Psychiatric Consultation to the SFGH Ob/Gyn Service

1. Psychiatric Consultation to the SFGH Ob/Gyn Service Sudha Prathikanti, MD UCSF Dept of Psychiatry

2. Ob/Gyn Population at SFGH • Ethnically diverse; some over-representation of Latinas • Over 1200 deliveries / year, often with significant prenatal morbidities • SFGH provides prenatal services for patients from county jails, BAPAC, homeless clinics

3. Ob/Gyn Clinical Sites Within SFGH • 5M Outpatient Women’s Clinic • Gyn Clinic • Teen Clinic • Nurse-midwife Prenatal Clinic • High Risk (MD) Prenatal Clinic • 6G Women’s Options Clinic • 6C Labor and Delivery (inpatient) • 6C Triage Area (outpatient)

4. Psych Interface with Hi-Risk OB • Thursday AM: Anna Spielvogel and psych residents available in 5M Clinic until noon • “one-stop shopping” : outpatients coming for prenatal care get regular co-follow from Anna et al for mental illness or for severe drug abuse/psychosocial stressors • Anna et al hold weekly rounds with OB team and keep written log of all active patients • Formal psych tx plan placed in prenatal chart • NO automatic follow-up when woman delivers, but Anna/residents often available by page and will see patient at 2wk postpartum check

5. Core Ob/Gyn Knowledge for the Psychiatric Consultant • Common Acronyms/Terminology • Contraceptive Technology • Conception Technology • Normal Fetal Development by Trimester • Evidence of Fetal Problems / Fetal Distress • Stages of Labor • HIV Transmission & Treatment in Pregnancy • State Abortion Timelines • Classification System for Drugs in Pregnancy

6. Emergent Consult Questions • Suicidal or Homicidal Ideation • Psychosis/ Agitation during Labor/Delivery • Consider etiology-pain, primapara, drugs, culture • Use Haldol IM if necessary • Avoid hypotension! • Capacity for Medical Decision-making : • Requesting Abortion • Refusing Vital Procedures (esp fetal monitering) • Leaving AMA

7. Some Non-Emergent Consult Questions • Diagnostic issues • Is this postpartum depression? (assuming no suicidal ideation) • Psychotropic meds during pregnancy/lactation • Should we stop this woman’s Paxil? • Capacity to parent • Is this schizophrenic woman a “fit mother”? • Behavioral treatment plan • How can we get this woman to stay in bed? • Outpatient resources • Ashbury House, Iris Center, BAPAC

8. Psych HPI : Questionsfor the Pregnant Patient • Was this a planned pregnancy? • Was the pregnancy the result of a sexual assault/incest? • When did you first discover you were pregnant? What was your reaction? • Do you know who the father is? • What has the father’s role been during the pregnancy? • Do you want to carry the baby to term? • What do you hope will happen after the pregnancy?

9. Core Psychiatric Knowledge re: OB/Gyn Patients • Gender theory • Societal vulnerabilities for girls/women • Development thru the life cycle • Developmental tasks of pregnancy • Psychiatric disorders : prepartum, peripartum, postpartum • Psychotropic medications during pregnancy/breastfeeding

10. Gender Theory • Gender identity: core sense of femaleness or maleness well established by 18 mos • Gender role: conscious expectations and behaviors considered appropriate for a given gender in a given culture • Gender personality: largely unconscious way of relating to world/self/others as a result of early attachment experiences (Chodorow -object relations theorist)

11. Societal Vulnerabilities • Rape (6-26% lifetime prevalence) • Only 1/5 raped by stranger • Stranger rape less likely to lead to other injuries • Incest (12% of girls under 17) • Domestic Violence (20-30% life prev) • Almost half of murdered women killed by partners • Account for large number of ER visits

12. Life Cycle • Menarche • Reproductive capacity • Infertility • Loss of desired pregnancy • Birth experience • Menopause

13. Tasks of Normal Pregnancy Pregnancy: key opportunity to revive/ re-work core identity, unresolved childhood conflicts • First Trimester • Acknowledge pregnancy, decide what to do • Confidence greatly influenced by own mother • Confirms femaleness regardless of decision • Second Trimester • Assimilate altered body image (fertility vs. control) • Affective bond with fetus can resolve ambivalence • Third Trimester • Anticipation vs. dread (pain, health, change in role) • Ambivalence/rejection of fetus can signal serious prob

14. Psych Disorders and Reproductive Life Cycle • Much higher risk for mood disorders in the year following birth • Fluid, electrolyte, hormonal shifts? • Psychosocial stress + biologic diathesis? • Otherwise, no convincing data linking severe psych conditions to biological cycle • “Minor” depression/anxiety prepartum • PMDD • Menopausal depression

15. Postpartum Psychosis • Rare ( 0.1-0.4% ) but severe w/ rapid onset • Elevated risk up to one year postpartum • Most significant etiologic factor is genetic loading for Bipolar Disorder • Diff dx: Schizophrenia, MDD, drugs • May involve bizarre delusions re: infant • Must remove from infant until tx complete • 50% recurrence in later pregnancies

16. Postpartum Depression • Common: 20% incidence • Often undetected due to mom’s shame • Gradual onset 2 wks-1 yr postpartum; most commonly month 3 and month 9 • Same diagnostic criteria as MDD • Risk of suicide/infanticide rare, but high risk of neglect and inadequate parenting • Recurrence depends on initial severity and psychosocial stressors

17. Post Partum Blues • Extremely common (50%) • Considered normal • NO link to other psych disorders • Sx appear within days of delivery, peak from day 3-7, resolve within 2 wks • High rate of recurrence: provide mom reassurance and support

18. Medications during Pregnancy • Traditionally withheld due to fears of teratogenicity • Consider risks of untreated psych illness • Poor nutrition/low birth weight • Poor prenatal care • Precipitous delivery/self-delivery • Neonatal neglect/abuse

19. Psych Meds during Pregnancy • Review of FDA Classification • More data emerging re: safety of TCAs, some SSRIs, high-potency neuroleptics • Avoid benzos / mood stabilizers in first trimester • Definite teratogenic effects of mood stabilizers • Lithium- cardiovasc anomalies • Valproate-neural tube defects • Carbamazapine-craniofacial anomalies

20. Handy References • Ob/Gyn Basic Knowledge • HIV and Pregnancy • Key Textbooks • Review Articles on Psychopharm during Pregnancy and Lactation • Review Articles on Mood Disorders during Pregnancy Patient Information ReproRisk Database