Management of women with psychosis during pregnancy

Abstract

It is increasingly recognised that many women with psychotic disorders have children 1,2 and that pregnancies of these women are high-risk. Psychotic disorders increase the risk of stillbir th and infant mortality 3 and can affect a woman's ability to care for herself and her infant. 4 Although women with psychoses are less fertile than the general population, 5 partly as a result of hyperprolactinaemia secondary to antipsychotic drugs, the increasing use of newer atypical drugs such as clozapine and olanzapine, which do not have this effect, is likely to lead to a rise in fertility, particularly in women with affective psychosis. 5 Women come into contact with many healthcare professionals during pregnancy and there are therefore many potential opportunities for prevention or attenuation of these risks. The challenge for health workers caring for women who are pregnant is how to ensure mental health problems are recognised and adequately treated. The NICE guideline on antenatal and postnatal mental health (2007) 6 recommends that at a women's first contact with services in the antenatal period, healthcare professionals should ask about past or present severe mental illness, previous treatment by a psychiatrist/specialist mental health team, including inpatient care, and a family history of perinatal mental illness.There is evidence from North America that women with psychotic disorders may start antenatal care later than controls and that women with mental health disorders receive poorer prenatal care. 7,8 Good liaison between services is therefore essential; healthcare professionals need to ensure that adequate systems are in place to ensure continuity of care and effective transfer of information. If a patient in contact with psychiatric services becomes pregnant, psychiatric services need to support the patient in engaging with primary care (including health visitors and community midwives) and obstetric services as early as possible in the pregnancy and liaise closely about the multidisciplinary care plan for the pregnancy and postnatal period. Risk of complications of pregnancyAll pregnancies carry risk, particularly to the fetus, with a base rate of obstetric risk and risk of congenital malformation of between 2 and 4 per cent. Patients with schizophrenia are at increased risk of impaired glucose tolerance and incident diabetes, 9 particularly if they are taking cer tain atypical antipsychotic drugs. 10 They are therefore at high risk of gestational diabetes. Women with psychotic disorders are also more likely to abuse substances, smoke and consume alcohol during pregnancy. 11,12 It is clear from a number of systematic reviews that women with psychotic disorders are at increased risk of obstetric complications 12,13 and stillbirths, 3 though these findings may be explained by confounding factors such as smoking, substance misuse, socioeconomic status, genetic susceptibility, poorer antenatal care, or possible effects of psychotropic medication. Risk of relapse during pregnancy and postpartumWhen counsell...

Atención obstétrica a mujeres diagnosticadas de esquizofrenia

“…Los resultados obstétricos están determinados por la enfermedad en sí misma y su sintomatología, el tratamiento médico, los factores de riesgo propios de un estilo de vida no saludable y otros problemas médicos concomitantes no reconocidos. Dada la coexistencia de factores, no se pueden atribuir ciertos resultados únicamente al empleo de psicofármacos 26 .…”