Transcript Psychiatric Consultation to the OB/Gyn Service

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
• 5M Outpatient Women’s Clinic
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Gyn Clinic
Teen Clinic
Nurse-midwife Prenatal Clinic
High Risk (MD) Prenatal Clinic
• 6G Women’s Options Clinic
• 6C Labor and Delivery (inpatient)
• 6C Triage Area (outpatient)
Psych Interface with Hi-Risk OB
• Thursday AM: Anna Spielvogel and psych
residents available in 5M 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 2wk postpartum check
Core Ob/Gyn Knowledge for the
Psychiatric Consultant
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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
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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
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Menarche
Reproductive capacity
Infertility
Loss of desired pregnancy
Birth experience
Menopause
Tasks of Normal Pregnancy
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
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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
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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
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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
ReproRisk Database