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Psychosis
What is the incidence of women who experience Psychosis during pregnancy and who experience Postpartum Psychosis?
- Psychosis arising for the first time in pregnancy is very uncommon. Women who have a past history of a psychotic illness (like Schizophrenia and Bipolar Disorder) may become pregnant and may need to be maintained on medication during pregnancy.
- Between one to two women per 1,000 births experience a Postpartum Psychosis This is also a rare occurrence, but if psychosis does occur, it is most likely to happen during the postpartum period rather than during pregnancy.
What is Psychosis?Psychosis is a condition occurring in the context of an underlying psychiatric disorder like: Bipolar Affective Disorder, Schizophrenia, or Major Depression. For some women, a Postpartum Psychosis may be the only psychotic episode they will experience. For others, a Postpartum Psychosis may be the first episode of a psychiatric disorder or an acute exacerbation of an underlying disorder.
During a psychotic episode, the woman losses touch with reality. The woman may be:
- hallucinating e.g. hearing voices when nobody is around
- delusional - having ideas that she believes despite all proof that they are false (e.g. convinced that someone is trying to harm her, or that her baby is the devil)
- thought disordered - her thought process may be illogical or chaotic
It can be a very frightening condition and needs immediate treatment. Postpartum Psychosis occurs usually within two to four weeks after delivery.
What are the risk factors of Psychosis?Women are at greater risk of having a Psychotic experience if they have a:
- Previous history of Postpartum Psychosis (having a previous episode of Postpartum Psychosis increases your risk by 50 per cent with a subsequent pregnancy)
- Previous history of Bipolar Mood Disorder or Schizophrenia
- Family history of Bipolar Mood Disorder or Schizophrenia
What are the signs and symptoms experienced by women with Psychosis?You may experience some of the following:
- disturbed sleep
- emotional lability
- confusion and disorientation
- disorganized thoughts and behavior
- hallucinations (hearing voices when there is no one there)
- delusions (thinking that people are trying to harm you or that you have special powers)
- usually occurs within 2 to 4 weeks after delivery, but may occur within the first three months after delivery.
What should pregnant or postpartum women having a Psychotic experience seek treatment?
- Women experiencing a psychosis are at risk of committing suicide and, in very rare cases, of harming their unborn child or infants. These women need to be hospitalized for their safety and to safeguard their infants.
- This is a psychiatric emergency and the woman needs to be hospitalized immediately. Because of her confusion the woman may not have the insight to recognize how ill she is, therefore, the decision for hospitalization will be made by her physician.
Ideally women should not be separated from their babies during hospitalization. We would recommend special mother-baby units or designated beds on maternity wards where the baby could be assigned to the nursery and supervised by neonatal nurses.
What are the treatments options for women with Post Partum Psychosis?
- Psycho education: Involve the significant other, friends and family supports. Teach coping strategies and how to build social networks and supports.
- Supportive Psychotherapy - offers support, reassurance and education for women with postpartum depression.
- Family and Relationship Counseling - assists women and their significant others to develop strategies to cope with this stressful time.
- Pharmacotherapy - rules out conditions that may present as psychosis (e.g. infection, seizure disorder, electrolyte disturbance). Antipsychotic medication, Mood Stabilizing medication.
For more detailed information about antipsychotic and mood stabilizing medication, see Best Practices Guideline 6.
Antipsychotic and Mood Stabilizing MedicationsThe most commonly used antipsychotic medications:
- Loxapine (Loxapac)
- Haloperidol (Haldol)
- Risperidone (Risperidal)
- Clozapine (Clozaril)
- Olanzapine (Zyprexa)
Most commonly used mood stabilizing medications:
- Lithium
- Carbamazepine (Tegretol)
- Valproate (Epival)
How do antipsychotic medications work?Antipsychotic medications work by blocking primarily dopamine receptors in the brain. Although they show some effect immediately, it may take between one and two weeks for them to show a significant antipsychotic response.
All antipsychotic medications have some adverse effects including sedation, constipation, and extra pyramidal side effects.
Antipsychotic Medication during PregnancyThe goal of treatment is to minimize risk of fetal exposure to psychotropic drugs while limiting risks of untreated psychiatric disorders. Ideally the woman should be on the lowest possible dose of antipsychotic medication to treat her symptoms.
Avoid the use of low potency neuroleptics (e.g. chlorpromazine) especially in the first trimester, during organ formation in the fetus. Mid or high potency neuroleptics (e.g. haloperidol) are safer. Two small retrospective studies found no association between fetal exposure to haloperidol and congenital deformities. With regards to the atypical neuroleptics, no adverse effects were described in the one case reported of clozapine use during pregnancy. No information is available yet regarding the reproductive safety of risperidone or olanzapine in pregnancy. It is important to observe the infants closely after delivery to look for exposure effects (e.g. motor restlessness or tremor).
How do mood stabilizing medications work during pregnancy?Lithium is the most commonly used mood stabilizing medication. In the past, it was felt that there was a significant increased risk for the development of Ebstein’s Anomaly (a rare congenital heart abnormality in the fetus) if exposed to lithium in utero. Today we believe the true incidence of lithium induced malformations is substantially lower than previously thought. Nonetheless, detailed ultrasonography including cardiac ultrasonography should be carried out on the developing fetus in the second trimester. Ideally, women should attempt to discontinue lithium prior to pregnancy. This should be done slowly to minimize chances of relapse. If the woman’s symptoms recur, she can be restarted on lithium in the second trimester. If she requires lithium maintenance, she should be on the lowest possible dose that will stabilize her mood.
It is important to remember to reduce the dose of lithium by 50 per cent prior to delivery to avoid toxicity. This is necessary because of changing fluid volumes at the time of delivery.
Both carbamazepine and valproate are associated with increased risk for spina bifida in fetuses exposed in the first trimester. It is suggested that supplementation with four mg. per day of folic acid may reduce the risk of neural tube detects.
Breastfeeding on Antipsychotic MedicationsAntipsychotic medications pass into the mother’s breast milk. It is important to monitor the baby for any side effects (e.g., drowsiness or floppiness). Ideally, the breastfeeding woman should be on the lowest possible dose of Antipsychotic medication to treat her symptoms. Split the dosage (e.g. taking smaller doses of the Antipsychotic medication twice a day) to avoid higher peak doses of medication.
Breastfeeding on Mood Stabilizing MedicationsLithium is water soluble and therefore the concentration in breast milk is the same as in the mother’s system. Breastfeeding while on lithium can result in toxicity in the infant. Avoid breastfeeding if on lithium.
In contrast, both carbamazepine and valproate are considered compatible with breastfeeding with the American Academy of Pediatrics. Valproate can be found in the breast milk at five to 10 per cent of the maternal level. It is important to closely monitor maternal serum levels of these medications.
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