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Pregnancy Psychological Counseling

Date: May 24,2015   Read: 
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·Postnatal mental health problems have been focus of attention
·Postnatal depression (PND)-up to 15% of women, public education, screening, effective treatments, support groups
·Puerperal psychosis-long recognised, uncommon, severe
·Suicide the leading indirect cause of maternal death in late pregnancy or following delivery (infanticide)
·Mental health problems during pregnancy relatively neglected
·Why is mental health care in pregnancy important?
·Frequency of mental health problems in pregnancy
·Effects of mental health problems in pregnancy
Prevalence of psychiatric disorders
·National Survey of Mental Health and Wellbeing 2007 (12 month prevalence)-women
·Any mental disorder 22.3%
·Anxiety disorder 17.9%
·Mood disorder 7.1%
·Substance abuse disorder 5.1%
·Low prevalence disorders
·Psychosis 0.5%
·Bipolar disorder 1-2%
Depression during pregnancy
·Depressive symptoms are common during pregnancy, peak during T3 and fall following delivery
·25% have high rates of depressive symptoms,
·10% have depressive disorder during pregnancy
·Recurrent major depression
·Bipolar disorder
·New onset antenatal depression
Impact of untreated depression in pregnancy
·Morbidity associated with depression
·Lack of enjoyment, loss of interest and motivation
·Fatigue, sleep disturbance, weight loss
·Poor self-care and poor compliance with antenatal care
·More likely to smoke and to use alcohol or illicit drugs
·Social, occupational and financial effects
·Effect on interaction with partner and other children
·Risk of self-harm and/or suicide
·Increased risk gestational hypertension
·2.5 fold increase risk for preeclampsia
·Increased rate of spontaneous abortion
·Foetus of depressed mother
·Spends more time in sleep and exhibits less body movement than foetus of non-depressed mother
·Reduced foetal heart rate response to vibroacoustic stimulation
·Increased frequency of intrauterine growth retardation (<2500g)
·Increased rates of spontaneous preterm birth (< 37 weeks gestation)-risk increases with increasing severity of depression
·Smaller head circumference, lower APGAR scores, admission to NICU, and small for gestational age(<10th percentile)
·Cry excessively, and difficult to soothe
·Poor motor ability, less active, more lethargic and more withdrawn than is typical for their age
·Poorer performance during examination
·Less expressive
·Less motor tone, lower activity levels, more irritability, less robustness and less endurance during the examination
·Physiologically less developed
·Greater  relative right frontal EEG asymmetry (due to reduced left hemisphere activation)
·Lower vagal tone
·Have elevated baseline cortisol levels
·Poor maternal infant bonding in utero with later effects on attachment and bonding between mother and infant
·Poorer long term developmental outcomes for the child
·Developmental delay measured at 18 months
·Impaired language development
·Lowered IQ in adolescence
·Psychopathology in children
·Increased risk of behavioural and emotional problems
·Significant association with criminality
Anxiety during pregnancy
·Peak age of onset of anxiety disorders in women occurs in mid- to late-20s
·Panic disorder and GAD prevalence unchanged in pregnancy
·Onset of OCD commonly pptd by pregnancy
·PTSD may follow invasive medical procedures, O&G procedures
Impact of untreated anxiety in pregnancy
·Morbidity associated with anxiety
·Worry, restlessness, irritability fatigue
·More likely to smoke and to use alcohol or illicit drugs
·Commonly associated depression
·Social, occupational and financial effects
·Effect on interaction with partner and other children
·Risk of self-harm and/or suicide
·Increased risk of pre-eclampsia
·Foetus of anxious mother
·Evidence of increased arousal of foetus- alterations of foetal heart rate variability (a marker for foetal distress), foetal movement patterns and foetal sleep-wake cycles
·Increased frequency of intrauterine growth retardation (<2500g)
·Increased rates of spontaneous preterm birth (< 37 weeks gestation)
·Found to be highly reactive, irritable and difficult
·Have poorer interaction with mother
·Poorer performance on Bayly Scales of Infant Development
·Physiological differences
·Greater relative frontal EEG activation
·Lower vagal tone
·Spend more time in deep sleep and less time in quiet and active alert states
·Poorer performance during examination
·Lower motor organisation and autonomic stability
·Regulation problems at the cognitive, behavioural and emotional levels
·At 24 months infants have more sleeping, activity and feeding problems
·At age 4yo and 7yo- increased rate of emotional and behavioural problems
·At age 8-9yo- increased rate of ADHD, externalising problems and anxiety
·Up to 14-15yo increased behavioural disorders
·Adolescents- impulsive behaviour when performing computerised cognitive tasks; lower scores on intelligence subtests
Mechanisms by which antenatal stress may affect the foetus
·Cortisol thought to play a key role
·Maternal stress hormones, esp cortisol are transmitted across the placenta
·May be down regulation of 11β-HSD2 activity in the placenta, so more cortisol crosses from maternal to foetal blood
·Alteration of uterine blood flow
·Acute- due to increase in noradrenaline
·Chronic-due to failure in placental trophoblastic invasion in early pregnancy
What can we do about it?
·If mother is stressed in pregnancy, the outcome for the child is influenced by
·Timing of the stress – different regions of the brain develop at different times
·Nature of the stress
·Genetic vulnerability of mother and child
·What happens in the post-natal period
Interventions need to start in pregnancy
·Early interventions have greater potential for gain- especially in utero/early infancy when neuroplasticity is greatest
·Screen for emotional problems
·Tailored interventions
·Reducing anxiety/stress in pregnancy may prevent effects in children

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