evaluation and treatment options. A list of resources for patients and clinicians is also included (Table 1).

PRENATAL PSYCHIATRIC ILLNESSES

Pregnancy

Historically, pregnancy was considered a time of well-being for many women, even for women who had histories of mood disorders, such as depression or bipolar disorder. Some of this mythology may have been related to the idealized view that societies have of pregnant women. Some may have been the result of confusion between anxiety and depression, which can be affected differently by pregnancy. Some may also be related to assumptions made from early retrospective studies. Whatever the reasons for earlier misconceptions, recent prospective and larger epidemiologic studies indicate that the rates of depression among pregnant women are similar to those of women of similar age who are not pregnant.1

The prevalence of depression among pregnant women is approximately 10%.1,2 Women who may be at greater risk for depression during pregnancy include those who are young, are ambivalent about the pregnancy, have a personal or family history of depression, and are experiencing marital problems. 3,4Symptoms of depression during pregnancy are consistent with those found at other times in women's lives. However, it is often difficult for clinicians and patients to distinguish the cause of neurovegetative symptoms, such as fatigue, sleep disruption, weight gain, appetite changes, energy loss, and decreased concentration.5 Each of these hallmark symptoms of depression, in isolation, can be a simple effect of pregnancy. Therefore, many women disregard their depressive symptoms because they believe that they are a normal part of pregnancy.

The number and severity of symptoms and their relationship to stressors and mood and physical changes must be thoroughly assessed to ensure neither underdiagnosis nor overdiagnosis of depression. Thoroughly assessing risk factors, feelings about this pregnancy, future plans, mood, and anxiety are critical in distinguishing the cause of the neurovegetative symptoms. Although pregnancy appears to be a lower-risk time for suicide among women,6,7 it is not without risk of self-harm, suicide attempts, and for some women, completed suicide. Thus, suicidality must be assessed in any depressed woman, regardless of pregnancy status.

Bipolar I disorder affects approximately 1% to 2% of the population and is equally distributed among men and women. Women with bipolar disorder tend to experience a greater number of depressed, mixed, and rapid-cycling episodes than men.8Many women with bipolar disorder experience an episode during their childbearing years and appear to be at greatest risk during the perinatal period. Among women with bipolar disorder, retrospective studies originally suggested a lower risk of recurrence of a mood episode.9 This is controversial.

Recent studies found high rates of relapse during pregnancy among women with bipolar disorder who discontinued their medication.10 The rates of a recurrent affective episode are similar for pregnant and nonpregnant women who discontinued maintenance lithium.11 Except for a history of chronic depression10 and the discontinuation of medications (especially rapid discontinuation), risk factors for an episode of depression or mania occurring during pregnancy among women with bipolar disorder have not yet been established.

Because of the high risk of teratogenicity of many mood stabilizers, women may abruptly discontinue their medications or be advised to discontinue their medications during or in preparation for pregnancy. The dose of some medications may actually need to be increased during pregnancy to maintain mood stability. Because providers and mothers are often trying to minimize fetal exposure to the medication, affective symptoms may recur because of inadequate treatment. Emergency physicians may see women who have an abrupt onset of depression, mania, or a mixed episode in the context of these medication issues. The decision to increase or restart medications is complicated, and a comprehensive riskbenefit analysis is critical (see "Treatment during pregnancy," below).12

Pregnancy loss

Therapeutic abortions and spontaneous pregnancy losses are often lumped together when the relationship between pregnancy loss and mental health is considered. Each event can affect a woman's mental health. No one event should be assumed to be of lesser or greater magnitude than another. The rate of depression among women who have undergone therapeutic terminations has not been established. While data indicate no increase in serious psychiatric sequelae, women who have a history of psychiatric illness, who feel coerced into the termination, who are ambivalent about the termination, and who have limited social supports have a greater risk of depression developing after a therapeutic termination.13

Miscarriage, defined as an involuntary pregnancy loss before 20 weeks' gestation, is relatively common, affecting 15% to 25% of recognized pregnancies. In contrast, perinatal loss, defined as an involuntary loss after 20 weeks' gestation, is relatively rare, affecting 1.2% of pregnancies. The relative risk for an episode of major depression within 6 months after a pregnancy loss is 2.5, but it is as high as 5 among women who do not have other living children.14 Among women with a history of depression, more than half will experience a recurrence of their depression in the 6 months after a pregnancy loss.14 Other risk factors for development of depression after pregnancy loss include being older and the gestational age of the fetus at the time of the loss.15

Some women may present immediately after a pregnancy loss in an acute crisis with severe grieving, but others may not present for weeks or months. Women are often not prepared for the extent of grief that they experience. Women who have repeated miscarriages may be at increased risk because of the repeated roller coaster of hope and grief. Miscarriages and therapeutic terminations are often private matters, rarely discussed outside the immediate couple and medical providers. Therefore, many women do not have the support from family and friends that would be available in the context of other deaths or losses.

In contrast, perinatal losses, including stillbirths, are often very public losses, because many pregnancies are obvious at the time of the loss. These women may have more support but are often faced with questions from persons who are not close to them who may ask about the baby and the delivery. Repeated discussion of the loss may be particularly difficult. Anniversary dates that may precipitate crises include the anniversary of the birth/loss as well as the anniversary of the original anticipated birth date. The birth of a subsequent child can also be a trigger for bereavement and even depression for some women who are still grieving a previous pregnancy loss. Many women who may require treatment for depression or anxiety after a pregnancy loss wish to become pregnant again quickly. These women often require special consideration when choosing medication.

Table 1
Resources that can benefit patients and clinicians
• Antiepileptic Drug Pregnancy Registry: www.mgh.harvard.edu/aed or 888-233-2334
• Depression After Delivery, Inc: www.depressionafterdelivery.com
• Massachusetts General Hospital (MGH) Center for Women’s
Mental Health Perinatal Information Resource Center: www.womensmentalhealth.org
• Motherisk Helpline: www.motherisk.org
• National Institute of Mental Health: www.nimh.nih.gov
• National Women’s Health Information Center: www.4women.gov
• Postpartum Support International: www.postpartum.net
• The Marcé Society: www.marcesociety.com
• Women’s Behavioral HealthCARE: www.womensbehavioralhealth.org

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