This chapter should be cited as follows: This chapter was last updated:
Zager, R, Glob. libr. women's med.,
(ISSN: 1756-2228) 2009; DOI 10.3843/GLOWM.10155
May 2009

General considerations

Psychological Aspects of High-Risk Pregnancy

Ruth P. Zager, MD
Clinical Professor of Pediatrics, Clinical Professor of Psychiatry, Jefferson Medical College, Philadelphia, Pennsylvania, USA

INTRODUCTION

A high-risk pregnancy traditionally was defined as one complicated by a serious medical condition that may jeopardize its outcome. Now, there is a veritable "explosion" of clinical research and anecdotal reports, describing multiple factors with psychological influences on women before, during, and after their pregnancy, which may often determine its course, outcome, and that of the infant(s). The psychological status of the pregnant patient may determine her ability to, and probability of, following instructions and caring for herself while pregnant and afterwards. Risk factors of pregnancy do not end at delivery, often continuing into the perinatal period, when the woman may be especially vulnerable to the onset or relapse of serious psychiatric disorders. Awareness of these factors and possible interventions, presents an added responsibility for the obstetrician, since he/she probably is the most important professional with whom the patient comes in contact. Failure to recognize and promptly refer for psychiatric treatment any woman with a serious emotional problem may entail devastating and tragic consequences for the woman, her child(ren), and family.

This review focuses on pregnancies accompanied by a variety of these conditions, common psychological responses to some of the medical illnesses which can complicate pregnancy, and the influence of various psychiatric disorders. Interventions are suggested.

Each woman's pregnancy experience is qualitatively influenced by her conscious and unconscious responses to it. These can be considered as biological, psychological, and psychosocial. Particularly pertinent are her age, past history of psychiatric disorders, socioeconomic status, and circumstances of the current pregnancy. The obstetrical history, especially about miscarriages, stillbirths, low birth weight infants, prior perinatal psychological disturbances, perinatal deaths, and the patient's response to them, should be carefully elicited. If mourning of any prior miscarriage(s) or other loss(es) has not been addressed, the patient may experience a resurgence of memories of the prior, lost pregnancies, along with feelings of increased anxiety during the current one.1, 2 Such grieving has also been found, although to a lesser degree, in fathers.2 A detailed family history about any prior episodes of depression or mania, prior postpartum depression or mania during pregnancy, and/or diagnosis of bipolar disorder (BPD) in first degree female relatives should be sought. It is not unusual for a previous episode of depression or mania in the patient or a close relative not to have been recognized. 

More than any other medical condition, pregnancy requires constant attention to the patient's emotional and physical well-being. Despite today's sophisticated technology and advances in fetal and neonatal care, the changing family structures and the lack of adequate prenatal care contribute to significant problems in some women's pregnancies. Not all pregnancies are simple, straightforward events; sometimes these complicating emotional and psychosocial factors are overlooked. 

PSYCHOLOGY OF PREGNANCY

For most women, pregnancy is a natural and joyful event. The discovery that she is pregnant is usually accompanied by a sense of fulfillment and excitement.3 There may be a psychological withdrawal into herself, in which "her attention, both biological and emotional, is claimed for the new and creative process taking place within her."3 Pregnancy may be viewed as a developmental process, unique to women, during which new levels of emotional maturity may be achieved. Deutsch recognized pregnancy as a time in which several psychological processes may occur simultaneously: "fulfillment of her deepest yearnings" and emergence of "old conflicts that have hitherto remained dormant."4 The re-working and resolving of some of these conflicts is one of the psychological tasks of pregnancy.5 Preparation for the new baby, and for the subsequent changes in social and partner relations are generally recognized as tasks of pregnancy. 

More contemporary theories of female psychology, while not focusing exclusively on pregnancy, do add to our understanding of it. The concept of "primary femininity", first described by Stoller,6 has gained much acceptance as an essential underpinning in the development of sexual identity in women. Becoming pregnant can be seen as part of a natural progression along this line. Another important concept is that women more naturally base their sense of self on their connections with others, whereas men seem to base theirs on autonomy and achievement.7 The maternal–fetal attachment that occurs is aided by the physiological symbiosis, as well as the psychological readiness of the mother to engage with the fetus.

It is important to ascertain the patient's emotional response to her pregnancy, what it means to her and her significant others, and what she expects will happen during the pregnancy. Unrealistic expectations and assumptions can fuel unnecessary apprehension and anxiety, which increase the emotional stress on the patient. The use of several general screening questions to ascertain whether the patient has "early signs of maladaptation to pregnancy" has been advocated.8 The questions are about the patient's prior untoward pregnancy experiences which may influence the present pregnancy, her problematic experiences with support systems, experiences in child care, and her own pregnancy health worries as there are certain "indicators" which merit further scrutiny of the patient.8 Theut1 developed scales measuring a prospective mother's and prospective father's anxiety related to the pregnancy.

 

HIGH-RISK PREGNANCY: GENERAL FACTORS

Certain groups are more vulnerable to psychological problems during pregnancy and perinatally. These include: (1) adolescents; (2) substance abusers; (3) women with prior psychiatric disorders (e.g., depression, BPD, schizophrenia, etc.); (4) women with a history of prior unfortunate pregnancy outcomes; (5) women with multiple pregnancies; (6) women with active or serious medical or physical problems (e.g., cancer, diabetes); and (7) women with prior postpartum depressions or psychosis. Additionally, women without an adequate support system, or without a helpful partner, or who are homeless, or victims of domestic violence, or other physical or emotional trauma and stresses have a high risk for psychological problems while pregnant. Such psychosocial stresses during pregnancy and perinatally can affect unfavorably the woman's mental state, perhaps resulting in a low birth weight child.9 Women experiencing psychological distress due to daily stresses as well as psychological disorders, were followed with cortisol and other biometric measurements; during 16–29 weeks, they showed elevated cortisol levels considered to be associated with lower fetal weights.10 Concurrent reports note untoward consequences for children's behavior and other functioning by the ages of 3 years and older when their mothers were not treated for depression.11, 12

The occurrence of a medical illness in the expectant mother increases the complexity of her care, creating stress and difficulty for both patient and obstetrician. Many medical conditions are subsumed under the term high-risk pregnancy, including diabetes, hypertension, anemia, pulmonary disease, seizure disorders, lupus, venereal diseases, AIDS, tuberculosis, etc. In addition, various genetically transmitted diseases, such as myotonic dystrophy, phenylketonuria, Tay-Sachs disease, sickle-cell anemia, are considered potentially high risk; preconception counseling is generally recommended. However, most women, even in the more developed countries, postpone visiting a physician until the second month of pregnancy, so that, unfortunately, they have not availed themselves earlier of genetic counseling.13 

Pregestational diabetes is one of the commonest of the high-risk conditions. Most women will cooperate with the monitoring, dietary restrictions, and hypoglycemic agents used, but may express a sense of emotional unease and worry throughout the pregnancy. Recognition of the patient's subjective reactions will allow the obstetrician to suggest brief counseling as needed. 

The woman who has had a previous cancer will experience strong feelings about her pregnancy; ambivalence may be heightened by her fears about her own prognosis in terms of recurrence or survival. In breast cancer, there are additional psychological considerations: the breast traditionally symbolizes nurturing, caring, and femininity.14, 15 Women with breast cancer worry about exacerbation of the cancer, as a result of hormonal stimulation from the pregnancy. Young women who have been treated for breast cancer, especially those with a genetic predisposition, may worry about this for their offspring.

The pregnant woman's reaction to the diagnosis of a medical condition will depend partly on the chronology of the illness. If it is a newly diagnosed condition, the woman must cope with the initial shock and distress accompanying such a diagnosis. Disbelief and initial denial may be quite strong, as most young adults do not expect to become ill; especially during pregnancy, the discovery of disease runs counter to the "usual" psychological state of mind described earlier. This may be particularly difficult for the woman who has endured many infertility treatments or postponed pregnancy for educational or career reasons. Psychological denial may lead to noncompliance with medical treatment recommendations, especially early in the pregnancy.

The woman with a chronic illness who becomes pregnant may be more psychologically adjusted to her illness, but still have fears that the pregnancy may exacerbate her illness, in addition to worrying that her condition may potentially harm her baby. These fears are usually reality-based; the obstetrician should determine to what extent the patient may present with excessive worry. 

Women at high risk of anxiety and depression have been shown to have greater levels of anxiety and depression than women at low risk.16 The woman's emotional response may also be affected by lifestyle changes, necessitated by the high-risk condition (e.g., hospitalization, prolonged bedrest, frequent examinations to monitor fetal growth). For some women, these parameters may be viewed as infringements on their freedom, and may increase resentment of the fetus. If the woman must make major lifestyle changes, such as absence from a career, she must also deal with the loss of that aspect of her life. Clearly, psychosocial support systems will play a major part in her adjustment to such stressors.17

The psychological sequelae of cesarean section should be noted. Cesarean section is very common today; indications and statistics are elaborated elsewhere. Short-term effects are notable as this is the only major surgery that one undergoes in which the postoperative period is spent caring for another human being. The immediate tasks of new motherhood cannot be postponed until the mother's recovery. Recognition of this inherent conflict and recommending additional support for the new mother can be invaluable parts of the obstetrician's advice. Despite tremendous advances in prenatal care and in perinatal intensive care, the management of the medically high-risk mother remains a challenge.

PSYCHOLOGICAL RESPONSE TO TECHNOLOGY

Ultrasound evaluation is an expected procedure, which induces little tension and worry, unless an abnormality has been detected. Then, considerable anxiety is stimulated, and more procedures will be undertaken, with understandable increasing patient apprehension over the status of the fetus(es).18 Obviously, a good working relationship between the obstetrician and the radiologist is essential, so that the woman receives this information in the most appropriate and compassionate manner. 

As with any medical procedure, the patient's comfort and acceptance of it is dependent on adequate education and preparation for the procedure. Informed consent should encompass those aspects of preparation for the various prenatal technologies that are available. The psychological response to other commonly used procedures: amniocentesis, chorionic villi sampling (CVS), fetal surgery, and fetal monitoring during labor and delivery will vary from one woman to another and the intensity of the procedure(s). The usual response is anxiety, apprehension, and worry about potential harm to the fetus. One study19 of psychological response to amniocentesis demonstrated significant reduction in anxiety and depressive affect after the results of the test were relayed to the patient. However, in this study, there were no abnormal findings, which may have altered the outcome to some extent. Another study20 comparing emotional responses to CVS versus amniocentesis found that there was earlier reduction of anxiety and depression in the CVS group; but study samples were relatively small. Discussion of responses to fetal surgery is beyond the scope of this article. Generally, procedures which are invasive and anxiety-provoking, should be undertaken after adequate patient preparation and compassionate attention to the pregnant woman's emotional needs.

HIGH-RISK PREGNANCY: SPECIFIC GROUPS

Adolescents represent an especially high-risk group.21 They frequently engage in high-risk behaviors, including unsafe sexual activity, substance abuse (tobacco, alcohol, marijuana, other licit and illicit drugs), and believe in their invulnerability. The pregnancy may be unplanned, perhaps the result of a casual sexual encounter, sexual abuse, date rape, incest. Studies by Stiffman22 suggest that pregnant adolescents, especially those from lower SES groups, generally come from the most unstable, dysfunctional, and "psychologically disadvantaged environments". Adolescent girls who are psychologically stressed, deprived or needy, may become pregnant in a misguided effort at relieving their unhappy feelings and obtaining love. Adolescents may be ongoing victims of domestic relationship violence, particularly when pregnant. For some adolescents, obtaining prenatal care may force an unwanted confrontation with parental anger, disapproval, and rejection,23 so they deny the presence of the pregnancy until the onset of labor and delivery, which may result in a tragic outcome for girl and infant. For yet other pregnant girls, attention to prenatal care may make the girl face her own sexuality, which may have been very threatening and conflictual for her. Many adolescents are unable to utilize adult help or community agencies for their difficulties. For the impulsive, "acting-out" adolescent who has not been able to exercise appropriate impulse control previously, the prenatal care regimen may be seen as another "authority" against whom the girl rebels. The pregnant teen may drop out of school, which may end her formal education and also deprive her of peer relationships and other important supports. The pregnant girl may get minimal or no prenatal care.9, 24, 25

On a positive note, the obstetrician has an opportunity to model nurturant caring to an adolescent who may unconsciously yearn for an accepting, parent-like figure to set limits. In forming such a caring, limit-setting, yet consistent relationship with the pregnant adolescent, the obstetrician may be in a unique position to help the girl towards obtaining treatment for alcohol and substance abuse and other adolescent problems, while aiding her in complying with the needed prenatal regimen. 

Substance use and abuse impact very adversely on the pregnancy and the ensuing child(ren).9, 12 Substance abuse  probably increases if the woman has another psychiatric disorder, although the prevalence of substance abuse in pregnant women is not known. Problems may be severe for the fetus (e.g., fetal alcohol syndrome); the infant may have congenital or other malformations depending on the substances taken, the timing and extent of their use, and may experience withdrawal symptoms. Risks are probably maximal during the third trimester.26 Substance abuse and domestic violence events during pregnancy have been reported associated with increasing behavior problems in children to the age of 3 years.12 The substance abusing patient should be given information about treatment facilities for substance abuse. Since she may have another psychiatric disorder (dual diagnosis), she needs a prompt referral for psychiatric treatment.

HIGH-RISK PREGNANCY: PSYCHIATRIC ILLNESS DURING PREGNANCY

The commonest mental illnesses in the pregnant and postpartum woman are reviewed in this section. Identification of these problems can lead to the initiation of helpful intervention(s).    

Affective disorders   

Any patient with a history of an affective disorder prenatally should be screened repeatedly for relapse or recurrence. There are several screening instruments available. The Edinburgh Postnatal Depression Scale (EPDS), is well-known, and can be easily utilized.27 Every patient with a history of depression, and a prior perinatal psychological problem needs frequent screening for depression and/or other psychiatric disturbances.28 The EPDS can be used.27 Altshuler et al.29 have developed a "scale that can be quickly administered [by an obstetric clinician] to identify with high probability those women most likely to be clinically depressed."29 Whatever method is used, it is important that depressed patients be referred urgently for psychiatric evaluation and treatment.

Major depression during pregnancy represents a serious problem in and of itself, and also as a portent for the probable occurrence of a postpartum depression (PPD) in that patient.9, 25, 30 The prevalence of depression in pregnant women varies,25 but there seems to be general agreement that it is fairly common and may result in a preterm birth, a low birth weight baby, and a higher incidence of cesarean section deliveries.29 Yet, many depressed women are neither diagnosed nor treated during pregnancy.31

A depressed woman may have been taking antidepressants before becoming pregnant highlighting the importance of what may have already affected the fetus, and whether to continue the medication during the pregnancy. This is a complex issue as all psychotropic medications can be assumed to cross the placenta. There are significant risks with abrupt discontinuation, tapered discontinuation, continuation of the medication, or changing the medication.32 Not treating the patient, who then may relapse during the pregnancy and perinatal period, poses significant risk to the woman, her fetus, and infant.25, 32 At best, the illness may preclude her from caring for herself (and her infant) properly; at worst, she may engage in harmful behaviors to herself and/or infant.25, 33 Women who have bipolar disorder (BPD) and/or a history of major depression during a prior pregnancy or postpartum are particularly vulnerable in this regard.

The selective serotonin reuptake inhibitors (SSRIs) are very commonly prescribed antidepressants. They and other "second generation" antidepressants (bupropion, duloxetine, mirtazapine, nefazadone, trazadone, venlafaxine), have largely replaced the older, tricyclic antidepressants. Their effects on the fetus differ depending on when during the pregnancy the SSRI is used. Taken during the first trimester, there may be certain birth defects.34 Taken after the 20th week of gestation, the SSRIs have been associated with persistent pulmonary hypertension in newborns.35 Paroxetine has been associated with the risk of congenital malformations, especially cardiac malformations; the FDA advises against its use during the first trimester.36 A population-based study37 of outcomes of women who had taken SSRIs during their pregnancy, reported that their pregnancies were of shorter gestation, their deliveries more likely by cesarean section, and their infants of lower birth weights, with longer hospital stays due to respiratory distress, jaundice, feeding difficulties. Toh et al.38 reported that "periconceptional SSRI treatment" was "associated with a higher risk for gestational hypertension" and preeclampsia, more so if the woman continued the SSRI after the first trimester. They also reported that women taking nonSSRI antidepressants (compared to the SSRI group) had a higher occurrence of gestational hypertension and preeclampsia, and suggested that depression itself may be linked to metabolic, endocrine, and genetic factors involved in gestational hypertension and preeclampsia.38 Some infants of depressed mothers who had not been treated with SSRIs were also of low birth weight and had respiratory distress.37 Studies were needed clearly separating responses of neonates when SSRIs were used during the pregnancy from the effects of depression itself during pregnancy.10, 32, 37, 39 Wisner et al.40 followed prospectively, throughout their pregnancies, several groups: women who were not depressed nor medicated; women depressed and taking SSRIs; or women depressed and not taking medication. They found that rates of preterm delivery were essentially the same for women with untreated depression compared with those receiving SSRIs throughout their pregnancies.40 Another report found brief, interpersonal psychotherapy helpful for a small sample of depressed obstetric clinic patients treated during their pregnancies.30 As an aid, Wisner et al.41 presented a "conceptual model' for decision making by the pregnant woman, the family, and the psychiatrist in these instances.

Bipolar disorder (BPD) represents a very high risk for patient and infant, although there is little agreement about its incidence during pregnancy. One population study of US women, while noting the high incidence of psychiatric disorders in pregnant women, found no increased incidence of BPD per se, although postpartum recurrences were closely related to its incidence during pregnancy.9 Others42, 43 have reported that pregnancy is "not protective against relapse", especially if there has been a previous episode. Pregnant patients with BPD, when in a manic or hypomanic phase, may engage in reckless behaviors, not care for themselves adequately, abuse substances, and receive inadequate nutrition. Sleep deprivation represents another serious problem, especially postpartum.44, 45 There is a consensus that the presence of BPD during pregnancy (either recurrence or new onset) is an untoward event and a high indicator for the occurrence of a postpartum depression.43

Lithium has been used for many years as a mood stabilizer for BPD patients. It has also been cited for its teratogenic potential. Early animal studies with lithium demonstrated a teratogenic effect in rats, invertebrates, and nonmammalian embryos.46 Retrospective data in humans were collected in the "Lithium Baby Register" in 1979; 25 out of 225 lithium babies (11%) had congenital malformations.47 There were six cases of Ebstein's anomaly, a rare cardiac anomaly, in babies born to mothers who had taken lithium during the first trimester.48, 49 However, another study, retrospective, of the mothers of 59 children with Ebstein's anomaly revealed that none of them had taken lithium.50 Cohen et al. in their "reevaluation of risk of in utero exposure to lithium",51 asserted that the "teratogenic risk of first trimester lithium exposure is lower than previously suggested."51 This report was widely cited; subsequently, Newport et al.52 revisited the issue. They obtained blood lithium levels at delivery from infants whose mothers had received lithium during their pregnancies and delivery and found that "lithium completely equilibrates across the placenta."52 The infants with higher lithium levels had "lower Apgar scores, longer hospital stays, and higher rates of CNS and neuromuscular complications."52 They recommended stopping lithium administration shortly before delivery.52 This reiterated an earlier suggestion by Schou48 who previously recommended that lithium be substantially reduced or stopped several days prior to delivery.48       

If lithium is given during the third trimester, lithium levels should be closely monitored. Lithium has many drug–drug interactions with commonly used agents such as nonsteroidal antiinflammatory drugs (NSAIDs), calcium channel blockers, etc. A pregnant patient taking lithium should be very closely followed by a psychiatrist in close collaboration with the obstetrician.

The anticonvulsants used for treatment of patients with BPD, are the same as those cited in a 2001 report discussing their teratogenicity as antiepileptic agents.53 The teratogenicity of anticonvulsant drugs commonly used as major bipolar treatment agents has recently been reviewed again.54 Valproate has the highest rate of major congenital malformations (6.2–16%); neural tube defects (1–5%); and greater risk of developmental problems with lower verbal IQ scores in offspring. A recent, nonrandomized study of these same anticonvulsant drugs, taken by pregnant women with epilepsy, reported significantly lower IQ scores in their children at age 3 years with valproate, but not with the other anticonvulsants.55 Neural tube defects (spina bifida, craniofacial anomalies, microcephaly) were reported to occur in 0.5–1% with carbamazepine; lamotrigine had a relative risk of cleft lip, palate especially in first trimester; lithium of Ebstein's anomaly (cardiac); and risks associated with olanzapine-fluoxetine unknown.54 Unfortunately, there are few data supporting the adequacy of complementary or alternative agents.

Treatment of the pregnant woman with BPD must balance the risk of relapse and its related serious morbidity, versus the risk of the teratogenic effects of antibipolar medications. Close collaboration between obstetrician and psychiatrist is warranted in the care of the pregnant BPD patient. Moreover, it is essential for the obstetrician caring for a patient with BPD to document a discussion of the risks and benefits of utilizing (or not) these medications, and obtain her clear, informed consent for the course followed. Such an informed consent is not static, so the subject should be reviewed on follow-up visits, as new information becomes available. Once again, consultation with knowledgeable colleagues is indicated. 

Schizophrenia/psychotic disorders: psychosis during pregnancy is relatively uncommon. In most cases, there is a pre-existing psychiatric condition, e.g., schizophrenia. Schizophrenic women often are obese, smoke, abuse substances, and get relatively poor prenatal care.56 They experience more obstetric complications, such as placental abruption, and have low birth weight infants who may have cardiovascular congenital anomalies.57, 58, 59 During pregnancy, especially in the first trimester, antipsychotic medications should be avoided if at all possible. Ongoing treatment by a psychiatrist throughout the pregnancy is advisable.60 Psychiatric hospitalization may be indicated if the woman has severe symptomatology. The perinatal care of mother and child should be planned long before delivery.

Antipsychotic medications

First generation (chlorpromazine, haloperidol, trifluoperazine, and perphenazine), when studied in the 1960s, were not found to be associated with an increased incidence of teratogenicity.61, 62, 63 However, other large-scale studies suggested connections between phenothiazine use during the first trimester, and congenital malformations.64, 65 Edlund's review of epidemiologic data in California65 concluded that the most dangerous time period – the "toxic window"  – for phenothiazines, seems to be between 4 and 10 weeks after fertilization.65 Risks are highest in the first trimester,57 when, if possible, antipsychotic medication should not be administered at all. This includes the phenothiazine antiemetic drugs, such as Compazine. Meclizine was listed as one of the drugs with suspected developmental toxicity (orofacial abnormalities).66 With second generation antipsychotics, folic acid must also be given; many patients are obese with an inadequate intake. Additionally, there are dangers of metabolic syndrome, and increased gestational diabetes.57 Newport et al., who prospectively studied women who took haloperidol and several second generation antipsychotics during their pregnancy, found they had more obstetrical complications.59 The newer second, generation antipsychotics need more extensive studies.42

Other psychiatric medications

Benzodiazepines were linked with an increased incidence of cleft palate in several studies.67, 68 Other large-scale studies, reviewed by Calabrese,69 failed to show any increases in congenital malformations. More recent studies reiterate that benzodiazepine use during pregnancy involves fetal risk.70, 71

Their use in the first and third trimesters is best avoided. These medications can cause withdrawal symptoms in newborns.72, 73 The neonate's liver is not yet able to quickly metabolize benzodiazepines, which therefore leads to greater toxicity of these drugs in the infant.69 If used, discontinuing them 2–3 weeks prior to delivery is recommended.74

POSTPARTUM/PERINATAL PROBLEMS

"Postpartum blues"

"Postpartum blues", commonly occurring in the postpartum period, are a milder from of depressed mood that resolves fairly quickly. Sometimes called "the baby blues", they occur in 50–80% of women during the first week after delivery.75 Typical symptoms of the "baby blues" are lability of mood, tearfulness, sleep disturbance, and irritability. In addition, the woman may have fleeting hostile thoughts and feelings toward the newborn, alternating with more positive emotions. Fatigue and somatic complaints are fairly common. While the nature of these symptoms is similar to those of major depression, in postpartum "blues", they are neither as severe nor as protracted. The onset of these depressive symptoms can be within the first week postpartum; they usually last for a week to 10 days.

Treatment for "postpartum blues" can usually be done by the obstetrician, with a combination of supportive and educational approaches. Sleep deprivation often starts during the first week postpartum, particularly for the nursing mother. The obstetrician can help the new parents support each other in adjusting to the infant's sleep–wake cycle.76 Reassuring the new mother that these symptoms are nearly universal, and usually transient, can be very helpful. Depressive symptoms, failing to resolve, or symptoms continuing for longer than 2 weeks must be considered as evidence of progression to a true postpartum depression.5 This, and inadequate social supports to aid the mother in coping during this period, should initiate a referral to a psychiatrist and a social service agency.

More serious perinatal problems

The perinatal period is now recognized as problematic for many women.9, 33, 44, 77, 78 Munk-Olsen et al.78 found that for Danish women, the first month postpartum was associated with an increased risk for admission to an inpatient psychiatric unit. Women with a history of BPD were at even higher risk, particularly 10–19 days postpartum. Schou reported an eight-fold increase in hospitalizations of BPD patients in the first month after delivery.48

Postpartum depression/perinatal depression (PPD) and postpartum psychosis (PPP)

These perinatal disorders represent a serious threat to the welfare of mother and child. Postpartum women routinely should be screened with the EPDS.27 Careful evaluation is even more urgent if the woman has: (1) experienced a previous episode; (2) had a new onset or recurrence or relapse of depression, BPD, or other psychiatric disorder during the pregnancy; or (3) had a family member who had a postpartum psychosis or mood disorder. Sleep disruption is deleterious for the postpartum woman, even more so in those with mood disorders.79

Speculation about the etiology of perinatal depression/psychosis has focused on the endocrine system, especially the hypothalamus–pituitary–adrenal (HPA) axis.25, 80, 81 Yim et al.77 report that placental corticotropin-releasing hormone (pCRH) level at 25 weeks' gestation may be a "strong predictor" of PPD symptoms. Future genetic work may identify at risk individuals.82 Clearly, much more research is needed in this area.

Increasing attention to PPD/PPP by members of the general public and the media, is also reflected in psychiatric practice guidelines for recognition and management.83 In the US, the New Jersey State Depression Law,84 effective October 10, 2006, mandates "licensed health care professionals" to screen postpartum patients before discharge and for several visits thereafter. 

The statute estimates an incidence of 10–20% of PPD, and emphasizes the dangers of suicide and infanticide in women with PPP. Of women with BPD, 50% reportedly are at risk for relapse or decompensation postpartum.84 For those women, the reintroduction of lithium either at delivery or within 24–48 hours postpartum is recommended.56

Women with BPD, a major depression history, prior PPD, or who may have discontinued or decreased their medication during their pregnancy are particularly susceptible to PPD. Sleep deprivation, obstetrical complications, prematurity and low birth weight infants, psychosocial stresses with minimal support, combine to worsen PPD, and interfere markedly with the new mother's capability of caring adequately for herself and her infant.28

Symptoms of PPD are those of major depression, and include feelings of hopelessness, helplessness, sadness, difficulty concentrating, irritability, and fatigue. Anxiety and sleep disturbances are common. Persistent negative thoughts about herself and/or the newborn may exist, including thoughts of suicide, and of hurting herself or the baby. Psychiatric treatment is needed.

In the outpatient management of the woman with PPD, psychosocial interventions are helpful and should be instituted.85 Medication is often indicated, which presents a problem for women planning to breast feed their baby. For all practical purposes, it can be assumed that medications taken by the mother will be secreted in her breast milk.83 The psychological and physical benefits of breast feeding for mother and child are clear, although the troublesome side effect of the sleep deprivation associated with nursing is often overlooked. The disadvantages to the child if the mother decompensates or is otherwise impaired are obvious. Untreated depression will have a deleterious effect on mother–infant bonding, especially during the first 3 months.86, 87, 88 Hence, there are recommendations for the resumption of medications immediately postpartum or shortly thereafter.56 Medications such as lithium are excreted in breast milk, although one study reported that "serum lithium levels in nursing infants were low and well tolerated."43 For the woman with BPD there is much at risk if she has a recurrence of the BPD. If she wants to nurse her baby, the quandary of taking the needed medications versus their effects on the infant, is renewed. In such cases, there is no substitute for the careful coordination of care among the patient, family (if available), obstetrician, pediatrician, and psychiatrist. 

Psychiatric hospitalization is less common, but can be indicated, especially in the treatment of depression with psychotic features. There is often reluctance to hospitalize the new mother, because of the enforced separation of mother and infant that occurs. In Great Britain, this problem has been circumvented by the admission of mother–infant dyads to specially designed units located throughout England, for this purpose.89 The effects of this program were reviewed recently.90 The nature and extent of the services offered in the in-patient operating units varied, but overall the programs have resulted in seriously mentally ill mothers being satisfactorily served alongside their infants.90 Similar programs have been instituted in Australia and New Zealand.91

PPP is a "psychiatric emergency".92 The incidence was thought to be about 1–2 per 1000 births.93 The onset of psychosis is usually within the first 3 weeks after delivery but may occur as soon as the patient is home, experiences sleep deprivation or other psychosocial stresses, and may not receive effective support. The categorical distinction between PPP and PPD with psychotic features, especially in a woman with BPD (a risk for PPP), can be difficult. Mothers with PPP may show more mood lability, bizarre behavior, confusion, delusions, paranoia, irrational thoughts, recurrent thoughts of harm to the infant, lack of reality testing, and little insight into their bizarre thinking and behavior. Some cases of infanticide are probably the result of psychotic delusions which the mother enacts. The danger to child and mother in the presence of maternal psychosis is extremely high, and the infant's safety must be assured by immediate, continuous supervision of the mother and her separation from the infant. Psychiatric treatment should be obtained on suspicion of PPP. In-patient psychiatric hospitalization is the safest course for mother and child when the woman is psychotic.92, 94 The patient who is noncompliant and overtly mistrustful of the physician may have a masked psychotic disorder. The help of a more reliable family member should be enlisted, to ensure that the patient follows through on psychiatric referral and treatment.   

Maternal–fetal interest conflicts

For the mother, the discovery that the fetus may be sick, damaged, or have a very severe congenital anomaly, may stimulate anxiety, guilt, disappointment, and other intense emotional reactions. Ambivalence over the pregnancy may be stirred up, which must be anticipated, to help the parents realistically appraise the threat to the fetus. Termination of the pregnancy may be considered as one option in certain high-risk conditions; fetal surgery may be another possibility. It is important for the obstetrician to remain an objective voice in such difficult, emotional situations. 

There are other facets of maternal–fetal interest conflicts.95 This is exemplified by the pregnant patient, perhaps the adolescent, who is noncompliant with the recommended medical regimen; or obtains no prenatal care whatsoever; or continues substance abuse behavior; or is grossly psychotic whose delusional denial of her pregnancy is part of her psychosis. These patients urgently need psychiatric referral and treatment. 

For the woman pregnant with two or more fetuses, issues of termination for one or more of them produces anxiety, guilt, and the need to cope with decisions well beyond those of a usual pregnancy, particularly when they have resulted from infertility or similar treatments. The decision to terminate selectively certain of the fetus(es) so that one (or more) can be carried more viably to term, represents a significant stress. The woman may continue the pregnancy with the remaining fetus(es), but she probably will be assailed with feelings of responsibility for the death(s) of the other fetus(es); feelings of sadness, guilt, grief, and mourning for them must co-exist with the more expected and positive anticipatory ones in the usual, wanted pregnancy. She will also be beset with increasing anxiety over the fate of the remaining fetus(es).

 

HIGH-RISK PERINATAL CONDITIONS: PREMATURE, LOW BIRTH WEIGHT, IMPAIRED, AND SICK INFANTS

The suddenness of premature labor and delivery leaves little time for the parents to prepare themselves for the stress of the impending birth. When a previous pregnancy has ended in a premature birth, the parents have prior experience, which may engender more apprehension about another, similar experience.1 Whenever the pregnancy, labor and/or delivery results in a distressed infant, there is the sudden reversal of the parental expectations of a normal, healthy, child. This disrupts parental coping mechanisms in a variety of ways. The parents, who have anticipated holding and nurturing their child in the delivery room, may be faced with the immediate removal of the baby from the delivery room to an intensive care nursery, where they may feel they have become somewhat superfluous observers in the technological care of their child.96 If the baby is transferred to a higher level nursery in another hospital, perhaps in another city, the parents are even more burdened; often the father alone must quickly make all the decisions and even accompany the child, while the mother remains a patient in the hospital where she delivered. In such cases, the mother, who may have had a cesarean section or otherwise difficult delivery, has little time to tend to her own physical needs before she must cope with feelings of "loss" for her absent child; also, she cannot start to bond physically with her child. The mother additionally is separated from the father at a time when both parents need each other for maximal support. She must deal alone with her feelings of apprehension, bewilderment, and confusion regarding the child, whom she may not have seen before he/she was transferred. If there are older siblings, the parents may feel even more torn; they want to be with their newborn baby at this critical time, yet they also are concerned about the effect of their absence on their other children. Financial considerations often exacerbate the psychological strains on the parents as their plans for returning to work are disrupted or deferred. Their employers may understand, and be sympathetic to parental needs for a short period, but not for the length of time the baby may be hospitalized. Equally pressing may be the expense of the baby's hospital course, which is often not covered adequately by health insurance plans. All of these further exacerbate the parental apprehension and distress. 

The baby's appearance, especially when very premature, often distresses parents, as it is counter to the usual expectations of what a newborn looks like. When the baby is surrounded by technical equipment, this intensifies the parental ambivalence. On the one hand, they welcome and are relieved that their baby is being treated carefully by the trained, skilful, nursery personnel. On the other hand, this heightens their immediate feelings of anxiety, failure, helplessness, loss of control, diminished self-esteem, and guilt; they, the parents, are not the primary caregivers for their own baby, and must depend exclusively on others. If the baby has been transferred to a nursery far from the parental home, the disruption of the parental lives and feelings is enormous. What was to have been an extremely joyful moment has been suddenly, and unexpectedly transformed into a bewildering, anxiety producing, near catastrophic event for the parents. 

Parental guilt probably is present whenever something abnormal or atypical occurs to the baby, regardless of the reality of the basis for their guilt feelings.97 These guilt feelings will be exacerbated if there was significant ambivalence about the pregnancy, particularly if the ambivalence was expressed behaviorally – e.g., if the mother was noncompliant regarding medical care, or neglected to obtain prenatal care, or abused alcohol or other substances while pregnant. 

If the child has an obvious genetic and/or congenital disorder, the parents may experience grief over the impairment, along with feelings of guilt, anger, and blame for the disability. Sometimes, parents may blame each other and each one's family for the baby's problem; where this is rooted in genetic reality, the parents will need maximal support. Parents whose babies have congenital infections, especially AIDS, will have strong emotional responses. The source of the mother's infection, her overall state of health, and her feelings about the baby influence her mental state and the responses of extended family members. Where the mother has been an active abuser of alcohol and/or other substances, during the entire pregnancy, more complex problems about the mother's status, and the future care of the baby are involved. In such cases, psychiatric and social work consultation is urgently needed in an ongoing way.

Mothers and fathers may respond differently to the problems of their newborn. Fathers may appear less affected because they may be less verbal and less communicative about their feelings.98 The mother, along with others, may misinterpret the paternal silence as indifference, aloofness, unconcern, and withdrawal.98 One or both parents may distance themselves from the intensive care nursery, and/or their baby in the nursery, in an effort to deal with their grief and distress. Sometimes only one parent will routinely visit despite the ability of both parents to come; sometimes parent(s) visit, but pay less attention to their own baby than to the other babies there. In this way they may be trying to shield themselves from their feelings of grief over the possible (or probable) death of the baby. Parents may abuse substances in their efforts to deal with their distressed feelings.98 Some parents may focus on the numerous procedures and laboratory studies performed on their baby, with insistent demands for frequent recitation of the baby's "symptoms" and laboratory results. They may focus on one specific, technical aspect of the baby's condition. They may insist that all technical aids be given to the baby, beyond the point where the nursery staff may know that it will not be helpful to the outcome of the baby. Parents may hover over the baby, question everything being done at any time to the baby, to the point of interfering with the routine of the intensive care nursery. 

Parental anger and guilt may be displaced onto certain nursery staff members with resultant splitting of the staff, and disruption of nursery functioning, especially in the area of setting adequate limits for parental behavior in the nursery. These complex feelings and behaviors are also not uncommon in staff members in the intensive care nurseries, and obstetrical and fetal medicine personnel must be alert to their own varying responses and behavior to the parents of their babies. Social workers routinely assigned to work with the nursery staff and the parents of these babies, should be readily available, along with a psychiatric consultant. 

PERINATAL DEATH/STILLBIRTHS

Parents who sustain the loss of a baby due to stillbirth are devastated, and often look to the obstetrician initially for help.99 Kirkley-Best reviewed responses to stillbirths when the fetus had died in utero, but the delivery was not immediate, and the mother may yet have hoped that the baby was still alive; some women may not have necessarily experienced anticipatory grief.100, 109 Stringham et al.101 consider this one of the most difficult stresses for the pregnant woman, and quote one of their patients who called herself a "walking coffin".101 More usually, the baby's death has become apparent during labor and/or delivery, so the mother's grieving process is ushered in by the baby's birth. The normal grieving process applies to parents who have had a stillborn child.99, 100, 101, 102, 103, 104, 105, 106 It is important for obstetricians and hospital personnel to recognize this immediately, the mothers are stunned, hope that an error has been made and that the baby is still alive. This is very quickly followed by a phase of "yearning and searching" during which the parents, especially the mother, often are filled with thoughts about the baby –  his or her appearance – and the mother often has feelings of still perceiving the baby moving.100, 109 For the mother who has not seen or held her stillborn baby, this phase is particularly difficult. Thereafter, mothers often feel very guilty about the stillbirth, and blame themselves. If the baby had any congenital defects or other abnormalities, mothers often felt ashamed and devalued.102 This was intensified if any hospital personnel commented on the abnormal appearance of the baby or suggested that it would be preferable for the mother not to see the baby for this reason.102 The difficulties attendant with stillbirths are exacerbated by the problems which many obstetricians and delivery/obstetrical personnel experience with the obstetrical loss this represents. For many reasons, stillbirths are often treated as nonevents,100, 101, 103, 109 thereby preventing the mother from talking about her loss, sense of failure, and feelings of grief. Mothers may be discouraged from seeing, feeling, holding, caressing their stillborn baby, thereby contributing to their feelings of distress and unreality, and disrupting the usual progression of the mourning process. Not uncommonly, mothers of stillborns are not returned to the obstetrical area, and may not receive much attention afterwards, thus leaving the parents, especially the mother, to grieve in silence.103

Kirkley-Best,100, 109 who studied some obstetricians' attitudes about stillborn children, found that half of the obstetricians in her sample realized that mothers would be sad after a stillbirth and/or neonatal death, and felt that these mothers should see, and even hold, their infants. Yet, most of the obstetricians questioned did not think that fathers of stillborns would be grief-stricken, or that mothers would grieve for a specific child.100, 109 She suggested that the obstetricians considered "stillbirth as a serious medical crisis rather than...the death of a son or a daughter."100, 109 Indeed, Condon states that a third of parents with stillborn children did not feel adequately supported by their obstetricians.104

To aid the parents of stillborn children, the obstetrical staff must acknowledge the reality of the loss of the child, give the mother and the father the opportunity to see, hold, and caress the child, and to make adequate funeral arrangements.101, 102 If an autopsy has been performed, the parents should be informed of the results promptly. Most importantly, the obstetrician should meet again with the parents in order to provide support, as the parents need to be able to mourn and grieve in an atmosphere of empathic understanding and support.103 This is of even greater importance in terms of future pregnancies, during which parental, especially maternal, anxiety can be anticipated because of the previous stillbirth. Maternal anxiety during succeeding pregnancies may become intensified if the mourning process for the prior stillborn child has not been dealt with adequately before the next pregnancy. Prolonged and/or pathological grief reactions following a stillbirth have been reported;104 such parents need a psychiatric referral for evaluation and treatment.  

Parents grieve in the same way for a child who has died during the perinatal period as for an older child or an adult who has died. The mourning was found to be more pronounced in mothers than in fathers,2 but occurred in both, even during succeeding pregnancies.97 They should be allowed time to mourn the child before being encouraged to attempt another pregnancy.

CONCLUSIONS

Patients who represent psychologically high risks need identification and careful assessment. A thorough history should include tactful, but definite questions about the patient's previous psychological problems and use of alcohol and/or other licit and illicit substances of abuse. High-risk patients may not be immediately apparent, and when the history is unrevealing or ambiguous, their detection may be difficult. One should carefully investigate any patient who provides an unexpected response to the physician's questions, statements or instructions. When a patient comments inappropriately in any way, with material not necessarily pertinent to the obvious topic being discussed, this often signifies an emotionally driven response. A patient may be so anxious that she does not "hear" what has been said; obviously, the source of the anxiety must be ascertained.107 Similarly, a patient may be so depressed that she has not been able to attend to what the physician has advised. When the patient is inappropriately active or jocular, or quickly becomes inappropriately belligerent, one should think about alcohol or other substance abuse, or that the patient may have some personality problem, or that she is overanxious but cannot spontaneously mention her anxiety. The patient may exhibit peculiar speech, which may suggest that her thinking is atypical, or that she may be under the influence of alcohol or other substances of abuse. The presence of a psychological problem may directly jeopardize the patient's and/or fetus' welfare, e.g., alcoholism, other substance abuse. It can also interfere with the patient's ability to cope with the pregnancy and to comply adequately with the medical needs of her condition. Careful listening to the pregnant patient may also reveal the presence of significant stresses, violence, past psychiatric problems, and the absence of an adequate support system. 

When a psychological problem has been identified in a pregnant or perinatal patient, she needs speedy referral for psychiatric evaluation and treatment. Management will depend on this careful assessment of the known or possible risks and benefits of the various treatment modalities during the different phases of the pregnancy and perinatal period. These must be balanced against the very real risks of nontreatment.108 There are now a variety of studies reporting results of treatment versus nontreatment during different trimesters and perinatally. When medications are used, the obstetrician must be apprised of all of them from whatever source (including over-the-counter remedies), so that drug–drug interactions can be monitored. Hence, adequate patient management necessitates close cooperation and coordination among the woman's various physicians and health care personnel. The pregnant patient with psychiatric problems presents unique challenges, for both the obstetrician and the psychiatrist. But the obstetrician may be the main medical professional with whom she establishes a truly trusting relationship during her pregnancy and thereafter.  

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