Williams Manual of Pregnancy Complications, 23 ed.

CHAPTER 79. Psychiatric Illnesses during Pregnancy

Approximately 15 to 20 percent of pregnant women will have mental health needs that must be considered in their management. Biochemical factors, including effects of hormones, and life stressors can markedly influence mental illness. It is thus intuitive that pregnancy would affect some coexisting mental disorders.

MAJOR MOOD DISORDERS

These include major depression—a unipolar disorder—and manic depression—a bipolar disorder with both manic and depressive episodes. Major mood disorders as a group contribute to two-thirds of all suicides.

Major Depression

Major depression, the most common mood disorder, is multifactorial and prompted by genetic and environmental factors. First-degree relatives have a 25 percent risk and female relatives are at even higher risk. It is unquestionable that pregnancy is a major life stressor that can precipitate or exacerbate depressive tendencies. Common symptoms are summarized in Table 79-1. Antidepressant medications along with some form of psychotherapy are indicated for severe depression during pregnancy or the puerperium. Electroconvulsive therapy (ECT) for depression during pregnancy is reserved for those in whom depression is refractory to intensive pharmacotherapy.

TABLE 79-1. Symptoms of Depressive Illnessa

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Bipolar Disorder

Manic-depressive illness also has a strong genetic component with the risk of first-degree relatives at 5 to 10 percent. Periods of depression last at least 2 weeks. At other times, there are manic episodes—distinct periods during which there is an abnormally raised, expansive, or irritable mood. Potential organic causes of mania should also be considered and include substance abuse, hyper-thyroidism, and central nervous system tumors. Pharmacologic treatment is reviewed in (see Table 80-3). Special caution is urged for use of lithium during fetal organogenesis.

SCHIZOPHRENIA

This major form of mental illness affects 1.1 percent of adults. Four major subtypes of schizophrenia are recognized: catatonicdisorganized, paranoid, and undifferentiated. The hallmarks of paranoid schizophrenia are delusions, hallucinations, flat or blunted affect, and confused or impoverished speech. Brain scanning has shown that schizophrenia is a degenerative brain disorder with a major genetic component. If one parent has schizophrenia, the risk to offspring is 5 to 10 percent. Signs of illness begin approximately at age 20, and commonly, work and psychosocial functioning deteriorate over time. Because schizophrenia has a high recurrence if medications are discontinued, it is advisable to continue therapy during pregnancy. After 40 years of use, there is no evidence that conventional drugs cause adverse fetal or maternal sequelae. These are listed in (see Table 80-3). Because less is known about “atypical” antipsychotics, the American College of Obstetricians and Gynecologists recommends against their routine use in pregnant and breastfeeding women.

ANXIETY DISORDERS

These common disorders include panic attack, specific phobia, obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder. All are characterized by irrational fear, tension, and worry, which are accompanied by physiologic changes such as trembling, nausea, dizziness, dyspnea, and insomnia. Patients with these disorders are treated with psychotherapy and medications, including SSRI, tricyclic antidepressants, and others.

It is unclear as to the effect these disorders may have on pregnancy. However, there does appear to be an important link with postpartum depression.

PERSONALITY DISORDERS

These disorders are characterized by the chronic use of certain mechanisms in an inappropriate, stereotyped, and maladaptive manner. There are three clusters of personality disorders: (1) paranoid, schizoid, and schizotypal personalities, which are characterized by oddness or eccentricity; (2) histrionic, narcissistic, antisocial, and borderline disorders, which are all characterized by dramatic presentations along with self-centeredness and erratic behavior; and (3) avoidant, dependent, compulsive, and passive–aggressive personalities, which are characterized by underlying fear and anxiety. Genetic and environmental factors are important in the genesis of these disorders. Management is through psychotherapy; however, only about 20 percent of affected individuals recognize their problems and seek psychiatric help.


For further reading in Williams Obstetrics, 23rd ed.,

see Chapter 55, “Neurological and Psychiatric Disorders.”