General

Physicians and other healthcare professionals in primary care have a role in encouraging women who are considering a pregnancy (or who are of childbearing potential) to improve their physical and mental health to improve pregnancy outcomes. Measures include stopping smoking; managing diabetes, hypertension and other chronic conditions well; for obese women, encouraging weight management; and for those using alcohol or illicit substances, addressing those difficulties. If domestic abuse is identified by any healthcare professional, then appropriate referral to domestic abuse services and, if needed, referral to safeguarding services need to occur. In addition, if a woman is the victim of domestic abuse the fact that rates increase in pregnancy and early postpartum should be sensitively explained and that it would be a reason for a safeguarding referral in the perinatal period. Obtaining appropriate support prior to pregnancy needs to occur.

All women of childbearing potential who are prescribed a psychotropic medication should also have a detailed discussion about contraception and be encouraged to use contraception. This is particularly important in women taking mood stabilisers and antipsychotics.

Ideally, mental health disorders should be treated prior to conception so a woman has had a period of stability in her mental health prior to conception. For some medications it may be necessary to consider changing these prior to conception, although this is dependent on the woman’s history and the evidence of the risk posed by her current medication. Women with serious mental illnesses who want to conceive should be offered referral for preconceptual counselling with a perinatal psychiatrist to discuss management of their mental health in pregnancy and postpartum. This discussion should cover the risk of relapse and medication options.

When a woman has received a diagnosis of bipolar disorder for the first time and is in a period of recovery, it is important her mental health team explain the high risk of relapse postpartum, the importance of contraception, planning pregnancies and of having a preconceptual counselling appointment with a consultant perinatal psychiatrist to discuss the management of her mental health in pregnancy and postpartum before she becomes pregnant. Mental health teams that may give a woman a diagnosis of bipolar disorder include mental health inpatient teams, crisis resolution and home treatment teams, community mental health teams or early intervention in psychosis teams. When a person experiences their first episode of psychosis, the common practice in the UK would be to refer the person to the early intervention in psychosis team to provide mental healthcare in the community for three years. Sometimes early intervention in psychosis teams do not give diagnoses as the working diagnosis can change over time as further episodes of relapse occur and there is more information to inform the diagnosis. This means that sometimes women can be referred to a consultant perinatal psychiatrist having experienced at least two episodes of mood disorder that would fulfil the diagnosis of bipolar disorder, but the community mental health team has not yet given the patient that diagnosis. This means that as part of the preconceptual counselling appointment the perinatal psychiatrist will have completed a diagnostic assessment, then have to explain the diagnosis of bipolar disorder and associated perinatal risks, and then go on to discuss prepregnancy care.

Pharmacological

Perinatal psychiatrists should offer preconceptual counselling appointments to women on psychotropic medications considering conceiving. During these appointments the perinatal psychiatrist, having completed a psychiatric assessment, would explain the current evidence regarding the risks of her condition relapsing during the perinatal period with and without medication, and the risks and benefits of medications for her. There would also be information shared around medication options in breastfeeding so that if a woman would like to consider breastfeeding and medication changes are needed to enable that to occur, these changes can be planned prior to conception. The psychiatrist will collaborate with the woman to develop a care plan for her mental health including medication and services to be involved in the perinatal period. Ideally, this consultation would also identify areas where physical health can be improved prior to conception and identify any substance misuse that needs addressing prior to conception.

Antidepressants are the most prescribed psychotropic medication, usually being managed in primary care. The BAP perinatal guidelines [Reference McAllister-Williams, Baldwin and Cantwell18] recommend that if an antidepressant is indicated, the medication used should be one that is known to work for that individual. Prior to conception, reviewing how long the person has been in recovery from their most recent depressive episode and how severe that depressive episode was will help inform whether to continue the antidepressant while the woman tries to conceive and into pregnancy, or whether to slowly reduce and stop it prior to conception.

Antipsychotics, which can also be used as mood stabilisers, increase the risk of gestational diabetes. Risperidone increases the risk of fetal anomalies and lithium increases the risk of cardiac abnormalities. In contrast, lamotrigine does not appear to increase risks above baseline rates. In the past, valproate was used as a mood stabiliser, but NICE guidelines [15] are clear: it should not be prescribed to women of childbearing potential for mental health disorders as it carries a 10% risk of causing neural tube defects and up to a 40% risk of causing neurodevelopmental delay, along with a range of other abnormalities such as the ‘valproate syndrome’. The Medicines and Healthcare Products Regulatory Agency (MHRA) in the UK has advised valproate is not prescribed in women of childbearing potential, but if it is prescribed there must be a current Pregnancy Prevention Programme in place [19]. Carbamazepine is rarely used as a mood stabiliser and should not be used in women of childbearing potential due to an increased rate of neural tube defects. For women on antipsychotics or mood stabilisers considering a pregnancy, a preconceptual counselling appointment with a perinatal psychiatrist is vital to enable an individual care plan that considers the risks and benefits of all options to be considered, including the option of changing medications prior to pregnancy to reduce specific risks to the fetus. For example, for some women on lithium, the increased rates of fetal cardiac defects combined with not being able to breastfeed while taking lithium means a person might choose to change from lithium to a different mood stabiliser prior to trying to conceive.

Psychological

For women who show signs of tokophobia, leading to them avoiding childbirth despite wanting to become a parent, referral for an appropriate psychological intervention prior to pregnancy is important to allow these women the opportunity to overcome their tokophobia and discuss reproductive choices with them. For women with repeated pregnancy losses leading to post-traumatic symptoms or an anxiety disorder, referral for an appropriate psychological intervention rather than waiting for a pregnancy to be established would be helpful. Women considering a pregnancy with current symptoms of mental health difficulties can be encouraged to consider an appropriate psychological intervention to improve their mental health prior to conception. Some women may want to try reducing and stopping psychotropic medication and have a psychological intervention to help them manage their mental health difficulties if they would prefer to avoid psychotropic medication in pregnancy. It will depend on their mental health condition and history of the individual risks of stopping their medication, so this would need to be discussed before changes occur.

General

Obstetricians, general practitioners (GPs), midwives and other healthcare professionals working with pregnant women should take a history that includes asking about current or previous mental health difficulties and identifying any psychotropic medications that a woman is taking. Screening questions can be used to try to increase the identification of mental health conditions in pregnancy such as PHQ-9 or GAD-7 [Reference Dama and Van Lieshout20]. In England, the Whooley questions are routinely used by midwives to screen for possible depressive symptoms [15]. The NICE guideline recommends that at a woman’s first contact with primary care or her booking visit, and during the early postnatal period, healthcare professionals should consider asking the following depression identification questions as part of a general discussion about a woman’s mental health and well-being:

• During the past month, have you often been bothered by feeling down, depressed, or hopeless?

• During the past month, have you often been bothered by having little interest or pleasure in doing things?

It also suggests considering asking about anxiety using the two‑item Generalised Anxiety Disorder scale (GAD‑2):

• Over the last two weeks, how often have you been bothered by feeling nervous, anxious or on edge?

• Over the last two weeks, how often have you been bothered by not being able to stop or control worrying?

Following positive identification on screening questions, referral to specialist mental health services for a diagnostic assessment is required. Assessments by maternity staff would routinely include questions regarding domestic abuse, because in some mental health conditions there is an increased rate of domestic abuse.

The American College of Obstetricians and Gynecologists recommends that all healthcare professionals providing obstetric care should complete a full assessment of mood and emotional well-being including the use of a validated screening tool during the postpartum visit for all patients. If a screening tool for depression and anxiety was used in pregnancy, this tool should be used again postpartum [21].

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) recommends using routine screening tools for depression and anxiety on four occasions – the first as early as possible in pregnancy, the second later in pregnancy, the third 6–12 weeks postnatal and finally one at 1-year postnatal [22].

Women who have a personal history of a mental health condition managed in primary care and/or a family history of a mental health condition in the perinatal period that required secondary mental health services should be referred to specialist services (‘amber flag’ in 2018 MBRRACE report [Reference Knight, Bunch and Tuffnell16]). Thus, healthcare workers caring for women with mental health problems should be aware of the specialist perinatal mental health referral pathways for women who currently have or are at risk of a serious mental illness. Referral pathways need to distinguish routine, urgent and emergency cases. Healthcare workers should consider how current mental health difficulties may impact on the woman’s engagement with the prenatal care service and what those services can do to facilitate improved engagement in prenatal care.

When women present with sudden onset of new symptoms possibly due to mental health difficulties, physical causes need to be investigated first to prevent misidentifying them as mental health conditions. This applies to both prenatal and postnatal periods.

Where there are known risks, fetal and/or neonatal screening and monitoring should be implemented. Discussion with the neonatologist should occur in advance of delivery.

NHS England recommends trauma-informed compassionate care would be expected from mental health and maternity services [23]. A thorough mental health assessment includes taking a personal history and identifying previous traumatic experiences; considering how these might impact on the care needed in the perinatal period is important. Where indicated, a trauma-informed birth plan can be developed with the woman that identifies psychological strengths and coping strategies the woman has along with identifying how services can provide trauma-informed care personalised to her needs.

Finally, it is essential that all healthcare workers caring for women with mental health problems in pregnancy work collaboratively and communicate well with each other. To that end, a written MDPP for women with or at risk of relapse of a serious mental illness should be agreed by 32 weeks’ gestation at the latest. It should be saved in the patient’s records in all relevant healthcare settings (for example, GP surgery, mental health services, maternity services and health visiting records) and a copy provided to the woman, so she also has ready access to it when required.

Pharmacological

Women need to be empowered to make informed decisions about the use of psychotropic medications in pregnancy. The information about medication in the prepregnancy section is also relevant in pregnancy. Prescribers need to keep their knowledge of medications they commonly prescribe to women of childbearing potential updated in relation to efficacy and safety of the medication in pregnancy. Prescribers whose patients contact them stating they are pregnant need to prioritise an appointment for the pregnant woman to discuss her psychotropic medication. If a prescriber wants to confirm the current evidence regarding a specific psychotropic medication in pregnancy the prescriber should contact a perinatal psychiatrist to get information about the medication in pregnancy. Then they can have an informed discussion with the woman. If, having received specialist advice, a general practitioner decides to continue to manage the woman’s mental health, it is important to maintain effective communication with the midwifery team.

Specialist perinatal mental health staff who are prescribers need to maintain their knowledge about medication in pregnancy and lactation. They should also communicate this information in a comprehensible and accessible way to each woman they see, explaining the risks and benefits, thus obtaining informed consent for the final agreed plan. This plan needs to use the lowest effective dose and monotherapy is preferred [Reference Jahan, Went and Sultan14,15,Reference McAllister-Williams, Baldwin and Cantwell18].

As stated above, sodium valproate and semi-sodium valproate should not be prescribed to women of childbearing potential without an effective Pregnancy Prevention Programme and a signed consent form that is reviewed annually. If a woman conceives on sodium valproate this will need to be stopped and urgent specialist advice obtained on what to prescribe as an alternative.

Urgent specialist advice from mental health services for women taking antipsychotics and mood stabilisers should be sought rather than stopping them abruptly, as this carries the risk of relapse. The exception is valproate, which should be reduced and stopped in parallel with seeking urgent specialist advice about alternative medication [Reference McAllister-Williams, Baldwin and Cantwell18].

Psychological

Pregnancy can be a time when women are more motivated to engage in a psychological intervention and they may want to improve their own mental health to impact positively on their parenting. When a woman is seen in pregnancy, along with the use of screening questions, midwives, obstetricians and GPs can also consider discussing a referral for a psychological intervention. The composition of local services and local policies along with the severity of the mental health condition will determine which service would provide that intervention.

General

The prebirth mental health care plan agreed by 32 weeks’ gestation should be shared with all professionals involved in the care of the woman and her baby and should include a plan for labour and delivery. This may include a trauma-informed care plan for women who have experienced past trauma that may be triggered by aspects of maternity care in labour, such as vaginal examinations. For women on the autistic spectrum certain sensory stimuli can be overstimulating and cause distress leading to difficulty managing emotions, so a care plan would provide recommendations on minimising those sensory stimuli.

Clear communication is vital for all women in labour and delivery and even more so for women with current symptoms of mental health disorders. Taking time to explain slowly and carefully benefits everyone involved. Risks should be explained clearly, particularly when women are making what appear to be unwise decisions. In such cases it may be necessary to consider a capacity assessment to see if a current mental health disorder is impacting on the woman’s specific decision-making capability.

General

The prebirth care plan agreed in pregnancy should include a postnatal plan for mental health care which should be followed. The plan may have recommendations about whether the woman needs a side room on the postnatal ward. It should also include an indication of whether the baby can sleep with the mother. The plan should also include a clear plan from mental health services of how a woman’s mental health will be monitored postnatally, including the frequency of face-to-face contacts and whether the woman needs to be seen by mental health staff prior to discharge from the maternity ward. When relapse prevention work has been undertaken with the woman it is helpful to include ‘early warning signs’, namely signs suggestive of relapse, in the care plan so that the woman, her ‘significant other(s)’ (partner or carer) and professionals involved in her care are vigilant for those signs.

Specialist perinatal mental health services use a multidisciplinary approach to providing mental health care with the appropriate clinicians for the individual woman involved in her care. These teams usually include a consultant perinatal psychiatrist, perinatal community psychiatric nurses, perinatal clinical psychologists, occupational therapists and nursery nurses [24]. There may be specialist mental health midwives with additional training in mental health difficulties involved in supporting these women in pregnancy. Specialist perinatal mental health services should work collaboratively with other services involved in the care of the postnatal woman and her baby including the midwife, health visitor and GP. The exact composition of these healthcare professional teams varies between countries. Contact details for accessing mental health services in and out of hours need to be shared with the woman, her partner and all other healthcare professionals involved in her care.

Mental health interventions need to treat both the woman’s mental health disorder and focus on the mother–infant relationship. The baby needs to be ‘held in mind’ by perinatal mental health staff. This includes an assessment of the wisdom of a mother sleeping with her baby.

If an admission to a mental health unit is required before 32 weeks’ gestation it would be to a general adult psychiatric unit. From 32 weeks’ gestation to term, ideally it would be to a specialist psychiatric mother and baby unit. Postnatally, it would normally be to a specialist psychiatric mother and baby unit unless there is a clinical reason for making a different arrangement, such as the infant having been removed from the woman’s care.

Healthcare professionals should know the ‘red flags’ from the 2015 MBRRACE [Reference Knight, Tuffnell and Kenyon17] report that should prompt urgent senior perinatal psychiatric assessment. These are:

• Recent significant change in mental state or emergence of new symptoms.

• New thoughts or actual acts of violent self-harm.

• New and persistent expressions of incompetency as a mother or estrangement from the infant.

It is important to detect sudden changes in mental state, particularly in the early postpartum period when most episodes of postpartum psychosis present. In these circumstances urgent care should be sought from secondary mental health services, which ideally will be the specialist perinatal mental health team. Guidelines for Australia and New Zealand also highlight the need for management of immediate risk for women who are identified as at risk of suicide and recommend an urgent mental health assessment [22].

Women at high risk of relapse should be monitored closely for the first few weeks postpartum. Midwives and health visitors need to know how to raise concerns with the perinatal mental health services if there are changes in the mental health of these women. New onset of acute symptoms that could be due to a mental health cause need to be investigated to exclude organic causes first.

Postnatally, women should be asked about their mental health and their relationship with their baby to identify any concerns and respond appropriately. Women known to have mental health disorders or who are at risk of relapse postnatally of a mental health disorder should have all midwifery appointments in person (‘face-to-face’).

Pharmacological

The birth plan will include information on whether the woman plans to breastfeed or formula feed her baby and whether she can breastfeed or give breast milk when taking specific psychotropic medications. Information on infant observations needed due to the psychotropic medication being taken by the woman needs to be in the care plan.

A clear discussion about the risks and benefits of pharmacological treatment in breastfeeding should have occurred in pregnancy and a subsequent agreed plan for psychotropic medication to be continued postnatally or a new medication started [12,Reference McAllister-Williams, Baldwin and Cantwell18].

General

An MDPP should be developed and implemented for each woman. Of note, a systematic review in 2023 of women’s experiences of care and treatment for perinatal depression identified one theme, namely that women want perinatal-specific care from practitioners with perinatal mental health experience and training [Reference Westgate, Manchada and Maxwell27].

Non-pharmacological

The NICE guideline CR192 [15] recommends that, for mild depressive episodes in pregnancy, the intervention should be psychosocial and not pharmacological. In the UK this would usually be available through NHS Improving Access to Psychological Therapies (IAPT) services and those services should prioritise people in the perinatal period. Cognitive behavioural therapy (CBT) is an example of a psychosocial intervention used in these women. There are other psychosocial interventions recommended by NICE that are offered for mild depressive episodes. There is conflicting evidence that one modality is superior to another although some modalities are easier to evaluate in research studies. One study identified CBT, interpersonal therapy (IPT), mindfulness-based interventions (MBI) and religious-based interventions [Reference Marques, Ihle, Souza, Peralta and de Matos28] as beneficial for depression. IPT was shown to be better than CBT for women with prenatal depression who have experienced childhood trauma [Reference Reuveni, Lauria, Monk and Werner29]. A review of clinical guidelines from 12 different countries found these guidelines supported a psychological intervention such as CBT for mild to moderate depression [Reference Molenaar, Kamperman, Boyce and Bergink30].

The US Preventive Services Task Force recommends counselling interventions for pregnant or postpartum women at increased risk of perinatal depression. The statement concludes that there is moderate certainty that counselling interventions have a moderate net benefit in preventing perinatal depression [Reference Curry31].

Transcranial magnetic stimulation (TMS) might be available in some settings and may be beneficial for treating depression during pregnancy as an alternative to antidepressants or a psychological intervention [Reference Konstantinou, Vigod, Mehta and Daskalakis32]. Electroconvulsive therapy (ECT) is not usually used in pregnancy due to conflicting evidence on the safety for the fetus unless the situation is immediately life-threatening for mother and the infant [15,Reference Rose, Dotters-Katz and Kuller33].

Pharmacological

For moderate and severe depressive episodes prescribing medication in addition to a psychological intervention is usually needed, although some women are anxious about taking medication in pregnancy. There is a good evidence base for the effectiveness of antidepressants in severe depression (see below). The BAP perinatal prescribing guidelines [Reference McAllister-Williams, Baldwin and Cantwell18] recommend continuing the antidepressant that is known to work for the woman unless there are specific risks regarding that antidepressant in pregnancy.

The most prescribed antidepressants are selective serotonin reuptake inhibitors (SSRIs), but tricyclic antidepressants (TCA), serotonin and noradrenaline reuptake inhibitors (SNRIs) and mirtazapine can also be prescribed [15].

A review of clinical guidelines from 12 different countries that included eight perinatal-specific guidelines also supported the use of antidepressants for severe depression, but with a preference for prescribing sertraline and a preference to avoid paroxetine [Reference Molenaar, Kamperman, Boyce and Bergink30]. That paper also highlighted that changing antidepressant for ongoing treatment is discouraged. A detailed discussion should be undertaken with each woman to establish that in general the benefits outweigh the risks when considering prescribing antidepressants in pregnancy [15].

For treatment-resistant depression, combinations of medications may be used, such as an SSRI and low-dose mirtazapine, or an SSRI and low-dose nortriptyline, or an antidepressant and a low-dose antipsychotic, or an antidepressant and a mood stabiliser. Such women should be offered discussions with specialist perinatal psychiatrists to consider these therapeutic options.

Current Evidence for Prenatal Use of Antidepressants

Tricyclic antidepressants have been prescribed since the late 1950s and there have been no concerns over the use of amitriptyline, clomipramine, imipramine or lofepramine in pregnancy. However, prescriptions of TCAs have reduced since the 1990s, whereas SSRIs prescriptions for depression increased after the NICE guidelines recommended using SSRIs as a first-line treatment. This means that more recent meta-analyses have far more data on SSRIs than TCAs.

There have been concerns about SSRIs in pregnancy. Currently the evidence can be summarised as follows:

• It is difficult to separate out the effects of antidepressants from the effects of maternal depression on the fetus.

• There may be a small effect on gestational age [Reference Sujan, Rickert and Oberg34] and on Apgar scores, with babies being born slightly preterm with lower Apgar scores, but these outcomes may be due to confounding factors.

• There have been concerns about SSRIs being associated with an increased risk of cardiac defects in the fetus. However, more recent large studies that adjusted for depression-associated confounders did not find a significant increase in the risk of cardiac defects [Reference McAllister-Williams, Baldwin and Cantwell18].

• There is an increased rate of the diagnosis of postpartum haemorrhage when SSRIs are taken in late pregnancy (aRR = 1.84; CI 1.39–2.44) [Reference Grzeskowiak, Morrison and Henriksen35], although the clinical significance and severity of this is unclear.

• The absolute risk of persistent pulmonary hypertension of the neonate (PPHN) is low. One study reported an increased risk of PPHN with SSRIs with adjusted odds ratio of 1.28 (CI = 1.01–1.64) [Reference Huybrechts, Bateman and Hernandez-Diaz36].

• Poor neonatal adaptation syndrome (PNAS) is a risk with SSRIs and SNRIs that is probably dose-related and appears to be a little worse with SNRIs. Usually, it resolves spontaneously, but at times symptomatic treatment is required [Reference Grigoriadis, VonderPorten and Mamisashvili37].

• There is an increased risk of admission to the neonatal intensive care unit (NICU) when antidepressants are used in late pregnancy (aOR = 1.6, CI = 1.5–1.8) [Reference Norby, Forsberg and Wide38].

• Autistic spectrum in the offspring is probably not associated with antidepressant use prenatally. Any reported link is probably due to confounding factors [Reference Vega, Newport and Bozhdaraj39,Reference Ames, Ladd-Acosta and Fallin40].

• There is no evidence of an increased risk of attention deficit hyperactivity disorder (ADHD) in offspring exposed to antidepressants in utero [Reference Sujan, Rickert and Oberg34,Reference Ames, Ladd-Acosta and Fallin40].

• There is no evidence of an increased risk of behavioural problems at age 7 in children whose mothers took antidepressants prenatally [Reference Grzeskowiak, Morrison and Henriksen41].

General

These are addressed in the ‘General approach to management of women with mental health problems in pregnancy’ section above.

Non-pharmacological

The level of supervision needed immediately after delivery if the woman is severely depressed and at risk of neglecting the baby. After delivery, the baby needs the normal neonatal examination and vigilance for any effects of maternal medications. They may show signs of PNAS but there is no specific guidance on how long the baby needs to remain in hospital. The baby should be feeding well before discharge.

Pharmacological

The MDPP should include a strategy for medication through labour, delivery and the immediate postpartum period, including the decision to start an antidepressant immediately after delivery if the woman does not want to start medication in pregnancy. Neonatologists should be informed of patients delivering on medications that can affect the newborn. This should also be in the care plan.

General

The MDPP should include the postnatal period. When managing depression in the postnatal period it is important to consider the baby and the whole family unit, as depression can impact on mother’s interaction with her infant, which in turn can impact on attachment of the infant to the mother [15].

Non-pharmacological

Psychosocial interventions such as CBT or compassion-focused therapy (CFT) are offered alongside medication. The evidence for these is discussed in the prenatal section for depression above. For a moderate or severe depressive episode care would usually be provided by the specialist perinatal mental health service using a multidisciplinary team (MDT) approach using a biopsychosocial approach to seek to address the multiple factors involved.

For severe depression, if there are imminent risks to mother and/or infant, then admission to a specialist psychiatric mother and baby unit may be necessary. In cases of severe depression ECT may be required [Reference Rose, Dotters-Katz and Kuller33].

Pharmacological

If a depressive episode occurs postnatally, the treatment will be dependent on its severity and any risks involved (see above for further details on treating depression). For a new onset of depression postnatally where a woman is breastfeeding, sertraline is commonly the preferred treatment due to it having the lowest relative infant dose (RID). The recommendation is if a medication has a RID of less than 10% of maternal plasma levels then it can be used in breastfeeding. British Association of Psychopharmacology perinatal guidelines also recommend for women who have had antidepressants in the past using a medication that is known to be beneficial.

For preterm infants, whose mothers are taking antidepressants postnatally, there needs to be a conversation between neonatologists and perinatal psychiatrists to discuss the use of expressed breast milk. A plan should be agreed on a case-by-case basis.

In the United States, zuranolone has recently been licensed for postpartum depression. It is an oral medication that is a ‘positive allosteric modulator of synaptic and extrasynaptic GABA_A receptors and neuroactive steroid’ [Reference Deligiannidis, Meltzer-Brody and Maximos42]. This is an exciting novel treatment that has been developed from intravenous infusion of brexanolone, which was demonstrated to be clinically effective but expensive and difficult to use in day-to-day clinical practice [Reference Jarman, MacLean, Barron, Wightman and McGregor43]. The research into this novel group of medications has also suggested there are inflammatory pathways involved in postpartum depression and this group of medications leads to a reduction in TNF-α and IL-6 [12].

Diagnosis of Bipolar Disorder [25]

Bipolar disorder is usually subdivided into bipolar disorder type 1 and bipolar disorder type 2.

Bipolar disorder type 1 requires one episode of mania with or without psychotic symptoms plus another mood disorder episode (which could be either hypomania or mixed affective, or depression or psychotic depression).

Bipolar disorder type 2 requires one episode of hypomania or mixed affective episode and one other mood disorder episode that is not mania (usually a depressive episode).

ICD-11 [25] symptoms of mania include:

• Extreme high mood lasting at least one week characterised by euphoria or irritability.

• Increased activity.

• Subjective experience of increased energy.

• Rapid speech or pressure of speech or flight of ideas.

• Racing thoughts.

• Grandiosity.

• Decreased need for sleep (usually sleeping 1–2 hours per 24 hours).

• Distractibility.

• Impulsive and reckless behaviour.

• Labile or irritable affect.

• Severe impairment of functioning, usually requiring admission to psychiatric hospital.

ICD-11 [25] symptoms of hypomania include:

• Persistent mild elated mood or irritability for at least several days.

• Increased activity.

• Rapid speech.

• Racing thoughts.

• Increased self-esteem.

• Increased libido or sociability.

• Decreased need for sleep.

• Distractibility.

• Impulsivity.

• Marked impairment of functioning but not to the extreme of mania and not requiring hospital admission.

A mixed affective episode has a combination of some symptoms of hypomania and some depressive symptoms.

Of all mental health disorders, bipolar disorder has the strongest link to postpartum psychosis, with most episodes of postpartum psychosis being the first presentation of bipolar disorder or a relapse of bipolar disorder. There is a strong heritability of bipolar disorder (approximately 80%), so family history is important in considering the risk of relapse postpartum. Risk of relapse overall postpartum for women with a diagnosis of bipolar disorder is 37% (CI 29%–45%) [Reference Wesseloo, Kamperman and Munk-Olsen11]. This relapse rate is of any episode of bipolar disorder postpartum. Prophylactic medication reduces the relapse rate from 66% (CI 57%–75%) without any prophylactic medication to 22% (CI 14%–37%) [Reference Wesseloo, Kamperman and Munk-Olsen11]. This information needs to be discussed with women in the prepregnancy, prenatal and postnatal periods to assist them in making informed decisions about family planning and management of their bipolar disorder in the perinatal period. Table 3 summarises these data.

A study looking at women with a diagnosis of bipolar disorder and the risk of relapse after their second delivery when stratified against their relapse following their first delivery suggests that women are more likely to have a similar relapse after their second delivery to the relapse after their first delivery (see Table 4). This further highlights the importance of prophylactic medication for women with bipolar disorder who had a severe relapse after their first delivery.

Maternal Risks

Risks can vary depending on whether the woman is in recovery or what type of relapse the woman is experiencing. These risks include:

• Increased risks of adverse outcomes in pregnancy including increased rates of induced labour or planned caesarean section (odds ratio = 2.12, 95% CI = 1.68–2.67). The risk of preterm birth is increased by 50% and there is an increased risk of antepartum haemorrhage [Reference Boden, Lundgren and Brandt45].

• Disengagement with maternity services.

• Discontinuation of medication leading to relapse or further deterioration.

• Disinhibition and recklessness leading to alcohol use or substance misuse or a vulnerability to exploitation by others or an increased risk of assaulting others.

• Suicide when severely depressed.

• Accidental death when manic.

• The medications normally used in the management of bipolar disorder including olanzapine and quetiapine have risks including metabolic syndrome, weight gain, gestational diabetes, prenatal and delivery risks associated with obesity and gestational diabetes.

• Impact on wider relationships and relationship breakdown.

Fetal/Neonatal Risks

These are:

• Increased risk of placental abnormalities, lower Apgar scores, 50% increased risk of preterm delivery and increased risk of infants being small for gestational age [Reference Boden, Lundgren and Brandt45].

• Prenatal maternal relapse leads to increased dosage of medications prenatally.

• Some medications used to treat bipolar are associated with an increased rate of fetal anomalies (see below for further details).

• Risks of neglect if the mother is severely depressed, manic, or hypomanic.

• Risk of infanticide if the mother has psychotic symptoms as part of severe depression or mania, although this is an extremely rare outcome and is far rarer than completed suicide [Reference Spinelli46].

Management Options

The ‘General approach to management of women with mental health problems in pregnancy’ above applies to women with bipolar disorder. Below are the additional specific management considerations regarding management of bipolar disorder.

Epidemiology

Postpartum psychosis

• Occurs in 1 in 500–1,000 maternities.

• Has a relapse risk after a subsequent delivery with a previous episode of postpartum psychosis of 33% (22–42%) [Reference Wesseloo, Kamperman and Munk-Olsen11].

• Is at greater risk with a personal or family history of bipolar disorder.

• Is more common in first pregnancies and in women having their first baby with a new partner.

Symptoms

These are:

• Hallucinations

• Delusions

• Affective symptoms – either symptoms of mania or depression or mixed affective symptoms

• Disturbed or bizarre behaviour

• Confusion

• Perplexity

• Fearfulness

Presentation

Most women report onset of symptoms within the first few days postpartum and the majority have presented to health services within a month postpartum. In practice, the maternity services are likely to be the services that women or their partners first present to or contact reporting possible psychotic symptoms. Women may present initially with being overtalkative (or the overuse of digital messaging systems), overactive, not sleeping when the infant sleeps, perplexed and having new, rapidly changing emotions (‘labile affect’) that are not in keeping with the normal emotional changes seen postpartum.

Maternal and Fetal Risks

These are:

• Maternal suicide

• Injury of mother due to disturbed behaviour

• Injury of infant due to disturbed behaviour

• Maternal self-neglect

• Risk to infant due to decrease in mother’s level of functioning

• Neglect of infant

• Relationship breakdown

Management Options

The ‘General approach to management of women with mental health problems in pregnancy’ above applies to women with postpartum psychosis. Below are the additional specific management considerations regarding management of postpartum psychosis.

Labour and Delivery

Postnatal

Epidemiology

The median prevalence of schizophrenia is 4.6 per 1,000 with no gender difference but a higher prevalence in immigrants [Reference Bhugra61]. There is limited information on relapse rates of schizophrenia postpartum [Reference Jones, Chandra, Dazzan and Howard62].

Risks [Reference Bhugra61]

Maternal risks are:

• Deterioration of the condition.

• Self-neglect.

• Suicide with an increased risk soon after resolution of a psychotic episode and the return of insight.

• Risk of harm to others when psychotic, although the risk of suicide is five times higher than risks of homicide.

• Lack of engagement with maternity care.

• Lack of engagement with mental health services.

• Smoking, obesity, metabolic syndrome (a side effect of some antipsychotics), diabetes, lack of exercise, substance misuse and alcohol use are all higher in people with schizophrenia, which will impact on pregnancy outcomes.

• Later presentation for prenatal care.

• Delayed recognition of labour.

• Increased risk of gestational diabetes, gestational hypertension, pre-eclampsia, domestic abuse and social adversity.

Risks for the fetus/infant are [Reference Vigod, Kurdyak and Dennis63]:

• Any maternal risks that impact on the fetus (gestational diabetes, hypertensive disease, maternal drug treatment).

• Fetal growth restriction (some of this risk is due to self-neglect leading to poor diet and failure to seek appropriate medical care in pregnancy).

• Clozapine reduces fetal heart rate variability [Reference McAllister-Williams, Baldwin and Cantwell18].

• The neonate may be sedated due to sedating antipsychotics, which can impact on neonate feeding sufficiently leading to weight loss.

• The neonate can experience withdrawal symptoms from antipsychotics. The exact symptoms will depend on the antipsychotic and the dose, they may be like neonatal adaptation syndrome seen with some antidepressants.

• The neonate can experience extrapyramidal side effects at birth if they are a side effect of the antipsychotic the mother is taking (commonly typical antipsychotics and risperidone), but these are usually transient and resolve spontaneously.

• Neglect of the infant.

• If delusions involve the infant, then there is an increased risk of harm to infant. Infanticide is very rare, and rates are hard to quantify [Reference Spinelli46].

• Negative symptoms impact on the mother–infant relationship and child development.

• Evidence of the long-term neurodevelopmental outcomes of infants exposed to antipsychotics in utero is limited [Reference McAllister-Williams, Baldwin and Cantwell18].

Management Options

The ‘General approach to management of women with mental health problems in pregnancy’ above applies to women with schizophrenia. Below are the additional specific management considerations regarding management of schizophrenia.

Risks for the Woman

Risks depend on the specific anxiety disorder and what the woman avoids due to her anxiety disorder. For example, if she has a needle phobia, she might decline all blood tests during pregnancy with the associated risks. If she has agoraphobia, she might not leave the house and so might not engage in antenatal care. If she has had a previous traumatic delivery leading to PTSD, she might avoid hospitals, which will impact on maternity care.

Risks for the Fetus/Infant

• Prenatal maternal anxiety and stress is associated with increased risk of the offspring having anxiety disorders, depression, ADHD and conduct disorders. One hypothesis is that the hypothalamic pituitary adrenal axis may, in some way, play a role in how maternal stress impacts on fetal brain development [Reference Lautarescu, Craig and Glover66]. However, research into this is limited.

• Women with OCD can have obsessional thoughts that they might sexually abuse their own baby, which would be an egodystonic thought that can lead to a woman not cleaning the infant’s genital area properly. It can also lead to an unhelpful and unnecessary referral to children’s services.

• If a woman with agoraphobia avoids going out, that could impact on her ensuring her infant gets medical care and could impact on the socialisation of the child.

• Comorbidity of anxiety disorders and depression is common so risk factors can be like those of depression.

• Poor neonatal adaptation syndrome can occur in women who are taking SSRIs at delivery, but this is usually self-limiting (see above).

Management Options [Reference Williams and Koleva67,Reference Thorsness, Watson and LaRusso68]

The ‘General approach to management of women with mental health problems in pregnancy’ (above) applies to women with anxiety disorders. Below are the additional specific management considerations regarding management of anxiety disorders.