2182017

1

Mental Wellness Across

the Reproductive Life Span

Guest Presenter

Chris Raines MSN APRN-BCAssistant Clinical Professor

Perinatal Psychiatry ProgramUNC Center for Womenrsquos Mood Disorders

Facilitators

February 15 2017

Jennifer Vickery

Western Regional

Program Coordinator

Brenda Stubbs

Triad Regional

Program Coordinator

Disclosures

bull Neither Brenda Stubbs Chris Raines nor Jennifer Vickery nor their respective partners have relationships with commercial companies that could be perceived as a conflict of interest (within the past 12 months)

bull There will be no discussion of a product that is still investigational or not labeled for the use under discussion

bull Per ACCME Content Validity Value Statements This talk is based on ldquoevidence that is accepted within the profession of medicinerdquo and all materials used ldquoconform to the generally acceptable standards of experimental design data collection and analysisrdquo

bull All materials related to this discussion are not libelous or unlawful will not cause harm or injury and do not infringe on any copyright or other proprietary personal or contractual rights of any other party

bull This webinar training was developed by the North Carolina Preconception Health Campaign a program of the North Carolina Chapter of the March of Dimes

bull It was developed in partnership and collaboration with the UNC Center for Womenrsquos Mood Disorders

bull Special thanks to Chris Raines for her expertise and significant contributions in developing and presenting this webinar training

bull Thanks to Area L AHEC for their support in providing continuing education credit for this webinar

Acknowledgements Housekeeping

bull Obtaining credits

ndash Groups viewing together should email

randersonmarchofdimesorg

bull Asking questions

bull Accessing slides at a later date

Perinatal Mood Disorders

Chris Raines MSN APRN-BC

Assistant Clinical Professor

Perinatal Psychiatry Program

UNC Center for Womenrsquos Mood

Disorders

Objectives

Discuss various mental health issues and

identification of Perinatal Mood Disorders

Review Treatment options for Perinatal Mood

Disorders

Identify local and state resources for referring

mothers who are experiencing mood disorders

with pregnancy

2182017

2

Perinatal Mood Disorders

What do you need to know

What does Perinatal Mood Disorder mean

What are the mechanisms and risk factors

associated with PMD

What are the special problems related to treating

women with perinatal mood and anxiety

symptoms

Assessments Evaluation tools and Treatments

Perinatal Mood Disorders

Depression During Pregnancy

Postpartum Blues (Not considered a disorder)

Postpartum Depression

Anxiety Disorders OCD Panic Disorder PTSD

Postpartum Psychosis

Bipolar Disorder

Perinatal Mood Disorders

Prevalence

40 weeks of pregnancy 184

(7-9 in the general population) 1st trimester 74-11

2nd Trimester 89-128

3rd Trimester 85-120

~ Robinson GE (2012)

Postpartum 10-15 Up to 50-80 increased risk with prior history

Perinatal Mood Disorder

COMMON

10-20 prevalence

4 million women give birth annually in US frac12 million with PPD

Most common unrecognized complication of perinatal period

Compare to prevalence rate of gestational diabetes at 2-5

MORBID

Devastating consequences for patient and family

low maternal weight gain preterm birth

Impaired bonding between mother and infant

Increased risk of suicide and infanticide

MISSED

No practice guidelines or routine screening

Symptoms often different from ldquoclassic DSM-IV depressionrdquoGavin et al Ob amp Gyn 2005 Gaynes et al AHRQ Systematic Review 2005

Normal changes in the HPA axis

during pregnancy and into the

postpartum period

The third trimester of pregnancy is characterized by high estrogen and progesterone levels and a hyperactive HPA axis with high plasma cortisol

At childbirth and during the transition to the postpartum period the following occur

estrogen and progesterone rapidly decline

there is blunted HPA axis activity due to suppressed hypothalamic CRH secretion

Barriers to Diagnosis amp

Treatment

Pregnant Pause May 2009

Vogue Article Slams Antidepressants

During Pregnancy

Study Links Autism With Antidepressant

Use During Pregnancy

2182017

3

ScreeningACOG

Recommendations Clinicians screen at least once during the perinatal period

for depressionanxiety symptoms using a standardized

validated tool

Women with current or a history of mood disorders

warrant close monitoring evaluation and assessment

Screening by itself is insufficient clinical staff in OGGYN

practices need to be prepared to initiate medical treatment

andor refer patient to appropriate behavioral health

resources

Systems should be in place to ensure follow up for

diagnosis and treatment

Screening Instruments

Edinburgh Postnatal Depression Scale (EPDS)

Most commonly employed screening tool

Beck Depression Inventory (BDI)

Montgomery-Asberg Depression Rating Scale

(MADRS)

Hamilton rating Scale for Depression (HRSD)

Nine Symptom Depression Checklist of the

Patient Health Questionnaire (PHQ)

Edinburgh Postnatal Depression Scale (EPDS)12

Ask patient how they have been feeling OVER THE LAST 7 DAYS not just todayTo use calculator click on appropriate answer and score appears in box when all

questions completed

1 I have been able to laugh and see the funny side of things

2 I have looked forward with enjoyment to things

3 I have blamed myself unnecessarily when things went wrong

4 I have been anxious or worried for no good reason

5 I have felt scared or panicky for no very good reason

6 Things have been getting on top of me

7 I have been so unhappy I have had difficulty sleeping

8 I have felt sad and miserable

9 I have been so unhappy that I have been crying

10 The thought of harming myself has occurred to me

Questions 1 2 and 4 are scored in reverse order (0-3)

Edinburgh Postnatal Depression Score = 30

Screening

Reasons for not screening

Donrsquot get paid

No resources

Liability of asking the questions

Barriers and misconception rt treatment

Donrsquot want to see a psychiatrist

Afraid of taking my baby away

Family may see me as crazy or weak

2182017

2

Perinatal Mood Disorders

What do you need to know

What does Perinatal Mood Disorder mean

What are the mechanisms and risk factors

associated with PMD

What are the special problems related to treating

women with perinatal mood and anxiety

symptoms

Assessments Evaluation tools and Treatments

Perinatal Mood Disorders

Depression During Pregnancy

Postpartum Blues (Not considered a disorder)

Postpartum Depression

Anxiety Disorders OCD Panic Disorder PTSD

Postpartum Psychosis

Bipolar Disorder

Perinatal Mood Disorders

Prevalence

40 weeks of pregnancy 184

(7-9 in the general population) 1st trimester 74-11

2nd Trimester 89-128

3rd Trimester 85-120

~ Robinson GE (2012)

Postpartum 10-15 Up to 50-80 increased risk with prior history

Perinatal Mood Disorder

COMMON

10-20 prevalence

4 million women give birth annually in US frac12 million with PPD

Most common unrecognized complication of perinatal period

Compare to prevalence rate of gestational diabetes at 2-5

MORBID

Devastating consequences for patient and family

low maternal weight gain preterm birth

Impaired bonding between mother and infant

Increased risk of suicide and infanticide

MISSED

No practice guidelines or routine screening

Symptoms often different from ldquoclassic DSM-IV depressionrdquoGavin et al Ob amp Gyn 2005 Gaynes et al AHRQ Systematic Review 2005

Normal changes in the HPA axis

during pregnancy and into the

postpartum period

The third trimester of pregnancy is characterized by high estrogen and progesterone levels and a hyperactive HPA axis with high plasma cortisol

At childbirth and during the transition to the postpartum period the following occur

estrogen and progesterone rapidly decline

there is blunted HPA axis activity due to suppressed hypothalamic CRH secretion

Barriers to Diagnosis amp

Treatment

Pregnant Pause May 2009

Vogue Article Slams Antidepressants

During Pregnancy

Study Links Autism With Antidepressant

Use During Pregnancy

2182017

3

ScreeningACOG

Recommendations Clinicians screen at least once during the perinatal period

for depressionanxiety symptoms using a standardized

validated tool

Women with current or a history of mood disorders

warrant close monitoring evaluation and assessment

Screening by itself is insufficient clinical staff in OGGYN

practices need to be prepared to initiate medical treatment

andor refer patient to appropriate behavioral health

resources

Systems should be in place to ensure follow up for

diagnosis and treatment

Screening Instruments

Edinburgh Postnatal Depression Scale (EPDS)

Most commonly employed screening tool

Beck Depression Inventory (BDI)

Montgomery-Asberg Depression Rating Scale

(MADRS)

Hamilton rating Scale for Depression (HRSD)

Nine Symptom Depression Checklist of the

Patient Health Questionnaire (PHQ)

Edinburgh Postnatal Depression Scale (EPDS)12

Ask patient how they have been feeling OVER THE LAST 7 DAYS not just todayTo use calculator click on appropriate answer and score appears in box when all

questions completed

1 I have been able to laugh and see the funny side of things

2 I have looked forward with enjoyment to things

3 I have blamed myself unnecessarily when things went wrong

4 I have been anxious or worried for no good reason

5 I have felt scared or panicky for no very good reason

6 Things have been getting on top of me

7 I have been so unhappy I have had difficulty sleeping

8 I have felt sad and miserable

9 I have been so unhappy that I have been crying

10 The thought of harming myself has occurred to me

Questions 1 2 and 4 are scored in reverse order (0-3)

Edinburgh Postnatal Depression Score = 30

Screening

Reasons for not screening

Donrsquot get paid

No resources

Liability of asking the questions

Barriers and misconception rt treatment

Donrsquot want to see a psychiatrist

Afraid of taking my baby away

Family may see me as crazy or weak

2182017

3

ScreeningACOG

Recommendations Clinicians screen at least once during the perinatal period

for depressionanxiety symptoms using a standardized

validated tool

Women with current or a history of mood disorders

warrant close monitoring evaluation and assessment

Screening by itself is insufficient clinical staff in OGGYN

practices need to be prepared to initiate medical treatment

andor refer patient to appropriate behavioral health

resources

Systems should be in place to ensure follow up for

diagnosis and treatment

Screening Instruments

Edinburgh Postnatal Depression Scale (EPDS)

Most commonly employed screening tool

Beck Depression Inventory (BDI)

Montgomery-Asberg Depression Rating Scale

(MADRS)

Hamilton rating Scale for Depression (HRSD)

Nine Symptom Depression Checklist of the

Patient Health Questionnaire (PHQ)

Edinburgh Postnatal Depression Scale (EPDS)12

Ask patient how they have been feeling OVER THE LAST 7 DAYS not just todayTo use calculator click on appropriate answer and score appears in box when all

questions completed

1 I have been able to laugh and see the funny side of things

2 I have looked forward with enjoyment to things

3 I have blamed myself unnecessarily when things went wrong

4 I have been anxious or worried for no good reason

5 I have felt scared or panicky for no very good reason

6 Things have been getting on top of me

7 I have been so unhappy I have had difficulty sleeping

8 I have felt sad and miserable

9 I have been so unhappy that I have been crying

10 The thought of harming myself has occurred to me

Questions 1 2 and 4 are scored in reverse order (0-3)

Edinburgh Postnatal Depression Score = 30

Screening

Reasons for not screening

Donrsquot get paid

No resources

Liability of asking the questions

Barriers and misconception rt treatment

Donrsquot want to see a psychiatrist

Afraid of taking my baby away

Family may see me as crazy or weak

2182017

4

Integrated Care

Embedding psychiatric providers in OBGYN

Pediatric departments Family Practice and

Birthing Centers

Reduce stigma

Establish rapport

Increase compliance of treatment

Education of non psychiatric providers

Timely response to issues

Can be Proactive not Reactive

Facts

Antidepressant use during Pregnancy

Spontaneous Abortion

Meta analysis of 735 articles on effects of antidepressant

use in pregnancy did NOT reach significance (Ross et al 2013)

Congenial malformations

Multiple studies and meta analysis have show the relative

risk of MCM to be 09 and 107 no different from the

general population

Cardiac malformations

Paroxetine (Paxil) showed increase risk but study was not

able to be replicated

Facts

Effects on Neonate

Prematurity (045 weeks)

Birth weight (lower by 75 grams)

Neonatal Adaptation Syndrome

Persistent Pulmonary Hypertension of the Newborn

Autism Spectrum Disorders

Neurodevelopment of Children

Perinatal Mood Disorders

What do you need to know

Donrsquot all women get emotional during

pregnancy and after they deliver Most women do get emotional and anxious during pregnancy

and in the postpartum period but that is not PMD

What is different about PMD Usually presents as anxiety andor insomnia

Feels different from depression moms have had before

ldquoI have every thing I ever wanted good partner new baby

home what do I have to be depressed aboutrdquo

Meets criteria for Major Depression

Major Depression

Must be present during the same

2 week period

Represents a change from previous

functioning

At least one of the symptoms is either

1) depressed mood

2) loss of interest or pleasure

Major Depression

Five (or more) of nine symptoms

Depressed Mood

Loss of interest or pleasure in almost all activities

Significant weight loss or gain

Insomnia or hypersomnia

Restlessness or feeling slowed down

Fatigue

Worthlessness or inappropriate guilt

Inability to concentrate

Suicidal ideation

2182017

5

Perinatal Mood Disorders

Risk factors

Giving birth is like taking your lower lip and forcing it over your headldquo --Carol Burnett

bull Rapid hormonal changes

bull Physical and emotional stress of birthing

bull Physical discomforts

bull Emotional letdown after pregnancy andor birth

bull Awareness and anxiety about increased responsibility

bull Fatigue and sleep deprivation

bull Disappointments including the birth spousal support nursing and the baby

Perinatal Mood Disorders

Risk Factors Depression or anxiety during pregnancy

Personal or family history of depressionanxiety

Abrupt weaning

Social isolation or poor support

Child-care related stressors

Stressful life events

Mood changes while taking birth control pill or

fertility medication such as Clomid

Thyroid dysfunction

50 to 80 risk if previous episode of PPD

Perinatal Mood Disorders

Risk Factors

Preterm Birth

Risk factors in this population

motherrsquos past psychiatric history

previous perinatal loss

psychosocial support including marital status

severity of the infantrsquos health status

degree of worry amp momrsquos coping skills

rehospitalization after the initial stay

bull (Miles et al 2007 Garel et al 2004 Mew et al

Increased Psychiatric Comorbidity After

Preterm Birth

Correlation between PTSD symptoms and preterm

delivery

Increased PTSD symptoms in women who have had a

ldquotraumaticrdquo birth experience

PTSD and depression are often comorbid

Integrated care is needed between obstetricals mental

health and neonatologypediatrics

ldquoWill allow for the development of innovative

assessment and treatment strategies to help the mother-

infant dyad throughout the difficult first year and

beyond after a preterm deliveryrdquo

bull (Holditch-Davis et al 2003 Rogal et al 2007)

Perinatal Mood Disorders

DepressionPerinatal Depression

Symptoms that are common but may be

different for general depression include Feeling sad irritable hopeless or overwhelmed

Crying spells

Guilty thoughts

Feeling inadequate to take care of your baby

Hypervigilance

Scary thoughts

Preoccupation with thoughts of death

Lack of control

Trouble concentrating

Withdrawal from friends and family

2182017

6

Perinatal Mood Disorders

AnxietyPanicOCDPerinatal AnxietyPanic

Symptoms in Anxiety Panic include

Excessive worry

Shortness of breath

Racing heart

Sweaty or cold clammy hands

Feeling keyed up or on the edge

Dizziness or light headed

Chest tightness

Scary thoughts

Perinatal AnxietyPanic Some of these thoughts can become compulsive

which means they are repetitive

Fear of going crazy or doing something

uncontrolled

Disoriented or that the world has become unreal

Fears of contamination

Fears that no one can take care of the baby like you

can or that someone could do a much better job so

she should just leave

Fears of something bad happening to the baby or

other family members

Perinatal Mood Disorder

Bipolar Disorder

Risk of Recurrence During the Postpartum

Period in Bipolar Disorder

Consistently the early postpartum period is a high risk time period for recurrence of bipolar and other psychiatric illnesses

Rates of relapse (usually a depressive episode) range from 60-80

Bipolar disorder is also associated with postpartum psychosis

Pregnant Women with Bipolar

Disorder Present a complex clinical challenge

Goal is to minimize the risk to the fetus while limiting

the impact of the psychiatric illness on the mother and

her family

Decisions surrounding psychotropic use are difficult

and associated with risks

2182017

7

Postpartum Psychosis Postpartum Psychosis

A rare but devastating condition with an estimated prevalence of 01-02 (one to two per thousand)

Women with Bipolar Disorder risk is 100 times higher at 10 - 20

Psychiatric emergency amp requires immediate treatment with a mood stabilizer amp antipsychotic

Onset usually 2-3 days postpartum

Has a 5 suicide amp 4 infanticide rate

Risk for recurrent episode with subsequent pregnancy is 90

TreatmentPerinatal Mood Disorders

Treatment

One size does not fit all

Critical for the well being of the woman baby and

family

Effective treatments are readily available

Psychotherapy

Medication Management

Other alternative

Skilled assessment and treatment by mental health

professionals in perinatal psychiatry makes a difference

in outcomes

Psychotherapy During Pregnancy

Psychotherapy can be an important form of

treatment of depression during pregnancy and

the postpartum period

Good data available for Cognitive-Behavioral

(CBT) and Interpersonal Psychotherapy during

pregnancy

Requires weekly visits and

motivationcompliance by the patient

Pharmacotherapy in Pregnancy

All psychotropics cross the placenta and none are approved by the FDA for use during pregnancy

Unethical to conduct randomized placebo controlled studies on medication safety in pregnant women

Thus most information about the reproductive safety of of drugs comes from case reports and retrospective studies

Prevalence of SSRIrsquos in pregnancy is 6-8

2182017

8

Risk of Relapse of Major

Depression in Pregnancy

High risk of depressive relapse following antidepressant

discontinuation during pregnancy ( Cohen et al JAMA

2006)

Of 201 women in the sample 86 (43) experienced a relapse

of major depression during pregnancy

Women who discontinued medication relapsed more

frequently (68 vs 26) compared to women who

maintained medication (hazard ratio 50 95 confidence

interval 28-91 Plt001)

Pregnancy is not protective with respect to risk of

relapse of major depression

Medications

What to do

SSRIs (especially fluoxetine and sertraline) and TCAs relatively safe even during first trimester

SSRIs (especially sertraline) and TCAs relatively safe in breast-feeding (Risk of fluoxetine accumulation in breastmilk and TCA-induced seizures

Avoid Paroxetine (unless riskbenefit analysis dictates otherwise)

Insufficient information about newer antidepressants (SNRIrsquos) and trazodone

Bupropion FDA risk category changed from B to C

Adverse Fetal Outcomes associated

with Depression during Pregnancy

Adverse outcomes have been documented in women with

depression during pregnancy

Cohort studies demonstrate that the rate of depression per 1000

deliveries increased significantly from 273 in 1998 to 141 in

2005 (plt0001)

New cohort study shows that depressed women were

significantly more likely to have

Cesarean delivery preterm labor anemia diabetes and

preeclampsia or hypertension compared with women without

depression

Worse fetal outcomes included fetal growth restriction fetal

abnormalities fetal distress amp death

bull Bansil et al 2010 J Womenrsquos Health

Risks of Untreated Antenatal

Depression Associated with low maternal weight gain increased rates of

preterm birth low birth wt increased smoking ETOH and

other substances

Increased ambivalence about the pregnancy and overall worse

health status

Prenatal exposure to maternal stress has consequences for the

development of infant temperament

Children exposed to perinatal maternal depression have higher

cortisol levels than infants of mothers who were not depressed

and this continues through adolescence

Maternal treatment of depression during pregnancy appears to

help normalize infant cortisol levels

Current Use of Antidepressants in the

United States and During Pregnancy

CDC Antidepressant use skyrockets 400 in past 20 yearsmdash

reported Oct 2011

Antidepressants are the most frequently used medications by

people ages 18-44

Nearly one in four women ages 40 to 59 are taking

antidepressants

Less than 12 of those antidepressants had seen a mental-health

professional in the past year

(Data are from the National Health and Nutrition Examination Surveys N=

12637 participants about prescription-drug use antidepressant use length of

use severity of depressive symptoms and contact with a health professional)

2182017

9

Outcome data on Antidepressant

Medications in pregnancy

Intrauterine fetal death -No evidence

Einarson et al (2009) concluded no increased risk of Major Congenital Malformations (MCM) with SSRI use in the 1st

trimester

Growth impairment- Possible for fluoxetine premature birth (143 late 41 early 59 control) low birth weight and length

No differences in cognitive function verbal comprehension expressive language mood arousability activity levels distractibility behavior problems temperament (TCA FLX)

SSRI Discontinuation Syndrome vs Pulmonary HTN of Newborn

Antidepressants Tx in Pregnancy Neonatal

Outcomes

SSRI withdrawal is possible but usually these are transient (restlessness rigidity tremor)

Late SSRI exposure carries an overall risk ratio of 30 (95 CI 20-44) for a neonatal behavioral syndrome -Moses-Kolko et al JAMA 2005

Warburton et al (2010) concluded that when controlled for maternal mental illness severity reducing exposure to SSRI in the last 2 weeks before delivery did not have a significant clinical effect on improving neonatal health

Primary Pulmonary Hypertension

of the Newborn

2006 case control study showed SSRI exposure after 20 weeks gestation increased risk (4-5x higher) of PPHN with absolute risk of lt1 (N England J Med 2006)

Recent studies show increased risk of PPHN with multiple other risk factors and absolute low risk with SSRI exposure

C-section high maternal BMI AA or Asian heritage

Study concluded that large BMI and C-section had greater risk than SSRI exposure (Pediatrics 2007)

Swedish Medical Birth Registerndash 3rd trimester exposure showed increased risk of 24 (Pharmacoepidemiology Drug Safety 2008)

Paroxetine and Pregnancy In 2005 FDA began investigated risks associated with

antidepressant use in pregnant women

Results of Investigation

Infants born to women taking Paroxetine (Paxil) may be at double the risk for cardiovascular birth defects (4) compared to other antidepressants (2)

Sept 2005 US health officials warned against the use of Paxil in the first trimester due to potential birth defects in infants though relationship may be incidental

Further research is necessary involving adequate well-controlled studies to prove the effects of Paxil on the fetus

Risk of Autism with SSRI Use

Croen LA Grether JK Yoshida CK Odouli R

Hendrick V

Antidepressant Use During Pregnancy and

Childhood Autism Spectrum Disorders

Arch Gen Psychiatry 2011 Jul 4 [Epub ahead of

print]

PMID 21727247

Psychotropics Used in the

Treatment of Bipolar Disorder

Lithium

Anticonvulsants-- ldquoOlderrdquo anticonvulsants have

2x higher risk of major birth defects

Valproic Acid

Carbamazepine

Other (newer) anticonvulsants

Lamotrigine

Antipsychotics

2182017

10

Lithium vs Anticonvulsants

LITHIUM

Ebsteinrsquos cardiac malformation

005 risk vs 01 base rate

Neonatal hypothyroidism

Diabetes Insipidus (rare)

Polyhydraminos (rare)

FDA Pregnancy Category D

VALPROIC ACID

Spina bifida (1-5 risk)

Structural defects of the heart limbs and face

FDA Pregnancy Class D

CARBAMAZEPINE

Spina bifida (1 risk)

Structural defects of the face (dysmorphic facies)

Secreted in breast milk

FDA Pregnancy Category C

Newer Anticonvulsants

Limited data is available with the ldquonewerrdquoagents such

as gabapentin lamotrigine oxcarbazepine and

topiramate

Lamotrigine has good safety record to date No

increased risk of birth defects

The benzodiazepines may have increased risk of cleft

lip and palate (07)

All are secreted in breast milk

FDA pregnancy class C

Antipsychotics

Teratogenic risks are probably low with the traditional neuroleptics (Haloperidol is safest)

There is inadequate information available to ascertain risk of newer atypical antipsychotics although safety profile is promising to date

Quetiapine has lowest transmission in breast milk (Stowe et al)

All are secreted in breast milk

FDA pregnancy class C (except for clozaril)

Conclusions Treatment

Perinatal psychiatric illness requires immediate

intervention

Coordination of care between OB-GYN and trained

mental health professionals is critical

Antidepressant medications can be safely used during

pregnancy and lactation

Assess risk of untreated illness versus greater risk of exposure

Chronic mental illness must be treated during pregnancy

to prevent severe PPD

Patients with preexisting psychosis must be treated as a

ldquohigh risk pregnancyrdquo during and after delivery

UNC Center for Womenrsquos Mood

Disorders

Perinatal Psychiatry ProgramClinical and Research Program

that provides assessment treatment and

support for women in the

perinatal period

Collaboration of doctors nurses

midwives

therapists amp social workers

wwwwomensmooddisordersorg

Unit

UNC Perinatal In-patient Psychiatric Unit

2182017

11

Program

Perinatal Inpatient Psychiatry Program provide

Comfort measures

Protected sleep times

Dedicated private and semi-private rooms and group

room

Gliders and supplies for pumpingnursing

Pumps supplies and refrigerator for milk storage

Specialty perinatal nursing staff

Extended visiting hours to maximize positive mother-

baby interaction

Resources

Postpartum Support International

(800) 944-4PPD wwwpostpartumnet

Postpartum Progress Blog

httpwwwpostpartumprogresscomweblog

National Womenrsquos Health Information Center

(800) 994-9662 www4womangov

Motherisk wwwmotheriskorg latest on studies

of medications in pregnancy and lactation

OTIS wwwOTISpregnancyorg

886-626-6847

Thanks bull UNC Psychiatry

bull Dr David Rubinow Department Chair

bull Dr Samantha Meltzer-Brody Director Perinatal Mood Disorder Program

bull Dr Mary Kimmel Medical Director In-patient Unit

bull Brenda Pearson and Katie Melvin

bull UNC OB-GYN bull Dr Kate Menard

bull DrBob Strauss

bull DrAlison Stuebe

bull DrJohn Thorp

Questions

References Andrade SE McPhillips H Loren D Raebel MA et al Antidepressant medication

use and risk of persistent pulmonary hypertension of the newborn Pharmacoepidemiol Drug Saf 2009 Mar18(3)246-52

Gavin N Gaynes B Lohr K Meltzer-Brody S et al 2005 Perinatal depression a systematic review of prevalence and incidenceObstet Gynecol 1061071-83

Cohen L Altshuler L Harlow B Nonacs R 2006 Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment JAMA 295(5)499-507

Chambers C Hernandez-Diaz S VanMarter L Werler M 2006 Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn N Engl J Med 354(6)579-87

Delatte R Meltzer-Brody S Cao H Menard K 2009 ldquoUniversal Screening for Postpartum Depression An Inquiry into Provider Attitudes and Practice American Journal of Obstetrics and Gynecology 200(5)e63-4

Einarson A Choi J Koren G 2009 Incidence of major malformations in infants following antidepressant exposure in pregnancy results of a large prospective cohort study Canadian Journal of Psych 54(4)242-6

McKenna K Koren G Tetelbaum M Wilton L et al 2005 Pregnancy outcome of women using atypical antipsychotic drugs A prospective comparative study J Clin Psychiatry 66444-449

References Meltzer-Brody S Payne J Rubinow D 2008 Postpartum Depression Evolving

Etiology amp Treatment Considerations Current Psych 7(5)87-95

Meltzer-Brody S Hartmann K Miller W Scott J 2004 A brief screening instrument to detect posttraumatic stress disorder in outpatient gynecologyObstet Gynecol104(4)770-776

Oberlander TF Warburton W Misri S et al 2006 Neonatal Outcomes After Prenatal Exposure to Selective Serotonin Reuptake Inhibitor Antidepressants and Maternal Depression Using Population-Based Linked Health Data Arch General Psychiatry 63898-906

Sit D Rothschild A Wisner K 2006 A Review of Postpartum Psychosis Journal of Womenrsquos Health 15(4)352-368

Viguera A amp Cohen L 1998 The course and management of bipolar disorder during pregnancy Psychopharmacology Bulletin 34339-353

Viguera A Cohen L et al 2002 Managing bipolar disorder during pregnancy weighing the risks and benefits Can J Psychiatry 2002 Jun47(5)426-436

Webb R Abel K et al 2005 Mortality in Offspring of Parents with Psychotic Disorders A Critical Review and Meta-Analysis Am J Psych1621045-1056

Yonkers K Wisner K Stowe Z et al 2004 Management of Bipolar Disorder during pregnancy and the postpartum period Am J Psychiatry161608-620

2182017

5

Perinatal Mood Disorders

Risk factors

Giving birth is like taking your lower lip and forcing it over your headldquo --Carol Burnett

bull Rapid hormonal changes

bull Physical and emotional stress of birthing

bull Physical discomforts

bull Emotional letdown after pregnancy andor birth

bull Awareness and anxiety about increased responsibility

bull Fatigue and sleep deprivation

bull Disappointments including the birth spousal support nursing and the baby

Perinatal Mood Disorders

Risk Factors Depression or anxiety during pregnancy

Personal or family history of depressionanxiety

Abrupt weaning

Social isolation or poor support

Child-care related stressors

Stressful life events

Mood changes while taking birth control pill or

fertility medication such as Clomid

Thyroid dysfunction

50 to 80 risk if previous episode of PPD

Perinatal Mood Disorders

Risk Factors

Preterm Birth

Risk factors in this population

motherrsquos past psychiatric history

previous perinatal loss

psychosocial support including marital status

severity of the infantrsquos health status

degree of worry amp momrsquos coping skills

rehospitalization after the initial stay

bull (Miles et al 2007 Garel et al 2004 Mew et al

Increased Psychiatric Comorbidity After

Preterm Birth

Correlation between PTSD symptoms and preterm

delivery

Increased PTSD symptoms in women who have had a

ldquotraumaticrdquo birth experience

PTSD and depression are often comorbid

Integrated care is needed between obstetricals mental

health and neonatologypediatrics

ldquoWill allow for the development of innovative

assessment and treatment strategies to help the mother-

infant dyad throughout the difficult first year and

beyond after a preterm deliveryrdquo

bull (Holditch-Davis et al 2003 Rogal et al 2007)

Perinatal Mood Disorders

DepressionPerinatal Depression

Symptoms that are common but may be

different for general depression include Feeling sad irritable hopeless or overwhelmed

Crying spells

Guilty thoughts

Feeling inadequate to take care of your baby

Hypervigilance

Scary thoughts

Preoccupation with thoughts of death

Lack of control

Trouble concentrating

Withdrawal from friends and family

2182017

6

Perinatal Mood Disorders

AnxietyPanicOCDPerinatal AnxietyPanic

Symptoms in Anxiety Panic include

Excessive worry

Shortness of breath

Racing heart

Sweaty or cold clammy hands

Feeling keyed up or on the edge

Dizziness or light headed

Chest tightness

Scary thoughts

Perinatal AnxietyPanic Some of these thoughts can become compulsive

which means they are repetitive

Fear of going crazy or doing something

uncontrolled

Disoriented or that the world has become unreal

Fears of contamination

Fears that no one can take care of the baby like you

can or that someone could do a much better job so

she should just leave

Fears of something bad happening to the baby or

other family members

Perinatal Mood Disorder

Bipolar Disorder

Risk of Recurrence During the Postpartum

Period in Bipolar Disorder

Consistently the early postpartum period is a high risk time period for recurrence of bipolar and other psychiatric illnesses

Rates of relapse (usually a depressive episode) range from 60-80

Bipolar disorder is also associated with postpartum psychosis

Pregnant Women with Bipolar

Disorder Present a complex clinical challenge

Goal is to minimize the risk to the fetus while limiting

the impact of the psychiatric illness on the mother and

her family

Decisions surrounding psychotropic use are difficult

and associated with risks

2182017

7

Postpartum Psychosis Postpartum Psychosis

A rare but devastating condition with an estimated prevalence of 01-02 (one to two per thousand)

Women with Bipolar Disorder risk is 100 times higher at 10 - 20

Psychiatric emergency amp requires immediate treatment with a mood stabilizer amp antipsychotic

Onset usually 2-3 days postpartum

Has a 5 suicide amp 4 infanticide rate

Risk for recurrent episode with subsequent pregnancy is 90

TreatmentPerinatal Mood Disorders

Treatment

One size does not fit all

Critical for the well being of the woman baby and

family

Effective treatments are readily available

Psychotherapy

Medication Management

Other alternative

Skilled assessment and treatment by mental health

professionals in perinatal psychiatry makes a difference

in outcomes

Psychotherapy During Pregnancy

Psychotherapy can be an important form of

treatment of depression during pregnancy and

the postpartum period

Good data available for Cognitive-Behavioral

(CBT) and Interpersonal Psychotherapy during

pregnancy

Requires weekly visits and

motivationcompliance by the patient

Pharmacotherapy in Pregnancy

All psychotropics cross the placenta and none are approved by the FDA for use during pregnancy

Unethical to conduct randomized placebo controlled studies on medication safety in pregnant women

Thus most information about the reproductive safety of of drugs comes from case reports and retrospective studies

Prevalence of SSRIrsquos in pregnancy is 6-8

2182017

8

Risk of Relapse of Major

Depression in Pregnancy

High risk of depressive relapse following antidepressant

discontinuation during pregnancy ( Cohen et al JAMA

2006)

Of 201 women in the sample 86 (43) experienced a relapse

of major depression during pregnancy

Women who discontinued medication relapsed more

frequently (68 vs 26) compared to women who

maintained medication (hazard ratio 50 95 confidence

interval 28-91 Plt001)

Pregnancy is not protective with respect to risk of

relapse of major depression

Medications

What to do

SSRIs (especially fluoxetine and sertraline) and TCAs relatively safe even during first trimester

SSRIs (especially sertraline) and TCAs relatively safe in breast-feeding (Risk of fluoxetine accumulation in breastmilk and TCA-induced seizures

Avoid Paroxetine (unless riskbenefit analysis dictates otherwise)

Insufficient information about newer antidepressants (SNRIrsquos) and trazodone

Bupropion FDA risk category changed from B to C

Adverse Fetal Outcomes associated

with Depression during Pregnancy

Adverse outcomes have been documented in women with

depression during pregnancy

Cohort studies demonstrate that the rate of depression per 1000

deliveries increased significantly from 273 in 1998 to 141 in

2005 (plt0001)

New cohort study shows that depressed women were

significantly more likely to have

Cesarean delivery preterm labor anemia diabetes and

preeclampsia or hypertension compared with women without

depression

Worse fetal outcomes included fetal growth restriction fetal

abnormalities fetal distress amp death

bull Bansil et al 2010 J Womenrsquos Health

Risks of Untreated Antenatal

Depression Associated with low maternal weight gain increased rates of

preterm birth low birth wt increased smoking ETOH and

other substances

Increased ambivalence about the pregnancy and overall worse

health status

Prenatal exposure to maternal stress has consequences for the

development of infant temperament

Children exposed to perinatal maternal depression have higher

cortisol levels than infants of mothers who were not depressed

and this continues through adolescence

Maternal treatment of depression during pregnancy appears to

help normalize infant cortisol levels

Current Use of Antidepressants in the

United States and During Pregnancy

CDC Antidepressant use skyrockets 400 in past 20 yearsmdash

reported Oct 2011

Antidepressants are the most frequently used medications by

people ages 18-44

Nearly one in four women ages 40 to 59 are taking

antidepressants

Less than 12 of those antidepressants had seen a mental-health

professional in the past year

(Data are from the National Health and Nutrition Examination Surveys N=

12637 participants about prescription-drug use antidepressant use length of

use severity of depressive symptoms and contact with a health professional)

2182017

9

Outcome data on Antidepressant

Medications in pregnancy

Intrauterine fetal death -No evidence

Einarson et al (2009) concluded no increased risk of Major Congenital Malformations (MCM) with SSRI use in the 1st

trimester

Growth impairment- Possible for fluoxetine premature birth (143 late 41 early 59 control) low birth weight and length

No differences in cognitive function verbal comprehension expressive language mood arousability activity levels distractibility behavior problems temperament (TCA FLX)

SSRI Discontinuation Syndrome vs Pulmonary HTN of Newborn

Antidepressants Tx in Pregnancy Neonatal

Outcomes

SSRI withdrawal is possible but usually these are transient (restlessness rigidity tremor)

Late SSRI exposure carries an overall risk ratio of 30 (95 CI 20-44) for a neonatal behavioral syndrome -Moses-Kolko et al JAMA 2005

Warburton et al (2010) concluded that when controlled for maternal mental illness severity reducing exposure to SSRI in the last 2 weeks before delivery did not have a significant clinical effect on improving neonatal health

Primary Pulmonary Hypertension

of the Newborn

2006 case control study showed SSRI exposure after 20 weeks gestation increased risk (4-5x higher) of PPHN with absolute risk of lt1 (N England J Med 2006)

Recent studies show increased risk of PPHN with multiple other risk factors and absolute low risk with SSRI exposure

C-section high maternal BMI AA or Asian heritage

Study concluded that large BMI and C-section had greater risk than SSRI exposure (Pediatrics 2007)

Swedish Medical Birth Registerndash 3rd trimester exposure showed increased risk of 24 (Pharmacoepidemiology Drug Safety 2008)

Paroxetine and Pregnancy In 2005 FDA began investigated risks associated with

antidepressant use in pregnant women

Results of Investigation

Infants born to women taking Paroxetine (Paxil) may be at double the risk for cardiovascular birth defects (4) compared to other antidepressants (2)

Sept 2005 US health officials warned against the use of Paxil in the first trimester due to potential birth defects in infants though relationship may be incidental

Further research is necessary involving adequate well-controlled studies to prove the effects of Paxil on the fetus

Risk of Autism with SSRI Use

Croen LA Grether JK Yoshida CK Odouli R

Hendrick V

Antidepressant Use During Pregnancy and

Childhood Autism Spectrum Disorders

Arch Gen Psychiatry 2011 Jul 4 [Epub ahead of

print]

PMID 21727247

Psychotropics Used in the

Treatment of Bipolar Disorder

Lithium

Anticonvulsants-- ldquoOlderrdquo anticonvulsants have

2x higher risk of major birth defects

Valproic Acid

Carbamazepine

Other (newer) anticonvulsants

Lamotrigine

Antipsychotics

2182017

10

Lithium vs Anticonvulsants

LITHIUM

Ebsteinrsquos cardiac malformation

005 risk vs 01 base rate

Neonatal hypothyroidism

Diabetes Insipidus (rare)

Polyhydraminos (rare)

FDA Pregnancy Category D

VALPROIC ACID

Spina bifida (1-5 risk)

Structural defects of the heart limbs and face

FDA Pregnancy Class D

CARBAMAZEPINE

Spina bifida (1 risk)

Structural defects of the face (dysmorphic facies)

Secreted in breast milk

FDA Pregnancy Category C

Newer Anticonvulsants

Limited data is available with the ldquonewerrdquoagents such

as gabapentin lamotrigine oxcarbazepine and

topiramate

Lamotrigine has good safety record to date No

increased risk of birth defects

The benzodiazepines may have increased risk of cleft

lip and palate (07)

All are secreted in breast milk

FDA pregnancy class C

Antipsychotics

Teratogenic risks are probably low with the traditional neuroleptics (Haloperidol is safest)

There is inadequate information available to ascertain risk of newer atypical antipsychotics although safety profile is promising to date

Quetiapine has lowest transmission in breast milk (Stowe et al)

All are secreted in breast milk

FDA pregnancy class C (except for clozaril)

Conclusions Treatment

Perinatal psychiatric illness requires immediate

intervention

Coordination of care between OB-GYN and trained

mental health professionals is critical

Antidepressant medications can be safely used during

pregnancy and lactation

Assess risk of untreated illness versus greater risk of exposure

Chronic mental illness must be treated during pregnancy

to prevent severe PPD

Patients with preexisting psychosis must be treated as a

ldquohigh risk pregnancyrdquo during and after delivery

UNC Center for Womenrsquos Mood

Disorders

Perinatal Psychiatry ProgramClinical and Research Program

that provides assessment treatment and

support for women in the

perinatal period

Collaboration of doctors nurses

midwives

therapists amp social workers

wwwwomensmooddisordersorg

Unit

UNC Perinatal In-patient Psychiatric Unit

2182017

11

Program

Perinatal Inpatient Psychiatry Program provide

Comfort measures

Protected sleep times

Dedicated private and semi-private rooms and group

room

Gliders and supplies for pumpingnursing

Pumps supplies and refrigerator for milk storage

Specialty perinatal nursing staff

Extended visiting hours to maximize positive mother-

baby interaction

Resources

Postpartum Support International

(800) 944-4PPD wwwpostpartumnet

Postpartum Progress Blog

httpwwwpostpartumprogresscomweblog

National Womenrsquos Health Information Center

(800) 994-9662 www4womangov

Motherisk wwwmotheriskorg latest on studies

of medications in pregnancy and lactation

OTIS wwwOTISpregnancyorg

886-626-6847

Thanks bull UNC Psychiatry

bull Dr David Rubinow Department Chair

bull Dr Samantha Meltzer-Brody Director Perinatal Mood Disorder Program

bull Dr Mary Kimmel Medical Director In-patient Unit

bull Brenda Pearson and Katie Melvin

bull UNC OB-GYN bull Dr Kate Menard

bull DrBob Strauss

bull DrAlison Stuebe

bull DrJohn Thorp

Questions

References Andrade SE McPhillips H Loren D Raebel MA et al Antidepressant medication

use and risk of persistent pulmonary hypertension of the newborn Pharmacoepidemiol Drug Saf 2009 Mar18(3)246-52

Gavin N Gaynes B Lohr K Meltzer-Brody S et al 2005 Perinatal depression a systematic review of prevalence and incidenceObstet Gynecol 1061071-83

Cohen L Altshuler L Harlow B Nonacs R 2006 Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment JAMA 295(5)499-507

Chambers C Hernandez-Diaz S VanMarter L Werler M 2006 Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn N Engl J Med 354(6)579-87

Delatte R Meltzer-Brody S Cao H Menard K 2009 ldquoUniversal Screening for Postpartum Depression An Inquiry into Provider Attitudes and Practice American Journal of Obstetrics and Gynecology 200(5)e63-4

Einarson A Choi J Koren G 2009 Incidence of major malformations in infants following antidepressant exposure in pregnancy results of a large prospective cohort study Canadian Journal of Psych 54(4)242-6

McKenna K Koren G Tetelbaum M Wilton L et al 2005 Pregnancy outcome of women using atypical antipsychotic drugs A prospective comparative study J Clin Psychiatry 66444-449

References Meltzer-Brody S Payne J Rubinow D 2008 Postpartum Depression Evolving

Etiology amp Treatment Considerations Current Psych 7(5)87-95

Meltzer-Brody S Hartmann K Miller W Scott J 2004 A brief screening instrument to detect posttraumatic stress disorder in outpatient gynecologyObstet Gynecol104(4)770-776

Oberlander TF Warburton W Misri S et al 2006 Neonatal Outcomes After Prenatal Exposure to Selective Serotonin Reuptake Inhibitor Antidepressants and Maternal Depression Using Population-Based Linked Health Data Arch General Psychiatry 63898-906

Sit D Rothschild A Wisner K 2006 A Review of Postpartum Psychosis Journal of Womenrsquos Health 15(4)352-368

Viguera A amp Cohen L 1998 The course and management of bipolar disorder during pregnancy Psychopharmacology Bulletin 34339-353

Viguera A Cohen L et al 2002 Managing bipolar disorder during pregnancy weighing the risks and benefits Can J Psychiatry 2002 Jun47(5)426-436

Webb R Abel K et al 2005 Mortality in Offspring of Parents with Psychotic Disorders A Critical Review and Meta-Analysis Am J Psych1621045-1056

Yonkers K Wisner K Stowe Z et al 2004 Management of Bipolar Disorder during pregnancy and the postpartum period Am J Psychiatry161608-620

2182017

6

Perinatal Mood Disorders

AnxietyPanicOCDPerinatal AnxietyPanic

Symptoms in Anxiety Panic include

Excessive worry

Shortness of breath

Racing heart

Sweaty or cold clammy hands

Feeling keyed up or on the edge

Dizziness or light headed

Chest tightness

Scary thoughts

Perinatal AnxietyPanic Some of these thoughts can become compulsive

which means they are repetitive

Fear of going crazy or doing something

uncontrolled

Disoriented or that the world has become unreal

Fears of contamination

Fears that no one can take care of the baby like you

can or that someone could do a much better job so

she should just leave

Fears of something bad happening to the baby or

other family members

Perinatal Mood Disorder

Bipolar Disorder

Risk of Recurrence During the Postpartum

Period in Bipolar Disorder

Consistently the early postpartum period is a high risk time period for recurrence of bipolar and other psychiatric illnesses

Rates of relapse (usually a depressive episode) range from 60-80

Bipolar disorder is also associated with postpartum psychosis

Pregnant Women with Bipolar

Disorder Present a complex clinical challenge

Goal is to minimize the risk to the fetus while limiting

the impact of the psychiatric illness on the mother and

her family

Decisions surrounding psychotropic use are difficult

and associated with risks

2182017

7

Postpartum Psychosis Postpartum Psychosis

A rare but devastating condition with an estimated prevalence of 01-02 (one to two per thousand)

Women with Bipolar Disorder risk is 100 times higher at 10 - 20

Psychiatric emergency amp requires immediate treatment with a mood stabilizer amp antipsychotic

Onset usually 2-3 days postpartum

Has a 5 suicide amp 4 infanticide rate

Risk for recurrent episode with subsequent pregnancy is 90

TreatmentPerinatal Mood Disorders

Treatment

One size does not fit all

Critical for the well being of the woman baby and

family

Effective treatments are readily available

Psychotherapy

Medication Management

Other alternative

Skilled assessment and treatment by mental health

professionals in perinatal psychiatry makes a difference

in outcomes

Psychotherapy During Pregnancy

Psychotherapy can be an important form of

treatment of depression during pregnancy and

the postpartum period

Good data available for Cognitive-Behavioral

(CBT) and Interpersonal Psychotherapy during

pregnancy

Requires weekly visits and

motivationcompliance by the patient

Pharmacotherapy in Pregnancy

All psychotropics cross the placenta and none are approved by the FDA for use during pregnancy

Unethical to conduct randomized placebo controlled studies on medication safety in pregnant women

Thus most information about the reproductive safety of of drugs comes from case reports and retrospective studies

Prevalence of SSRIrsquos in pregnancy is 6-8

2182017

8

Risk of Relapse of Major

Depression in Pregnancy

High risk of depressive relapse following antidepressant

discontinuation during pregnancy ( Cohen et al JAMA

2006)

Of 201 women in the sample 86 (43) experienced a relapse

of major depression during pregnancy

Women who discontinued medication relapsed more

frequently (68 vs 26) compared to women who

maintained medication (hazard ratio 50 95 confidence

interval 28-91 Plt001)

Pregnancy is not protective with respect to risk of

relapse of major depression

Medications

What to do

SSRIs (especially fluoxetine and sertraline) and TCAs relatively safe even during first trimester

SSRIs (especially sertraline) and TCAs relatively safe in breast-feeding (Risk of fluoxetine accumulation in breastmilk and TCA-induced seizures

Avoid Paroxetine (unless riskbenefit analysis dictates otherwise)

Insufficient information about newer antidepressants (SNRIrsquos) and trazodone

Bupropion FDA risk category changed from B to C

Adverse Fetal Outcomes associated

with Depression during Pregnancy

Adverse outcomes have been documented in women with

depression during pregnancy

Cohort studies demonstrate that the rate of depression per 1000

deliveries increased significantly from 273 in 1998 to 141 in

2005 (plt0001)

New cohort study shows that depressed women were

significantly more likely to have

Cesarean delivery preterm labor anemia diabetes and

preeclampsia or hypertension compared with women without

depression

Worse fetal outcomes included fetal growth restriction fetal

abnormalities fetal distress amp death

bull Bansil et al 2010 J Womenrsquos Health

Risks of Untreated Antenatal

Depression Associated with low maternal weight gain increased rates of

preterm birth low birth wt increased smoking ETOH and

other substances

Increased ambivalence about the pregnancy and overall worse

health status

Prenatal exposure to maternal stress has consequences for the

development of infant temperament

Children exposed to perinatal maternal depression have higher

cortisol levels than infants of mothers who were not depressed

and this continues through adolescence

Maternal treatment of depression during pregnancy appears to

help normalize infant cortisol levels

Current Use of Antidepressants in the

United States and During Pregnancy

CDC Antidepressant use skyrockets 400 in past 20 yearsmdash

reported Oct 2011

Antidepressants are the most frequently used medications by

people ages 18-44

Nearly one in four women ages 40 to 59 are taking

antidepressants

Less than 12 of those antidepressants had seen a mental-health

professional in the past year

(Data are from the National Health and Nutrition Examination Surveys N=

12637 participants about prescription-drug use antidepressant use length of

use severity of depressive symptoms and contact with a health professional)

2182017

9

Outcome data on Antidepressant

Medications in pregnancy

Intrauterine fetal death -No evidence

Einarson et al (2009) concluded no increased risk of Major Congenital Malformations (MCM) with SSRI use in the 1st

trimester

Growth impairment- Possible for fluoxetine premature birth (143 late 41 early 59 control) low birth weight and length

No differences in cognitive function verbal comprehension expressive language mood arousability activity levels distractibility behavior problems temperament (TCA FLX)

SSRI Discontinuation Syndrome vs Pulmonary HTN of Newborn

Antidepressants Tx in Pregnancy Neonatal

Outcomes

SSRI withdrawal is possible but usually these are transient (restlessness rigidity tremor)

Late SSRI exposure carries an overall risk ratio of 30 (95 CI 20-44) for a neonatal behavioral syndrome -Moses-Kolko et al JAMA 2005

Warburton et al (2010) concluded that when controlled for maternal mental illness severity reducing exposure to SSRI in the last 2 weeks before delivery did not have a significant clinical effect on improving neonatal health

Primary Pulmonary Hypertension

of the Newborn

2006 case control study showed SSRI exposure after 20 weeks gestation increased risk (4-5x higher) of PPHN with absolute risk of lt1 (N England J Med 2006)

Recent studies show increased risk of PPHN with multiple other risk factors and absolute low risk with SSRI exposure

C-section high maternal BMI AA or Asian heritage

Study concluded that large BMI and C-section had greater risk than SSRI exposure (Pediatrics 2007)

Swedish Medical Birth Registerndash 3rd trimester exposure showed increased risk of 24 (Pharmacoepidemiology Drug Safety 2008)

Paroxetine and Pregnancy In 2005 FDA began investigated risks associated with

antidepressant use in pregnant women

Results of Investigation

Infants born to women taking Paroxetine (Paxil) may be at double the risk for cardiovascular birth defects (4) compared to other antidepressants (2)

Sept 2005 US health officials warned against the use of Paxil in the first trimester due to potential birth defects in infants though relationship may be incidental

Further research is necessary involving adequate well-controlled studies to prove the effects of Paxil on the fetus

Risk of Autism with SSRI Use

Croen LA Grether JK Yoshida CK Odouli R

Hendrick V

Antidepressant Use During Pregnancy and

Childhood Autism Spectrum Disorders

Arch Gen Psychiatry 2011 Jul 4 [Epub ahead of

print]

PMID 21727247

Psychotropics Used in the

Treatment of Bipolar Disorder

Lithium

Anticonvulsants-- ldquoOlderrdquo anticonvulsants have

2x higher risk of major birth defects

Valproic Acid

Carbamazepine

Other (newer) anticonvulsants

Lamotrigine

Antipsychotics

2182017

10

Lithium vs Anticonvulsants

LITHIUM

Ebsteinrsquos cardiac malformation

005 risk vs 01 base rate

Neonatal hypothyroidism

Diabetes Insipidus (rare)

Polyhydraminos (rare)

FDA Pregnancy Category D

VALPROIC ACID

Spina bifida (1-5 risk)

Structural defects of the heart limbs and face

FDA Pregnancy Class D

CARBAMAZEPINE

Spina bifida (1 risk)

Structural defects of the face (dysmorphic facies)

Secreted in breast milk

FDA Pregnancy Category C

Newer Anticonvulsants

Limited data is available with the ldquonewerrdquoagents such

as gabapentin lamotrigine oxcarbazepine and

topiramate

Lamotrigine has good safety record to date No

increased risk of birth defects

The benzodiazepines may have increased risk of cleft

lip and palate (07)

All are secreted in breast milk

FDA pregnancy class C

Antipsychotics

Teratogenic risks are probably low with the traditional neuroleptics (Haloperidol is safest)

There is inadequate information available to ascertain risk of newer atypical antipsychotics although safety profile is promising to date

Quetiapine has lowest transmission in breast milk (Stowe et al)

All are secreted in breast milk

FDA pregnancy class C (except for clozaril)

Conclusions Treatment

Perinatal psychiatric illness requires immediate

intervention

Coordination of care between OB-GYN and trained

mental health professionals is critical

Antidepressant medications can be safely used during

pregnancy and lactation

Assess risk of untreated illness versus greater risk of exposure

Chronic mental illness must be treated during pregnancy

to prevent severe PPD

Patients with preexisting psychosis must be treated as a

ldquohigh risk pregnancyrdquo during and after delivery

UNC Center for Womenrsquos Mood

Disorders

Perinatal Psychiatry ProgramClinical and Research Program

that provides assessment treatment and

support for women in the

perinatal period

Collaboration of doctors nurses

midwives

therapists amp social workers

wwwwomensmooddisordersorg

Unit

UNC Perinatal In-patient Psychiatric Unit

2182017

11

Program

Perinatal Inpatient Psychiatry Program provide

Comfort measures

Protected sleep times

Dedicated private and semi-private rooms and group

room

Gliders and supplies for pumpingnursing

Pumps supplies and refrigerator for milk storage

Specialty perinatal nursing staff

Extended visiting hours to maximize positive mother-

baby interaction

Resources

Postpartum Support International

(800) 944-4PPD wwwpostpartumnet

Postpartum Progress Blog

httpwwwpostpartumprogresscomweblog

National Womenrsquos Health Information Center

(800) 994-9662 www4womangov

Motherisk wwwmotheriskorg latest on studies

of medications in pregnancy and lactation

OTIS wwwOTISpregnancyorg

886-626-6847

Thanks bull UNC Psychiatry

bull Dr David Rubinow Department Chair

bull Dr Samantha Meltzer-Brody Director Perinatal Mood Disorder Program

bull Dr Mary Kimmel Medical Director In-patient Unit

bull Brenda Pearson and Katie Melvin

bull UNC OB-GYN bull Dr Kate Menard

bull DrBob Strauss

bull DrAlison Stuebe

bull DrJohn Thorp

Questions

References Andrade SE McPhillips H Loren D Raebel MA et al Antidepressant medication

use and risk of persistent pulmonary hypertension of the newborn Pharmacoepidemiol Drug Saf 2009 Mar18(3)246-52

Gavin N Gaynes B Lohr K Meltzer-Brody S et al 2005 Perinatal depression a systematic review of prevalence and incidenceObstet Gynecol 1061071-83

Cohen L Altshuler L Harlow B Nonacs R 2006 Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment JAMA 295(5)499-507

Chambers C Hernandez-Diaz S VanMarter L Werler M 2006 Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn N Engl J Med 354(6)579-87

Delatte R Meltzer-Brody S Cao H Menard K 2009 ldquoUniversal Screening for Postpartum Depression An Inquiry into Provider Attitudes and Practice American Journal of Obstetrics and Gynecology 200(5)e63-4

Einarson A Choi J Koren G 2009 Incidence of major malformations in infants following antidepressant exposure in pregnancy results of a large prospective cohort study Canadian Journal of Psych 54(4)242-6

McKenna K Koren G Tetelbaum M Wilton L et al 2005 Pregnancy outcome of women using atypical antipsychotic drugs A prospective comparative study J Clin Psychiatry 66444-449

References Meltzer-Brody S Payne J Rubinow D 2008 Postpartum Depression Evolving

Etiology amp Treatment Considerations Current Psych 7(5)87-95

Meltzer-Brody S Hartmann K Miller W Scott J 2004 A brief screening instrument to detect posttraumatic stress disorder in outpatient gynecologyObstet Gynecol104(4)770-776

Oberlander TF Warburton W Misri S et al 2006 Neonatal Outcomes After Prenatal Exposure to Selective Serotonin Reuptake Inhibitor Antidepressants and Maternal Depression Using Population-Based Linked Health Data Arch General Psychiatry 63898-906

Sit D Rothschild A Wisner K 2006 A Review of Postpartum Psychosis Journal of Womenrsquos Health 15(4)352-368

Viguera A amp Cohen L 1998 The course and management of bipolar disorder during pregnancy Psychopharmacology Bulletin 34339-353

Viguera A Cohen L et al 2002 Managing bipolar disorder during pregnancy weighing the risks and benefits Can J Psychiatry 2002 Jun47(5)426-436

Webb R Abel K et al 2005 Mortality in Offspring of Parents with Psychotic Disorders A Critical Review and Meta-Analysis Am J Psych1621045-1056

Yonkers K Wisner K Stowe Z et al 2004 Management of Bipolar Disorder during pregnancy and the postpartum period Am J Psychiatry161608-620

2182017

7

Postpartum Psychosis Postpartum Psychosis

A rare but devastating condition with an estimated prevalence of 01-02 (one to two per thousand)

Women with Bipolar Disorder risk is 100 times higher at 10 - 20

Psychiatric emergency amp requires immediate treatment with a mood stabilizer amp antipsychotic

Onset usually 2-3 days postpartum

Has a 5 suicide amp 4 infanticide rate

Risk for recurrent episode with subsequent pregnancy is 90

TreatmentPerinatal Mood Disorders

Treatment

One size does not fit all

Critical for the well being of the woman baby and

family

Effective treatments are readily available

Psychotherapy

Medication Management

Other alternative

Skilled assessment and treatment by mental health

professionals in perinatal psychiatry makes a difference

in outcomes

Psychotherapy During Pregnancy

Psychotherapy can be an important form of

treatment of depression during pregnancy and

the postpartum period

Good data available for Cognitive-Behavioral

(CBT) and Interpersonal Psychotherapy during

pregnancy

Requires weekly visits and

motivationcompliance by the patient

Pharmacotherapy in Pregnancy

All psychotropics cross the placenta and none are approved by the FDA for use during pregnancy

Unethical to conduct randomized placebo controlled studies on medication safety in pregnant women

Thus most information about the reproductive safety of of drugs comes from case reports and retrospective studies

Prevalence of SSRIrsquos in pregnancy is 6-8

2182017

8

Risk of Relapse of Major

Depression in Pregnancy

High risk of depressive relapse following antidepressant

discontinuation during pregnancy ( Cohen et al JAMA

2006)

Of 201 women in the sample 86 (43) experienced a relapse

of major depression during pregnancy

Women who discontinued medication relapsed more

frequently (68 vs 26) compared to women who

maintained medication (hazard ratio 50 95 confidence

interval 28-91 Plt001)

Pregnancy is not protective with respect to risk of

relapse of major depression

Medications

What to do

SSRIs (especially fluoxetine and sertraline) and TCAs relatively safe even during first trimester

SSRIs (especially sertraline) and TCAs relatively safe in breast-feeding (Risk of fluoxetine accumulation in breastmilk and TCA-induced seizures

Avoid Paroxetine (unless riskbenefit analysis dictates otherwise)

Insufficient information about newer antidepressants (SNRIrsquos) and trazodone

Bupropion FDA risk category changed from B to C

Adverse Fetal Outcomes associated

with Depression during Pregnancy

Adverse outcomes have been documented in women with

depression during pregnancy

Cohort studies demonstrate that the rate of depression per 1000

deliveries increased significantly from 273 in 1998 to 141 in

2005 (plt0001)

New cohort study shows that depressed women were

significantly more likely to have

Cesarean delivery preterm labor anemia diabetes and

preeclampsia or hypertension compared with women without

depression

Worse fetal outcomes included fetal growth restriction fetal

abnormalities fetal distress amp death

bull Bansil et al 2010 J Womenrsquos Health

Risks of Untreated Antenatal

Depression Associated with low maternal weight gain increased rates of

preterm birth low birth wt increased smoking ETOH and

other substances

Increased ambivalence about the pregnancy and overall worse

health status

Prenatal exposure to maternal stress has consequences for the

development of infant temperament

Children exposed to perinatal maternal depression have higher

cortisol levels than infants of mothers who were not depressed

and this continues through adolescence

Maternal treatment of depression during pregnancy appears to

help normalize infant cortisol levels

Current Use of Antidepressants in the

United States and During Pregnancy

CDC Antidepressant use skyrockets 400 in past 20 yearsmdash

reported Oct 2011

Antidepressants are the most frequently used medications by

people ages 18-44

Nearly one in four women ages 40 to 59 are taking

antidepressants

Less than 12 of those antidepressants had seen a mental-health

professional in the past year

(Data are from the National Health and Nutrition Examination Surveys N=

12637 participants about prescription-drug use antidepressant use length of

use severity of depressive symptoms and contact with a health professional)

2182017

9

Outcome data on Antidepressant

Medications in pregnancy

Intrauterine fetal death -No evidence

Einarson et al (2009) concluded no increased risk of Major Congenital Malformations (MCM) with SSRI use in the 1st

trimester

Growth impairment- Possible for fluoxetine premature birth (143 late 41 early 59 control) low birth weight and length

No differences in cognitive function verbal comprehension expressive language mood arousability activity levels distractibility behavior problems temperament (TCA FLX)

SSRI Discontinuation Syndrome vs Pulmonary HTN of Newborn

Antidepressants Tx in Pregnancy Neonatal

Outcomes

SSRI withdrawal is possible but usually these are transient (restlessness rigidity tremor)

Late SSRI exposure carries an overall risk ratio of 30 (95 CI 20-44) for a neonatal behavioral syndrome -Moses-Kolko et al JAMA 2005

Warburton et al (2010) concluded that when controlled for maternal mental illness severity reducing exposure to SSRI in the last 2 weeks before delivery did not have a significant clinical effect on improving neonatal health

Primary Pulmonary Hypertension

of the Newborn

2006 case control study showed SSRI exposure after 20 weeks gestation increased risk (4-5x higher) of PPHN with absolute risk of lt1 (N England J Med 2006)

Recent studies show increased risk of PPHN with multiple other risk factors and absolute low risk with SSRI exposure

C-section high maternal BMI AA or Asian heritage

Study concluded that large BMI and C-section had greater risk than SSRI exposure (Pediatrics 2007)

Swedish Medical Birth Registerndash 3rd trimester exposure showed increased risk of 24 (Pharmacoepidemiology Drug Safety 2008)

Paroxetine and Pregnancy In 2005 FDA began investigated risks associated with

antidepressant use in pregnant women

Results of Investigation

Infants born to women taking Paroxetine (Paxil) may be at double the risk for cardiovascular birth defects (4) compared to other antidepressants (2)

Sept 2005 US health officials warned against the use of Paxil in the first trimester due to potential birth defects in infants though relationship may be incidental

Further research is necessary involving adequate well-controlled studies to prove the effects of Paxil on the fetus

Risk of Autism with SSRI Use

Croen LA Grether JK Yoshida CK Odouli R

Hendrick V

Antidepressant Use During Pregnancy and

Childhood Autism Spectrum Disorders

Arch Gen Psychiatry 2011 Jul 4 [Epub ahead of

print]

PMID 21727247

Psychotropics Used in the

Treatment of Bipolar Disorder

Lithium

Anticonvulsants-- ldquoOlderrdquo anticonvulsants have

2x higher risk of major birth defects

Valproic Acid

Carbamazepine

Other (newer) anticonvulsants

Lamotrigine

Antipsychotics

2182017

10

Lithium vs Anticonvulsants

LITHIUM

Ebsteinrsquos cardiac malformation

005 risk vs 01 base rate

Neonatal hypothyroidism

Diabetes Insipidus (rare)

Polyhydraminos (rare)

FDA Pregnancy Category D

VALPROIC ACID

Spina bifida (1-5 risk)

Structural defects of the heart limbs and face

FDA Pregnancy Class D

CARBAMAZEPINE

Spina bifida (1 risk)

Structural defects of the face (dysmorphic facies)

Secreted in breast milk

FDA Pregnancy Category C

Newer Anticonvulsants

Limited data is available with the ldquonewerrdquoagents such

as gabapentin lamotrigine oxcarbazepine and

topiramate

Lamotrigine has good safety record to date No

increased risk of birth defects

The benzodiazepines may have increased risk of cleft

lip and palate (07)

All are secreted in breast milk

FDA pregnancy class C

Antipsychotics

Teratogenic risks are probably low with the traditional neuroleptics (Haloperidol is safest)

There is inadequate information available to ascertain risk of newer atypical antipsychotics although safety profile is promising to date

Quetiapine has lowest transmission in breast milk (Stowe et al)

All are secreted in breast milk

FDA pregnancy class C (except for clozaril)

Conclusions Treatment

Perinatal psychiatric illness requires immediate

intervention

Coordination of care between OB-GYN and trained

mental health professionals is critical

Antidepressant medications can be safely used during

pregnancy and lactation

Assess risk of untreated illness versus greater risk of exposure

Chronic mental illness must be treated during pregnancy

to prevent severe PPD

Patients with preexisting psychosis must be treated as a

ldquohigh risk pregnancyrdquo during and after delivery

UNC Center for Womenrsquos Mood

Disorders

Perinatal Psychiatry ProgramClinical and Research Program

that provides assessment treatment and

support for women in the

perinatal period

Collaboration of doctors nurses

midwives

therapists amp social workers

wwwwomensmooddisordersorg

Unit

UNC Perinatal In-patient Psychiatric Unit

2182017

11

Program

Perinatal Inpatient Psychiatry Program provide

Comfort measures

Protected sleep times

Dedicated private and semi-private rooms and group

room

Gliders and supplies for pumpingnursing

Pumps supplies and refrigerator for milk storage

Specialty perinatal nursing staff

Extended visiting hours to maximize positive mother-

baby interaction

Resources

Postpartum Support International

(800) 944-4PPD wwwpostpartumnet

Postpartum Progress Blog

httpwwwpostpartumprogresscomweblog

National Womenrsquos Health Information Center

(800) 994-9662 www4womangov

Motherisk wwwmotheriskorg latest on studies

of medications in pregnancy and lactation

OTIS wwwOTISpregnancyorg

886-626-6847

Thanks bull UNC Psychiatry

bull Dr David Rubinow Department Chair

bull Dr Samantha Meltzer-Brody Director Perinatal Mood Disorder Program

bull Dr Mary Kimmel Medical Director In-patient Unit

bull Brenda Pearson and Katie Melvin

bull UNC OB-GYN bull Dr Kate Menard

bull DrBob Strauss

bull DrAlison Stuebe

bull DrJohn Thorp

Questions

References Andrade SE McPhillips H Loren D Raebel MA et al Antidepressant medication

use and risk of persistent pulmonary hypertension of the newborn Pharmacoepidemiol Drug Saf 2009 Mar18(3)246-52

Gavin N Gaynes B Lohr K Meltzer-Brody S et al 2005 Perinatal depression a systematic review of prevalence and incidenceObstet Gynecol 1061071-83

Cohen L Altshuler L Harlow B Nonacs R 2006 Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment JAMA 295(5)499-507

Chambers C Hernandez-Diaz S VanMarter L Werler M 2006 Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn N Engl J Med 354(6)579-87

Delatte R Meltzer-Brody S Cao H Menard K 2009 ldquoUniversal Screening for Postpartum Depression An Inquiry into Provider Attitudes and Practice American Journal of Obstetrics and Gynecology 200(5)e63-4

Einarson A Choi J Koren G 2009 Incidence of major malformations in infants following antidepressant exposure in pregnancy results of a large prospective cohort study Canadian Journal of Psych 54(4)242-6

McKenna K Koren G Tetelbaum M Wilton L et al 2005 Pregnancy outcome of women using atypical antipsychotic drugs A prospective comparative study J Clin Psychiatry 66444-449

References Meltzer-Brody S Payne J Rubinow D 2008 Postpartum Depression Evolving

Etiology amp Treatment Considerations Current Psych 7(5)87-95

Meltzer-Brody S Hartmann K Miller W Scott J 2004 A brief screening instrument to detect posttraumatic stress disorder in outpatient gynecologyObstet Gynecol104(4)770-776

Oberlander TF Warburton W Misri S et al 2006 Neonatal Outcomes After Prenatal Exposure to Selective Serotonin Reuptake Inhibitor Antidepressants and Maternal Depression Using Population-Based Linked Health Data Arch General Psychiatry 63898-906

Sit D Rothschild A Wisner K 2006 A Review of Postpartum Psychosis Journal of Womenrsquos Health 15(4)352-368

Viguera A amp Cohen L 1998 The course and management of bipolar disorder during pregnancy Psychopharmacology Bulletin 34339-353

Viguera A Cohen L et al 2002 Managing bipolar disorder during pregnancy weighing the risks and benefits Can J Psychiatry 2002 Jun47(5)426-436

Webb R Abel K et al 2005 Mortality in Offspring of Parents with Psychotic Disorders A Critical Review and Meta-Analysis Am J Psych1621045-1056

Yonkers K Wisner K Stowe Z et al 2004 Management of Bipolar Disorder during pregnancy and the postpartum period Am J Psychiatry161608-620

2182017

8

Risk of Relapse of Major

Depression in Pregnancy

High risk of depressive relapse following antidepressant

discontinuation during pregnancy ( Cohen et al JAMA

2006)

Of 201 women in the sample 86 (43) experienced a relapse

of major depression during pregnancy

Women who discontinued medication relapsed more

frequently (68 vs 26) compared to women who

maintained medication (hazard ratio 50 95 confidence

interval 28-91 Plt001)

Pregnancy is not protective with respect to risk of

relapse of major depression

Medications

What to do

SSRIs (especially fluoxetine and sertraline) and TCAs relatively safe even during first trimester

SSRIs (especially sertraline) and TCAs relatively safe in breast-feeding (Risk of fluoxetine accumulation in breastmilk and TCA-induced seizures

Avoid Paroxetine (unless riskbenefit analysis dictates otherwise)

Insufficient information about newer antidepressants (SNRIrsquos) and trazodone

Bupropion FDA risk category changed from B to C

Adverse Fetal Outcomes associated

with Depression during Pregnancy

Adverse outcomes have been documented in women with

depression during pregnancy

Cohort studies demonstrate that the rate of depression per 1000

deliveries increased significantly from 273 in 1998 to 141 in

2005 (plt0001)

New cohort study shows that depressed women were

significantly more likely to have

Cesarean delivery preterm labor anemia diabetes and

preeclampsia or hypertension compared with women without

depression

Worse fetal outcomes included fetal growth restriction fetal

abnormalities fetal distress amp death

bull Bansil et al 2010 J Womenrsquos Health

Risks of Untreated Antenatal

Depression Associated with low maternal weight gain increased rates of

preterm birth low birth wt increased smoking ETOH and

other substances

Increased ambivalence about the pregnancy and overall worse

health status

Prenatal exposure to maternal stress has consequences for the

development of infant temperament

Children exposed to perinatal maternal depression have higher

cortisol levels than infants of mothers who were not depressed

and this continues through adolescence

Maternal treatment of depression during pregnancy appears to

help normalize infant cortisol levels

Current Use of Antidepressants in the

United States and During Pregnancy

CDC Antidepressant use skyrockets 400 in past 20 yearsmdash

reported Oct 2011

Antidepressants are the most frequently used medications by

people ages 18-44

Nearly one in four women ages 40 to 59 are taking

antidepressants

Less than 12 of those antidepressants had seen a mental-health

professional in the past year

(Data are from the National Health and Nutrition Examination Surveys N=

12637 participants about prescription-drug use antidepressant use length of

use severity of depressive symptoms and contact with a health professional)

2182017

9

Outcome data on Antidepressant

Medications in pregnancy

Intrauterine fetal death -No evidence

Einarson et al (2009) concluded no increased risk of Major Congenital Malformations (MCM) with SSRI use in the 1st

trimester

Growth impairment- Possible for fluoxetine premature birth (143 late 41 early 59 control) low birth weight and length

No differences in cognitive function verbal comprehension expressive language mood arousability activity levels distractibility behavior problems temperament (TCA FLX)

SSRI Discontinuation Syndrome vs Pulmonary HTN of Newborn

Antidepressants Tx in Pregnancy Neonatal

Outcomes

SSRI withdrawal is possible but usually these are transient (restlessness rigidity tremor)

Late SSRI exposure carries an overall risk ratio of 30 (95 CI 20-44) for a neonatal behavioral syndrome -Moses-Kolko et al JAMA 2005

Warburton et al (2010) concluded that when controlled for maternal mental illness severity reducing exposure to SSRI in the last 2 weeks before delivery did not have a significant clinical effect on improving neonatal health

Primary Pulmonary Hypertension

of the Newborn

2006 case control study showed SSRI exposure after 20 weeks gestation increased risk (4-5x higher) of PPHN with absolute risk of lt1 (N England J Med 2006)

Recent studies show increased risk of PPHN with multiple other risk factors and absolute low risk with SSRI exposure

C-section high maternal BMI AA or Asian heritage

Study concluded that large BMI and C-section had greater risk than SSRI exposure (Pediatrics 2007)

Swedish Medical Birth Registerndash 3rd trimester exposure showed increased risk of 24 (Pharmacoepidemiology Drug Safety 2008)

Paroxetine and Pregnancy In 2005 FDA began investigated risks associated with

antidepressant use in pregnant women

Results of Investigation

Infants born to women taking Paroxetine (Paxil) may be at double the risk for cardiovascular birth defects (4) compared to other antidepressants (2)

Sept 2005 US health officials warned against the use of Paxil in the first trimester due to potential birth defects in infants though relationship may be incidental

Further research is necessary involving adequate well-controlled studies to prove the effects of Paxil on the fetus

Risk of Autism with SSRI Use

Croen LA Grether JK Yoshida CK Odouli R

Hendrick V

Antidepressant Use During Pregnancy and

Childhood Autism Spectrum Disorders

Arch Gen Psychiatry 2011 Jul 4 [Epub ahead of

print]

PMID 21727247

Psychotropics Used in the

Treatment of Bipolar Disorder

Lithium

Anticonvulsants-- ldquoOlderrdquo anticonvulsants have

2x higher risk of major birth defects

Valproic Acid

Carbamazepine

Other (newer) anticonvulsants

Lamotrigine

Antipsychotics

2182017

10

Lithium vs Anticonvulsants

LITHIUM

Ebsteinrsquos cardiac malformation

005 risk vs 01 base rate

Neonatal hypothyroidism

Diabetes Insipidus (rare)

Polyhydraminos (rare)

FDA Pregnancy Category D

VALPROIC ACID

Spina bifida (1-5 risk)

Structural defects of the heart limbs and face

FDA Pregnancy Class D

CARBAMAZEPINE

Spina bifida (1 risk)

Structural defects of the face (dysmorphic facies)

Secreted in breast milk

FDA Pregnancy Category C

Newer Anticonvulsants

Limited data is available with the ldquonewerrdquoagents such

as gabapentin lamotrigine oxcarbazepine and

topiramate

Lamotrigine has good safety record to date No

increased risk of birth defects

The benzodiazepines may have increased risk of cleft

lip and palate (07)

All are secreted in breast milk

FDA pregnancy class C

Antipsychotics

Teratogenic risks are probably low with the traditional neuroleptics (Haloperidol is safest)

There is inadequate information available to ascertain risk of newer atypical antipsychotics although safety profile is promising to date

Quetiapine has lowest transmission in breast milk (Stowe et al)

All are secreted in breast milk

FDA pregnancy class C (except for clozaril)

Conclusions Treatment

Perinatal psychiatric illness requires immediate

intervention

Coordination of care between OB-GYN and trained

mental health professionals is critical

Antidepressant medications can be safely used during

pregnancy and lactation

Assess risk of untreated illness versus greater risk of exposure

Chronic mental illness must be treated during pregnancy

to prevent severe PPD

Patients with preexisting psychosis must be treated as a

ldquohigh risk pregnancyrdquo during and after delivery

UNC Center for Womenrsquos Mood

Disorders

Perinatal Psychiatry ProgramClinical and Research Program

that provides assessment treatment and

support for women in the

perinatal period

Collaboration of doctors nurses

midwives

therapists amp social workers

wwwwomensmooddisordersorg

Unit

UNC Perinatal In-patient Psychiatric Unit

2182017

11

Program

Perinatal Inpatient Psychiatry Program provide

Comfort measures

Protected sleep times

Dedicated private and semi-private rooms and group

room

Gliders and supplies for pumpingnursing

Pumps supplies and refrigerator for milk storage

Specialty perinatal nursing staff

Extended visiting hours to maximize positive mother-

baby interaction

Resources

Postpartum Support International

(800) 944-4PPD wwwpostpartumnet

Postpartum Progress Blog

httpwwwpostpartumprogresscomweblog

National Womenrsquos Health Information Center

(800) 994-9662 www4womangov

Motherisk wwwmotheriskorg latest on studies

of medications in pregnancy and lactation

OTIS wwwOTISpregnancyorg

886-626-6847

Thanks bull UNC Psychiatry

bull Dr David Rubinow Department Chair

bull Dr Samantha Meltzer-Brody Director Perinatal Mood Disorder Program

bull Dr Mary Kimmel Medical Director In-patient Unit

bull Brenda Pearson and Katie Melvin

bull UNC OB-GYN bull Dr Kate Menard

bull DrBob Strauss

bull DrAlison Stuebe

bull DrJohn Thorp

Questions

References Andrade SE McPhillips H Loren D Raebel MA et al Antidepressant medication

use and risk of persistent pulmonary hypertension of the newborn Pharmacoepidemiol Drug Saf 2009 Mar18(3)246-52

Gavin N Gaynes B Lohr K Meltzer-Brody S et al 2005 Perinatal depression a systematic review of prevalence and incidenceObstet Gynecol 1061071-83

Cohen L Altshuler L Harlow B Nonacs R 2006 Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment JAMA 295(5)499-507

Chambers C Hernandez-Diaz S VanMarter L Werler M 2006 Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn N Engl J Med 354(6)579-87

Delatte R Meltzer-Brody S Cao H Menard K 2009 ldquoUniversal Screening for Postpartum Depression An Inquiry into Provider Attitudes and Practice American Journal of Obstetrics and Gynecology 200(5)e63-4

Einarson A Choi J Koren G 2009 Incidence of major malformations in infants following antidepressant exposure in pregnancy results of a large prospective cohort study Canadian Journal of Psych 54(4)242-6

McKenna K Koren G Tetelbaum M Wilton L et al 2005 Pregnancy outcome of women using atypical antipsychotic drugs A prospective comparative study J Clin Psychiatry 66444-449

References Meltzer-Brody S Payne J Rubinow D 2008 Postpartum Depression Evolving

Etiology amp Treatment Considerations Current Psych 7(5)87-95

Meltzer-Brody S Hartmann K Miller W Scott J 2004 A brief screening instrument to detect posttraumatic stress disorder in outpatient gynecologyObstet Gynecol104(4)770-776

Oberlander TF Warburton W Misri S et al 2006 Neonatal Outcomes After Prenatal Exposure to Selective Serotonin Reuptake Inhibitor Antidepressants and Maternal Depression Using Population-Based Linked Health Data Arch General Psychiatry 63898-906

Sit D Rothschild A Wisner K 2006 A Review of Postpartum Psychosis Journal of Womenrsquos Health 15(4)352-368

Viguera A amp Cohen L 1998 The course and management of bipolar disorder during pregnancy Psychopharmacology Bulletin 34339-353

Viguera A Cohen L et al 2002 Managing bipolar disorder during pregnancy weighing the risks and benefits Can J Psychiatry 2002 Jun47(5)426-436

Webb R Abel K et al 2005 Mortality in Offspring of Parents with Psychotic Disorders A Critical Review and Meta-Analysis Am J Psych1621045-1056

Yonkers K Wisner K Stowe Z et al 2004 Management of Bipolar Disorder during pregnancy and the postpartum period Am J Psychiatry161608-620

2182017

9

Outcome data on Antidepressant

Medications in pregnancy

Intrauterine fetal death -No evidence

Einarson et al (2009) concluded no increased risk of Major Congenital Malformations (MCM) with SSRI use in the 1st

trimester

Growth impairment- Possible for fluoxetine premature birth (143 late 41 early 59 control) low birth weight and length

No differences in cognitive function verbal comprehension expressive language mood arousability activity levels distractibility behavior problems temperament (TCA FLX)

SSRI Discontinuation Syndrome vs Pulmonary HTN of Newborn

Antidepressants Tx in Pregnancy Neonatal

Outcomes

SSRI withdrawal is possible but usually these are transient (restlessness rigidity tremor)

Late SSRI exposure carries an overall risk ratio of 30 (95 CI 20-44) for a neonatal behavioral syndrome -Moses-Kolko et al JAMA 2005

Warburton et al (2010) concluded that when controlled for maternal mental illness severity reducing exposure to SSRI in the last 2 weeks before delivery did not have a significant clinical effect on improving neonatal health

Primary Pulmonary Hypertension

of the Newborn

2006 case control study showed SSRI exposure after 20 weeks gestation increased risk (4-5x higher) of PPHN with absolute risk of lt1 (N England J Med 2006)

Recent studies show increased risk of PPHN with multiple other risk factors and absolute low risk with SSRI exposure

C-section high maternal BMI AA or Asian heritage

Study concluded that large BMI and C-section had greater risk than SSRI exposure (Pediatrics 2007)

Swedish Medical Birth Registerndash 3rd trimester exposure showed increased risk of 24 (Pharmacoepidemiology Drug Safety 2008)

Paroxetine and Pregnancy In 2005 FDA began investigated risks associated with

antidepressant use in pregnant women

Results of Investigation

Infants born to women taking Paroxetine (Paxil) may be at double the risk for cardiovascular birth defects (4) compared to other antidepressants (2)

Sept 2005 US health officials warned against the use of Paxil in the first trimester due to potential birth defects in infants though relationship may be incidental

Further research is necessary involving adequate well-controlled studies to prove the effects of Paxil on the fetus

Risk of Autism with SSRI Use

Croen LA Grether JK Yoshida CK Odouli R

Hendrick V

Antidepressant Use During Pregnancy and

Childhood Autism Spectrum Disorders

Arch Gen Psychiatry 2011 Jul 4 [Epub ahead of

print]

PMID 21727247

Psychotropics Used in the

Treatment of Bipolar Disorder

Lithium

Anticonvulsants-- ldquoOlderrdquo anticonvulsants have

2x higher risk of major birth defects

Valproic Acid

Carbamazepine

Other (newer) anticonvulsants

Lamotrigine

Antipsychotics

2182017

10

Lithium vs Anticonvulsants

LITHIUM

Ebsteinrsquos cardiac malformation

005 risk vs 01 base rate

Neonatal hypothyroidism

Diabetes Insipidus (rare)

Polyhydraminos (rare)

FDA Pregnancy Category D

VALPROIC ACID

Spina bifida (1-5 risk)

Structural defects of the heart limbs and face

FDA Pregnancy Class D

CARBAMAZEPINE

Spina bifida (1 risk)

Structural defects of the face (dysmorphic facies)

Secreted in breast milk

FDA Pregnancy Category C

Newer Anticonvulsants

Limited data is available with the ldquonewerrdquoagents such

as gabapentin lamotrigine oxcarbazepine and

topiramate

Lamotrigine has good safety record to date No

increased risk of birth defects

The benzodiazepines may have increased risk of cleft

lip and palate (07)

All are secreted in breast milk

FDA pregnancy class C

Antipsychotics

Teratogenic risks are probably low with the traditional neuroleptics (Haloperidol is safest)

There is inadequate information available to ascertain risk of newer atypical antipsychotics although safety profile is promising to date

Quetiapine has lowest transmission in breast milk (Stowe et al)

All are secreted in breast milk

FDA pregnancy class C (except for clozaril)

Conclusions Treatment

Perinatal psychiatric illness requires immediate

intervention

Coordination of care between OB-GYN and trained

mental health professionals is critical

Antidepressant medications can be safely used during

pregnancy and lactation

Assess risk of untreated illness versus greater risk of exposure

Chronic mental illness must be treated during pregnancy

to prevent severe PPD

Patients with preexisting psychosis must be treated as a

ldquohigh risk pregnancyrdquo during and after delivery

UNC Center for Womenrsquos Mood

Disorders

Perinatal Psychiatry ProgramClinical and Research Program

that provides assessment treatment and

support for women in the

perinatal period

Collaboration of doctors nurses

midwives

therapists amp social workers

wwwwomensmooddisordersorg

Unit

UNC Perinatal In-patient Psychiatric Unit

2182017

11

Program

Perinatal Inpatient Psychiatry Program provide

Comfort measures

Protected sleep times

Dedicated private and semi-private rooms and group

room

Gliders and supplies for pumpingnursing

Pumps supplies and refrigerator for milk storage

Specialty perinatal nursing staff

Extended visiting hours to maximize positive mother-

baby interaction

Resources

Postpartum Support International

(800) 944-4PPD wwwpostpartumnet

Postpartum Progress Blog

httpwwwpostpartumprogresscomweblog

National Womenrsquos Health Information Center

(800) 994-9662 www4womangov

Motherisk wwwmotheriskorg latest on studies

of medications in pregnancy and lactation

OTIS wwwOTISpregnancyorg

886-626-6847

Thanks bull UNC Psychiatry

bull Dr David Rubinow Department Chair

bull Dr Samantha Meltzer-Brody Director Perinatal Mood Disorder Program

bull Dr Mary Kimmel Medical Director In-patient Unit

bull Brenda Pearson and Katie Melvin

bull UNC OB-GYN bull Dr Kate Menard

bull DrBob Strauss

bull DrAlison Stuebe

bull DrJohn Thorp

Questions

References Andrade SE McPhillips H Loren D Raebel MA et al Antidepressant medication

use and risk of persistent pulmonary hypertension of the newborn Pharmacoepidemiol Drug Saf 2009 Mar18(3)246-52

Gavin N Gaynes B Lohr K Meltzer-Brody S et al 2005 Perinatal depression a systematic review of prevalence and incidenceObstet Gynecol 1061071-83

Cohen L Altshuler L Harlow B Nonacs R 2006 Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment JAMA 295(5)499-507

Chambers C Hernandez-Diaz S VanMarter L Werler M 2006 Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn N Engl J Med 354(6)579-87

Delatte R Meltzer-Brody S Cao H Menard K 2009 ldquoUniversal Screening for Postpartum Depression An Inquiry into Provider Attitudes and Practice American Journal of Obstetrics and Gynecology 200(5)e63-4

Einarson A Choi J Koren G 2009 Incidence of major malformations in infants following antidepressant exposure in pregnancy results of a large prospective cohort study Canadian Journal of Psych 54(4)242-6

McKenna K Koren G Tetelbaum M Wilton L et al 2005 Pregnancy outcome of women using atypical antipsychotic drugs A prospective comparative study J Clin Psychiatry 66444-449

References Meltzer-Brody S Payne J Rubinow D 2008 Postpartum Depression Evolving

Etiology amp Treatment Considerations Current Psych 7(5)87-95

Meltzer-Brody S Hartmann K Miller W Scott J 2004 A brief screening instrument to detect posttraumatic stress disorder in outpatient gynecologyObstet Gynecol104(4)770-776

Oberlander TF Warburton W Misri S et al 2006 Neonatal Outcomes After Prenatal Exposure to Selective Serotonin Reuptake Inhibitor Antidepressants and Maternal Depression Using Population-Based Linked Health Data Arch General Psychiatry 63898-906

Sit D Rothschild A Wisner K 2006 A Review of Postpartum Psychosis Journal of Womenrsquos Health 15(4)352-368

Viguera A amp Cohen L 1998 The course and management of bipolar disorder during pregnancy Psychopharmacology Bulletin 34339-353

Viguera A Cohen L et al 2002 Managing bipolar disorder during pregnancy weighing the risks and benefits Can J Psychiatry 2002 Jun47(5)426-436

Webb R Abel K et al 2005 Mortality in Offspring of Parents with Psychotic Disorders A Critical Review and Meta-Analysis Am J Psych1621045-1056

Yonkers K Wisner K Stowe Z et al 2004 Management of Bipolar Disorder during pregnancy and the postpartum period Am J Psychiatry161608-620

2182017

10

Lithium vs Anticonvulsants

LITHIUM

Ebsteinrsquos cardiac malformation

005 risk vs 01 base rate

Neonatal hypothyroidism

Diabetes Insipidus (rare)

Polyhydraminos (rare)

FDA Pregnancy Category D

VALPROIC ACID

Spina bifida (1-5 risk)

Structural defects of the heart limbs and face

FDA Pregnancy Class D

CARBAMAZEPINE

Spina bifida (1 risk)

Structural defects of the face (dysmorphic facies)

Secreted in breast milk

FDA Pregnancy Category C

Newer Anticonvulsants

Limited data is available with the ldquonewerrdquoagents such

as gabapentin lamotrigine oxcarbazepine and

topiramate

Lamotrigine has good safety record to date No

increased risk of birth defects

The benzodiazepines may have increased risk of cleft

lip and palate (07)

All are secreted in breast milk

FDA pregnancy class C

Antipsychotics

Teratogenic risks are probably low with the traditional neuroleptics (Haloperidol is safest)

There is inadequate information available to ascertain risk of newer atypical antipsychotics although safety profile is promising to date

Quetiapine has lowest transmission in breast milk (Stowe et al)

All are secreted in breast milk

FDA pregnancy class C (except for clozaril)

Conclusions Treatment

Perinatal psychiatric illness requires immediate

intervention

Coordination of care between OB-GYN and trained

mental health professionals is critical

Antidepressant medications can be safely used during

pregnancy and lactation

Assess risk of untreated illness versus greater risk of exposure

Chronic mental illness must be treated during pregnancy

to prevent severe PPD

Patients with preexisting psychosis must be treated as a

ldquohigh risk pregnancyrdquo during and after delivery

UNC Center for Womenrsquos Mood

Disorders

Perinatal Psychiatry ProgramClinical and Research Program

that provides assessment treatment and

support for women in the

perinatal period

Collaboration of doctors nurses

midwives

therapists amp social workers

wwwwomensmooddisordersorg

Unit

UNC Perinatal In-patient Psychiatric Unit

2182017

11

Program

Perinatal Inpatient Psychiatry Program provide

Comfort measures

Protected sleep times

Dedicated private and semi-private rooms and group

room

Gliders and supplies for pumpingnursing

Pumps supplies and refrigerator for milk storage

Specialty perinatal nursing staff

Extended visiting hours to maximize positive mother-

baby interaction

Resources

Postpartum Support International

(800) 944-4PPD wwwpostpartumnet

Postpartum Progress Blog

httpwwwpostpartumprogresscomweblog

National Womenrsquos Health Information Center

(800) 994-9662 www4womangov

Motherisk wwwmotheriskorg latest on studies

of medications in pregnancy and lactation

OTIS wwwOTISpregnancyorg

886-626-6847

Thanks bull UNC Psychiatry

bull Dr David Rubinow Department Chair

bull Dr Samantha Meltzer-Brody Director Perinatal Mood Disorder Program

bull Dr Mary Kimmel Medical Director In-patient Unit

bull Brenda Pearson and Katie Melvin

bull UNC OB-GYN bull Dr Kate Menard

bull DrBob Strauss

bull DrAlison Stuebe

bull DrJohn Thorp

Questions

References Andrade SE McPhillips H Loren D Raebel MA et al Antidepressant medication

use and risk of persistent pulmonary hypertension of the newborn Pharmacoepidemiol Drug Saf 2009 Mar18(3)246-52

Gavin N Gaynes B Lohr K Meltzer-Brody S et al 2005 Perinatal depression a systematic review of prevalence and incidenceObstet Gynecol 1061071-83

Cohen L Altshuler L Harlow B Nonacs R 2006 Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment JAMA 295(5)499-507

Chambers C Hernandez-Diaz S VanMarter L Werler M 2006 Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn N Engl J Med 354(6)579-87

Delatte R Meltzer-Brody S Cao H Menard K 2009 ldquoUniversal Screening for Postpartum Depression An Inquiry into Provider Attitudes and Practice American Journal of Obstetrics and Gynecology 200(5)e63-4

Einarson A Choi J Koren G 2009 Incidence of major malformations in infants following antidepressant exposure in pregnancy results of a large prospective cohort study Canadian Journal of Psych 54(4)242-6

McKenna K Koren G Tetelbaum M Wilton L et al 2005 Pregnancy outcome of women using atypical antipsychotic drugs A prospective comparative study J Clin Psychiatry 66444-449

References Meltzer-Brody S Payne J Rubinow D 2008 Postpartum Depression Evolving

Etiology amp Treatment Considerations Current Psych 7(5)87-95

Meltzer-Brody S Hartmann K Miller W Scott J 2004 A brief screening instrument to detect posttraumatic stress disorder in outpatient gynecologyObstet Gynecol104(4)770-776

Oberlander TF Warburton W Misri S et al 2006 Neonatal Outcomes After Prenatal Exposure to Selective Serotonin Reuptake Inhibitor Antidepressants and Maternal Depression Using Population-Based Linked Health Data Arch General Psychiatry 63898-906

Sit D Rothschild A Wisner K 2006 A Review of Postpartum Psychosis Journal of Womenrsquos Health 15(4)352-368

Viguera A amp Cohen L 1998 The course and management of bipolar disorder during pregnancy Psychopharmacology Bulletin 34339-353

Viguera A Cohen L et al 2002 Managing bipolar disorder during pregnancy weighing the risks and benefits Can J Psychiatry 2002 Jun47(5)426-436

Webb R Abel K et al 2005 Mortality in Offspring of Parents with Psychotic Disorders A Critical Review and Meta-Analysis Am J Psych1621045-1056

Yonkers K Wisner K Stowe Z et al 2004 Management of Bipolar Disorder during pregnancy and the postpartum period Am J Psychiatry161608-620

2182017

11

Program

Perinatal Inpatient Psychiatry Program provide

Comfort measures

Protected sleep times

Dedicated private and semi-private rooms and group

room

Gliders and supplies for pumpingnursing

Pumps supplies and refrigerator for milk storage

Specialty perinatal nursing staff

Extended visiting hours to maximize positive mother-

baby interaction

Resources

Postpartum Support International

(800) 944-4PPD wwwpostpartumnet

Postpartum Progress Blog

httpwwwpostpartumprogresscomweblog

National Womenrsquos Health Information Center

(800) 994-9662 www4womangov

Motherisk wwwmotheriskorg latest on studies

of medications in pregnancy and lactation

OTIS wwwOTISpregnancyorg

886-626-6847

Thanks bull UNC Psychiatry

bull Dr David Rubinow Department Chair

bull Dr Samantha Meltzer-Brody Director Perinatal Mood Disorder Program

bull Dr Mary Kimmel Medical Director In-patient Unit

bull Brenda Pearson and Katie Melvin

bull UNC OB-GYN bull Dr Kate Menard

bull DrBob Strauss

bull DrAlison Stuebe

bull DrJohn Thorp

Questions

References Andrade SE McPhillips H Loren D Raebel MA et al Antidepressant medication

use and risk of persistent pulmonary hypertension of the newborn Pharmacoepidemiol Drug Saf 2009 Mar18(3)246-52

Gavin N Gaynes B Lohr K Meltzer-Brody S et al 2005 Perinatal depression a systematic review of prevalence and incidenceObstet Gynecol 1061071-83

Cohen L Altshuler L Harlow B Nonacs R 2006 Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment JAMA 295(5)499-507

Chambers C Hernandez-Diaz S VanMarter L Werler M 2006 Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn N Engl J Med 354(6)579-87

Delatte R Meltzer-Brody S Cao H Menard K 2009 ldquoUniversal Screening for Postpartum Depression An Inquiry into Provider Attitudes and Practice American Journal of Obstetrics and Gynecology 200(5)e63-4

Einarson A Choi J Koren G 2009 Incidence of major malformations in infants following antidepressant exposure in pregnancy results of a large prospective cohort study Canadian Journal of Psych 54(4)242-6

McKenna K Koren G Tetelbaum M Wilton L et al 2005 Pregnancy outcome of women using atypical antipsychotic drugs A prospective comparative study J Clin Psychiatry 66444-449

References Meltzer-Brody S Payne J Rubinow D 2008 Postpartum Depression Evolving

Etiology amp Treatment Considerations Current Psych 7(5)87-95

Meltzer-Brody S Hartmann K Miller W Scott J 2004 A brief screening instrument to detect posttraumatic stress disorder in outpatient gynecologyObstet Gynecol104(4)770-776

Oberlander TF Warburton W Misri S et al 2006 Neonatal Outcomes After Prenatal Exposure to Selective Serotonin Reuptake Inhibitor Antidepressants and Maternal Depression Using Population-Based Linked Health Data Arch General Psychiatry 63898-906

Sit D Rothschild A Wisner K 2006 A Review of Postpartum Psychosis Journal of Womenrsquos Health 15(4)352-368

Viguera A amp Cohen L 1998 The course and management of bipolar disorder during pregnancy Psychopharmacology Bulletin 34339-353

Viguera A Cohen L et al 2002 Managing bipolar disorder during pregnancy weighing the risks and benefits Can J Psychiatry 2002 Jun47(5)426-436

Webb R Abel K et al 2005 Mortality in Offspring of Parents with Psychotic Disorders A Critical Review and Meta-Analysis Am J Psych1621045-1056

Yonkers K Wisner K Stowe Z et al 2004 Management of Bipolar Disorder during pregnancy and the postpartum period Am J Psychiatry161608-620

2182017

12

References Einarson A Choi J Einarson TR Koren G Incidence of major malformations

in infants following antidepressent exposure in pregancy results of a large perspective cohort study Can J Psychiatry 2009 54242-246

Warburton W Hertzman C Oberlander TF A register study of the impact of stopping third trimester selective serotonin reuptake inhibitor exposure on neonatal health Acta Psychiatr Scand 2010 121471-479

Robinson GE Psychopharmacology in Pregancy and Postpartum FOCUS The journal of Lifelong Learning in Psychiatry (2012) volX p1-12

bull Chris Raines

UNC Center for Womenrsquos Mood Disorders

christena_rainesmeduncedu

bull Jennifer Vickery Western Regional Program Coordinator

Mission Health System

JenniferVickerymsjorg

bull Brenda Stubbs Triad Regional Program Coordinator

March of Dimes

bstubbsmarchofdimesorg

Contacting the presenters

More webinars to comeDate Time Webinar Topic Register

March 15

2017

1130amndash

1pm

Paternal Involvement

in Pregnancy A Closer

Look at Menrsquos

Preconception Health

Click Here

April 16

2017

1130am-

130pm

Circle of Care

Innovations

Interconception Care

and the IMPLICIT

Toolkit

Click Here

Questions Comments

Brenda Stubbs

Triad Regional Program Coordinator

March of Dimes

bstubbsmarchofdimesorg

bull For more information about the Campaign and other preconception health topics visit wwwEveryWomanNCorg

bull Find us on Facebook httpwwwfacebookcomeverywomannc

bull Follow us on Twitter everywomannc

Thank you

2182017

13

bull A statewide initiative aimed at improving birth outcomes in NC by reaching out to women with important health messages before they become pregnant

bull Formerly functioned as the NC Folic Acid Campaign

bull Goals of the Campaign are to reduce infant mortality birth defects premature birth and chronic health conditions in women while also aiming to decrease unintended pregnancies in NC through promoting reproductive life planning

bull Seeks to raise awareness and inspire positive action among the general public health care professionals and community agencies

March of Dimes North Carolina Preconception Health Campaign