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Peripartum Depression

Peripartum Depression. Laura J. Miller, M.D. Women’s Services Division University of Illinois at Chicago. Risks from untreated major depression during pregnancy. Decreased prenatal care Insufficient weight gain Increased use of addictive substances

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Peripartum Depression

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  1. Peripartum Depression Laura J. Miller, M.D. Women’s Services Division University of Illinois at Chicago

  2. Risks from untreated major depression 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

  3. Obstetric & neonatal complications of depression • 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)

  4. Types of postpartum mood disorders • Postpartum “blues” • Postpartum depression • Postpartum psychoses

  5. Postpartum “blues” • Central features: tearfulness, lability, reactivity • Peaks 3-5 days after delivery • Present in 50-80% of women • Present in all cultures studied • Unrelated to environmental stressors • Unrelated to psychiatric history

  6. Postpartum “blues” : hormone withdrawal hypothesis • Ovarian steroid receptors in CNS are heavily concentrated in the limbic system • The magnitude of the postpartum drop in estrogens and progesterone correlates with presence of “blues”; absolute levels don’t • Neuroactive steroids (pregnanolone, allopregnanolone) decrease postpartum, affecting GABA

  7. Postpartum “blues”: biological attachment hypothesis • Neurobiological systems foster attachment between mammalian mothers & infants • Oxytocin activates limbic structures (e.g. the ACG) that mediate the interface between attention & emotion • Postpartum reactivity may stem from this • With stressors, depression may result

  8. Clinical features of postpartum depression • Despondency • Sleep disturbance, fatigue, irritability • Anorexia • Poor concentration • Feelings of inadequacy • Ego-dystonic thoughts of harming the baby

  9. Characteristics of postpartum depression • Begins within 4 weeks of baby’s birth • Clinical presentation peaks 3-6 months after delivery • Present in 10% of new mothers in U.S. • Much less prevalent in some cultures • Related to psychiatric history • Related to environmental stressors

  10. 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

  11. Postpartum cultural influences • Ceremonies • Cleansing rituals • Seclusion • Rest • Solicitude • Return to home of origin

  12. Postpartum psychoses • Usually related to a mood episode • More disorientation, agitation, lability • Peaks within 3 weeks of birth • Affects 1/1000 women overall, but 25 - 35% of women with bipolar diathesis • Predicted by absence of depression/anxiety in third trimester • Unrelated to environmental stressors

  13. Treating postpartum mood disorders • Psychotherapy • Interpersonal psychotherapy • Couples therapy • Somatic treatments • Antidepressant medication • Hormone therapy • ECT • Self help networks

  14. Interpersonal psychotherapy for postpartum depression • Focus on role transition • Integrate new role with established roles • Explore feelings & ambivalence about roles • Assess satisfaction with relationships • Define patient’s expectations of others • Renegotiate relationships • Maintain specific problem focus

  15. Couples therapy for postpartum depression: evaluation • Evaluation begins with family, then each parent individually, then couple together • Relevant history • parents’ families of origin • history of parents’ relationship • parents’ expectations about the baby • circumstances surrounding becoming pregnant, pregnancy, labor, delivery, postpartum

  16. Couples therapy for postpartum depression • Create accepting atmosphere • Educate about wide range of normal feelings postpartum • Establish common ground • Articulate “ideal family” • Find compromises to approximate the ideal and replace fantasies with a real family

  17. Antidepressants: teratogenicity • Morphologic: none for SSRI’s, tricyclics & venlafaxine; not enough systematic data about newer agents (e.g. nefazodone, bupropion, mirtazapine) • Behavioral • none for fluoxetine, tricyclics • fluoxetine protects against brain effects of maternal separation in rats

  18. Antidepressants: fetal & neonatal side effects • SSRI’s: “colic”, decreased weight gain; tremor; tachypnea; motor automatisms; increased bleeding diathesis • Tricyclics: tachycardia; (rare) tachyarrhythmia, urinary retention • All antidepressants: • neonatal withdrawal • questionable association with prematurity

  19. Guidelines for antidepressants during pregnancy • Consider better-studied agents • Agents to avoid during pre-eclampsia: bupropion, maprotiline • Vitamin C with SSRI’s • Dosing considerations • increase sometimes needed in 2nd trimester • consider reduction during last month

  20. Postpartum pharmacotherapy: side effect concerns • Sedation • Insomnia • Weight gain • Decreased sexual desire • Effects on breastfeeding infant

  21. Antidepressants & lactation: relative doses to nursling • Sertraline: 0.4% - 1.0% • Fluvoxamine 0.5% - 1.6% • Paroxetine: 0.1% - 4.3% • Fluoxetine: 1.2% - 12.0% • Venlafaxine: 5.2% - 7.4% • Citalopram: 0.7% - 9.0% • (% of weight-adjusted maternal doses)

  22. Antidepressants & lactation: reported side effects • Usually none • Fluoxetine case report of “colic” -- e.g. crying, restlessness, decreased sleep, vomiting, watery stools • Citalopram case report of uneasy sleep • Doxepin case report of pallor, hypotonia, respiratory depression

  23. Prescribing during lactation • Explain potential risks & benefits, ideally to both parents • Obtain description of baby’s baseline behavior • For possible infant side effects, check serum level & confer with pediatrician • Some mothers pump breast milk prior to each dose & use pumped milk after dose

  24. Postpartum estrogen treatment • Effective in placebo-controlled studies • Dose: 200 micrograms as transdermal patch, changed twice weekly, or sublingual 1mg QID • Contraindications: breast cancer, hypercoagulability, pregnancy • Efficacy & safety relative to antidepressants not yet established

  25. Preventing peripartum depression • 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)

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