PROBLEMS RELATED TO CONCEPTION

PREGNANCY AND PUERPERIUM OF ITS

MANAGEMENT

M . P R I YA D E R S I N I
M.SC NURSING
 INTRODUCTION

Pregnancy Is A Time Of Psychological Change And Challenge And

For Some It Is A Developmental Crisis
Pregnancy And The Post –Partum Period Are Considered To Be
Relatively High-risk Times For Women With Pre-existing Psychiatric
Illnesses, Especially For Depressive Episodes In Women
PSYCHIATRIC DISORDERS IN
PREGNANCY
Antepartum depression
Adjustment disorders
Anxiety and panic attacks in pregnancy
Personality disorder in pregnancy
Bipolar affective disorder
Substance use disorders
ANTEPARTUM DEPRESSION

 Depression during pregnancy, or

antepartum depression, is a mood
disorder just like clinical depression.
Mood disorders are biological
illnesses that involve changes in
brain chemistry
RISK FACTORS
• History of depression, Maternal anxiety
• Life stress
• Lack of social support
• Unintended pregnancy
• Medicaid insurance
• Domestic violence
• Lower income, Lower education
• Smoking
• Single status
• Poor relationship quality
 POSSIBLE TRIGGERS OF DEPRESSION
DURING PREGNANCY
• Relationship problems
• Family or personal history of depression
• Infertility treatments
• Previous pregnancy loss
• Stressful life events
• Complications in pregnancy
• History of abuse or trauma
 SIGNS AND SYMPTOMS
• DIFFICULTY CONCENTRATING
• PERSISTENT SADNESS

Change in eating habits

SLEEPLESSNESS Recurring thoughts of death, suicide,

or hopelessness
Symptoms often seen in non-depressed pregnant women
• Sleep and appetite disturbance
• Diminished libido
• Low energy

Pregnancy related conditions are associated with

depressive symptoms
• Anemia
• Gestational diabetes
• Thyroid dysfunction Antepartum Depression
MANAGEMENT OF
ANTEPARTUM DEPRESSION
 ADJUSTMENT DISORDERS
• Emotional disturbance, interfering with social functioning, which arise when adapting
to significant life change
• Associated with unwanted pregnancy, pregnancy loss, or other major changes
occurring during pregnancy e.g. separation from a partner or change in employment
status
SYMPTOMS
• Depressed mood, anxiety and feelings of inability to cope, although not of a severity
to warrant a diagnosis of depressive disorder. Patients may describe overwhelming
irritability and frustration
MANAGEMENT
Counselling or brief psychotherapy is often effective
ANXIETY AND PANIC ATTACKS IN PREGNANCY
Anxiety is a feeling of unease, worry or fear that can be mild or severe.
Everyone feels anxious sometimes, but some people find it hard to control
their worries. Some people with anxiety also have panic attacks, which can be
very frightening
CAUSES
• A family history of anxiety or panic attacks
• Had anxiety or panic attacks in the past
• Experienced a traumatic event or abuse
• Used some illegal drugs , A long-term or painful condition
• Extra stress due to things like relationship problems, money worries or
unemployment.
SYMPTOMS:
• Feeling anxious all or most of the time and not able to control it
• Restlessness,
• Feeling irritable
• Feeling very worried (for example, in pregnancy you may feel constantly
worried about your baby)
• Feeling a sense of dread
• Being unable to concentrate, or feeling like your mind goes blank
• Feeling constantly on edge
• Difficulty falling or staying asleep.
• Panic attacks can come on very quickly and for no apparent reason.
Other Symptoms can include:
• A racing heartbeat
• A feeling of dread or fear of dying
• Chest pain, Shortness of breath
• Dizziness, Sweating, Feeling faint
• Shaky limbs
• Tingling
• A churning stomach
• Most panic attacks last for between 5 and 20 minutes. They can be very
frightening, but they are not dangerous
• Some people can also have depression in pregnancy because of anxiety
MANAGEMENT
• Anxiety, phobias and panic attacks are usually treated using self-help
treatments based on cognitive behavioral therapy (cbt).
• BEHAVIORAL TECHNIQUES
• Offered therapy, such as cognitive behavioral- a form of psychotherapy that
helps the patient recognize maladaptive or unhelpful patterns of thinking and,
using diaries to record and then challenge such thoughts, enables the patient to
develop new and more realistic beliefs about themselves and the world about
them therapy
• Anti-depressant drugs – SSRI – eg. Fluoxetine, sertraline
• Anxiolytics -
TOKOPHOBIA ?
Prevent or manage anxiety in pregnancy
• Talk to someone you trust, such as your partner, family or a friend about how
you are feeling.
• Try not to feel guilty or embarrassed. These feelings are not your fault.
• Look after yourself - try some of our top tips for looking after your emotional
wellbeing.
• Exercise
• Avoid caffeine
• Eat well
• Avoid smoking and drinking alcohol. This can harm you and your baby.
• Try learning about simple relaxation techniques and practice them regularly.
BIPOLAR AFFECTIVE DISORDER
 Women with bipolar affective disorder (also known as manic depressive
disorder).
 Bipolar disorder can begin during pregnancy or after the birth of a baby. This
may be a first episode, the continuation, or relapse from an episode before the
pregnancy. Women with a prior history or a family history of bipolar disorder
are at increased risk of an episode occurring during pregnancy and childbirth
and so should be alert to any early symptoms.
Management
• Treatments when pregnant or breastfeeding. There are special issues associated
with the use of medications by pregnant and breastfeeding women.
Psychiatrists can be helpful in explaining how best to manage medication use
during this time. The need for effective treatment has to be balanced against
the risk to the fetus and infant of the mother using medication.
PROBLEMS RELATED TO PUERPERIUM
OF ITS MANAGEMENT
 PROBLEMS RELATED TO
PUERPERIUM
 Duringthe postpartum period, about 85% of women experience
some type of mood disturbance.
 For most the symptoms are mild and short-lived; however, 10 to
15% of women develop more significant symptoms of depression
or anxiety.
 Postpartum blues
 Postpartum depression
 Postpartum psychosis.
 POSTPARTUM BLUES
 Baby blues are feelings of sadness a woman may
have in the first few days after having a baby. Baby
blues are also called postpartum blues.
Postpartum means after giving birth.
 About 4 in 5 new moms (80 percent) have baby
blues.
 Baby blues can happen 2 to 3 days after you have
your baby and can last up to 2 weeks
 If sad feelings that last longer than 2 weeks more
serious condition called postpartum depression
ETIOLOGY
• Changes in hormonal level
• Stress to child birth
SYMPTOMS
These Symptoms Typically Peak On 4th Or 5th Day After Delivery And
May Last For A Few Hours Or A Few Days, Remitting Spontaneously
Within 2 Weeks Of Delivery.
While These Symptoms Are Unpredictable And Often Unsettling, They
Do Not Interfere With A Woman’s Ability To Function.
TREATMENT
• NO BIOLOGICAL TREATMENT ONLY EDUCATION AND
SUPPORT
• IF SYMPTOMS OF DEPRESSION PERSIST FOR LONGER THAN
TWO WEEKS, THE PATIENT SHOULD BE EVALUATED TO RULE
OUT A MORE SERIOUS MOOD DISORDER
Postpartum depression (PPD) is a major form of depression and is less
common than postpartum blues.
PPD includes all the symptoms of depression but occurs only following
childbirth. It can begin any time after delivery and can last up to a year.
PPD is estimated to occur in approximately 10 to 20 percent of new mothers.

CAUSES
• Hormonal level
• Marital dissatisfaction/social support
 RISK FACTORS
Previous Depression History of
episode of during depression or
PPD pregnancy bipolar disorder

Recent stressful Inadequate

Marital problem
life events social supports
SYMPTOMS
• Change in appetite
• Suicidal thoughts
• Feelings of guilt
• Feelings of worthlessness
• Sense of being overwhelmed
• Unable to care for baby
• Feelings of inadequacy
• Not bonding with the baby
 FACTORS
• Hormonal changes:A woman experiences the greatest hormonal
fluctuation levels after giving birth. Intense hormone fluctuations, such as
decreased serotonin levels, occur after delivery, play a role in the
development of PPD.
• Situational risks: Childbirth itself is a major life change and transition,
and big changes can cause a great deal of stress and result in depression.
If a major event coincides with childbirth, a mother may be more
susceptible than average to PPD.
• Life Stresses: Ongoing stressful circumstances can compound the
pressures of having a new baby and may trigger PPD. For example,
excessive stress at the office added to the responsibilities of being a
mother can cause emotional strain that could lead to PPD.
 MANAGEMENT
• Antidepressant
(fluoxetine, sertraline, fluvoxamine, and venlafaxine)
• Psychotherapy alone may also be used to treat PPD
New mothers should be encouraged to talk about their feelings or fears with
others
Socializing through support groups and with friends can play a critical role in
recovery
• Exercise and good nutrition may improve a new mother’s mood and also aid
in recovery
• Caffeine should be avoided because it can trigger anxiety and mood changes
PPD LEAD TO OTHER
PROBLEMS TO INFANT
A N D P R E V E N TA B L E
ANY
GUESS?
• When a new mother has severe depression, the vital
mother-child relationship may become strained. She may
be less able to respond to her child’s needs
• Several studies have shown that the more depressed a new
mother is, the greater the delay in the infant’s
development.
• A new mother’s attention to her newborn is particularly
important immediately following birth because the first
year of life is a critical time in cognitive development.
 PREVENTABLE ?
• Early identification can lead to early treatment
• A major part of prevention is being informed about the risk
factors
• social support is also a vital factor in prevention, early
identification of mothers who are at risk can enable a woman
to seek support from physicians, partners, friends, and
coworkers
• Clinical evaluation for postpartum mood and anxiety
disorders
• Medication management
• Consultation regarding breastfeeding and psychotropic
medications
• Recommendations regarding non-pharmacological
treatments
• Referral to support services within the community
POSTPARTUM
PSYCHOSIS
• In rare/severe cases, women may experience postpartum
psychosis (PPP), a condition that affects about one-tenth
of 1 percent of new mothers
• Onset is quick and severe, and usually occurs within the
first two to three weeks ( 48 to 72 hrs) following childbirth.
• Usually a manifestation of bipolar disorder
• Typically presents within 2 weeks of delivery
• May develop few months after birth as delusional depression
• Postpartum Psychosis (PP) is a severe, but treatable, form
of mental illness that occurs after having a baby. It can
happen ‘out of the blue’ to women without previous
experience of mental illness
• There are some groups of women, women with a history of bipolar
disorder for example, who are at much higher risk.
• PP normally begins in the first few days to weeks after childbirth. It
can get worse very quickly and treated as a medical emergency.
Most women need to be treated with medication and admitted to
hospital.
 CAUSES
• Not really sure what causes postpartum psychosis, but more at risk

 Family history of mental health illness

 Already have a diagnosis of bipolar disorder or schizophrenia
 Traumatic birth or pregnancy
 Developed postpartum psychosis after a previous pregnancy
 SYMPTOMS
Symptoms are similar to those of general psychotic reactions such as delusions and
hallucinations
 Physical symptoms: Refusal to eat, inability to cease activity, frantic energy
 Mental symptoms: Extreme confusion, memory loss, incoherence
 Behavioral symptoms: Paranoia, irrational statements, preoccupation
 A manic mood
 A low mood
 Feeling suspicious or fearful
 Restlessness
 Feeling very confused
 Behaving in a way that's out of character
 MANAGEMENT
• With the right treatment, women with PP do make a full recovery. Recovery
takes time and the journey may be tough.
• A woman who is diagnosed with PPP should be hospitalized until she is in
stable condition.
• Doctors may prescribe a mood stabilizer, antipsychotic or antidepressant
medications to treat postpartum psychosis.
• Mothers who experience PPP are highly likely to suffer from it again following
their next pregnancy.
MBU - ?
MEDICATION
• Anti-depressants – to help ease systems of depression
• Anti-psychotics – to help with manic and psychotic symptoms, such as
delusions or hallucinations
• Mood stabilisers (for example, lithium) – to stabilise your mood and prevent
symptoms recurring
PSYCHOLOGICAL THERAPY
Refer you to a therapist for cognitive behavioural therapy (CBT). CBT is a talking
therapy that can help you manage your problems by changing the way you think
and behave.
 REDUCING THE RISK
E L E C T RO C O N V U L S I V E
O F P O S T PA RT U M P S Y C H O S I S
THERAPY (ECT)

• ECT is used only very rarely. this • Aware of risk of

therapy if your symptoms are
postpartum psychosis
particularly severe – for example, if
have severe depression or mania. • Have regular
• Most women with postpartum home visits from a
psychosis make a full recovery as
midwife, health visitor and
long as they receive the right
treatment. mental health nurse
 SUPPORTING PEOPLE WITH THEIR RECOVERY
• Being calm and supportive
• Taking time to listen
• Helping with housework and cooking
• Helping with childcare and night-time feeds
• Letting them get as much sleep as possible
• Helping with shopping and household chores
• Keeping the home as calm and quiet as possible
• Not having too many visitors
• Support for partners, relatives and friends
• Postpartum psychosis can be distressing for partners, relatives and
friends, too.
• If your partner, relative or friend is going through an episode of postpartum
psychosis or recovering, don't be afraid to get help yourself.
• Talk to a mental health professional or approach one of the charities listed.
BIRTH-RELATED POST- TRAUMATIC
STRESS DISORDER (PTSD)
• After childbirth, women may also experience post- traumatic stress
disorder (PTSD). PTSD includes two key elements:
(1) Experiencing or witnessing an event involving actual or threatened
danger to the self or others, and
(2) Responding with intense fear, helplessness or horror.
CAUSES
• Stressful experiences, including the amount and severity of trauma you've gone
through in your life
• Inherited mental health risks, such as a family history of anxiety and depression
• Inherited features of your personality — often called your temperament
• The way your brain regulates the chemicals and hormones your body releases
in response to stress
RISK FACTORS
• Experiencing intense or long-lasting trauma
• Having experienced other trauma earlier in life, such as childhood abuse
• Having a job that increases your risk of being exposed to traumatic events,
such as military personnel and first responders
• Having other mental health problems, such as anxiety or depression
• Having problems with substance misuse, such as excess drinking or drug use
• Lacking a good support system of family and friends
• Having blood relatives with mental health problems, including anxiety or
depression
Kinds of traumatic events
• Combat exposure
• Childhood physical abuse
• Sexual violence
• Physical assault
• Being threatened with a weapon
• An accident
• Many other traumatic events also can lead to PTSD, such as fire, natural
disaster, mugging, robbery, plane crash, torture, kidnapping, life-threatening
medical diagnosis, terrorist attack, and other extreme or life-threatening
events.
SYMPTOMS OF BIRTH-RELATED PTSD
• Obsessive thoughts about the birth
• Feelings of panic when near the site where the birth occurred
• Feelings of numbness and detachment
• Disturbing memories of the birth experience
• Nightmares
• Flashbacks
• Sadness, fearfulness, anxiety or irritability
• Intrusive memories
• Avoidance
• Negative changes in thinking and mood
• Changes in physical and emotional reactions
 MANAGEMENT
• Post-traumatic stress disorder treatment can help you regain a sense of
control over your life. The primary treatment is psychotherapy, but can also
include medication
• Teaching you skills to address your symptoms
• Helping you think better about yourself, others and the world
• Learning ways to cope if any symptoms arise again
• Treating other problems often related to traumatic experiences, such as
depression, anxiety, or misuse of alcohol or drugs
PSYCHOTHERAPY
C O G N I T I V E T H E R A P Y.
• This type of talk therapy helps you
recognize the ways of thinking
(cognitive patterns) that are
keeping you stuck — for example,
negative beliefs about yourself and
the risk of traumatic things
happening again.
For PTSD, cognitive therapy often is
used along with exposure therapy
EXPOSURE THERAPY
• This behavioral therapy helps you
safely face both situations and
memories that you find frightening
so that you can learn to cope with
them effectively.
• Exposure therapy can be
particularly helpful for flashbacks
and nightmares
 EYE MOVEMENT DESENSITIZATION AND
REPROCESSING (EMDR)
• EMDR combines exposure therapy with a series of guided eye
movements that help you process traumatic memories and change
how you react to them
• develop stress management
• help you gain control of lasting fear after a traumatic event
 MEDICATIONS
• Antidepressants.These medications can help symptoms of depression and anxiety.
They can also help improve sleep problems and concentration.
(SSRI) - sertraline (Zoloft) and paroxetine (Paxil) are approved by the Food and Drug
Administration (FDA) for PTSD treatment
• Anti-anxiety medications
• prazosin (Minipress) may reduce or suppress nightmares in some people with
PTSD
 Take care of yourself. Get enough rest, eat a healthy diet, exercise and take time to
relax. Try to reduce or avoid caffeine and nicotine, which can worsen anxiety.
 Don't self-medicate
 Break the cycle
 Stay connected. Spend time with supportive and caring people — family, friends,
faith leaders or others.
COMPLICATIONS
• Post-traumatic stress disorder can disrupt your whole life ― your
job, your relationships, your health and your enjoyment of everyday
activities.
• Having PTSD may also increase your risk of other mental health
problems, such as:
• Depression and anxiety
• Issues with drugs or alcohol use
• Eating disorders
• Suicidal thoughts and actions
POSTPARTUM ANXIETY /PANIC DISORDER
The condition which characterized by symptoms of intense anxiety or
panic and may involve many somatic symptoms such:
• cardiac palpitations, tachycardia, tachypnea, dyspnea
• hot or cold flashes , chest pain, abdominal pain
• dizziness
• Tremor and feelings of doom and helplessness.
MANAGEMENT
Benzodiazepine (e.g., clonazepam, lorazepam)
 GENERAL MANAGEMENT FOR POSTPARTUM ILLNESS
Psychosocial Therapies
• Group therapy – Helps to increase support network
• Family and marital therapy – More rapid recovery – More appreciative of
partner’s contribution
• Peer-support groups
Interpersonal Therapy (IPT)
– Grief
– Interpersonal disputes
– Role transitions
– Interpersonal deficit
INSTRUMENT

• Beck’s Depression Inventory (PDI)

• Postpartum Depression Screening Scale (PDSS)
• Edinburgh Postnatal Depression Scale (EPDS)
 JOURNAL
REFERENCE
A RANDOMIZED CONTROLLED
T R I A L O D V I TA M I N D
S U P P L E M E N TAT I O N O N P E R I N ATA L
DEPRESSION IN IRNIAN PREGNANT
M OT H E R S

VA Z I R I . F E T, A L
B M C P R E G N A N C Y A N D C H I L D B I RT H
CONCLUSION