Psychiatric Consultation to the SFGH ObGyn Service

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Psychiatric Consultation to the SFGH
Ob/Gyn Service

• Sudha Prathikanti, MD
• UCSF Dept of Psychiatry

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Ob/Gyn Population at SFGH

• Ethnically diverse
  some over-representation of Latinas
• Over 1200 deliveries / year,
  often with significant prenatal morbidities
• SFGH provides prenatal services for patients from
  county jails, BAPAC, homeless clinics

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Ob/Gyn Clinical Sites Within SFGH

• 5M Outpatient Womens Clinic
• Gyn Clinic
• Teen Clinic
• Nurse-midwife Prenatal Clinic
• High Risk (MD) Prenatal Clinic
• 6G Womens Options Clinic
• 6C Labor and Delivery (inpatient)
• 6C Triage Area (outpatient)

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Psych Interface with Hi-Risk OB

• Thursday AM Anna Spielvogel and psych residents
  available in 5M Clinic until noon
• one-stop shopping outpatients coming for
  prenatal care get regular co-follow from Anna
  et al for mental illness or for severe drug
  abuse/psychosocial stressors
• Anna et al hold weekly rounds with OB team and
  keep written log of all active patients
• Formal psych tx plan placed in prenatal chart
• NO automatic follow-up when woman delivers, but
  Anna/residents often available by page and will
  see patient at 2wk postpartum check

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Core Ob/Gyn Knowledge for the Psychiatric
Consultant

• Common Acronyms/Terminology
• Contraceptive Technology
• Conception Technology
• Normal Fetal Development by Trimester
• Evidence of Fetal Problems / Fetal Distress
• Stages of Labor
• HIV Transmission Treatment in Pregnancy
• State Abortion Timelines
• Classification System for Drugs in Pregnancy

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Emergent Consult Questions

• Suicidal or Homicidal Ideation
• Psychosis/ Agitation during Labor/Delivery
• Consider etiology-pain, primapara, drugs, culture
• Use Haldol IM if necessary
• Avoid hypotension!
• Capacity for Medical Decision-making
• Requesting Abortion
• Refusing Vital Procedures (esp fetal monitering)
• Leaving AMA

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Some Non-Emergent Consult
Questions

• Diagnostic issues
• Is this postpartum depression?
  (assuming no suicidal ideation)
• Psychotropic meds during pregnancy/lactation
• Should we stop this womans Paxil?
• Capacity to parent
• Is this schizophrenic woman a fit mother?
• Behavioral treatment plan
• How can we get this woman to stay in bed?
• Outpatient resources
• Ashbury House, Iris Center, BAPAC

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Psych HPI Questionsfor the Pregnant Patient

• Was this a planned pregnancy?
• Was the pregnancy the result of a sexual
  assault/incest?
• When did you first discover you were pregnant?
  What was your reaction?
• Do you know who the father is?
• What has the fathers role been during the
  pregnancy?
• Do you want to carry the baby to term?
• What do you hope will happen after the pregnancy?

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Core Psychiatric Knowledge re
OB/Gyn Patients

• Gender theory
• Societal vulnerabilities for girls/women
• Development thru the life cycle
• Developmental tasks of pregnancy
• Psychiatric disorders
  prepartum, peripartum, postpartum
• Psychotropic medications during
  pregnancy/breastfeeding

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Gender Theory

• Gender identity core sense of femaleness or
  maleness well established by 18 mos
• Gender role conscious expectations and behaviors
  considered appropriate for a given gender in a
  given culture
• Gender personality largely unconscious way of
  relating to world/self/others as a result of
  early attachment experiences (Chodorow -object
  relations theorist)

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Societal Vulnerabilities

• Rape (6-26 lifetime prevalence)
• Only 1/5 raped by stranger
• Stranger rape less likely to lead to other
  injuries
• Incest (12 of girls under 17)
• Domestic Violence (20-30 life prev)
• Almost half of murdered women killed by partners
• Account for large number of ER visits

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Life Cycle

• Menarche
• Reproductive capacity
• Infertility
• Loss of desired pregnancy
• Birth experience
• Menopause

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Tasks of Normal Pregnancy

• Pregnancy key opportunity to revive/ re-work
  core identity, unresolved childhood conflicts
• First Trimester
• Acknowledge pregnancy, decide what to do
• Confidence greatly influenced by own mother
• Confirms femaleness regardless of decision
• Second Trimester
• Assimilate altered body image (fertility vs.
  control)
• Affective bond with fetus can resolve ambivalence
• Third Trimester
• Anticipation vs. dread (pain, health, change in
  role)
• Ambivalence/rejection of fetus can signal serious
  prob

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Psych Disorders and Reproductive Life Cycle

• Much higher risk for mood disorders in the year
  following birth
• Fluid, electrolyte, hormonal shifts?
• Psychosocial stress biologic diathesis?
• Otherwise, no convincing data linking severe
  psych conditions to biological cycle
• Minor depression/anxiety prepartum
• PMDD
• Menopausal depression

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Postpartum Psychosis

• Rare ( 0.1-0.4 ) but severe w/ rapid onset
• Elevated risk up to one year postpartum
• Most significant etiologic factor is genetic
  loading for Bipolar Disorder
• Diff dx Schizophrenia, MDD, drugs
• May involve bizarre delusions re infant
• Must remove from infant until tx complete
• 50 recurrence in later pregnancies

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Postpartum Depression

• Common 20 incidence
• Often undetected due to moms shame
• Gradual onset 2 wks-1 yr postpartum most
  commonly month 3 and month 9
• Same diagnostic criteria as MDD
• Risk of suicide/infanticide rare, but high risk
  of neglect and inadequate parenting
• Recurrence depends on initial severity and
  psychosocial stressors

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Post Partum Blues

• Extremely common (50)
• Considered normal
• NO link to other psych disorders
• Sx appear within days of delivery, peak
  from day 3-7, resolve within 2 wks
• High rate of recurrence provide mom reassurance
  and support

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Medications during Pregnancy

• Traditionally withheld due to fears of
  teratogenicity
• Consider risks of untreated psych illness
• Poor nutrition/low birth weight
• Poor prenatal care
• Precipitous delivery/self-delivery
• Neonatal neglect/abuse

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Psych Meds during Pregnancy

• Review of FDA Classification
• More data emerging re safety of TCAs, some
  SSRIs, high-potency neuroleptics
• Avoid benzos / mood stabilizers in first
  trimester
• Definite teratogenic effects of mood stabilizers
• Lithium- cardiovasc anomalies
• Valproate-neural tube defects
• Carbamazapine-craniofacial anomalies

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Handy References

• Ob/Gyn Basic Knowledge
• HIV and Pregnancy
• Key Textbooks
• Review Articles on Psychopharm
• during Pregnancy and Lactation
• Review Articles on Mood Disorders
• during Pregnancy
• Patient Information
• ReproRisk Database