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Mental health problems in pregnancy or post partum

Specialties > Mental health

Differential Diagnosis Schema 🧠

Antenatal Mental Health Problems

  • Antenatal Depression: Common, often underdiagnosed; presents with low mood, fatigue, and changes in appetite or sleep during pregnancy.
  • Anxiety Disorders: Generalized anxiety disorder, panic disorder, and OCD can all present during pregnancy; characterized by excessive worry, panic attacks, or obsessive-compulsive behaviors.
  • Bipolar Disorder: Women with a history of bipolar disorder are at increased risk of relapse during pregnancy; presents with mood swings, elevated or depressed mood.
  • Post-Traumatic Stress Disorder (PTSD): May be related to past trauma, including previous pregnancy losses or traumatic childbirth experiences.

Postpartum Mental Health Problems

  • Postpartum Depression: Affects around 10-15% of women; presents with low mood, anhedonia, fatigue, and feelings of guilt or worthlessness within 6 weeks to 6 months postpartum.
  • Postpartum Anxiety: Includes generalized anxiety, panic disorder, and OCD; characterized by excessive worry, panic attacks, or intrusive thoughts, often focused on the baby’s health.
  • Postpartum Psychosis: Rare but severe; presents within the first 2 weeks postpartum with delusions, hallucinations, and disorganized thinking; medical emergency requiring urgent psychiatric intervention.
  • Adjustment Disorder: Emotional disturbance following childbirth, often related to the stress of adapting to new motherhood.

Substance Use Disorders

  • Alcohol Use Disorder: Can have detrimental effects on both mother and fetus; assess for alcohol use throughout pregnancy and postpartum.
  • Substance Use: Illicit drug use, including opioids, cannabis, and stimulants, can complicate pregnancy and postpartum care; assess for withdrawal symptoms and provide appropriate support.
  • Prescription Medication Misuse: Includes overuse of anxiolytics, sedatives, or pain medications; can affect maternal mental health and fetal development.

Key Points in History 🥼

Symptomatology

  • Onset and Duration: Determine when symptoms began, whether they were present before pregnancy or developed during the antenatal or postpartum period.
  • Mood Symptoms: Assess for symptoms of depression (low mood, anhedonia, guilt) and anxiety (worry, panic attacks, obsessive thoughts).
  • Sleep and Appetite: Changes in sleep patterns and appetite may indicate mood disorders, especially if severe or persistent.
  • Suicidal Ideation: Always assess for suicidal thoughts or intent, particularly in severe depression or postpartum psychosis.
  • Psychotic Symptoms: Hallucinations, delusions, or paranoia, particularly if they involve the baby, require urgent attention.
  • Functionality: Evaluate how symptoms impact daily functioning, including the ability to care for the baby and engage in normal activities.

Background

  • Past Medical History: Inquire about previous mental health issues, including depression, anxiety, or psychosis, and any past treatments.
  • Drug History: Review current and past use of psychiatric medications, including antidepressants, mood stabilizers, and antipsychotics; assess adherence and side effects.
  • Family History: A family history of mental health disorders, particularly bipolar disorder or postpartum psychosis, increases risk.
  • Obstetric History: Previous pregnancies, including complications such as pre-eclampsia or gestational diabetes, and previous postpartum mental health issues.
  • Social History: Consider the impact of social stressors such as relationship difficulties, lack of support, financial concerns, and substance use.

Possible Investigations 🌡️

Laboratory Tests

  • Thyroid Function Tests: Hypothyroidism or hyperthyroidism can present with depressive or anxiety symptoms; important to rule out in perinatal mental health assessments.
  • Vitamin D Levels: Low vitamin D has been associated with depressive symptoms; consider supplementation if deficient.
  • Full Blood Count: Rule out anemia, which can contribute to fatigue and exacerbate depressive symptoms.
  • Electrolytes and Glucose: Check for imbalances that might mimic or exacerbate psychiatric symptoms.
  • Toxicology Screen: Consider if there is a suspicion of substance use or prescription medication misuse.

Imaging and Specialist Tests

  • Mental Health Screening Tools: Use Edinburgh Postnatal Depression Scale (EPDS) or Generalized Anxiety Disorder (GAD-7) scale to assess severity and track progress.
  • Electrocardiogram (ECG): If considering the use of certain psychotropic medications, especially in patients with cardiovascular risk factors.
  • Neuroimaging: Generally not indicated unless there are focal neurological symptoms or suspicion of an organic cause of psychosis.
  • Referral to Psychiatry: Consider early referral for severe depression, postpartum psychosis, or complex cases requiring specialist input.

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Mental health