Nice | Antenatal and postnatal mental health

This is an updated guideline from Nice on antenatal and postnatal mental health. There really isn't anything earth shattering in this - most of it we would do anyway. I have highlighted some key points that I hadn't necessarily appreciated. This is not an exhaustive summary, just the things that were new for me.

General guidance on antenatal and postnatal mental health

  • Refer women with a history of severe mental health problems.
  • Remember that women may be reluctant to discuss their mental health through fear of stigma, or fear that the baby could be taken from them, so we need to be proactive in discussing it and in screening for depression and anxiety at all stages antenatally and postnatally.
  • Bipolar disorder has a higher risk of causing problems during and after pregnancy.
  • Women with either a personal history or a first-degree family history of severe mental illness are more at risk of postpartum psychosis.

Drugs

  • Antipsychotics 
    • There is a higher risk of gestational diabetes and weight gain; women should be screened with an OGTT.
    • Check PRL if they are planning a pregnancy
  • Valproate - do not use in women planning a pregnancy. Withdraw if they fall pregnant
  • Carbamazepine - do not use in women planning a pregnancy. Discuss withdrawal if they fall pregnant
  • Lamotrigine - levels can vary significantly during pregnancy, so they need monitoring 'regularly'
  • Lithium 
    • There is a risk of cardiac malformations, though the size of the risk is uncertain. Stopping it if they fall pregnancy may not remove this risk.
    • It is present in breastmilk and there is a risk of toxicity in the baby
    • Monitor levels 4 weekly until 36/40, then weekly
    • Consider withdrawing it over 4 weeks if they fall pregnant. Restarting it in the second trimester could be considered.

Specific Conditions

  • Depression - they are actually quite prescriptive in the advise, depending on whether the woman has mild, moderate or severe depression. In reality, this is often not obvious and I suspect that people will manage individuals depending on how they present at the time. The advice is there if needed however.
  • Eating Disorders - discuss maternal and infant nutrition with the mother. Consider the need for fetal growth scans. Monitor the woman.
  • Sleep disorders - promethazine can be considered.

 

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton.

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