CONSULTATION DRAFT
3 Antenatal care for women with mental health disorders1
Mental health disorders have been identified as a leading cause of maternal morbidity and
mortality in the UK (Lewis 2007) and as one of the top three causes of indirect maternal mortality
in Australia (Austin et al 2007). There is increasing evidence that untreated maternal depression
(Davalos et al 2012), stress and anxiety (Zelkowitz & Papageorgiou 2012) also adversely affect the
developing fetus, with implications extending into childhood. Use of antidepressants in
pregnancy has also been associated with adverse effects in the fetus and newborn, but they
are believed to be relatively safe (Udechuku et al 2010). Assessment of the risks and benefits for
the individual woman is appropriate when use of antidepressants is being considered (see
Section Error! Reference source not found.).
Australian research indicates a high prevalence of depression and anxiety during pregnancy,
with up to one in ten (9%) women experiencing depression (Buist & Bilszta 2006) and anxiety
disorders likely to be as, or more, common (beyondblue 2011). Refugee women with a history of
torture or trauma are at increased risk of mental health disorders, including anxiety and
depression (Costa 2007).
While specific data on low prevalence mental health disorders (eg schizophrenia, bipolar
disorder, severe personality disorders) in pregnant women in Australia are not available, recent
studies suggest that schizophrenia is present in 1% of the population world wide, lifetime
prevalence of bipolar disorder in Australia is estimated as 1.2% (University NSW 2002) and
personality disorders are present in 6.5% of Australian adults, with borderline personality disorder
in approximately 1% (Jackson & Burgess 2000).
To match the needs, preferences and expectations of women with mental health disorders,
maternity services need to work within collaborative and consultative frameworks. This includes
clearly defining roles and responsibilities for everyone involved in a woman’s care and working
within established clinical networks and systems to facilitate timely referral and transfer to
relevant services when appropriate. Continuity of care and carer also contribute to improved
experiences for women.
3.1
Identifying and managing mental health disorders during pregnancy
“Depression and related disorders affect the wellbeing of the woman, her baby and her
significant other(s) (eg partner), and have an impact on relationships within the family, during a
time that is critical to the future health and wellbeing of children.” (beyondblue 2011)
Early identification and management of mental health disorders can minimise their detrimental
effects during pregnancy and early parenthood.
Depression and anxiety during pregnancy are assessed using the Edinburgh Postnatal
Depression Scale (EPDS)2 and clinical judgement, as outlined in Part B of Module I of the
Guidelines.
Bipolar disorder is characterised by episodes of hypomania or mania and depression (APA
2000). Women who have already experienced bipolar disorder have a significant risk of
relapse in the early postnatal period. Relapse may also occur during pregnancy, especially
if a woman ceases medication when planning to become pregnant or on confirmation of
pregnancy.
1
This section is a revised version of material included in Module I of the Guidelines.
2
While the Edinburgh Postnatal Depression Scale was developed for use postnatally, antenatal
evaluation is generally associated with an adequate sensitivity and specificity to detect depressive
symptoms antenatally. There is also evidence to support its use in detecting symptoms of anxiety.
CONSULTATION DRAFT
Puerperal psychosis is a relatively rare but severe psychotic illness with risks of potential serious
self or infant harm. While puerperal psychosis is rare in the general population (1–2 women
per 1,000 live births), women who have had bipolar disorder or a previous episode of
puerperal psychosis have a one in two chance of puerperal psychosis recurring in the early
postpartum period. Preventive medication from immediately after the birth is usually
indicated (Bergink et al 2012). Psychiatric referral antenatally is essential.
Borderline personality disorder typically emerges in adolescence or young adulthood (Chanen
et al 2007) and has a higher prevalence (Moran et al 2006) and number of symptoms (Cohen
et al 2005) at this time (eg in childbearing years). It is characterised by a pattern of instability
of interpersonal relationships, self-image and affects, and marked impulsivity (APA 2000)
and is associated with severe impairment of psychosocial function and a high risk of selfharm or suicide (Leichsenring et al 2011). Recognising borderline personality disorder allows
health professionals to better tailor treatment goals and expectations, manage personal
reactions, set effective boundaries and avoid potential confrontations (Ricke et al 2012).
Schizophrenia is characterised by delusions, hallucinations, disorganised speech, grossly
disorganised or catatonic behavior and negative symptoms (ie low levels of emotion, loss
of motivation), with one or more major areas of functioning such as work, interpersonal
relations or self-care markedly below the level achieved prior to the onset (APA 2000).
It is appropriate for health professionals in primary care to have an understanding of the basic
issues facing women with mental health disorders. Clinical practice guidelines developed for
the general population may be useful (see Section Error! Reference source not found.). Overall,
collaboration with the woman and her family and providing compassionate and nonjudgemental care are the cornerstones of management.
For more severe mental health issues, such as schizophrenia and drug-related psychoses,
working collaboratively with trained mental health professionals is recommended where
possible. When risk of suicide is identified (eg through question 10 of the EPDS; see Section 7.6,
Module I) immediate referral to a psychiatrist or other mental health professional is required.
Sources of information about mental health disorders in perinatal practice and mental health
referral and advice are included in Section Error! Reference source not found..
Table 3.1: Components of care for minimising the detrimental effects of mental health disorders
Women are assessed during pregnancy for symptoms of high prevalence mental health
disorders (depression and anxiety) and asked about their personal and family history of
mental health disorders
Women with symptoms of a mental health disorder are linked with appropriate services
Women are given appropriate information about the purpose, process and voluntary nature
of proposed clinical assessments and screening tests
Care for women who have experienced, received treatment for, or are currently
experiencing low prevalence mental health disorders, is provided in collaboration with
relevant mental health professionals, with continuing care provided by a health professional
with whom the woman has established trust
Current psychotropic medicine use is discussed and women receive appropriate information
on the risks/benefits of treatment, timing of onset of effect and risk of relapse if medicines are
discontinued
Preventive treatment is considered for women at risk of bipolar disorder or puerperal psychosis
When risk of suicide is identified, immediate safety is assessed and referral made to a
psychiatrist or other mental health professional