Psychiatric Consultation to the SFGH Ob Gyn Service Sudha

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

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

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

Psych Interface with Hi-Risk OB • Thursday AM: Anna Spielvogel and psych residents available in 5 M 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 2 wk postpartum check

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

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

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

Psych HPI : Questions for 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?

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

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)

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

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

Tasks of Normal 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

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

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

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

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

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

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

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 Repro. Risk Database