week 13 pregnancy and lactatiob

The purpose of this post is to answer the following questions regarding the treatment of depression and bipolar mania in a pregnant female and potential changes to the treatment if the patient was breastfeeding.

1. How would your treatment plan (medications, therapy, etc) change.

 a. For the pregnant female with Depression

Depression treatment aims to effect remission of the major depressive episode so that the patient can return to an optimal level of functioning. However, the treatment of depression in pregnant women is complicated by the question of risk to the infant. As such, their care should include a multi-professional team that preferably includes the primary provider, the obstetrician, a psychiatric provider, and any other providers involved. This ensures that there are communication and collaboration between all the parties which ensures the safety of the mother and unborn child (Grigoriadis, 2020); Molenaar et al., 2018). Also, before any treatment modality is chosen, shared decision-making between the patient and provider should be facilitated so that the patient is aware of the risk versus harm benefits of treatment (Grigoriadis, 2020). The utilization of a screening scale such as the Edinburgh Postnatal Depression Scale, history of past and present symptoms as well as history to help determine the severity of the depression and helps guide treatment modality (Burt, 2016).

 The treatment of depression in a pregnant patient may vary depending on whether this is an initial occurrence and the patient is not on any treatment for it or the patient is already on antidepressants. For patients who experience a first-time depression episode while pregnant, the first line of treatment is structured psychotherapy for mild to moderate depression. Research has shown that cognitive-behavioral therapy (CBT) or interpersonal psychotherapy to be efficacious. Other psychotherapy options are behavioral activation, couples/family therapy, problem-solving therapy, psychodynamic, and supportive therapy (Grigoriadis, 2020). Also, the patients should receive psychoeducation which will teach them about the disease, and about the benefits of self-care, rest, exercise, consistency, sleep hygiene, decreasing stressors as well as reaching out to significant-other or trusted friend/relative for support. This is significant because it helps de-stigmatize depression, reduces feelings of guilt, promotes self-acceptance, and boosts adherence to treatment and self-care. Other treatments, bright light therapy, yoga, acupuncture, and Tai chi may be helpful (Grigoriadis, 2021).

 However, if psychotherapy alone does not reduce depression symptoms, antidepressants may be used to adjunct psychotherapy after the patient has had the opportunity to make an informed decision. The consensus amongst experts in the American Psychiatric Association (APA), American College of Obstetricians and Gynecologists (ACOG), and the United Kingdom National Institute for Health and Care Excellence is that the benefits of antidepressants outweigh the potential risks (Grigoriadis, 2019). In this case, I would prescribe a selective serotonin reuptake inhibitor (SSRI) like Sertraline 25-50 mg by mouth daily. When treatment for major depressive disorder is initiated for the first-time during pregnancy, sertraline is one of the preferred SSRIs (Lexicomp, n.d.b; Molenaar, et al., 2018).

 In patients who are already on antidepressants due to mild to moderate depression, they may choose to discontinue their antidepressants with a gradual taper for safety and instead get psychotherapy if it was not being utilized. Alternatively, after benefits versus risk discussion with their provider, they may choose to stay on their antidepressants except if they are on monoamine oxidase inhibitors (MAOIs) which have been shown to stunt fetal growth in animal studies (Grigoriadis, 2019; Stewart & Vigod, 2021).

Patient Education: Psychoeducation for the patient, significant-other, and family is necessary so that the patient and loved ones understand the disease, signs, and symptoms of worsening such as increased lack of interest in activities and suicidal ideation as well as benefits of reducing stressors and adhering to the chosen treatment plan. Teach the patients about the increased risk for violence against pregnant women and to report any issues in the home that may be exacerbating her symptoms for possible formal social support interventions (Grigoriadis, 2020).

Plan: Check in with the patient weekly to monitor the effects of the medication on her mood initially until her response is stable. I would assess for increasing depression and SI every visit. I would monitor treatment adherence and continue psychoeducation. I would plan to be connected to the patient’s obstetrician and follow the recommended fetus monitoring throughout the pregnancy.

b. For the pregnant female Bipolar Mania?

 Like depression, the management of bipolar mania in pregnancy should be managed in collaboration with the primary care provider as well as the obstetrician and any other health professionals involved with the patient. While medication may not be indicated for some episodes of hypomania, psychotropics are the first-line of treatment for mania. Without adequate and effective management, manic patients can be a danger to others and themselves, this is especially significant in the pregnant patient. Psychotherapy should be added to psychopharmacology as these two combined are more efficacious than medication alone (Hendrick, 2020). I would therefore start this patient on Olanzapine 5 mg by mouth daily, dose may be increased by 5mg/day once a week only if needed (Stahl, 2017). It is an atypical antipsychotic which has been shown to be efficacious in bipolar mania management, is not teratogenic nor has it been linked to stillbirths (Hendrick, 2020). Psychotherapy like CBT and psychoeducation should be offered concurrently with the medication.

Patient Education: The patient should be educated about the risk of weight gain as well as an increased risk for prenatal diabetes. As such, the patient’s weight and blood glucose should be monitored closely throughout and after pregnancy (Lexicomp, n.d.a; Stahl, 2017). Also, these patients should be monitored for suicidal ideation and psychosis and taught to report any of these symptoms to their providers immediately (Hendrick, 2020). The patient should be taught about the benefits of treatment adherence.

Plan: Check in with the patient weekly to monitor the effects of the medication on her mood. I would assess for increasing depression and SI every visit. I would monitor treatment adherence. Provide psychoeducation. I would plan to be connected to the patient’s obstetrician and follow the recommended fetus monitoring throughout the pregnancy.

2. How would this change if the female were lactating?

Depression

SSRIs like sertraline are excreted in breast milk. However, research has shown that there is a minimal to no risk of harm from sertraline exposure to a breastfeeding infant and I would therefore not change this patient’s medication; sertraline is considered the safety SSRI in lactation (Molenaar et al., 2018; Grigoriadi, 2021). I would therefore continue the patient on this medication after a risk versus harm benefits discussion with her.

Patient Education: Patients should be educated about the benefits of adhering to the chosen mode of treatment for their safety as well as that of the child. They should also be educated to report any signs of worsening depression or suicidal ideation immediately to their provider. Patients should be educated to seek and accept support from their loved ones, sleep hygiene benefits, exercise benefits as well as self-care benefits.

Plan: I would see the visit weekly for the first 4 weeks until she is stable. Monitor for SI, psychosis, or depression every visit. Monitor treatment adherence as well as stress and strength of available support system

Bipolar Mania:

Olanzapine has been shown to pause only a minuscule risk if any to the breastfeeding infant in a majority of cases and I would therefore continue olanzapine therapy. Also, it is more efficacious than lithium and quetiapine in mood elevation syndromes (Hendrick, 2020). However, a discussion of infant exposure to the drug, the benefits of breastfeeding to the infant, and the benefits of treatment to the mother should be had with the patient to facilitate informed decision making (Lexicomp n.d.b). For safety, these infants should be monitored weekly for the first month of exposure for side effects of atypical antipsychotics like appetite changes, insomnia, irritability, or lethargy, etc (Lexicomp n.d.b).   The post-partum mother should be closely monitored for any signs and symptoms of psychosis or any suicidal ideation which can increase in BD patient’s post-partum (Hendrick, 2020).

Patient Education: It is imperative that the patient is educated about an increased risk for postpartum depression, psychosis, and SI in bipolar patients postpartum and to report any of the associated symptoms immediately to the provider. The patient should be educated to report any signs of antipsychotic effects on the infant as mentioned above. The patient should be educated about the benefits of adherence to treatment for both her safety and the baby’s, benefits of sleep hygiene (avoiding cell phone use or television 2 hours before bedtime, avoiding caffeinated or sugary drinks in the afternoon, etc.), and the need for adequate rest. The patient should be encouraged to accept assistance and support from the significant -other if applicable, friends and relatives. If there is an inadequate support system, the patient should be connected to local community support groups for lactating mothers, or bipolar mothers (Grigoriadis, 2019; Henrick, 2020). The patient should be provided crisis numbers to call if needed for depression and suicide prevention

Plan: I would see the visit weekly for the first 4 weeks until she is stable. Monitor for SI, psychosis, or depression every visit. Monitor treatment adherence as well as stress and strength of available support system

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References

Burt, V. (2016, July). Regis college library proxy: Login to access databases. https://www-thecarlatreport-com.regiscollege.idm.oclc.org/the-carlat-psychiatry-report/how-evaluate-and-treat-mood-disorders-pregnancy/

Grigoriadis, S. (2019, November 14). UpToDate. https://www.uptodate.com/contents/severe-antenatal-unipolar-major-depression-choosing-treatment?search=depression%20treatment %20in% 20pregnancy &topicRef=1725&source=see_link#H87155478 

Grigoriadis, S. (2020, January 14). UpToDate. https://www.uptodate.com/contents/unipolar-major-depression-in-pregnant-women-general-principles-of-treatment?search=depression %20treatment% 20in%20pregnancy&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3

Grigoriadis, S. (2021, February 14). UpToDate. https://www.uptodate.com/contents/mild-to-moderate-episodes-of-antenatal-unipolar-major-depression-choosing-treatment?search=depression%20treatment %20in%20pregnancy&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H3069899809

 Hendrick, V. (2020, October 9). UpToDate. https://www.uptodate.com/contents/bipolar-disorder-in-pregnant-women-treatment-of-mania-and-hypomania?search=bipolar%20mania%20 treatment& topicRef=679&source=see_link#H87627918

 Lexicomp. (n.d.a).Olanzapine: Drug information.https://www.uptodate.com/contents/olanzapine-drug-information?search=bipolar%20mania%20treatment&topicRef=14647&source=see_link

 Lexicomp (n.d.b). Sertraline: Drug information. https://www.uptodate.com/contents/sertraline-drug-information?search=depression%20treatment%20in%20pregnancy&topicRef=1703&source=see_link#F220669

 Molenaar, N. M., Kamperman, A. M., Boyce, P., & Bergink, V. (2018). Guidelines on treatment of perinatal depression with antidepressants: An international review. Australian and New Zealand Journal of Psychiatry, 52(4), 320–327. https://doi.org/10.1177/0004867418762057

 Stahl, S. M. (2017). Stahl’s essential psychopharmacology: The prescriber’s guide (7th ed.). Cambridge, UK ; New York: Cambridge University Press.

 Stewart, D., & Vigod, S. (2021, February 25). UpToDate. https://www.uptodate.com/contents/antenatal-use-of-antidepressants-and-risks-of-teratogenicity-and-adverse-pregnancy-outcomes-drugs-other-than-selective-serotonin-reuptake-inhibitors?search=depression%20treatment%20in %20pregnancy &topic Ref=89067&source=see_link#H25947019