Psychiatry and reproductive Medicine
Psychiatry 5th class
Dr.Asmaa
1. Recognize disorders that arise in relation to women’s reproductive life cycle .
2. Design a treatment plan including psychotherapy and medications where indicated
3. Describe the risks and benefits associated with various psychotropic medications used in pregnancy
and lactation
The physiological processes associated with menarche, menstrual cycling ,pregnancy ,postpartum, and
menopause occur within the context of a women's physiological and interpersonal life, interfering with
psychosocial functioning through out adolescent, young adulthood, midlife and late life.
The fields of psychiatry and reproductive medicine are just beginning to elaborate the multiple mechanisms by
psyche and soma interact to determine a women's gynecological and psychological function.
Premenstrual dysphoric disorder(PMDD):
Premenstrual dysphoric disorder is a somato -psychic illness triggered by changing levels of sex steroids that
accompany an ovulatory menstrual cycle.
It occurs about 1 week before the onset of menses and is characterized by irritability, emotional liability
,headache ,anxiety ,and depression.
Somatic symptoms include edema, weight gain, breast pain ,syncope ,and parasthesias.
The exact etiology unknown, the hormonal changes during the menstrual cycle are probably involved in
producing symptoms.
Epidemiology
Up to 80% of all women experience some alteration in mood, sleep or somatic symptoms during premenstrual
period.
40% of these women have at least mild to moderate premenstrual symptoms.
Only 3-7% of women have PMDD
Treatment
1-Support for the patient about the presence and recognition of the symptoms.
2-SSRI has been reported to be effective.
Pregnancy
Psychology of pregnancy
Pregnancy is a time of psychological change and challenge.
Their attitude toward pregnancy reflects deeply felt beliefs about all aspects of reproduction.
Psychologically healthy women often find pregnancy a means of self realization.
Many women report that being pregnant is a creative act gratifying a fundamental need.
Still others view pregnancy negatively; they may fear childbirth or feel inadequate about mothering.
In the 1st trimester a women may have increased emotional liability ,which may be exacerbated by nausea,
breast tenderness and other physical changes typical of early pregnancy. As pregnancy progresses, further
bodily changes, alteration in sexual interests and anxieties about the delivery may all contribute to mood
changes.
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Late pregnancy may be associated with social withdrawal and increased absorption and preoccupations with
preparation for delivery and caring for the baby.
Psychiatric disorders are more common in the first and third trimesters of pregnancy than in the second.
The mental health of the mother influences fetal well being.obstetric outcome, and child development.
Depression during pregnancy
Approximately 10% of pregnant women develop a depressive illness.
.
The etiology remains illusive, with general consensus upon complex interactions among biological,
psychological and social factors.
Risk factors for developing depression during pregnancy
1. Unwanted pregnancy
2. History of previous psychiatric disorder or family history of psychiatric disorders.
3. History of medical problems during pregnancy (D.M, ,hypertension)
4. Fear about the impending of delivery or doubts about the normality of the fetus.
5. Relationship problems.
Clinical features
Symptoms of depression during pregnancy are similar to those seen among non pregnant women, but can be
more difficult to disentangle from physical symptoms related to pregnancy.
Depression during pregnancy is an important and significant health concern for women and their developing
babies.
Depression during pregnancy is one of the strongest indicators of postpartum depression.
Treatment
*Patients who are receiving antidepressants are at high risk of relapse are best maintained on antidepressants
during and after pregnancy.
*Those who develop a moderate or sever depressive illness during pregnancy should be treated with
antidepressant drug if psychological management has failed.
*There is most experience with amitryptline ,imipramine and fluoxetine.
*There is no evidence to suggest that ECT causes harm to either the mother or the fetus during pregnancy
although general anesthesia is of course not without risk.
PURPERIUM
Postpartum psychiatric disorders:
It can be divided into maternity blues, puerperal psychosis, postnatal depression.
1) Minor mood disturbance "Maternity Blue”
30-75% of women will experience blues.
Common symptoms are liability of the mood, episodes of crying ,irritability ,dysphoria ,subjective confusion.
Symptoms reach their peak on the third or fourth day postpartum and lasting one to two days.
Is more frequent among primigravida ,those experience anxiety and depression during last trimester of
pregnancy, those give history of premenstrual tension syndrome ,fear of labor and poor social adjustment.
The cause is unknown but there is weak evidence that it may be related to postpartum reductions in levels of
oestrogen ,progesterone ,and prolactin(which do occur around 72 hrs after the birth)
No professional treatment is required other than education and support for the new mother.
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2) Postpartum depression
The onset is generally with in 4 weeks after delivery. Usually begin 2weeks after childbirth.
Incidence is 10-15%
May last months to years if untreated.
Risk factors for postpartum depression
1. personal or family history Of depression
2. unwanted pregnancy
3. poor social support
4. Previous post partum psychosis
5. presence of psychosocial stressor
6.sever ' baby blues'
Postpartum depression characterized by depressed mood, excessive anxiety ,insomnia, and a change in weight,
although thought content may include worries about the baby's health or her ability to cope adequately with the
baby.
There is evidence that postnatal depression adversely affects the mother-infant relationship and the cognitive
and emotional development of the infant.
Studies indicate that an episode of postpartum depression increases the risk of life time episode of major
depression.
The risk of not treating the depression include;
 Harm to the mother through poor self -care, self harm
 Harm to the neonate(infanticide).
Management`
1. Early identification and close monitoring of those at risk.
2. Support the patient.
3. The depressive episode treated with in usual way with antidepressant and or brief cognitive behavioral
therapy.
4. If depression is sever or associated with thoughts of self harm or harm to the baby, may require admission to
hospital.
3)Postpartum psychosis
Incidence is about 1 to 2 per1000 births
Are more frequent
1- Among primiparous women
2-Those who have suffered previous major psychiatric disorders.
3-Those with family history of mental illness.
There is no clear relationship between psychosis and obstetric factors.
The onset is usually within the first 1- 2week s after delivery, but rarely with in first 2 days.
Puerperal illnesses are especially common in developing countries.
Clinical features
Three types of clinical picture are observed:
1. Delirium
2. Affective
3. Schizophreniform
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Delirium was common in the past, but is now much less frequent .Nowadays affective syndromes predominant
either bipolar disorder or schizoaffective disorder.
Schizophrenia like illnesses presenting for the first time are rare.
The onset of florid psychotic symptoms is usually preceded by prodromal signs such as insomnia, restlessness,
agitation, liability of the mood, delusional material may involve the idea that the baby is dead or defective,
hallucination with similar content may involve voices telling the patient to kill the baby or herself. Once the
psychosis occurs, the patient may be danger to the self or to her newborn.
Management
Postpartum psychosis is a psychiatric emergency.
Most patients will require admission to hospital
It is essential to ascertain the mother's idea concerning the baby ,severely depressed patients may have
delusional ideas that the child is malformed or otherwise imperfect, schizophrenic patients may also have
delusional beliefs about the child (for e.g. may be convinced that the child is abnormal or evil),such beliefs may
point to the risk of an attempt to kill the child.
There should be special mother and baby units to minimize adverse effects on maternal bonding, all contacts
between mother and baby should initially be supervised by nursing staff and thereafter reviewed in the light of
clinical progress.
Treatment is given according to the clinical syndrome, for less urgent depressive disorders antidepressant may
be tried, if the patient has predominantly schizophrenia like symptoms, an antipsychotic drugs may be
prescribed
ECT is often the best treatment for patients with affective or psychotic disorders of marked or moderate
severity, because is rapidly effective and enables the mother to resume the care of her baby quickly.
All mothers who have suffered postpartum psychosis should be considered for special psychiatric review during
any further pregnancies.
Prognosis
Most patients recover fully from a puerperal psychosis, but those with a schizophrenic disorder remain
chronically ill.
After subsequent childbirth the recurrence rate for depressive illness in the peu rperium is 20-30%.
At least half of women who have suffered a puerperal depressive illness will later suffer a depressive illness that
is not puerperal.
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Psychotropic medication during pregnancy


Try to avoid all drugs in the first trimester (when major organs are being formed)unless benefits
outweigh risks.
If non-drug treatments are not effective/ appropriate ,use an established drug at the lowest effective
dose.
In all pregnant women
 Ensure that the prospective parents are as involved as possible in all decisions.
 Use the lowest effective dose
 Use the drug with the lowest risk to mother and fetus.
 Prescribe as few drugs as possible both simultaneously and in sequence.
 Inform the obstetric team of psychotropic use and possible complications.
 Monitor the neonate for withdrawal effects after birth.
 Document all decisions.
Psychotropic drugs
Antidepressants
Antipsychotics
Mood-stabilisers
Sedatives
Recommendations
Nortriptyline
Amitriptyline
Imipramine
Fluoxetine
Conventional drugs have been widely used
(chlorpromazine, ,haloperidol,l,trifluperazine)
Use antipsychotic as a mood stabilizer
Avoid Lithium, carbamazepine and valproate they
carry the risk of teratogenicity)
No drug measures are preferred
Benzodiazepines are not teratogen but are best
avoided in late pregnancy.
Antidepressant: No evidence that tricyclic or SSRI cause fetal anormaly.
Antipsychotic: Continue in minimal dose if major clinical indications.
There is most experience with chloropromazine, trifluoperazine, haloperidol, olanzapine.
Mood stabilizers: no mood stabilizer is clearly safe.
Lithium: it carries the risk of teratogenicity and of toxic effects on fetus ,should be avoided in
period of conception and early pregnancy.
Both carbamazepine and valporate are teratogen
Sedatives.
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