Ch36 Pregnancy

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History andIntroductionIn 1894, Copeman, then president of theBritish Medical Association, was called toconsult on a pregnant woman with intractablevomiting !er condition was so severe thatCopeman decided to terminate the preg"nanc# !is onl# available instrument was arubber probe, which he inserted into thecervi$ in an unsuccessful attempt to rupturethe membranes Much to his astonishment,the patient immediatel# stopped vomitingand continued with s#mptom relief throughout the rest of the night Copeman

promptl# announced the discover# of a newtreatment for h#peremesis in pregnanc#%dilatation of the cervi$ uteri &or the ne$t'uarter of a centur#, this was the standard of care in obstetrics, although some authorscontended that dilatation of the anusproduced the same e(ect )1* +ractitioners atthe time would not have viewed this as aps#chosomatic intervention, but the resultscertainl# seem to attest to the power of themind bod# relationship

-he .rst true advance came in 19//, when 0 2ead described an approach he called

3natural childbirth, in which h#pnoticsuggestion was used to help women achievea rela$ed and relativel# painless state duringlabor and deliver# !is wor5 received almostno attention until the mid"1967s%perhapsbecause h#pnosis in the earl# 1977s hadman# enemies in the medical setting ) *

bstetrics was still not addressing theemotional state of the patient as a ma:orconcern during pregnanc# and deliver#

-he modern era of obstetrics began in 1949,with the advent of 3ps#choproph#la$is;elvovs5i ) * developed this program in2ussia, which prepared women for childbirththrough education, social support, ande$ercises in breathing and rela$ation &ernardoviet

approach, wor5ing from 196 onward tofoster its development in &rance and othercountries in ?urope and >outh America In19@1, Cherto5 attributed their success to 3aremar5able convergence of the in uencefrom the left"wing political parties and the2oman Catholic Church )1* !ow theseusuall# antithetical groups united to embraceps#choproph#la$is is a matter of speculation

-he emergence of childbirth classes did,however, emphasi=e the centralit# of thefamil# and challenge the traditional,authoritarian structure of medicine?li=abeth Bing )/* pla#ed a 5e# role inbringing the techni'ues of tates

hat developed subse'uentl# were not onl#

the


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could improve the course of medicaldiseases in ob


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stetrics


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;omiting during pregnanc# was the ob:ect of a great deal of theoretical speculation In19@ , Cherto5 )6* wrote 3It is ta5en to havethe general meaning of s#mbolic re:ection, anoral attempt at abortion !owever, he wasinclined toward a more moderate viewJ3!elen eutsch has pointed out the ratherambivalent attitude in such cases in themother child relationship the woman whovomits has chosen to vomit and not tomiscarr# !is research involved ps#chologicalinterviews to uncover this 3ambivalence invomiting women In a similar vein, 2ingrose)G* tal5ed about 3a pre"e$isting concealedpersonalit# abnormalit# in to$emic patients

nfortunatel#, most of the ps#choanal#ticstudies featured small sample si=es, bigassumptions, methodologic aws, and norandom control trials -here was also a failure

to establish whether an emotional conditionwas the cause or e(ect of an associateddisease >hortcomings aside, however, theseinvestigators often provided their sub:ectswith various ps#chosocial supports, and thewomen often reported improvements in theircondition Mann )@*, for e$ample, studiedwomen who had su(ered from at least threeor more consecutive abortions All sub:ectswere o(ered wee5l# discussion sessions withtheir obstetrician for the entire course of theirne$t pregnanc# f the 1@6 women whocompleted the stud# after screening for

identi.able g#necologic abnormalities, 81Kcarried to term

?ventuall#, ps#chod#namic formulationsabout the etiolog# of medical illness fell out of favor as research focused more rigorousl# onbiological processes )4* In the 1987s, newps#choactive medications were entering themar5et in e$ponential numbers, and the .eldof ps#chiatr# turned toward genetic researchand laborator# testing for answers aboutmental illness &or a time, well"being duringpregnanc# was described in terms of ph#sicalstatus, hormones, and medications Mooddisorders such as postpartum depressionwere investigated as the products of hor"monal shifts occurring at deliver#Interventions tended to be framed aroundmedications that could be prescribedCurrentl#, ps#chiatric research is emphasi=inga biops#chosocial model that balancesps#chod#namic and biological thin5ing aboutmedical illness A growing bod# of literature isshowing the ph#siological effects of stressand loss )4* >tudies have shown that lifeevents can a(ect the immune response, aswell as the release of hormones a(ectingm#riad ph#siological responses, includinglabor and deliver# -here is also growingconcern that untreated depression andan$iet# ma# a(ect pregnanc# outcome )8*

-hus, ps#chosomatic medicine in obstetrics

now must address how a womanEs innerd#namics interact with her environment

to relieve or worsen stress, which in turn cana(ect her health and pregnanc#

Stress and Its Efects onPregnancy

-here is no doubt that a pregnant motherEshealth has far"reaching e(ects on her futurechild Babies e$posed to drugs in utero aremore li5el# to have neural, cognitive, andbehavioral problems )8,9* Maternal nutritionand smo5ing have 5nown e(ects on fetalgrowth, whereas folic acid supplementationcan reduce the incidence of neural tubedefects )8* More recentl#, however,researchers have been stud#ing the e(ects of maternal ps#chosocial stress on thepregnanc# and fetus

sing the crucible of medical training as theirmodel for stress during pregnanc#, +inhas"!amiel et al )17* conducted a cross"sectionalsurve# of female ph#sicians at the three

largest universit# hospitals in Israel &ourhundred 'uestionnaires were sent out, with a6 K response rate -he data were thencompared with base rates for the generalpopulation According to the results, 1 in /8respondents was estimated to have a still"birth related to being a ph#sicianAppro$imatel# 1 in 8 had a prematuredeliver# associated with residenc# trainingAt the time of 'uestioning, these womenfaced not onl# the usual rigors of training, butalso additional coverage responsibilities formale colleagues on militar# dut# -his stud#

was limited b# lac5 of controls for other ris5factors a(ecting preterm birth !owever, thenumbers certainl# point to the importance of loo5ing more closel# at stress during preg"nanc# According to &inch )11*, femaleph#sicians in the nited >tates show a similartrend toward increased ris5 for adverseevents during late pregnanc#%especiall#preterm labor

f course, stress in the wor5place ta5esman# forms and is not limited to medicaltraining Mo=ur5ewich et al)1 * conducted a meta"anal#sis of 9 studiesfrom ?nglish Medline from 19GG to August1999 -he# found that ph#sicall# demandingwor5 during pregnanc# could increase the ris5of h#pertension or pre"eclampsia b# G K -heris5 of delivering a small for gestational ageneonate was increased b# 68K +rolongedstanding at wor5 and shift or night wor5increased the ris5 of a preterm birth b# 66KAnother stud# )1/* followed 4, 69 womenwho wor5ed past the thirtieth wee5 ofpregnanc#, assessing them at 1G and /7wee5sE gestation omen whose :obsre'uired long periods )more than .ve hoursper da#* of both standing and wal5ing werefound to be at signi.cantl# increased ris5 forpreterm deliver# -he# tended to be childcaregivers, shop5eepers, cleaners, nurses,and nursesE aides Because neither prolongedwal5ing nor prolonged standing alone was

associated with preterm birth in this stud#, itwas suggested that other


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variables speci.c to these particularoccupations might have been involved


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ata from the anish Lational Birth Cohort)including //,G94 pregnancies of da#timewor5ers and 8,7@6 pregnancies of shiftwor5ers* revealed an association between.$ed night wor5 and fetal loss )14*adhwa et al )16* cited evidence thatpregnant women under high levels of ps#chological or social stress are at increasedris5 for shorter gestation, earlier onset of spontaneous labor, and preterm deliver#%even after ad:ustments were made for otherbiomedical, sociodemographic, andbehavioral ris5 factors In enmar5,Lordentoft et al )1G* assessed ,4/ womenat 7 wee5sE gestation for stressful lifeevents Controlling for age, education, andcohabitation, the# found an associationbetween severit# of life events and pretermdeliver# !edegaard et al )1@* prospectivel#studied 6,8@/ anish women and found thatone or more highl# stressful life eventsincreased the ris5 for preterm deliver#

-he motherEs perceptions appear to bealmost as crucial as the stress itself In onemulticenter stud#, ,69/ women wereassessed at appro$imatel# G wee5sE ges"tation )18* omen who answered 3#es tothe following items were at signi.cantl#greater ris5 for preterm deliver# than thecontrol groupJ 3-here is a great deal of nervous strain associated with m# dail#activities and 3In general, I am ver# tenseand nervous -he groups were matched forrace, age, marital status, insurance,education, and substance abuse In 199/,

adhwa et al

)19* found a signi.cant association betweenpregnanc# an$iet# )as measured b# a .ve"item inde$ focusing speci.call# on concernsabout the pregnanc#* and earl# labor anddeliver# -hese results were replicated 6#ears later ) 7* 2ini et al ) 1* demonstratedthat levels of an$iet# could predict the lengthof gestation in /7 women matched forobstetric and sociodemographic ris5 factors>tress was associated with length of gesta"tion, whereas personal resources )master#,self"esteem, and optimism* correlated withbirth weight

>urel#, not all women with high levels ofstress deliver prematurel# Multiple factors,including the onset and course of the stress,appear to determine its impact 2ui= and+earson ) * found that stress appeared to

in uence gestation the most when itoccurred between wee5s and 4 ofpregnanc# !edegaard et al) /* demonstrated a correlation between theris5 for preterm birth and severit# ofps#chological distress at /7 wee5sE gestationIn contrast, !erbert and Cohen found thatlong"term e$posure to stress appeared toshorten gestation more than acute stress) 4*Stress and thepathophysiology opreterm birth Investigators are now loo5ing at howstress directl# in uences the biologicalprocesses involved in normal

and preterm birth 2esearch reveals thatneuroendocrine, immune, in ammator#, andvascular processes are involved in both thestress response and the ph#siolog# )orpathoph#siolog#* of labor ) 6*>tress a(ects pregnanc# on a neuroendocrinelevel b# stimulating the production of placental corticotrophin"releasing hormone)C2!*, which appears to pla# a central role inorchestrating labor ) G, @* omen inpreterm labor have signi.cantl# elevatedlevels of C2! compared with gestational age"matched controls -hese elevations precedethe onset of preterm birth b# several wee5sAt birth, C2! appears to increase at a signi."cantl# accelerated pace in women who aredelivering prematurel# compared with thosegoing to term

>tress also elevates plasma cortisol levelsthrough activation of the h#pothalamic"pituitar#"adrenal a$is Cortisol in uenceslabor b# stimulating the production of placental C2! ) 8* and b# suppressing the

immune s#stem ) *Compromised immune function is anotherpossible conse'uence of stress thatpredisposes women to preterm labor >tresselevates cortisol levels and correlates withsigni.cant depression of l#mphoc#te activit#) 9*, which also predisposes the individual toinfection Bacterial vaginosis, the mostcommon lower genital tract infection inwomen of reproductive age, increases b#twofold the chances of preterm labor andpremature rupture of membranes )/7 / *

-his appears to be at least partl# due toproin ammator# c#to5ines, secreted as part

of the maternal or fetal response to microbialinvasion )//,/4* -hese c#to5ines have beenshown to promote spontaneous labor andrupture of membranes b# stimulating multipleprocesses, including the s#nthesis of prostaglandinsD the release of metalloproteases in the gestational tissuesDand the production and release of fetalcortisol, fetal deh#droepiandrosterone sulfate,and placental C2! )/6*

Maternal cardiovascular disorders, includingpregnanc#"induced h#pertension and pre"eclampsia, are among the ma:or indicationsfor elective preterm deliver# )/G* 2esearch isbeginning to demonstrate that stress, a5nown ris5 factor for other cardiovascular dis"orders, also a(ects h#pertensive disorders inpregnanc# ur5i et al )/@* assessed G /pregnant women at 17 to 1@ wee5sEgestation and then at deliver# -he# foundthat depression andNor an$iet# during earl#pregnanc# could as much as triple thesubse'uent ris5 for preeclampsia -his ris5was further increased b# bacterial vaginosis>:ostrom et al )/8* showed a signi.cant cor"relation between high"level maternal traitan$iet# and hemod#namic processes withh#po$ia and compensator# redistribution ofblood ow to the fetal brain !errera et al)/9* found that measuring biops#chosocialris5 factors doubled the possibilit# ofidentif#ing patients that would subse'uentl#develop arterial h#pertension andpreeclampsia McCubbin et al )47*


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were able to signi.cantl# predict length ofgestation and infant birth weight b#measuring the reactivit


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# of diastolic blood pressure in pregnantmothers who were otherwise at low ris5 forpreterm deliver#


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PSYCH S CI!" I#$E%&E#$I #S

-he role of ps#chosocial intervention forpregnant women at ris5 is not #et clear, andresearch is still in the beginning stages -heCochrane +regnanc# and Childbirth 0roup)41* reviewed 1G randomi=ed trials of ad"ditional support given during at"ris5pregnancies involving 1/,G61 women>upport was de.ned as some form of emotional support occurring during home vis"its, clinic appointments, andNor via phoneAdditional information and advice ma# alsohave been given -here was not a signi.cant

improvement found in perinatal outcomes forthese women, but there was a reduction inthe li5elihood of cesarean birthS'((!%Y

>tudies are indicating that pregnant womenunder stress are vulnerable to adverseoutcomes such as preterm labor, which is themost common .nal pathwa# of pregnanc#complications -he ph#siological response tostress is multidimensional, and labor ma# behastened through numerous di(erentmechanisms If preterm labor is to be moree(ectivel# prevented, it is crucial that wemore full# understand and implement

measures to alleviate the e(ects of stress onpregnanc#PregnancyComplications ust as stress complicates pregnanc#, so canpregnanc# create its own stress, as stated b#a neonatal intensive care unit )LIC * nursewho found herself hospitali=ed for pretermlaborJ 3-here are times when #ou canEt standit and all #ou want to do is to get out Oou5now what it would do to #our bab#, but for amoment, it doesnEt matter -he followingsection describes a few of the ordeals

e$pectant mothers ma# have to face)E* %ES$>ome mothers su(er conditions that re'uirebed rest and admission to the hospital%thatis, preterm labor at less than 8 wee5s withbulging or ruptured membranes, severeh#pertension, pre"eclampsia, placentaprevia, or placenta accreta -his often meansbeing in the patient role, far from home,famil#, friends, and other supports

-here is growing debate regarding thebene.ts of bed rest for pregnanc#complications such as preterm labor andh#pertension 2esearch is limited, and thestudies are generall# inconclusive )4 44*!owever, bed rest is still

widel# recommended b# obstetricians forvarious conditions As a result, a woman witha high"ris5 pregnanc# ma# .nd herselfcon.ned to a prison the si=e of a bed Be"cause she is immobili=ed, the rest of herfamil# will have to perform her usual duties,including care of other children ?$hausted,the# ma# have diPcult# understanding theiron# of :ust how grueling bed rest can be?speciall# painful can be the ambiguit# of thewomanEs situation Although she is doingever#thing in her power to have a health#bab#, there is no guaranteed outcome >hema# .nd herself cr#ing more, arguing more,panic5ing more, and sleeping less Medica"tions that slow or inhibit the uterinecontractions ma# magnif# her discomfort,causing :itteriness, irritabilit#, or palpitationsMagnesium sulfate can produce a musclerela$ation so profound that one patientdescribed feeling paral#=ed

hen a ps#chiatric consult is called, it isoften because the woman has reached the

point of wanting to ee the hospital At thesetimes, the most important service theclinician can provide is to listen to her frus"tration and validate the sacri.ces she isma5ing for her bab# Comfort measures suchas free access to television and telephone,assistance with long distance calls, orproviding a window view can also help

C!SE E+!(P"E A 6"#ear"old hewas torn between the needs of this child andfears for her unborn bab# At times, she wasoverwhelmed with an$iet# and the impulse toget up and run -he language barrier oftenmade it impossible for her to communicate herda#"to"da# needs, deepening her sense of isolation and helplessness

As soon as the consultant presented herdilemma, the sta( moved this patient ne$t to a>panish"spea5ing roommate !er mood almostimmediatel# lifted, and she was able tocomplete her hospital sta#

hen mar5ed an$iet# and sleeplessness are partof the picture, the ps#chiatrist should considersleeping aids and low"dose ben=odia=epines, givenon an as needed basis In the authorsE e$perience,patients tend to use these sparingl#, andcomplications are rare At most, one bab# had atemporar# decrease in reactivit# on monitoring,with a normal ultrasound -his ris5 must beweighed against the conse'uences of notintervening,


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which could include severe distress in the mother,noncompliance with treatment, or even adischarge against medical advice Medication isdiscussed in more detail later


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HYPE%E(ESIS ,%!&I*!%'(

!#peremesis gravidarum is a condition of intractable vomiting during pregnanc# thatcan result in electrol#te imbalance, weightloss, 5etosis, acetonuria, andNor organdamage if untreated Although mild nauseaand vomiting are e$perienced in most normalpregnancies, h#peremesis gravidarum isrelativel# rare, occurring in less than 1K of all pregnancies )46*

-o date, the onl# 5nown cause of thiscondition is pregnanc# 2esearchers havee$amined numerous biological factors thatma# pla# a contributing role -hese includeelevated levels of human chorionic

gonadotropin hormone, h#perth#roidism, andalterations in gastric p! and motilit# )4G*+s#chological factors have also been studied,including increased vulnerabilit# to stress anddecreased social supports, immaturit# ande$cessive dependence on the mother, and,.nall# )as noted previousl#*, s#mbolicre:ection of pregnanc# )4G* !owever,evidence"based data are limited, and much of h#peremesis gravidarum remains a m#ster#

hat is not enigmatic is the level of stressresulting from this condition -here is noaspect of life that is not severel# derailed

ne woman statedJ 3I had to 'uit wor5, 'uitlaw school, and sta# home all da# M#QnewR husband gives me an allowance Iwent shopping with m# mother andvomited in the changing room Anothertal5ed about the e(ects on her self"imageJ3ItEs hard to feel se$# when #ouEve got thisterrible breath all the time and #ouEresurrounded b# cups of #our own spit

ccasionall#, patients welcome ps#chiatricintervention ne woman became clinicall#depressed, partl# in reaction to the isolatinge(ect of this illness >he improved with aserotonergic antidepressant and visitingnurse referral In most cases, however, the

overwhelming concern is the vomiting itself and the desire for relief A receptive andnon:udgmental attitude on the part of sta( iscrucial, especiall# given earlier punitivenotions about h#peremesis being an 3oralattempt at abortion )6*

*E!$H - -E$'S % #E.) %#

3?ver#thing #ou do for parents who have hada loss will be remembered ?ver# singlenuance Because this is the onl#, onl# timethe# will get to spend with their bab#, the#will remember ever#thing )from > , whosebab# died of cardiac malformations a fewda#s after birth* 2egardless of whether weli5e it, it is at times of loss that our patientsare most aware of usMedicine has shifted dramaticall# since themid19@7s in its approach to perinatal lossand grief ntil

the 19@7s, contact with the dead bab# was3virtuall# unthin5able )4@*, and tran'uili=erswere prescribed to dull the distress of theparents -he loss was not viewed ase'uivalent to the loss of a more mature child,and parents were encouraged to getpregnant again as soon as the# wereph#sicall# able > spo5e about her bab#daughter, who lived onl# / da#s after beingborn in the late 19G7s with severe ano$icbrain damageJ 3-he nurse held her up behindthe nurser# glass, but we never got to touchher -here was no closure -o this da# Icannot visit m# husbandEs grave because it isne$t to her grave the pain is too raw

-oda#, the standard of care is the e$actopposite )4@* -he obstetric sta( encourage,but do not push, parents to see, hold, andname the bab#, no matter how premature ordamaged, to help them e$perience thisbab#Es life and death as real -he# often helpmothers put together a memor# bo$

containing pictures, clothing, a loc5 of hair,and other ob:ects associated with the bab# Anurse is available throughout this time to pro"vide support +arents are advised to givethemselves time to grieve before attemptinganother pregnanc# -he# are o(eredinformation about supports in thecommunit#, including bereavementorgani=ations and groups -he famil# or thesta( ma# call the ps#chiatrist for anevaluation or to provide additional support,especiall# if there is concern aboutdepression in the mother 0rieving mothers

have repeatedl# emphasi=ed the importanceof being recogni=ed as parentsJ 3-hat was afact even though some cannot imagine it,said

> >uch statements as 3IEm never going tobe the same need to be validated ase$pressions of a basic truth, as well ascon.rmation of the bab#Es impact on thisparentEs life Mothers also value doctors 3whoseemed to feel responsible for us withoutimpl#ing something went wrong ) > *Clinicians must be aware of their patientsEobstetric histories &or the mother who haslived through a previous miscarriage orstillbirth, memories of her lost bab# ma# beparticularl# powerful during subse'uentpregnancies 3 hen a mom gets near thegestational age of the loss, ta5e care ?ver#one 5nows the e$act gestational age of the babies the# lost that da# was one of the hardest da#s of m# life ) > *In conclusion, it is crucial that the clinicianhonor the deep attachment of parents totheir babies, especiall# when there is a lossAs one parent stated, 3Imagine a love sostrong that sa#ing hello and goodb#e in thesame da# was worth the sorrow* (ES$IC !)'SE

More than 16K of pregnant womenreport ph#sical and se$ual abuseduring pregnanc# )48* +regnanc# doesnot protect women from abuse, and

there has been some controvers# overwhether pregnanc# itself is a


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ris5 factor for abuse


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In:uries place women at greater ris5 forpreterm labor and fetal loss Cliniciansmust speci.call# as5 women aboutwhether the# are e$peri


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encing abuse or fear being hurt b# theirpartners be


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cause the# are not li5el# to volunteer thisinformation rgani


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=ations and toll"free crisis lines are available,and sometimes provide information on smallcards that can be easil# hidden eep in mindthat battered women are at greater ris5 fordeath when the# attempt to leave therelationship )49* A safet# plan mu


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s


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t be in place before this step is ta5en Mostorgani=ations for survivors of domestic abuseemphasi=e the importance of support andeducation, cautioning against pushing womento ta5e a particular action


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*I--IC'"$IES .I$H )%E!S$-EE*I#,

2esearch has repeatedl# con.rmed thebene.ts of breastfeeding for both babies and

mothers, and man# medications appear to berelativel# safe during nursing )67* -his doesnot mean, however, that breastfeeding is forever#one, or that ever#one who nurses feelsbetter &ar from being a purel# instinctualbehavior, it is a s5ill that must be learned b#both mother and bab# >ome .nd the processrelativel# carefree, but others do not Man#mothers initiall# .nd themselves e$haustedand sore, with crac5ed or bleeding nipplesand hungr#, inconsolable babies nlesssupport is available, this state of a(airs canlead to deh#dration for the babies and de"spair for the mothers It is crucial that newmothers anticipate the need for closermonitoring of their babies during the initialwee5s of lactation If the# have a mooddisorder, the# ma# need additional supportsto help prevent re"emergence of s#mptomsdue to disrupted sleep and other demands of breastfeeding -he# should also be informedabout communit# supports, including


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the time span for


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3


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postpartum onset


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E


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1* viewed 9 wee5s as the critical period forpostpartum depression when comparinga(ected women with controls 2obinson and>tewart )G * described postnatal depressionas usuall#


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3


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within 1 to G months after deliver#


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McLeil )G/* categori=ed postpartum p


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s


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#chosis as either


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3


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earl# onset


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3


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late onset


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)up to G months* >ome authors haveconsidered an event postpartum if it occurredwithin 1 #ear of deliver#


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-here is also diversit# of opinion regardingthe in uence of biological factors onpostpartum disorders -hus far, e(orts tocorrelate the occurrence of postpartum moods#mptoms with hormone levels )estrogen,progesterone, cortisol, or th#roid* have beenunsuccessful )G * -here has also been noconclusive evidence regardingneurotransmitter s#stems or tr#ptophan

levels -here has onl# been a minorassociation between depression and th#roidd#sfunction in th#roid antibod#"positivewomen )G * Lumerous investigators insistthat mood must be a(ected b# the powerfulhormonal and ph#siological shifts that occurwith deliver#, predicting that improvement inresearch techni'ue will ultimatel# elucidatethat relationship thers maintain that it isthe life changes occurring with birth and the'ualit# of supports that determine themotherEs emotional state*EP%ESSI #

!ntepartum *epression

Clinicians fre'uentl# fail to recogni=eantepartum depression because of its overlapwith normal s#mptoms of pregnanc#)including insomnia, decreased energ# andconcentration, and appetite changes* -hishighlights the importance of in'uiringspeci.call# about low mood and loss of pleasure or interest Man# obstetric programsare advocating for more formal screening aswell

-o date, there are no oPcial standards forps#chosocial screening of pregnant women Itis also not clear whether screening actuall#accomplishes its goals of identif#ing

individuals at ris5 and ma5ing them moreavailable for treatment +riest et al )G4*, incollaboration with the Cochrane +regnanc#and Childbirth 0roup, will be evaluating thee(ectiveness of ps#chosocial screening withthe methods currentl# in use -he mostcommonl# used tools are 3s#mptom"basedself"report measures of maternal distress,such as the ?dinburgh epression >cale,andNor 3ris5"based indices for mental illnessduring pregnanc#, such as the Antenatal 2is5Tuestionnaire developed in Australia Bothtools appear to be most valuable when

combined with a clinical interview of thewomen scoring as high"ris5 for depressionand an$iet# )G4*

2is5 factors for antenatal depression includepersonal or famil# histor# of mood disorder,marital d#sfunction and lac5 of spousalsupport, increased number of children,#ounger age of the mother, and low level of education )G6,GG*epression during pregnanc# imposessigni.cant ris5s on both mother and bab# Itis one of the strongest predictors of postpartum depression, and man# depressedmothers report that their s#mptoms beganwell before deliver# )GG* A(ected women aremore li5el# to have poor nutritional statusand use drugs or alcohol, while being lessli5el# to obtain ade'uate prenatal care -heirbabies tend to be more withdrawn andirritable )GG*

-here are currentl# no guidelines for thetreatment of depression during pregnanc#)GG*%perhaps because the diagnosis is sofre'uentl# missed, and perhaps because of ageneral reluctance to prescribe an#

medications that might a(ect the fetusomen with mild to moderate s#mptomsfre'uentl# bene.t from supportiveps#chotherap#, cognitive therap#, or inter"personal therap# )61* >pinelli and ?ndicott)G@* found that interpersonal ps#chotherap#appeared signi.cantl# more bene.cial onmeasures of mood than the controlintervention )a parenting education program*+s#chotherap# is therefore generall#considered a .rst"line treatment forantepartum depression

It is important to remember that man#women have become debilitated b#s#mptoms )e g , being unable to eat or sleep,get out of bed, or ta5e care of other children*before even admitting the# were depressed

ne woman re'uired intravenous uidsmultiple times for vomiting related to severean$iet# and depression -his .nall# resolvedwhen she resumed the antidepressant shehad been ta5ing before pregnanc# hen themotherEs abilit# to manage her health andher pregnanc# becomes :eopardi=ed,medications and even hospitali=ation shouldbe considered in addition to ps#chotherap#C!SE E+!(P"E A 6"#ear"old woman,

admitted for rupture of membranes with hersi$th child at / wee5s, later informed the sta( that she had persuaded her spouse to brea5 herwater with a tool stolen from her midwifeBecause her last bab# had been bornprematurel# and done well, she had assumed%at least on a conscious level%that this bab#would have a similar outcome nable to carefor her home and other children as well as shethought she should, she could see no other wa#to deal with her constant ph#sical discomfortand fatigue >he had hoped that after deliver#she would immediatel# regain her strength andresume her regular chores n interview, shedescribed feeling overwhelmed, depressed, andan$ious during most of this pregnanc#


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-his patient was diagnosed


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with ma:or depres


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tient treatment >he and her husband


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were evalu


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ated b# Child +rotective >ervices )C+>* andvisiting nurse services with the intent ofmonitoring their parenting and the safet# of thechildren at home -he# were also referred tocommunit# supports, in


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cluding visiting nurse services and poss


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i


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bl# a home health care wor5er -his patient


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E


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s mood disorder ma# have been consideredboth antepartum and post


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partum because her .fth child was onl# 17months old In these and other cases, it iscrucial that clini


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cians help patients accept supports, in


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c


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luding ps#


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chotherap#, and realisticall# e$plore the optionof medications during pregnanc#


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Postpartum *epression

After birth, the health of mother and bab#continue to be intertwined ine$tricabl#+ostpartum depression interferes with themother bab# relationship, thus placing theentire famil# at ris5 )GG* epressed mothersappear to have more diPcult# responding toinfant cues, fostering insecure attachmentbehavior -heir children are more li5el# tohave signi.cant behavioral problems, such as

sleep and eating disorders, fre'uent tempertantrums, and dela#ed languagedevelopment Maternal depression is alsoassociated with increased rates of accidentalin:ur#, child abuse, and child neglect )GG*

-he di(erential for postpartum depressionincludes bipolar disorder , in which depressiveor mi$ed episodes are common )6 *, baby blues , and bereavement Bipolar disorder isdiscussed in a later sectionBaby blues is 'uite common, reported inabout 67K of women It is characteri=ed b#mood s#mptoms, but lac5s the severit#,persistence, or pervasive 'ualit# of postpartum depression -he cardinal featureis labilit#% women ma# describe cr#ing 3atthe drop of a hat or 3when something comeson the television )G * Clinicians shouldconsider a more serious diagnosis when thereis sleeplessness, persistent d#sphoria andanhedonia, disturbance in realit# testing, orloss of self"esteemBereavement after a loss )whether from amiscarriage, stillbirth, traumatic pregnanc#or deliver#, severe disabilit# in the infant, orfamil# strife* is characteri=ed b# depressives#mptoms, but there should be intervals inwhich the mother e$periences some relief from her pain After the initial shoc5 of loss,grief tends to 3come in waves If it isrelentless, a diagnosis of depression should

be considered

Clinicall#, postpartum depression oftenpresents with prominent an$iet# andobsessive thoughts or behavior epressedmothers ma# worr# e$cessivel# about theirbab#Es safet# or feeding habits, interpretingan# diPculties as evidence of theirinade'uac# )G * hen the# come fortreatment, the# often refer to themselves as3cra=# or 3out of control ne womane$pressed a sense of despair over herhusbandEs ease with their bab#, immediatel#concluding that she was inept and ancillar#Another woman attac5ed herself over her in"abilit# to feel the happiness she wase$pected to feel with 3such a good bab#Lumerous women report intrusive thoughtsand fears of causing some sort of harm to theinfant, either through loss of control or negli"gence Although the incidence of actualph#sical harm to newborns is low, thedistress of the mother is 'uite high, andfamil# members ma# be alarmed as well n"going support and monitoring are crucial topreserving the motherEs self"esteem andpreventing a worsening of these s#mptoms?ven if postpartum depression is not sodi(erent from other depressive episodes inits biochemistr#, it is distinct in its cripplinge(ect on the womanEs self"image as amother, as well as its impact on the famil# ata vulnerable stage

Although the general prevalence of depression in postpartum women )1/K* doesnot di(er substantiall# from that of age"matched controls )17K*, certain subgroupsare at much higher ris5 for this disorder Asstated previousl#, women with a past histor#of depression are at a /7K ris5 fordeveloping postpartum depression -hosewho have su(ered from a previous episode of postpartum depression have a 67K ris5 )68*+s#chiatrists have debated whetherpostpartum depression should have a speci.cdiagnostic categor# n the one hand, studieshave not shown this disorder to bebiochemicall# distinct from other episodes of depression n the other hand, the high ratesof recurrence for postpartum depression, aswell as its characteristic s#mptoms, dosuggest that depression during this period isat least e$perienced in a uni'ue wa# b# thewomen who su(er from it 2egardless of outcome, the active debate has 5ept thespotlight on this disorder as a ma:or publichealth concern+ostpartum depression rarel# progresses tops#chosis, which occurs in about 1 to per1,777 pregnancies )G * -his potential wastragicall# illustrated in the case of Andrea

Oates, who reportedl# drowned her .vechildren in the belief that she was savingthem from eternal damnation )G8* Accordingto records that have been made public, shehad su(ered three episodes of postpartumdepression, each increasing in severit# anddangerousness uring the second episode,she had become suicidal over impulses to 5illher children, and one ps#chiatrist had

reportedl# warned her about the danger of further pregnancies )G8*


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e$perience, postpartum depression tends torespond well to treatment -he women, fright


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ened b# their s#mptoms but determined toimprove their functioning as mothers, tend toform strong al


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liances with their therapists and ps#chiatrists -he# are generall# compliant with andresponsive to medica


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a


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nd better able to sleep even before thee$pected onset of thera


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peutic antidepressant e(ects ;isiting nurseservices can be particularl# helpful, providingmuch needed support and monitoring of newmothers who are homebound &orbreastfeeding mothers, t


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h


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ere are a number of antidepressants )to bediscussed later* that appear reasonabl# safefor the bab#, especiall# with carefulmonitoring )67*


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2ecentl#, there has been interest inproph#lactic antidepressant treatment forwomen who have had at least one previousepisode of postpartum depression In one

stud# of / such women )G9*, those whochose to start antidepressant treatmentimmediatel# after birth had a much lowerrelapse rate )G @K* than those who elected tohave monitoring alone )G 6K*!#+IE$Y *IS %*E%S !#*

)SESSI&E/C (P'"SI&E*IS %*E% -he course of an$iet# disorders duringpregnanc# is variable In one stud#, thema:orit# )@@K* of women with panic disorderhad reported improvement during pregnanc#,but the# also tended to have milder s#mp"toms than the group ) 7K* that reportedworsening with pregnanc# )@7*An$iet# is fre'uentl# prominent duringepisodes of mood disorder, and reportedl#accompanies pre" and postpartum depressionin up to 67K of cases )@1* It also can be partof the prodrome for worsening a(ectiveillness or even ps#chosis A complicated ordiPcult pregnanc# ma# cause high levels of an$iet#, progressing to generali=ed an$iet#or panic disorder as a result ne woman,who had previousl# miscarried at / wee5s,began having panic attac5s as her ne$t bab#approached this gestational ageAs stated in a previous section, there isgrowing concern about the e(ects of stress

and untreated an$iet# during pregnanc#,especiall# in relationship to thecardiovascular status of the mother )/G /9*and the mechanisms of preterm labor ) 6*+anic attac5s can even be confused with pre"eclampsia )@ *+regnanc# and the postpartum period appearto worsen the course of C , and man#women report that their s#mptoms .rstbegan during pregnanc# )@/* +regnanc#"associated C is often characteri=ed b#comorbid ma:or depression, intrusive violentthoughts, contamination obsessions, and agood response to treatment with serotoninreupta5e inhibitors As stated previousl#,

although the violent thoughts tend to be

distressing to the mother, the# are rarel#associated with harm to the bab# !owever,e$aggerated fears, rituals, procrastination, oravoidance behaviors could cause harm b#interfering with the motherEs self"care duringpregnanc# or bonding with the bab#afterward )@/* omen with C should beaware of the possible e(ects of pregnanc#and childbirth on their condition so the# canta5e measures to protect themselvesaccordingl#)IP "!% *IS %*E%

&or a bipolar woman, treatment planning forpregnanc# should ideall# begin when shereaches childbearing age In fact, it hasbecome the standard of care to test forpregnanc# and provide contraception coun"seling before beginning certain moodstabili=ers, such as valproic acid );+A*, whichis associated with increased ris5 for neuraltube defects )@4*Bipolar women who choose to becomepregnant )or .nd themselves pregnant* needto be informed that the ris5 of relapse is highwhen their medications are suddenl#discontinued%about 67K with lithium )6 *

-here is evidence that gradual taperattenuates that ris5 and lengthens the timeperiod before recurrence )6 * +atients whohave maintained long periods of stabilit# ma#choose to attempt medication taper prior toconception, with the plan of resumingmedications if necessar# after the .rsttrimester If the patient has dif.cult#conceiving, however, this approach becomesimpractical

-reatment of bipolar patients during

pregnanc# is inherentl# complicated becausethe 3.rst line mood"stabili=ing medicationsall carr# some ris5 for congenital anomalies,as is discussed later At the same time, theuntreated mood disorder imposes its ownris5s, including conse'uences of depressionmentioned earlier Manic patients are moreli5el# to abuse substances or engage in high"ris5 se$ual behavior, and ma# be morevulnerable to altercations ending in violence)G6* -he# ma# also have more diPcult#compl#ing with prenatal care and measuressuch as diabetic diet or bed rest to addresscomplications of pregnanc#, as described inthe following caseC!SE E+!(P"E A /8"#ear"old woman

admitted for preterm labor complained ofmar5ed an$iet#, sleeplessness, and beingunable to 3sit still for bed rest 0enerall#gregarious, pressured, and highl# active, shetried to occup# herself with paperwor5 and3chores in bed espite clona=epam given onan as needed basis and intensive support, hersleeplessness continued, and she constantl#felt compelled to get up, ma5e her bed,organi=e and decorate her


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3


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one cigarette a da#


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hen not in motion, she found herself over


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s


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sibilit# that she might have a mood disorder>he refused to consider an# medications e$ceptfor clona=epam, which she discontinued afterdeliver# of her bab#


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In the authorsE e$perience, man# e$pectantmothers, especiall# those with bipolardisorder, have their own ideas abouttreatment In fact, the scenario of a womanannouncing she is pregnant and stopping allher medications is probabl# more common

than that of one re'uesting help with ananticipated pregnanc# -he clinicianEs .rstchallenge is to persuade patients to acceptps#chiatric treatment and fre'uentmonitoring during pregnanc#%with orwithout medications -he ne$t challenge is anhonest and realistic discussion about theris5s and bene.ts of medications >ome pa"tients will insist on going through at least the.rst trimester o( all medications, acceptingthe ris5 of sudden discontinuation thersma# insist that the# will decompensate if an#of their medications are changed, accepting

the potential teratogenic ris5 A third groupwill report not 5nowing that the# arepregnant until well into the second trimesterIt is not uncommon for a clinician to researchand carefull# deliberate over a treatmentrecommendation, onl# to .nd that the patienthas alread# ta5en the decision out of his orher hands

-he individual treatment contract re'uiresboth patient and clinician to openl# acceptris5s%in one direction or the other%thatinvolve a developing fetus +atients whobecome ps#chotic o( their medications orwho have a histor# of multiplehospitali=ations should be encouraged tocontinue their medications through thepregnanc# If anticonvulsants are used formood stabili=ation, then folic acid should beprescribed ne ma# consider graduall#changing from ;+A to a mood stabili=er withlower teratogenic ris5 )5eeping in mind thatthe critical period for neural tube defects isduring the .rst 6 wee5s of gestation Q@4R*An# modi.cations should be accompanied b#more fre'uent appointments and monitoringConsultation with a perinatologist or geneticcounselor ma# also be helpful +atients whohave had longer periods of stabilit# ma# wantto graduall# wean certain medications beforeattempting to conceive -he# should beencouraged to pursue fertilit# counseling toshorten as much as possible the re'uiredtime o( medications Active and informedparticipation in treatment is crucial for bothpatients and clinicians

&or pregnant women re'uiring maintenancetherap#, lithium has been considered atreatment of choice )@4*, although there isalso growing interest in lamotrigine )@6 @@*?stimates of lithiumEs teratogenic ris5 arevariable and are discussed in a later section

-here appears to be a small increase in therate of congenital anomalies, includingcardiac malformations, with maternal use of lithium during the .rst trimester !owever,lithium is considered safer than ;+A andcarbama=epine, which are associated withincreased ris5 for spina bi.da among otheranomalies &re'uent monitoring of mother,bab#, and lithium levels are important,particularl# near the time of deliver#, whenthere are mar5ed shifts in the motherEs uidand electrol#te balance >ome researchershave suggested that lithium be given in / to6 dail# doses in order to avoid high pea5s of serum concentration )@4* -here iscontrovers# over whether the lithium doseshould be partiall# tapered during the last 17da#s before deliver# )6 ,@4* >ome authorsmaintain that this will help prevent neonatalto$icit#, whereas others e$press concernsabout the high ris5 for relapse in thepostpartum period


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)6 *, and postpartum ps#chosis reaches arate of /7K for bipolar mothers )A C;iguera, personal communi


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cation, April 9, 776*


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+erhaps the most daunting tas5 facing aclinician is determin


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ing which infants might be at ris5 for harmfrom their mothers As a rule, women whomurder newborns within 4 hours after birthhave not been found to be ps#chotic at thetime )86* !owever, moth


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ers who 5ill after this point are oftenresponding to delu


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s


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ions or hallucinations, tr#ing to save childrenfrom what the# perceive as an evil destin#, orthe# are suicidal )G * -he# ma# also haveviolent outbursts leading to accidental death


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(aternalCapacity -here are times when a ps#chiatrist will bere'uired to evaluate a motherEs capacit# toensure the care and safet# of her newbornbab# outside the hospital 0enerall#, themother has a histor# of mental illness or ad"

diction ) ther red ags for the obstetricteam include lac5 of prenatal care,homelessness, isolation from supports, lac5of preparation for the bab#, or unusualbehavior with the bab# or sta( after birth *

-his is not an eas# tas5, and if one e$pects toprovide an absolute answer, it becomesimpossible ver the #ears, the authors havearrived at certain guidelines to structure thiswor5 more realisticall#

&irst, the most important mission here is notto predict the future based on a diagnosticevaluation, but rather to assist the mother,her famil#, health care wor5ers, and agenciessuch as C+> in planning for the care andsafet# of a bab# Ideall#, ever#one togetherwill be e$ploring supports and deciding onthe level of intervention re'uired foraccomplishing this goal -he 'uestions thatarise are then fairl# straightforwardJ hat5ind of da#"to"da# supervision does thismother needU oes she have diPcult#functioning alone or under stressU If so,would regular therap# sessions and visitsfrom a nurse be suPcient, or would shere'uire a case manager and an intensive da#treatment programU ould a supportiveresidence be appropriateU Is a spouse, groupof relatives, or partner prepared to assumeguardianship at times when she is unable toparentU

>econd, the motherEs willingness to

ac5nowledge the need for support andmonitoring is generall# even more importantthan the severit# of her condition enial andisolation are problematic for an# motherchild pair, but fran5l# dangerous when themother has a mental illness or addiction+erhaps the most worrisome presentation isof a mother who tests positive multiple timesfor cocaine and claims the tests are wrong Inthis case, there is generall# no opportunit#for intervention or treatment planning, andthe mother is essentiall# unpredictable necan then onl# rel# on observation from

outside agencies, such as C+>

C!SE E+!(P"E A 9"#ear"old patient with ahistor# of bipolar disorder and borderlinepersonalit# traits presented to the obstetricward as articulate, well related, and a(ectionatewith her bab# >he described her mood asstable on medications since her lasthospitali=ation for suicidal behavior about months previousl# >he declared she would doan#thing for her bab#, including accept 4"hoursupervision !owever, some behavior in thepast suggested otherwise >he had recentl#become homeless after leaving a supervisedresidence for mentall# ill mothers, stating 3IcouldnEt tolerate the structure According tothe sta( there, she had not been attendingtreatment sessions or following house rules>he was not viewed as being able to function intheir program, even if she applied forreadmission >he had no famil# supports andhad last been hospitali=ed about monthspreviousl# for suicidal behavior

Appearing unable to cooperate with constantsupervision, this patient was assessed at thetime as being too unpredictable to care for herbab# outside the hospital C+> placed the bab#in foster care after consulting her regarding an#preferences she might have for the bab#Estemporar# guardian

C!SE E+!(P"E A / "#ear"old woman with ahistor# of drug use and possible mood disorderpresented as guarded and irritable with theobstetric sta(, becoming loud and oppositional

when frustrated >he fre'uentl# re'uiredreassurance and clari.cation of unit procedures,and was initiall# indignant to be seen b# aps#chiatrist As time passed, she appearedcalmer and more approachable After shedelivered her bab#, she re'uested an increasein her antips#chotic medications !er mannerwith her bab#, who was admitted to the LIC ,was reportedl# an$ious but loving

-his patient had been sta#ing the last 4 monthsat a supervised residence for mentall# illmothers and planned to return there afterdischarge >he hoped to wor5 with theresidence sta( to obtain her 0? and ultimatel#transition to her own home >ta( at theresidence described this patient as engaged inher treatment program and helpful with theother mothers !er urine drug screens were allreportedl# negative during her sta#

-his patient was assessed as having thecapacit# to provide for the care and safet# of her bab# with the support of her residentialprogram Although occasionall# guarded, shehad shown over a period of months that sheresponded well to structure and appearedhighl# motivated to continue her treatment


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C!SE E+!(P"E


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ne woman with cognitive im


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pairment and previous C+> involvement was'uite convincing in h


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E


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s a(ecti


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o


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n for her children, but gave an account of anolder infant becoming severel# ill while livingwith her, ultimatel# having to be placed -he#had found her living 'uarters to be .lth#, andthe bab# bottles crusted over with la#ers ofdried, spoiled mil5


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Collateral information is essential, especiall#with regard to the patientEs parenting histor#In the hospital, even severel# impairedmothers become attached to their children,

and it is e$tremel# rare to encounter awoman who does not appear loving with hernewborn )unless of course her mental statusis a(ected b# being sic5, in pain, andNorrecovering from surger#* A single diagnosticinterview, even when thorough, can bedeceptive$HE . (!# .H%E-'SES $%E!$(E#$

In some cases, the ps#chiatrist must assessthe capacit# of a woman before she givesbirth, especiall# when she is refusingtreatment and demanding to leave the hos"pital against medical adviceA common scenario is the woman whoendures a long period of bed rest, then insistson leaving the hospital ften, there is a crisisat home or a toddler who needs her care -hestress of such con icting demands is severe,but so is the ris5 to mother and bab# outsidethe hospital Most of these patients decide tosta# after venting their concerns andreceiving additional support from theirfamilies and sta( In rare cases, however, awoman will ac5nowledge her condition andthe ris5s involved, but remain determined toleave% sometimes promising to return whenthe crisis at home is resolved If she canpresent an outpatient alternative fortreatment, she will probabl# be released!owever, the sta( should ma5e ever#reasonable e(ort to encourage her to sta# orreturn as 'uic5l# as possible

ccasionall#, a woman ma# demand toleave, insisting there is no ris5 or that shehas no concerns in this area In this case, her

:udgment might be impaired, and shere'uires a ps#chiatric evaluation

C!SE E+!(P"E A /"#ear"old woman withpoorl# controlled diabetes demanded to leavedespite high and widel# uctuating bloodsugars >he

stated that her husband had left her so she didnot care what happened to her In fact, she hadstopped chec5ing her blood sugars or ta5inginsulin for several wee5s >he admitted tofeeling hopeless and overwhelmed, withfre'uent suicidal thoughts >he was diagnosedwith depression and placed on constantobservation in the hospital, where she sta#eduntil her blood sugars improved, her suicidalthoughts lifted, and further wor5 was done withher marital crisis

In this case, the patient had shown a pattern of endangering herself and her pregnanc# inreaction to her loss


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Substance

Abuse


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Caring for addicted patients duringpregnanc# is perhaps the most diPcultchallenge in all of medicine As soon asclinicians are aware that drugs are an issue,

the# are bound to e$perience a sense of helplessness and fear for the bab# !owever,man# patients 5eep their use a secret, orsimpl# do not see5 prenatal care -he .rsttas5 of the clinician is to accept thatsubstance abuse is a common problem androutinel# in'uire about it -he second tas5 isto create an alliance that 5eeps the patientcoming to appointments Mac0regor et al)8G* observed that regular prenatal care wasthe most important determinant of pregnanc#outcome, regardless of whether substanceuse was continued

-he third tas5 is to help the patient obtaintreatment nl# about 6K to 17K of pregnantwomen in need of substance abusetreatment actuall# receive it )8@* Cliniciansoften fail to detect the addiction, andpatients ma# have a host of reasons toconceal it, including fear of losing childcustod# or being prosecuted for child abuse)88* +unitive measures, such as removal of newborn infants from their mothers solel# onthe basis of a positive drug test, ma# serveonl# to alienate patients from care and ma5eclinicians reluctant to order to$icolog#screens )88* An additional barrier is isolationfrom supports and resources +atientsfre'uentl# report lac5 of programs,transportation, or child care

-he following paragraphs review e(ects of commonl# used substances on thedeveloping fetus eep in mind that addicted

patients often simultaneousl# smo5e, abusemultiple drugs and alcohol, and have poornutrition and health status )89* +s#chiatricassessment is an important part of the careof drug"abusing patients% an estimated G7Khave a comorbid ps#chiatric condition )97*Clinicians need to be aware of resources inthe communit# because man# patients donot 5now their options!"C H "

It is estimated that 7K of pregnant womenconsume some alcohol during pregnanc#

)91*, and that G million infants are borneach #ear in the nited >tates withsigni.cant alcohol e$posure and a wide rangeof abnormalities )9 * ne 199G surve# )9/*indicated that about 67,777 children showedsigns of fetal alcohol e(ects, whereas 6,777children were born with fetal alcohols#ndrome )&A>*, the leading 5nown cause of mental retardation in the nited >tates )9 *Appro$imatel# 86K of &A> children havesome degree of mental retardation )9 *Alcohol persists in the amniotic uid abouttwice as long as in the maternal bloodstreamAs a result, the fetus is e$posed to higherlevels of alcohol for longer

periods of time than the mother is e$posedIn addition, cigarette smo5ing ma#e$acerbate the teratogenic e(ect of prenataldrin5ing )94*C C!I#E

According to a stud# b# >hi5les in 1997, 6

million Americans were estimated to usecocaine dail#, while 7 million use it once permonth or moreD at least half of these arewomen of childbearing age )96* -he .rstnationwide surve# of /G hospitals found anaverage of 11K of women using cocaineduring pregnanc#, with the percentageranging from 7 K to 8K )9G*

omen who use cocaine are at greater ris5for no prenatal care, shorter gestation,premature rupture of membranes, pretermlabor and deliver#, spontaneous abortion,abruptio placentae, decreased uterine blood

ow, and death -he babies are more li5el# tosu(er ma:or congenital anomalies involvingthe brain, genitourinar# tract, bowel, heart,limbs, and face -he incidence of intrauterinegrowth retardation, fetal distress, andmortalit# is also increased Cerebrovascularaccidents have been reported in both motherand fetus )89*HE% I#

!abitual use of opiates during pregnanc#does not increase the ris5 of congenitalanomalies, but there are other potentialadverse outcomes +regnant heroin addictsand their children often develop severeinfections related to intravenous drug use,such as hepatitis, s#philis, and !I; Abruptioplacentae, neonatal withdrawal, pretermbirth, and fetal growth retardation are alsoassociated with maternal opiate use Childrenwith in utero e$posure di(er from nondrug"e$posed children on measures of cognitiveabilities, motor development, and behavior!owever, the postnatal environment appearsto in uence the childrenEs developmentalprogress more than prenatal e$posure toheroin )89*

A number of authors have recommended thatwithdrawal from heroin or methadone not beattempted after / wee5sE gestation becauseof the possible ris5 of abruptio placentae,preterm labor, premature rupture of mem"branes, or fetal death in more advancedpregnanc# )89* Methadone is mostcommonl# used as maintenance treatmentfor pregnant, heroin"addicted mothers, but itsePcac# is controversial Most infants )@7K97K* with chronic in utero e$posure tomethadone su(er from abstinence s#mptoms)89*, generall# re'uiring e$tendedobservation in the hospital !owever,because of dail# dosing, man# methadoneprograms provide structure and compulsor#monitoring that is not possible in othersettings +atients are generall# e$pected togive random urine samples for to$icolog# andhave regular sessions with their drugcounselors -his level of care would augmentand perhaps improve compliance with regularprenatal care


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C!##!)I# I*S !#* $ )!CC


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About /K of Americans use mari:uana dail#,and 17K to 16K use it once or more permonth ?stimated rates of use duringpregnanc# var# from /K to about 7K )9@*

-hus far, mari:uana use during pregnanc#

appears to be associated with mild fetalgrowth retardation and maternal lungdamage, but more research is needed toevaluate long"term e(ects )89* Cigarettesmo5ing has been associated with increasedris5 of spontaneous abortion, placentaprevia, and abruptio placentae )88*Psychotropic(edications -he most critical period for the introduction of congenital anomalies is the .rst trimester)speci.call# the .rst 68 da#s postconception*,a time when most women are unaware of

being pregnant )89* It follows that preven"tion of birth defects should ideall# beginbefore conception ever occurs%perhaps assoon as a woman reaches childbearing agebecause up to 67K of pregnancies areunplanned )98* omen are routinel# warnedto avoid radiographs, radioactive materials,and to$ins such as mercur# or lead +ublicservice announcements also caution againstuse of alcohol, drugs, and tobacco duringpregnanc# -he medical communit# is clearregarding these ha=ards to unborn children!owever, there is much more ambiguit# inthe area of medications, a huge arra# of potentiall# dangerous chemicals that somewomen need to ta5e ever# da# An# decisionin this area re'uires a realistic assessmentand careful weighing of ris5s and bene.ts

$YPES - %IS I# P%E,#!#CY

hen evaluating medications, clinicians andresearchers are generall# loo5ing at thefollowing t#pes of ris5J )a* organmalformation or teratogenesis, )b* fetale(ects,)c* neonatal e(ects, and )d* long"termneurobehavioral se'uelae )99* It is importantto remember that damage associated with aparticular medication ma# actuall# be causedb# the condition being treated, rather thandrug to$icit# )177* &or e$ample, neonatalirritabilit# and decreased activit# areassociated with both e$posure to certainantidepressants and maternal depressionitself )171*+atients tend to overestimate the potentialdangers of medications, as indicated b# onestud# of women presenting to a teratogeninformation service )-I>* for consultation

hen as5ed about the possibilit# of mal"formations with the medications in 'uestion,the women gave a mean response of 4K, ahigh rate, even for agents 5nown to benonteratogenic )17 * -his mind"set couldlead to unnecessar# fear and even a sense of

pressure to terminate a pregnanc# uringtherapeutic trials of

uo$etine, the elective abortion rate was ashigh as /7K )17/* -his .nding highlights theneed for prenatal counseling in pregnantwomen on medications

$eratogenicity

A teratogen is de.ned as an# agent that canproduce a permanent abnormalit# of structure or function in an organism e$posedduring embr#onic life )177* &or e$ample,;+A, which is associated with increased inci"dence of neural tube defects )1K K*, aswell as fetal valproate s#ndrome, isconsidered teratogenic )174* -?2I>, a -I>organi=ation that provides a database as wellas other information, also includes in thisde.nition agents that produce permanentabnormalities through to$icit# to the fetus)177*

Before implantation in the uterus, whichoccurs about 1 wee5 postconception, theblastoc#st is separate from the mother and is

essentiall# protected from substancestransported through maternal circulation -heperiod of the embr#o starts with implantationand e$tends through the .rst 68 to G7 da#spostconception -he organs and tissues of theunborn bab# are being formed during thisperiod, which is also called organogenesis


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defects )174* nfortunatel#, teratogenscontinue to be discovered onl# aft


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er numerous children have alread# been bornwith malformations )99*


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-etoto1ity

uring the fetal stage, growth through cell

multiplication is the predominant event,accompanied b# some cell migration&etoto$ic agents most commonl# causegrowth retardation isrupted histogenesis,fetal death, or stillbirth can also occur>ome agents, including warfarin and cocaine,ma# attac5 normall# developed organs b#interrupting blood ow or otherwise causingcell necrosis )99* -he result could be anabnormalit# mimic5ing an organ malfor"mation occurring earlier in development

-hus, there are rare conditions in whichmedications cause serious congenitalanomalies during the second trimester -?2I>would consider warfarin and Coumadin to beteratogens, even though the damageoccurred after the period of organogenesis

thers might, more strictl# spea5ing,categori=e these agents as fetoto$ic#eonatal $o1icity

-he fetus has a lower hepatic e$cretion ratethan the mother and has more diPcult#tolerating pharmacologic compounds )179*Leonatal to$icit#, or perinatal s#ndrome, canresult from e$posure to certain medicationsduring the third trimester or at the time of deliver# -he s#mptoms are variable andgenerall# time limited, lasting from hours tomonths after birth ?$amples of neonatalto$icit# include transient metabolic abnor"malities, h#pogl#cemia, withdrawals#ndromes, and h#potonia )3 opp# bab#s#ndrome * )99*

ata on fetal and neonatal e(ects of medications are still limited, generall#consisting of isolated case reports withalmost no case"controlled studies Causee(ect relationships are largel# unclear%whatis described as to$icit# in one report ma# benamed withdrawal in another ?ven less clearare the magnitude of ris5s involved and thee(ects of medication dosage

ne e$ception, however, is the e(ects of methadone, which are relativel# wellunderstood and predictable omen treatedwith methadone late in pregnanc# usuall#give birth to babies with neonatal narcoticwithdrawal s#mptoms -he presentation ma#var# but tends to include h#pertonicit#,tremor, irritabilit#, diarrhea, and vomiting)117* >#mptoms are usuall# observed in the.rst da#s after birth, but the onset ma# bedela#ed for to 4 wee5s -hese e(ects,although prolonged, are still time limited#eurobeha2ioral Se uelae

-here is growing concern about the long"term e(ects of prenatal e$posure tomedications, particularl# the

neurobehavioral se'uelae -hedeveloping brain is shaped throughcomple$ mechanisms of cell migra tion,di(erentiation, and programmed cellreduction or 3pruning, which continuethroughout intrauterine development andlong afterward )111* o far, however, theresults of the longer"term studies appear tofollow trends suggested b# e$amination of in"fants at birth Medications associated withhigher teratogenic ris5, such as ;+A, are also

associated with more adverse outcomes#ears later ata seem to be more reassuringwith medications carr#ing little or noteratogenic ris5SPECI-IC C"!SSES -(E*IC!$I #S I# P%E,#!#CY

-his subsection describes ongoing researchon some of the more widel# usedps#chotropic medications Because the dataare constantl# evolving, the goal here canonl# be to give readers a starting point fortheir own in'uiries in this .eld!ntidepressants

Teratogenicity

-o date, the antidepressants, especiall#selective serotonin reupta5e inhibitors )>>2Is*and tric#clic antidepressants )-CAs*, have notbeen associated with an overall increasedincidence of ma:or malformations in babiese$posed during the .rst trimester &luo$etineis the best studied of the >>2Is, with multiplecase"controlled studies and registr# data)64,11 11G* nl# one stud# showed ami$ed result regarding minor malformations)11 *

ata are less e$tensive for the other >>2Is

but show similar results )11@ 119* ne morerecent e$ception, however, is a retrospectivestud# b# 0la$o>mith line loo5ing at ma:orcongenital malformations in infants born to/,@74 women ta5ing antidepressants duringthe .rst trimester of pregnanc# )1 7,1 1*

-he .nal anal#sis is pending, but thus far, theprevalence of congenital malformations in theparo$etine group was found to be / of 6 @infants with .rst"trimester e$posure )4 /GK*

-his represented an increased ris5 ascompared with other antidepressants )oddsratio Q 2R 7D 96K con.dence interval QCIR

1 /4 / G/* -here was also an increasedprevalence of cardiovascular


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formations for paro$etine compared withother an


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tidepressantsJ 14 of @74 e$posed infants, or1 9K ) 2 78D 96K CI 1 7/


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4 /* ;entricular septal defect oc


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curred in 17 of these 14 infants )1 7,1 1*ne must 5eep in mind that in the


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the ov


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e


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rall prevalence of congenital malformations isestimated at /K &or cardiovascularmalformations alone, the overall estimatedprevalence is 1K )1 * In this stud#, therewere other antidepressants with an increased

2, but the numbers were too small for


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a


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96K CI


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!allberg and >:oblom )1 /* performed ane$tensive review of studies on >>2Is duringpregnanc# and lactation up to 77/ Includedwere .ndings of the >wedish Birth 2egistr#)1996 >eptember 77/*, in which the rate of congenital anomalies for children e$posed to>>2Is during the .rst trimester was 9K)1 / a(ected among a total of 4, 91* -hisdid not di(er from the e$pected rate amongnone$posed children Lo particular t#pe of malformation was overrepresented &or indi"vidual >>2Is, n 6@4 for uo$etine )/ /Kmalformations*, n 1,G9G for citalopram )/ 1Kmalformations*, n @78 for paro$etine )/ 4Kmalformations*, and n 1,7G@ for sertraline) 7K malformations*

-here is some concern regarding anonsigni.cant increase in the rate of spontaneous abortions in >>2I"treatedwomen )e g , 1/ 6K vs 8 9K in oneteratogen information services Q-I>R stud#*)11@* Mc?lhatton et al )1 4* found similarrates in one uncontrolled stud# of women on

-CAs )11K for those e$posed to -CAs alone,and 1/ K for those e$posed to -CAs plus

other drugs*?$tensive data from pregnanc# registries and

-I> services have shown no increase inmalformations in babies with .rst"trimestere$posure to -CAs )1 6* Imipramine andamitript#line are the most e$tensivel#studied -CAs

Fetal and neonatal efects

More recentl#, the & A and drugmanufacturers agreed to a class labelingchange for >>2Is and serotonin andnorepinephrine reupta5e inhibitors )>L2Is*%grouped together under the term 3>2Is

>2Is, there is some suggestion thathigher doses of uo$etine could beassociated with lower birth weight andgestational age )119*, but other studies areinconsistent!uman placental passage has been studiedfor most of the >>2Is In one of the morecomprehensive studies, the ratios betweencord vein and maternal venous serumconcentrations were 7 9 for sertraline ) n17*, 7 4 for paro$etine ) n G*, 7 G4 for

uo$etine ) n 16*, and7 @7 for citalopram ) n 4* ther >>2Is thathave not been studied would be consideredli5el# to cross the placenta due to their lowmolecular weights )1 @* -here have been reports suggesting anassociation between third"trimester e$posureto -CAs and anticholinergic e(ects)irritabilit#N:itteriness, h#poactivit#, colonbloc5age, andNor urinar# retention* innewborns -hese s#mptoms tend to occurwithin the time interval re'uired foreliminating these drugs, which is e$tended inneonates )1 6*Mc?lhatton et al )1 4* followed 8/ womenta5ing -CAs in monotherap# beginning in the.rst trimester and another 1@4 women on

-CAs plus other prescription drugs -here was

no increase in malformation rates comparedwith historical controls !owever, the authorsdid .nd what the# considered to be a high in"cidence of neonatal disorders, such asdrowsiness and withdrawal s#mptoms )e gh#pothermia, c#anosis*% 9 GK of neonatese$posed to -CAs plus other medications and4 GK of those e$posed to -CAs alone>ei=ures that were believed to be secondar#to drug withdrawal have also been reported intwo cases with clomipramine )1 8*

verall, the neonatal e(ects ofantidepressants appear to be limited inoccurrence, scope, and time !owever, thisdoes present both clinician and mother


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h the tas5 of weighing the ris5s and bene.tsof anti


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%


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most par


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ticularl# when one is considering startingmedications during this period versus waitinguntil after deliver# !allberg and >:oblom)1 /* have reco


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mended using the minimum e(ective dose of >>2Is during late preg


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nanc# because of the possibilit# of prematurebirth and adverse drug e(ects in thenewborn


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Neurobehavioral efects

Lulman et al )11/* evaluated the e(ects of prenatal antidepressant e$posure overperiods of up to @ #ears -he# started withcomparing three groups of pregnant womenJthose treated from the .rst trimester with tri"c#clic antidepressants ) n 87* or uo$etine ) n66*, and an untreated control group ) n 84*After these women gave birth, the

researchers found no increase in ma:ormalformations or perinatal complications inbabies e$posed to antidepressants Childrenbetween 1G months and @ #ears old werethen e$amined for IT and languagedevelopment, and no di(erences were foundbetween e$posed and une$posed groups

In another series, partiall# overlapping withthe previous stud#, there were 47 children,ages 16 to @1 months, whose mothers hadta5en uo$etine throughout pregnanc# )64*

-he# did not di(er from controls on measuresof intellectual development, language de"velopment, or behavior Mattson et al )1 9*performed comprehensiveneurops#chological evaluations on GG

children, ages 4 to G, with prenatal e$posureto uo$etine -here were no signi.cantdi(erences between these children andcontrols

Caspar et al )1/7* found lower A+0A2 scoresat birth )8 4 vs 9 7 at 6 minutes* in /1infants of mothers who too5 sertraline oranother >>2I during pregnanc# >ertralinewas the antidepressant for about half themothers in the stud# -he controls wereinfants of depressed women who did not ta5emedication during pregnanc# At ages G to 47months, these children scored lower than 1/controls on the Ba#le# ps#chomotordevelopment inde$ and testing for behavioralmotor 'ualit# -he Ba#le# mentaldevelopmental inde$es were similar in bothgroups Lo signi.cant difference between thetwo groups of children was found onmorpholog# e$amination -he authors havepostulated that these subtle motor .ndingsare consistent with the pharmacologicproperties of the drugs !owever, the#caution readers that this stud# is limited b#its sample si=e, use of di(erent >>2Is,depression ratings based on self"reports, anddi(erences in mean age between the twogroups studied In addition, the age range of the children studied was wide )G 47 months*,but the average age was #ounger than 18months in both groups It is not clear whathappens to the motor .ndings described asthe e$posed children develop further

Electrocon2ulsi2e $herapy

Teratogenicity

?lectroconvulsive therap# )?C-* involveslimited e$posure to medications, and it ispossible to minimi=e transfer of substancesinto the fetoplacental s#stem b# the choice of anesthetic agents ?C- ma# be the treatmentof choice for ps#chotic depression duringpregnanc#, given the largel# un5nown ris5 of combining antidepressant, antips#chotic, andsedative medications )1 6*Miller )1/1* reviewed the literature on /77cases of ?C- during pregnanc# &ive cases of congenital abnormalities )1 G@K* werereported%an incidence lower than the Kseen in an historical control population )1/ *

-here was no clustering of speci.cabnormalitiesFetal and neonatal efects

In this case review )1/1*, 9 /K of the womentreated during pregnanc# su(eredcomplications during the course of ?C-administration &re'uentl#, there was noapparent causal relationship with thetreatment -here were cases of transientbenign fetal arrh#thmias ).ve cases*, vaginalbleeding ).ve cases*, and uterinecontractions or abdominal pain )four cases*observed soon after ?C- administration!owever, there were no apparent adversee(ects on these infants after deliver# -herehave been four reported cases of prematurelabor with ?C-, but none of these episodesimmediatel# followed a treatment, so othercauses are not ruled outNeurobehavioral efects

-he authors have not found formal data onthe long"term e(ects of prenatal e$posure to?C-)en4odia4epines

Teratogenicity

?pidemiologic data on the benzodiazepineshas been plentiful but not entirel# consistent

>ome studies show no increase inmalformations among infants with .rst"trimester e$posure, whereas others show asmall but signi.cant increase Anal#sis of case"control studies alone revealed asigni.cantl# increased ris5 for either ma:ormalformations or oral cleft, but pooled )case"control and cohort* studies showed no suchassociation )1//* -o date, the available datahave suggested that ben=odia=epinee$posure during the .rst trimester increasesthe ris5 for congenital anomalies )i e , from7 7GK for oral cleft to 7 @K*, but the absolute

ris5 remains low )1/4* ia=epam is the beststudied of the ben=odia=epines, followed b#chlordia=epo$ide


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-here has been some concern regarding thefetal and neonatal e(ects of ben=odia=epines, especiall# with larger dosesin continuous use Most of the reports in thisarea are on dia=epam, and the e(ects appear

to be transient Minimi=ing the dosage ma#be one wa# to mitigate adverse e(ects onthe fetus ne advantage of ben=odia=epinesis that the# can be given on an as"neededbasis for acute s#mptom relief

hen pregnant women are treated withdia=epam, loss of beat"to"beat heart ratevariabilit# and decreased fetal movementma# occur )1/6,1/G* &etal monitoring andperiodic ultrasound e$ams are importantwhen this occurs ia=epam use during thethird trimester or at the time of deliver# ma#lead to apnea, h#potonia, or h#pothermia inthe newborn Conversel#, tremors, irritabilit#,and h#pertonia, similar to neonatal narcoticwithdrawal, can occur in some babies whosemothers were treated chronicall# withdia=epam through the third trimester )1/@*In one report, however, clona=epam wasgiven in doses ranging from 7 6 to / 6 mgdail# to women with panic disorder duringlabor and deliver#, and there were noapparent perinatal adverse e(ects )1/8*

C=ei=el and -oth )1/9* found that /,G7infants with prenatal e$posure to dia=epamweighed, on average, 116 g less thanune$posed infants 2eports are inconsistentregarding head circumference )147,141*Neurobehavioral efects

In one stud#, 1@ children with prenatal

e$posure to dia=epam or otherben=odia=epines were observed to havedela#ed gross motor development at G to 17months of age !owever, few di(erencesfrom controls were apparent at 18 months)14 ,14/* Be#ond 18 months, the previousdi(erences appeared to normali=eMc?lhatton )144* studied 667 e$posedchildren for various times up to the age of 4#ears and found no increase in malformationrate or adverse e(ects on eitherneurobehavioral development or IT It wasnot possible to establish a direct cause e(ect

relationship with prenatal ben=odia=epinee$posure for children in whom developmentalde.cits persisted

>ti5a et al )146* anal#=ed the statisticalrelationships between prescription data of pregnant mothers and evaluations of theirchildrenEs subse'uent behavior in school Losigni.cant di(erence was found between thetwo groups and their controls!ntipsychotics

Teratogenicity

>tudies of neuroleptic use during pregnanc#are complicated b# multiple confoundingvariables, including ris5 factors associatedwith ps#chotic illness itself >till,

animal studies and reviews of humanpregnancies have failed to clearl#demonstrate an# speci.c organ malformationwith use of chlorproma=ine, haloperidol, orperphena=ine )14G* In 199G, Altshuler et al)14@* performed a meta"anal#sis of reportson phenothia=ines given in the .rst trimesterto nonps#chotic women -he# found a 4Kincidence of anomalies, with a baseline rateof 7K, and concluded that the additionalris5 was 7 4K 2eports on haloperidol andperphena=ine have some variabilit#, but an#increase in ris5 for congenital anomaliesappears to be small )178,148 161*

ata are still limited with the at#picalantips#chotics Mc enna et al )16 * revieweddata from a cohort of pregnant women whohad contacted the Motheris5 +rogram inCanada, the Israeli -eratogen Information>ervice, or the rug >afet# 2esearch nitdatabase in ?ngland omen who had beene$posed to at#pical antips#chotics during

pregnanc# were matched to a comparisongroup of pregnant women without suche$posure -here were 161 pregnanc#outcomes with e$posure to olan=apine ) nG7*, risperidone ) n 49*, 'uetiapine ) n /G*,and clo=apine ) n G* -here were nostatisticall# signi.cant di(erences in an# of the pregnanc# outcomes of interest betweenthe e$posed and comparison groups, with thee$ception of low birth weight )17K in thee$posed babies compared to K in thecomparison groupD p 7 76* and the rate of therapeutic abortions ) p 7 77/*


!igh"potenc# antips#chotics given in thethird trimester have been associated withe$trap#ramidal s#mptoms )?+>* in thenewborn -hese s#mptoms reportedl# began1 to / da#s after birth if the mother wastreated orall#, and / to 4 wee5s later if depotin:ections were used -here have beenreports of ?+> persisting in babies for up to Gto 17 months )69,16/* ther potential neu"roleptic e(ects on the neonate includeincreased cr#ing and suc5ing, sluggishprimitive re e$es, vasomotor instabilit#,wea5ness, h#pertonicit#, and increased

cr#ing )164* -hese reports tend to be older,raising such issues as dosage andconfounding maternal factors -he# do pointto the importance of limiting the dosage andavoiding depot in:ections as much aspossible

Neurobehavioral efects

2eports on the long"term e(ects of prenatale$posure to neuroleptics are largel# limited toolder studies of women being treated forh#peremesis In one such stud# )166*, therewere 6 babies whose mothers had ta5enchlorproma=ine 67 to 177 mg per da# duringpregnanc# -he# were followed for 4 to 6#ears after birth and found to be health#, withno behavioral or mental ab

Ch36 Pregnancy

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Transcript of Ch36 Pregnancy