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Bryony Gibson
Perinatal Lead
TVSCN
26 September 2018
Thames Valley SCN
Perinatal Mental Health
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Pre-conceptual advice
• Women who have personal history of serious or significant mental health
issues including those during a previous pregnancy i.e. post natal
psychosis
• Women who have a close female relative who has a psychotic disorder or
who experienced post partum psychosis
• Women who have a diagnosis of Bi-Polar 1 are at significantly increased
risk
• Guidance indicates that such women should be referred to specialist
services for:
• Assessment of risk and risk management planning
• Medication advice-addressing the risk of both taking or not taking
medication
• Maternity planning-completion of document shared with all those involved
in her care to help mitigate risk
• Close monitoring during pregnancy and in the post partum period
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Specialist Assessment:
Perinatal Mental Health
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• Whole range of disorder seen at other times however with the perinatal
frame of mind need to consider the impact on treating or not treating MH
• The range of presentations will be similar to those occurring outside of the
perinatal period.
• Approx 20% of women experience a MH issue during the perinatal period-
4% will require the specialist perinatal mental health services
• Increase in OCD-sometimes with thoughts of harm to the baby
• Evidence that low mood and anxiety in pregnancy is an increased risk
factor for post natal illness and impact on the child
• Women presenting with serious or significant mental health presentations
during pregnancy and in the first year post partum
• Previous significant personal history of MH, close family history of
psychosis requiring pre-conceptual advice or pregnant but planning
required for support during perinatal period
• Birth Trauma assessment-birth trauma pilot in BHFT
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Emergency Assessment:
Psychosis an urgent response • Risk of 1-2 per 1000 live births with no previous history (increased risk if bi-
polar diagnosis)
• Onset is usually within the 14 days of birth with 80% presenting by 28 days
post partum
• Most mums will report subsequently report symptoms starting on day 1.
• Onset is the most acute, most rapid, most florid of all mental health
presentations and onset can take place over hours rather than days
• Presentation is most often of mania but can initially present with perplexity,
confusion and anxiety often leading to misdiagnosis (Saving Lives 2011)
• Mania poses increased risk to the baby due to the dangerous situation the
mum may put herself in as a consequence of her psychotic phenomena
• Hallucinations or delusions relating to the baby will increase the risk to that
child.
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Psychosis an urgent response
• Bi-Polar Disorder carries the highest known risk of all mental health
disorders
• Episodes of postpartum psychosis occur after approximately 25% or 1 in 4
births to women with bipolar disorder.
• This is many hundred times higher than for women who have not had
previous psychiatric illness. (1-2 per 1000 live births)
• Postnatal depression follows a further 25% or 1in 4 births.
• Therefore, about 50% of women with bipolar disorder stay well after
• having a baby and about 50% are likely to have an episode of illness.
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• If you suspect a psychosis do not wait to see if it settles - take urgent
action immediately.
• Refer to your local mental health services requesting an assessment
for suspected psychosis.
• NICE recommend that this assessment commences within 4 hours.
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Psychological Interventions Provided both within IAPT services and specialist perinatal MH service
Perinatal frame of mind
Delivered in timely manner-to mitigate impact of the mothers mental health on the
child and with prescribing limitations
IAPT:
Developing silver cloud for perinatal (part of GDE)
Delivering CBT, counselling
phone, face to face
Specialist Team:
CBT, birth trauma, IPT
Home assessment and interventions-all assessment are face to face
Support from nursery nurses to support CBT interventions
Specialist birth trauma service following assessment from perinatal service
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Urgent Admission to MBU • Specialist Mother and Baby Unit provision-admission can be to any unit in
England
• Nationally funded beds -Increased number of MBU beds being built (4 new
MBUs commissioned) but no intention for MBU in Thames Valley
• Admission to MBU during final stages of pregnancy and up to one year post
partum-any woman who requires admission to an adult mental health unit
should be considered for admission to MBU. Thresholds are lower.
• If you feel a woman may be requiring admission to MBU please make an
urgent referral to MH service
• Minimal exclusion criteria for admission to MBU:
• If baby is not/will not be with the mother
• Where the risk is sufficiently high for MBU to be unable to manage risk to self
or to infant/others
• MBU do not routinely provide court reported parenting assessment
• Following assessment by MH services (including MHA) and where care
is not manageable within the community provision available - admission
can be directly to MBU with the infant
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MBBRACE – Red Flags SUICIDE REMAINS ONE OF THE LEADING CAUSES OF MATERNAL
DEATH UP TO ONE YEAR POST PARTUM
• Presenting in the first four weeks post-partum (highest risk period
for presenting psychosis)
• Sudden deterioration of mental health presentation
• Thoughts of violent method of suicide (even if fleeting)-women use
violent methods more than at other times
• Estrangement/feeling estranged from infant bonding
• Thoughts of absconsion
• Previous history of suicide or self-harm
• Last trimester of pregnancy and first 12 weeks post birth
• Any thoughts of harm to child or psychotic thoughts relating to
child increases risk – if the woman says she would never leave her
child ask if she has thoughts of taking her child with her
• Be wary of the ‘gated community’ of high achieving, well educated,
financially stable women.
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PERINATAL PRESCRIBING CONSIDERATIONS
Pre-Conception, Pregnancy and Breastfeeding
• The possibility of pregnancy should be discussed with all women of child-
bearing potential before any medication is prescribed. Advice and
contraception should be made available if necessary.
• Valproate is of particular risk to an unborn child; women of child-bearing
potential should be on the Pregnancy Prevention Programme (PPP) and
regularly reviewed by a Consultant Psychiatrist / Neurologist if prescribed.
• Women may wish to exclude pregnancy if they deem the risks associated with
undergoing treatment whilst being pregnant as unacceptable. Once excluded, it
would be prudent to discuss contraception or signpost woman to appropriate
services to explore contraceptive options.
• All prescribing in pregnancy and breastfeeding is off-label.
• Women should be informed that whilst it is not possible to guarantee the safety
of any medication prescribed during pregnancy or breastfeeding, an individual
assessment of potential risks and benefits may help to guide treatment
decisions.
12 Slide provided by Beki Inglis Berkshire Perinatal Pharmacist
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PERINATAL PRESCRIBING CONSIDERATIONS
Pre-Conception, Pregnancy and Breastfeeding
• Risks associated with untreated or deteriorating maternal mental illness should
be weighed against the risks associated with exposing a foetus / baby to
medication. The mother (and if the mother agrees, the partner / significant
carer) must always be involved in the decision-making process where
possible.
• Prescribing during the first trimester is generally considered the time of
greatest risk to the foetus as major organ development will be taking place.
Based on an assessment of potential risks and perceived benefits, it may be
preferable to temporarily discontinue or delay medication until the second
trimester.
• Consider the potential effects of medication on the foetus during labour and
immediately following the birth. Delivery within a hospital setting and additional
monitoring of the newborn may be required.
13 Slide provided by Beki Inglis Berkshire Perinatal Pharmacist
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PERINATAL PRESCRIBING CONSIDERATIONS
Pre-Conception, Pregnancy and Breastfeeding
• Switching medication during the perinatal period carries a risk of relapse or
deterioration in mental state but also exposes the foetus / baby to more
drugs. Careful consideration of potential risks should be undertaken before a
change in treatment is commenced.
• Where possible, monotherapy should be prescribed in order to limit foetal /
infant exposure to medication.
• Unless a women is already open to a CMHT (or has been discharged from a
CMHT in the last 6 months), all women with a diagnosis of bipolar affective
disorder, history of psychosis or a history of severe perinatal mental ill-
health should be referred to the Perinatal Mental Health Team for pre-
conceptual counselling and / or assessment.
• Prescribing slides provided by Beki Inglis Berkshire Perinatal Pharmacist
Please contact the Berkshire Perinatal Mental Health Team on
0300 365 0300 if you require further advice.
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Takeaway messages
Treat MH disorders across the whole spectrum: Consider a referral to SHaRON for peer support from others who have a shared
experience-no open MH referral needed(media based peer support-referral
made via referral point at CPE)
Refer on to services sooner rather than later i.e. Talking Therapies for
psychological intervention (where presentation is mild to moderate, low risk etc)
– late referrals may mean intervention is not completed or effective prior to
delivery
If the presenting situation is causing concern seek advice from or refer to your
local specialist perinatal mental health service
For women at high risk please offer a referral to the specialist perinatal mental
health service for pre-conceptual counselling/maternity planning
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Takeaway messages
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Consider the risks of not prescribing or not treating MH – the impact/risks
could be higher for the child if the mother becomes unwell. Avoid poly
pharmacy.
If the woman says she is FINE but doesn’t look it just ask again-about 70-
80% of women wont say how they feel or how much they are struggling
Do not wait to see if a suspected psychosis settles-make an urgent referral
to your local (perinatal) MH services 24 hours a day.
Don’t forget the dads – they can experience MH during this time too and
possibly PTSD following traumatic events during pregnancy and birth.
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Referral Options in Berkshire
Mild – moderate MH conditions,
low risk, CBT / Counselling.
Variety of CBT based
interventions
0300 3652000
Perinatal Service
Admission-vulnerable
women, moderate to severe
MH conditions, complex,
higher risk
0300 3650300
Urgent/emergency out of
hours – CRHTT
0300 3659999
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Further opportunities
• If you have a specific interest in the field of perinatal mental health and
wish to be kept informed of any future opportunities that arise to support
training for GPs
• If there are any specific subjects or areas that you would wish to be
covered in training-webinars etc re prescribing/sim training
• Any ideas as to how we can make training opportunities more accessible
for GPs
• Please contact me at:
• Thames Valley Perinatal Lead and Co-Chair of the TVSCN Regional
Perinatal Network
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