Mental Health Problems in Pregnancy and Postpartum
Definition | Aetiology | Pathophysiology | Risk factors | Signs and symptoms | Investigations | Management
Definition
Mental health problems in pregnancy and postpartum refer to a range of psychiatric disorders that can develop during pregnancy or in the postpartum period, including anxiety, depression, psychosis, and postpartum psychosis.
Aetiology
- Hormonal changes: rapid fluctuations in oestrogen and progesterone.
- Psychosocial factors: stress, lack of social support, previous trauma.
- Biological factors: genetic predisposition to mental illness.
- Pre-existing psychiatric conditions: bipolar disorder, schizophrenia, depression.
- Obstetric factors: traumatic birth, unplanned pregnancy, complications.
Pathophysiology
- Hormonal dysregulation affecting neurotransmitter systems (serotonin, dopamine).
- HPA axis hyperactivity contributing to stress response and mood instability.
- Neuroinflammatory processes linked to depressive symptoms.
Risk factors
- Personal or family history of mental illness.
- Lack of social or partner support.
- Adverse life events (e.g., domestic violence, financial stress).
- History of miscarriage, stillbirth, or traumatic birth.
- Teen pregnancy or unintended pregnancy.
- Sleep deprivation and fatigue.
Signs and symptoms
- Depression: low mood, anhedonia, fatigue, feelings of guilt or worthlessness.
- Anxiety: excessive worry, panic attacks, intrusive thoughts.
- Postpartum psychosis: hallucinations, delusions, severe mood disturbance, confusion.
- Obsessive-compulsive disorder: intrusive thoughts related to harm, compulsions.
- Suicidal ideation: risk of self-harm or suicide.
Investigations
- Edinburgh Postnatal Depression Scale (EPDS): screening for perinatal depression.
- Generalised Anxiety Disorder (GAD-7) and PHQ-9: assessing anxiety and depression severity.
- Clinical assessment: detailed psychiatric and obstetric history.
- Blood tests: if organic causes suspected (e.g., thyroid dysfunction, anaemia).
- Risk assessment: evaluating suicide/self-harm risk and safeguarding concerns.
Management
1. Psychological interventions:
- Cognitive behavioural therapy (CBT) for anxiety and depression.
- Interpersonal therapy (IPT) for relationship and social difficulties.
- Peer support and mother-baby bonding interventions.
2. Pharmacological management:
- First-line for depression/anxiety: SSRIs (e.g., sertraline, fluoxetine – lowest effective dose).
- Avoid benzodiazepines: due to neonatal withdrawal risk.
- Antipsychotics: used in postpartum psychosis (e.g., olanzapine, quetiapine).
- Mood stabilisers: lithium requires close monitoring due to teratogenic risk.
3. Crisis and safeguarding:
- Emergency psychiatric referral if postpartum psychosis or high suicide risk.
- Involvement of perinatal mental health team.
- Child safeguarding referrals if concerns about maternal care capacity.
4. Referral:
- Perinatal mental health service: specialist assessment and support.
- Health visitor/midwife: ongoing monitoring and support.
- Psychiatrist: if severe symptoms requiring medication or admission.