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Mental Illness and Pregnancy

1 Contact Hour
This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Saturday, June 11, 2022
Outcomes

≥90% of participants will understand how to care for the pregnant woman with mental illness.

Objectives

After completing this continuing education course, the participant will be able to:

  1. Identify what mental illness during pregnancy is.
  2. List signs and symptoms of mental illness during pregnancy.
  3. Prioritize treatment for patients with mental illness during pregnancy.
  4. Identify risks and complications of mental illness during pregnancy.
  5. Plan nursing care for the woman with mental illness during pregnancy.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Kelly LaMonica (DNP(c), MSN, RNC-OB, EFM)

Background

It is estimated that as many as 20% of all women experience mood or anxiety disorders during pregnancy.1 Nurses caring for these women must know signs, symptoms, and treatments for mental illness during pregnancy. Some women may experience mental illness for the first time during pregnancy or after pregnancy. These women need to consult a specialist about their mental illness while pregnant. Medications may prevent relapse.

Types of Mental Illness During Pregnancy

During pregnancy, several types of mental illness occur, such as depression, anxiety, and bipolar disorder. Postpartum depression and psychosis are types of mental illness that can occur after delivery. Other types of psychiatric disorders that may exist in women who get pregnant are schizophrenia, drug addiction, and eating disorders. Depression and anxiety are the most common psychiatric disorders during pregnancy.

Signs and Symptoms

Depression

Prenatal depression may often be overlooked. Prenatal depression, anxiety, and stress are most frequently seen in the third trimester of pregnancy.2 Women with depression are less likely to seek treatment while pregnant than while not pregnant. Patients with depression may experience a depressed mood, loss of interest in most activities, insomnia or hypersomnia, change in appetite, agitation, low energy, poor concentration, feelings of guilt, or recurrent thoughts of death.3 Mild to moderate depression is diagnosed with five or six symptoms, and severe depression is diagnosed with seven to nine symptoms. Pregnancy can make some of the symptoms difficult to identify because appetite or sleep may be affected by pregnancy.

Anxiety

Anxiety may be observed with or without depression. Anxiety is the most common issue. People with anxiety disorders frequently have intense, excessive, and persistent worry and fear. Panic attacks are repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes. These feelings of anxiety and panic can interfere with daily activities and are difficult to control.4

Bipolar

Bipolar disorder is characterized by episodes of mania, hypomania, and depression. Rates of postpartum relapse in women with bipolar disorder range from 32 to 67 percent. Perinatal episodes of the disorder tend to be depressive.5

Risks and Complications

Depression

There are risks to the mother and fetus for a woman who experiences depression and does not receive treatment. Suicide is a risk. Poor appetite can lead to poor nutrition, poor weight gain, weight loss, or cognitive impairment. Poor nutrition can lead to poor prenatal care and poor fetal outcomes. Psychosis, catatonia, and substance abuse may be associated with depression.

Anxiety

Anxiety and stress during pregnancy are associated with spontaneous abortion, preterm delivery, and delivery complications, although a direct causal relationship has not been established.4

Bipolar

Patients with bipolar disorder are at risk for suicidal or homicidal ideation, aggressive behavior, psychotic features, poor judgment, and impaired social functioning. Bipolar is a serious disorder that can cause harm to the mother or fetus; this requires closed supervision and possible hospitalization.5

Treatment

Depression

Selective serotonin reuptake inhibitors (SSRIs) late in pregnancy have been associated with transient neonatal complications. The potential risks associated with SSRI use must be weighed against the risk of relapse if treatment is discontinued. Treatment with SSRIs during pregnancy should be individualized and should ideally be discussed before pregnancy. Paroxetine (Paxil®) should be avoided by pregnant women and women who plan to become pregnant. If a woman gets pregnant while on Paxil®, fetal echocardiography should be considered. Abrupt discontinuation of this drug can be associated with withdrawal symptoms and a high rate of relapse, so a treatment plan should be followed.6 Dosage should be optimized by the provider, and multiple or different medications may be needed. Electroconvulsive therapy (ECT) can be used during pregnancy for depression that does not respond to medication.

Anxiety

The use of benzodiazepines in women with anxiety disorders does not carry significant teratogenic risk, although long term use can cause withdrawal symptoms in the newborn.6 Benzodiazepines should not be used for longer than two weeks near term. Cognitive therapy may be useful.

Bipolar

The use of lithium during pregnancy has been associated with congenital cardiac malformations, fetal and neonatal cardiac arrhythmias, hypoglycemia, premature delivery, and other adverse outcomes. Long-term consequences have not been found. The decision to discontinue lithium therapy during pregnancy because of fetal risks should be weighed against the maternal risks of the illness. The physiologic changes of pregnancy may affect the absorption, distribution, metabolism, and elimination of lithium, and close monitoring is recommended. Some antiepileptic drugs are used in the treatment of bipolar disorder, including valproic acid (Depakene®), carbamazepine (Tegretol®), and lamotrigine (Lamictal®). Depakene® and Tegretol® have been shown to cause birth defects. Lamictal® is generally considered safe.6

Other Considerations

Schizophrenia

Adverse outcomes in women with schizophrenia include preterm delivery, low birth weight, placental abnormalities, increased rates of congenital malformation, and a higher incidence of postnatal death. If left untreated during pregnancy, schizophrenia can have devastating effects. Atypical antipsychotics are the first-line therapy for psychotic disorders because these drugs are better tolerated and may be more effective in managing the negative symptoms of schizophrenia.6

Eating Disorders

Eating disorders during pregnancy can cause serious complications for the mother, including poor nutrition, dehydration, cardiac irregularities, gestational diabetes, severe depression during pregnancy, premature birth, labor complications, difficulties in nursing, and postpartum depression. There are also serious risks for the fetus, including poor development, premature birth, low birth weight, respiratory distress, feeding difficulties, and other perinatal complications.7 It may be difficult for these women to get pregnant. These women must see a specialist to help manage an eating disorder during pregnancy.

Postpartum Depression and Psychosis

Postpartum depression and psychosis are an important part of nursing when caring for postpartum moms. This is a separate topic and will not be discussed in the activity.

Nursing Care

Women with mental illness need to be treated without bias. These women need education, especially before getting pregnant. Medications should not be stopped abruptly during pregnancy. Ideally, a woman with mental illness should receive preconception counseling to determine her treatment during pregnancy. 

Nurses should counsel women with mental illness to cut down on other commitments when pregnant or caring for a new baby,  avoid getting involved in stressful situations, and avoid drinking alcohol and excessive amounts of caffeine because these can all interfere with sleep.8 It is also essential to teach these women to look for the positive things in life, make time to rest and relax, be open about feelings, ask for help, look for local support groups, and eat well.8

During labor, delivery, and postpartum, the nurse needs to ensure that these women have everything explained to her, to decrease anxiety. These women must know what resources are available to them. They may need home health care, support groups, and follow up psychiatric care.

Case Study

AS is a 24-year-old G1P0 who presents to labor and delivery complaining of regular contractions for the past 6 hours. She is anxious and worried about labor. She has a history of anxiety and severe depression. She was taking Zoloft® throughout pregnancy until 32 weeks when she stopped it because she thought it could harm the baby. She has a flat affect on admission and admits to thoughts of killing herself. 

What is a priority for the RN caring for this patient?

  • It is important to keep this woman safe. Find out if she has a plan to harm herself. Make sure that she is not left alone. She may need 1:1 supervision throughout labor and postpartum. 

What else does this woman need?

  • This woman needs to go back on her medication. She should have a consult with a psychiatrist while in the hospital to determine a plan of care for when she is discharged. She may need social work or home health to help with the infant after discharge.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

References

  1. Psychiatric Disorders During Pregnancy. MGH Center for Women’s Mental Health. Published May 29, 2018. Accessed December 29, 2019. Visit Source.
  2. Parcells DA. Women’s mental health nursing: depression, anxiety, and stress during pregnancy. Journal of Psychiatric and Mental Health Nursing. 2010;17(9):813-820. doi:10.1111/j.1365-2850.2010.01588.x.
  3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
  4. Anxiety disorders. Mayo Clinic. Published May 4, 2018. Accessed December 29, 2019. Visit Source.
  5. UpToDate. Accessed December 29, 2019. Visit Source.
  6. ACOG Practice Bulletin No. 92: Use of Psychiatric Medications During Pregnancy and Lactation. Obstetrics & Gynecology. 2008;111(4):1001-1020. Reaffirmed Obstet Gynecol 2018, 131:185 doi:10.1097/aog.0b013e31816fd910.
  7. Pregnancy and Eating Disorders. National Eating Disorders Association. Published February 22, 2018. Accessed December 29, 2019. Visit Source.
  8. NHS Choices. Accessed December 29, 2019. Visit Source.