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Obstentrics_Williams. Souza ]P, Oliveira-Neto A, Surita FG, et al: he prolongation of somatic support in a pregnant woman with brain-death: a case report. Reprod Health 27:3, 2006 Sperling ]D, Dahlke ]D, Huber l, et al: The role of headache in the classification and management of hypertensive disorders in pregnancy. Obstet GynecoI 126(2):297, 2015 Sullivan FM, Swan IR, Donnan PT, et al: Early treatment with prednisolone or acyclovir in Bell's palsy. N Engl] Med 357:1598, 2007 hambisetry M, Lavin P], Newman N], et al: Fulminant idiopathic intracranial hypertension. Neurology 68:229, 2007 homas SV, Ajaykumar B, Sindhu K, et al: Cardiac malformations are increased in infants of mothers with epilepsy. Pediatr Cardiol 29:604, 2008 Tiel Groenestege AT, Rinkel G], van der Bon ]G, et al: The risk of aneurysmal subarachnoid hemorrhage during pregnancy, delivery, and the puerperium in the Utrecht population: case-crossover study and standardized incidence ratio estimation. Stroke 40(4):1148, 2009


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Obstentrics_Williams. Turner K, Piazzini A, Franza A, et al: Epilepsy and postpartum depression. Epilepsia 50(1):24, 2009 Tversky S, Libman RB, Reppucci ML, et al: Thrombolysis for ischemic stroke during pregnancy: a case report and review of the literature. ] Stroke Cerebrovasc Dis 25(10):e167, 2016 Vajda F], Hitchcock A, Graham ], et al: Seizure control in antiepileptic drugtreated pregnancy. Epilepsia 49(1): 172, 2008 VanderPluym ]: Cluster headache: Special considerations for treatment of female patients of reproductive age and pediatric patients. Curr Neurol Neurosci Rep 16(1):5, 2016 van der Worp HB, van Gijn ]: Acute ischemic stroke. N Engl ] Med 357(6):572, 2007 Van Teen TR, Panerai RB, Haeri S, et al: Changes in cerebral autoregulation in the second half of pregnancy and compared to non-pregnant controls. Pregnancy Hypertens 6(4):380, 2016


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Obstentrics_Williams. Van Teen TR, Panerai RB, Haeri S, et al: Changes in cerebral autoregulation in the second half of pregnancy and compared to non-pregnant controls. Pregnancy Hypertens 6(4):380, 2016 Viale L, Allotey ], Cheong-See F, et al: Epilepsy in pregnancy and reproductive outcomes: a systematic review and meta-analysis. Lancet 386: 1845, 2015 Vukusic S, Confavreux C: Pregnancy and multiple sclerosis: the children of PRIMS. Clin Neurol Neurosurg 108:266, 2006 Wabnitz A, Bushnell C: Migraine, cardiovascular disease, and stroke during pregnancy: systematic review of the literature. Cephalalgia 35(2): 132, 2015 Wang IK, Chang SN, Liao CC, et al: Hypertensive disorders in pregnancy and preterm delivery and subsequent stroke in Asian women: a retrospective cohort study. Stroke 42:716, 2011 Wasay M, Bakshi R, Bobustuc G, et al: Cerebral venous thrombosis: analysis of a multicenter cohort from the United States. ] Stroke Cerebrovasc Dis 17:49, 2008


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Obstentrics_Williams. Wasay M, Bakshi R, Bobustuc G, et al: Cerebral venous thrombosis: analysis of a multicenter cohort from the United States. ] Stroke Cerebrovasc Dis 17:49, 2008 Wen ]C, Liu TC, Chen H, et al: No increased risk of adverse pregnancy outcomes for women with myasthenia gravis: a nationwide population-based study. Eur] NeuroI 16:889, 2009 Westgren N, Hultling C, Levi R, et al: Pregnancy and delivery in women with a trauma spinal cord injury in Sweden, 1980-1991. Obstet Gynecol 81:926, 1993 Weston ], Bromley R, Jackson CF, et al: Monotherapy treatment of epilepsy in pregnancy: congenital malformation outcomes in the child. Cochrane Database Syst Rev II:CDOI0224, 2016 Wijdicks EFM, Varelas PN, Gronseth GS, et al: Evidence-based guideline update: determining brain death in adults. Neurology 74:1911, 2010 Wisof ]H, Kratzert K], Handwerker SM, et al: Pregnancy in patients with cerebrospinal fluid shunts: report of a series and review of the literature. Neurosurgery 29:827, 1991


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Obstentrics_Williams. Wisof ]H, Kratzert K], Handwerker SM, et al: Pregnancy in patients with cerebrospinal fluid shunts: report of a series and review of the literature. Neurosurgery 29:827, 1991 Wood ME, Frazier ]A, Nordeng HM, et al: Longitudinal changes in neurodevelopmental outcomes between 18 and 36 months in children with prenatal trip tan exposure: findings from the Norwegian Mother and Child Cohort Study. BM] Open 6(9):eOI1971, 2016 Wyszynski DF, Nambisan M, Surve T, et al: Increased rate of major malformations in ofspring exposed to valproate during pregnancy. Neurology 64:961, 2005 Yager PH, SinghalAV, Nogueira RG: Case 31-2012: an 18-year-old man with blurred vision, dysarthria, and ataxia. N Engl] Med 367: 1450, 2012 Yerby MS: Pregnancy, teratogenesis, and epilepsy. Neurol Clin 12:749, 1994


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Obstentrics_Williams. Yerby MS: Pregnancy, teratogenesis, and epilepsy. Neurol Clin 12:749, 1994 Yoshida K, Takahashi ]C, Takenobu Y, et al: Strokes associated with pregnancy and puerperium. A nationwide study by the Japan Stroke Society. Stroke 48:276, 2017 Zeeman GG, Fleckenstein ]L, Twickler DM, et al: Cerebral infarction in eclampsia. Am] Obstet Gynecol 190:714, 2004a Zeeman GG, Hatab M, Twickler DM: Increased cerebral blood low in preeclampsia with magnetic resonance imaging. Am ] Obstet Gynecol 191:1425, 2004b Zeeman GG, Hatab M, Twickler DM: Maternal cerebral blood low changes in pregnancy. Am] Obstet Gynecol 189:968, 2003 Zofkie A, Cunningham FG: A 33-year single-center experience with pregnancy-associated strokes. Abstract. Presented at the 38th Annual Meeting of the Society for Maternal-Fetal Medicine. February 1-3, 2018 CHAPTER 61 . PSYCHOLOGICAL ADJUSTMENTS TO PREGNANCY .. 1173 MAJOR DEPRESSION.. . . . . . . . . . . . . . . . . . . . . . . . . .. 1175


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Obstentrics_Williams. CHAPTER 61 . PSYCHOLOGICAL ADJUSTMENTS TO PREGNANCY .. 1173 MAJOR DEPRESSION.. . . . . . . . . . . . . . . . . . . . . . . . . .. 1175 BIPOLAR AND RELATED DISORDERS .............. 1178 ANXIETY DISORDERS. . . . . . . . . . . . . . . . . . . . . . . . . .. 1179 SCHIZOPHRENIA SPECTRUM DISORDERS.. . . . . . . . .. 1180 EATING DISORDERS. . . . . . . . . . . . . . . . . . . . . . . . . . .. 1180 PERSONALITY DISORDERS.. . . . . . . . . . . . . . . . . . . . .. 1181 he insaniy ofpregnancy is usualy a manestation of autointoxication, and may be accompanied by melancholic or maniacal symptoms. It usualy persists throughout gestation, but disappears shorty ater labour, unless the patient has an hereditary tendency to mental derangement. -]. Whitridge Williams (1903)


Obstentrics_Williams

Obstentrics_Williams. -]. Whitridge Williams (1903) The subject of mental illness was only briely addressed by Williams in 1903, when it appears that acute puerperal psychoses were manifestations of eclampsia or sepsis. More than 100 years later, we have learned that pregnancy and the puerperium are at times suiciently stressful to provoke mental illness. Such illness may represent recurrence or exacerbation of a preexisting psychiatric disorder, or it may signal the onset of a new condition. his 25th edition of Williams Obstetrics marks only the second edition with a focused chapter dedicated to psychiatric illnesses. To emphasize the rising national interest, American College of 0bstetricians and Gynecologists President Dr. Gerald F. Joseph Jr. declared postpartum depression as an initiative in 2009.


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Obstentrics_Williams. Psychiatric disorders during pregnancy are associated with less prenatal care, substance use, poor obstetrical and neonatal outcomes, and higher rates of postpartum psychiatric illness (Frieder, 2008). Despite these known risks, obstetrical providers often are reluctant to confront or fail to identiy some of these mental health issues during pregnancy. For example, Lyell and colleagues (2012) found that the diagnosis of depression was not documented in nearly half of the records of depressed women. Yet, perinatal mood disorders can have far-reaching consequences beyond the immediate efect on maternal mental health and social function by adversely afecting the motherchild relationship (Weinberg, 1998).


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Obstentrics_Williams. lso, suicide is a primary cause of death among women during the perinatal period in the United States, and major depression is among the strongest predictors of suicidal ideation (Melville, 2010). Between 2004 and 2012, self-harm, suicide, or drug overdose was the leading cause of maternal death in Colorado (Metz, 2016). In a 10-year analysis of Washington state hospitalizations, Comtois and associates (2008) studied 355 women with a postpartum suicide attempt. Substance abuse was linked with a sixfold higher and prior psychiatric hospitalization with a 27 -fold greater risk for suicide. These rates rose further if there were multiple hospitalizations. Also of note, 54 percent of pregnancy-associated suicides involve intimatepartner conlict (Palladino, 201r1).


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Obstentrics_Williams. Biochemical factors and life stressors can markedly inluence mental health and mental illness during the perinatal period. Intuitively, pregnancy exacerbates some coexisting psychological disorders. Namely, an increased risk for mood disorders is linked with pregnancy-related shifts in sex steroid and monoamine neurotransmitter levels, dysfunction of the hypothalamicpituitary-adrenal axis, thyroid dysfunction, and alterations in immune response (Yonkers, 2011). These changes, coupled with familial clustering of depression cases, suggest that there may be a subgroup of women at risk for developing a unipolar major depressive disorder during pregnancy.


Obstentrics_Williams

Obstentrics_Williams. Women respond in various ways to stressors of pregnancy, and some express persistent concerns regarding fetal health, child care, lifestyle changes, or fear of childbirth pain. Anxiety, sleep disorders, and unctional impairment are common (Romero, 2014; Vythilingum, 200S). However, according to Littleton and coworkers (2007), anxiety symptoms in pregnancy are associated with psychosocial variables similar to those for nonpregnant women. he level of perceived stress is significantly higher for women whose fetus is at high risk for a malformation, for those with preterm labor or delivery, and for those with other medical complications (Alder, 2007; Ross, 2006). Hippman and colleagues (2009) screened for depression in Sl women who had an increased risk for a fetus with aneuploidy. Half of these women had a positive depression screening score, whereas only 2.4 percent of those with a normal pregnancy did so.


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Obstentrics_Williams. Several steps can be taken to diminish psychological stress in the event of a poor obstetrical outcome. For example, following a stillbirth, Gold (2007) encouraged parental contact with the newborn and provision of photographs and other infant memorabilia. Addressing associated sleep disorders also seems reasonable Quulia Paavonen, 2017; Romero, 2014). • The Puerperium This is a particularly stressful time for women, and risks for mental illness are increased. Up to 15 percent of women develop a nonpsychotic postpartum depressive disorder within 6 months of delivery (Tam, 2007; Yonkers, 201r1). A few have a psychotic illness following delivery, and half of these manifest a bipolar disorder. Depressive disorders are more likely in women with obstetrical complications such as severe preeclampsia or fetal-growth restriction, especially if associated with early delivery. Houston and coworkers (2015) found that expectations at delivery also increased the risk for postpartum depression.


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Obstentrics_Williams. Importantly, stressors beyond those directly related to the pregnancy can raise perinatal depression rates. T arney and colleagues (2015) identified spouse deployment as a factor for postpartum depression in a study at Womack Army Medical Center. But, among women with a history of bipolar disorder, these elements playra lesser role in the development of mania or depression (Yonkers, 2011). Also called pospartum blues, this is a time-limited period of heightened emotional reactivity experienced by half of women within the irst week after parturition. Prevalence estimates for the blues range from 26 to S4 percent depending on diagnostic criteria (O'Hara, 2014). his emotional state generally peaks on the fourth or ifth postpartum day and normalizes by day 10 (O'Keane, 2011).


Obstentrics_Williams

Obstentrics_Williams. he predominant mood is happiness, but afected mothers are more emotionally labile. hey also may have insomnia, weepiness, depression, anxiety, poor concentration, and irritability. Mothers may be transiently tearful for several hours and then recover completely, only to be tearful again the next day. Supportive treatment is indicated, and afected women are reassured that the dysphoria is transient and most likely due to biochemical changes. They should be monitored for development of depression and other severe psychiatric disturbances.


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Obstentrics_Williams. Both the American College of Obstetricians and Gynecologists (2016a) and the United States Preventative Services Task Force now recommend screening at least once during the perinatal period for depression and anxiety (Siu, 2016). Identiication of psychiatric disorders in pregnancy can be challenging because changes in behavior and mood are often attributed to pregnancy. To diferentiate these, Yonkers (2011) recommends assessment of cognitive symptoms-for example, loss of concentration. Excessive symptoms of anxiety and insomnia-even during periods of infant sleep-can also suggest postpartum depression. Speciic factors for depression are reviewed and include a prior personal or family history of depression.


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Obstentrics_Williams. Universal-screening programs for depression continue to evolve (Venkatesh, 2016). At Parkland Hospital, mental illness screening is generally done at the irst prenatal visit using a brief risk-based query and again postpartum using a universalapplied screening tool for postpartum depression. Questions search for psychiatric disorders, related therapy, prior or current use of psychoactive medications, and current symptoms. Women with a history of sexual, physical, or verbal abuse; substance abuse; and personality disorders are also at greater risk for depression (man, 2007; Janssen, 2012). History of neglect and abuse are especially powerful antecedents of depression in adolescent pregnancy (Meltzer-Brody, 2014). Smoking and nicotine dependence and obesity also raise rates of all mental disorders in pregnancy (Goodwin, 2007; Molyneaux, 2014). Finally, because eating disorders may be exacerbated by pregnancy, afected women are followed closely (p. l1S0).


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Obstentrics_Williams. Several screening instruments shown in Table 61-1 are available and have been validated for use during pregnany and the puerperium. Use of one of these screening tools is encouraged because symptom-or risk-based screening alone may be insuficient (American College of Obstetricians and Gynecologists, 2016a). Cerimele and colleagues (2013) found that obstetricians and gynecologists failed to identiY 60 percent of depressed women in clinical practice. As mentioned earlier, at Parkland Hospital, all women are screened during their irst postpartum visit using the Edinburgh Postnatal Depression Scale (EPDS). In an analysis of more than 17,000 women, 6 percent had scores that indicated either minor or major depressive symptoms, and 12 women had thoughts of self-harm (Nelson, 2013). Similarly, Kim and coworkers (2015) assessed suicidal ideation in more than 22,000 women screened using the EPDS both during pregnancy and postpartum. They found rates of depression as high as 3.4 percent during


Obstentrics_Williams

Obstentrics_Williams. and coworkers (2015) assessed suicidal ideation in more than 22,000 women screened using the EPDS both during pregnancy and postpartum. They found rates of depression as high as 3.4 percent during the puerperium. A small fraction of those with thoughts of self-harm had a credible plan, intent, and means for attempted suicide. Obviously, suicidal ideation warrants prompt psychiatric consultation for evaluation and management.


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Obstentrics_Williams. Screening for perinatal depression without appropriate subsequent treatment is insuicient (American College of Obstetricians and Gynecologists, 20 16a). hat said, mechanisms to ensure adequate ensuing care can be problematic. In TABLE 61 -1 . Depression Screening Toolsa Time to Complete Edinburgh Postnatal 10 <5 http://www.fresno.ucsf.ed u/ped iatricsl down loadsl edi nbu rg hsca Ie. pdf Patient Health 9 <5 http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf Center for Epidemiologic 20 5-10 http://www.perinatalweb.org/assets/cms/uploads/files/CES-D.pdf aAIl depression screening tools are also available in Spanish. bAvailable free online.


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Obstentrics_Williams. the study by Nelson and associates (2013) more than three fourths of the 1106 women with abnormally elevated EPDS scores did not keep their later appointment, which ofered more formal psychiatric evaluation. Barriers include diiculties with access to care, personal perception of depression, and societal stigmata (Flynn, 2010; Smith, 2008). Women referred to a behavioral health provider located at the same site as their obstetrical care are four times more likely to access treatment than those referred elsewhere (Smith, 2009). To take advantage of this, at Parkland Hospital, mental health counselors also practice at postpartum clinic sites. Other promising interventions for puerperal depression include home visits, telephonebased peer support, and interpersonal psychotherapy (Dennis, 2013; Lavender, 2013; Yonemoto, 2017). A report from Kaiser Permanente, which describes the benefits and hurdles to system-based perinatal mental health care, provides a glimpse into the possible future of


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Obstentrics_Williams. Lavender, 2013; Yonemoto, 2017). A report from Kaiser Permanente, which describes the benefits and hurdles to system-based perinatal mental health care, provides a glimpse into the possible future of universal perinatal screening and treatment (Avalos, 2016; Flanagan, 2016).


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Obstentrics_Williams. Many psychiatric disorders can be improved with counseling and psychotherapies. In some instances, psychotropic medications are needed. Treatment decisions are ideally shared between patients and their health-care providers. In particular, women taking psychotropic medication are informed of likely side efects. Many of these drugs are discussed in Chapter 12 and by the American College of Obstetricians and Gynecologists (2016b) in their Practice Bulletin No. 92. Some of these drugs are discussed subsequently.


Obstentrics_Williams

Obstentrics_Williams. Emerging information on psychiatric disorders and pregnancy outcomes suggest a link between maternal psychiatric illness and untoward outcomes such as preterm birth, low birthweight, and perinatal mortality (Grigoriadis, 2013; Steinberg, 2014; Straub, 2012; Yonkers, 2009). In a study of 16,334 deliveries, Shaw and coworkers (2014) identiied a signiicant association between posttraumatic stress disorder and spontaneous pre term delivery. Domestic abuse-another aforementioned risk factor for perinatal mood disorder-is also linked with adverse perinatal outcomes (Yost, 2005). Finally, Littleton and associates (2007) reviewed 50 studies and concluded that anxiety symptoms, which are commonly comorbid with depression, had no adverse efect on perinatal outcomes. is the most recent version by the American Psychiatric Associa tion (2013). It assists in classiying mental disorders and speci fies criteria for each diagnosis.


Obstentrics_Williams

Obstentrics_Williams. is the most recent version by the American Psychiatric Associa tion (2013). It assists in classiying mental disorders and speci fies criteria for each diagnosis. Of categories, depressive disorders are common. According to the National Institute of Mental Health (2010), the life time prevalence of depressive disorders in the United States is 21 percent. Historically, depressive disorders include major bipolar disorder with both manic and depressive episodes. It also includes dysthymia, which is chronic, mild depression. This is the most common depressive disorder, and the 12-month prevalence of major depressive episodes among U.S. women is 8.2 percent (Center for Behavioral Health Statistics and Quality, 2015). In 2011 to 2014, 16 percent of U.S. women had used an antidepressant in the prior month (Pratt, 2017). The diagnosis is made by identiying symptoms listed in Table 61-2, but very few patients manifest all of these.


Obstentrics_Williams

Obstentrics_Williams. Major depression is multifactorial and prompted by genetic and environmental factors. Families of afected individuals often also have members sufering with alcohol abuse and anxiety disorders. Provocative conditions leading to depression include life events that prompt grief reactions, substance abuse, use of certain medications, and other medical disorders. Although life events can trigger depression, genes influence the response to these events and render the distinction between genetic and environmental factors diicult. One genome-wide linkage analysis of more than 1200 mothers suggests that variation in chromosomes 1 and 9 raises susceptibility to postpartum mood symptoms (Mahon, 2009). It is unquestionable that pregnancy is a major life stressor that can precipitate or exacerbate depressive tendencies. In TABLE 61-2. Symptoms of Depressive IIlnessa Persistent sad, anxious, or "empty" feelings worthlessness, and/or helplessness Irritabi Iity, restlessness


Obstentrics_Williams

Obstentrics_Williams. TABLE 61-2. Symptoms of Depressive IIlnessa Persistent sad, anxious, or "empty" feelings worthlessness, and/or helplessness Irritabi Iity, restlessness Loss of interest in activities once pleasurable, including sex Fatigue and decreased energy Difficulty concentrating, remembering details, and making decisions Insomnia, early-morning wakefulness, or excessive sleeping Overeating or appetite loss Thoughts of suicide, suicide attempts Persistent aches or pains, headaches, cramps or digestive problems that do not ease with treatment aNot all patients experience the same symptoms. Modified with permission from National Institute of Mental Health, 2010.


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Obstentrics_Williams. addition, various pregnancy-induced efects are implicated. Hormones certainly afect mood, as evidenced by premenstrual Major or minor depression develops postpartum in 10 to 20 syndrome and menopausal depression. Estrogen has been percent of women (Mental Health America, 2016). Available linked to increased serotonin synthesis, decreased serotonin data indicate that unipolar major depression may be slightly breakdown, and serotonin-receptor modulation (Deecher, more prevalent during the puerperium than among women in 2008). Concordantly, women who experience postpartum the general population (Yonkers, 2011). Postpartum depressive depression often have higher predelivery serum estrogen and symptoms are associated with young maternal age, antenatal progesterone levels and experience a greater decline postpardepression, unmarried status, smoking, newborns requiring tum (Ahokas, 1999). intensive care, and those with a history of stressors during preg


Obstentrics_Williams

Obstentrics_Williams. Dennis and associates (2007) queried the Cochrane Datanancy (Ko, 2017; Silverman, 2017). Speciically, physical or base and reported that the prevalence of antenatal depression verbal abuse during pregnancy is a potent risk for postpartum averaged 11 percent. Melville and coworkers (2010) found it depression (McFarlane, 2014). Finally, serious adverse obstetriin nearly 10 percent of more than 1800 women enrolled for cal events, especially those involving the neonate, are strongly prenatal care at a single university clinic. Others have reported linked to postpartum depression (Nelson, 2013, 2015). the incidence to be much higher depending on the population Depression is frequently recurrent. Up to 70 percent of studied (Gavin, 2005; Hayes, 2012; Lee, 2007). women with previous postpartum depression have a subsequent aChapter 12 (p. 245). bChapter 60 (p. 11r60). SSRI = Selective serotonin-reuptake inhibitor. Data from Briggs, 2015; Huybrechts, 2015; Koren, 2012.


Obstentrics_Williams

Obstentrics_Williams. SSRI = Selective serotonin-reuptake inhibitor. Data from Briggs, 2015; Huybrechts, 2015; Koren, 2012. Immediate referral to psychiatrist if no response, consider antidepressant Rx; antidepressant psychotherapy beneficial for pregnant women with mood disorders. episode. Women with both prior puerperal depression and a current episode of "maternity blues" carry an inordinately high risk for major depression. Indeed, 2 to 9 months postpartum, assistance with postpartum depression was the fourth most common challenge identiied in women in the Pregnancy Risk Assessment Monitoring System-PRAMS (Kanotra, 2007).


Obstentrics_Williams

Obstentrics_Williams. Postpartum depression is generally underrecognized and undertreated. Major depression during pregnancy or after delivery can have devastating consequences for afected women, their children, and families. One of the most significant contributions to the mortality rate among new mothers is suicide, which is most frequent among women with mental illness (Koren, 2012; Palladino, 2011). If left untreated, up to 25 percent of women with postpartum depression will be depressed 1 year later. As the duration of depression increases, so too does the number of sequelae and their severity. Maternal depression during the first weeks and months after delivery can lead to insecure attachment and later behavioral problems in the child.


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Obstentrics_Williams. Therapy for mood disorders during pregnancy and postpartum has undergone a significant evolution during the past decade. Babbitt (2014) and Pozzi (2014) and their associates have reviewed principles of antenatal and intrapartum care of women with major mental disorders. In general, for mild and mild-moderate depression, psychological treatment options, such as cognitive behavioral therapy, are considered irst (Yonkers, 2011). Antidepressant medications together with some form of psychotherapy are indicated for moderate to severe depression during pregnancy or the puerperium (American College of Obstetricians and Gynecologists, 2016b).


Obstentrics_Williams

Obstentrics_Williams. Shown in Figure 61-1 is one algorithm regarding treatment of mood disorders. Some of these medications are listed in 1 able 61-3. For women with severe depression, a selective sero tonin-reuptake inhibitor (SSRI) is selected initially. In contrast, tricyclic antidepressants and monoamine oxidase inhibitors are infrequently selected in contemporary practice. If depressive symptoms improve during a 6-week trial, the medication is continued for a minimum of 6 months to prevent relapse (Wisner, 2002). At least 60 percent of women taking antidepressant medication before pregnancy have symptoms during pregnancy. According to Hayes and colleagues (2012), approximately three fourths of women taking antidepressants before pregnancy stopped taking them before or during early pregnancy. For those who discontinue treatment, almost 70 percent have a relapse compared with approximately 25 percent who continue therapy. If the response is suboptimal or a relapse occurs, another SSRI is substituted,


Obstentrics_Williams

Obstentrics_Williams. discontinue treatment, almost 70 percent have a relapse compared with approximately 25 percent who continue therapy. If the response is suboptimal or a relapse occurs, another SSRI is substituted, or psychiatric referral is considered.


Obstentrics_Williams

Obstentrics_Williams. Various dietary deiciencies have suggested links to perinatal depression (Yonkers, 2011). Supplements that include omega-3 fatty acids, iron, folate, ribolavin, vitamin D, calcium, and docosahexaenoic acid (DHA) have been studied (Keenan, 2014; Miller, 2013). However, evidence currently is insuicient to support use of these dietary supplements for this purpose.


Obstentrics_Williams

Obstentrics_Williams. Importantly, in a metaanalysis by Huang and coworkers (2014), women using antidepressants during pregnancy have higher rates of preterm birth and low-birthweight neonates. Nevertheless, in their review, Ray and Stowe (2014) concluded that the relative reproductive safety data are reassuring and that antidepressants remain a viable treatment option. Furthermore, recurrence sometime after medication is discontinued develops in 50 to 85 percent of women with an initial postpartum depressive episode. Women with a history of more than one depressive episode carry greater risk (American Psychiatric Association, 2000). Surveillance includes monitoring for thoughts of suicide or infanticide, emergence of psychosis, and response to therapy. For some women, the course of illness is severe enough to warrant hospitalization.


Obstentrics_Williams

Obstentrics_Williams. Fetal and Neonatal Efects of Therapy. Some known and possible fetal and neonatal efects of treatment are listed in Table 61-3. Some studies suggest that SSRIs pose an elevated teratogenic risk for fetal cardiac defects, and these have mainly focused on paroxetine (Paxil). Associations were most consistent for ventricular septal defects. The estimated risk is no greater than 1 in 200 exposed newborns (Koren, 2012). Nevertheless, the American College of Obstetricians and Gynecologists (20 16b) recommends that paroxetine be avoided in women who are either pregnant or planning pregnancy. In women exposed to paroxetine in the irst trimester, fetal echocardiography is considered. Jimenez-Solem and coworkers (2013) in their analysis of SSRIs found no association between exposure to SSRIs during pregnancy and perinatal mortality. Andersen and associates (2014) found that women discontinuing SSRI treatment in early pregnancy had a small increased risk of miscarriage, but that this was similar


Obstentrics_Williams

Obstentrics_Williams. pregnancy and perinatal mortality. Andersen and associates (2014) found that women discontinuing SSRI treatment in early pregnancy had a small increased risk of miscarriage, but that this was similar to the risk in women discontinuing SSRI treatment months before pregnancy. Taken together, these investigators concluded that treatment with SSRIs during pregnancy should not be discontinued for fear of miscarriage.


Obstentrics_Williams

Obstentrics_Williams. Of other potential efects, the risk of persistent pulmonary hypertension of the newborn rose sixfold in neonates exposed to SSRIs after 20 weeks' gestation (Chambers, 2006). his translates to an overall risk of pulmonary hypertension that would be less than 1 in 100 exposed newborns (Koren, 2012). In contrast, a population-based cohort study of 1.6 million pregnancies identiied a twofold greater rate in exposed neonates. his yields an estimated attributable risk of 2 cases per 1000 births (Kieler, 2012). In a study of more than 120,000 gravidas prescribed antidepressants, Huybrechts and coworkers (2015) found an attributed risk of 1 case per 1000 births. In sum, the maternal risk associated with discontinuing or tapering SSRI use during pregnancy must be weighed against marginally increased neonatal risks (Ornoy, 2017). Women who abruptly discontinue either serotonin-or norepinephrinereuptake inhibitor therapy typically experience some form of withdrawal.


Obstentrics_Williams

Obstentrics_Williams. Not surprisingly, up to 30 percent of exposed neonates may also exhibit withdrawal symptoms. Symptoms are similar to opioid withdrawal, but typically are less severe. Neonatal SSRI withdrawal is usually self-limited, and the newborn rarely remains in the nursery more than 5 days (Koren, 2009). Currently, convincing evidence of long-term neurobehavioral efects of fetal exposure to these medications is lacking (Koren, 2012). Grzeskowiak and coworkers (2016) found no increased risk of behavioral problems in 7 -year-old children exposed to antidepressants prior to their birth. Some psychotropic medications pass into breast milk. In most cases, however, levels are very low or undetectable. Efects may be transient irritability, sleep disturbances, and colic.


Obstentrics_Williams

Obstentrics_Williams. Electroconvulsive Therapy. This form of depression treatment is occasionally necessary during pregnancy for women with major mood disorders unresponsive to pharmacotherapy. Women undergoing electroconvulsive therapy (ECT) should be fasting for at least 6 hours. hey are given a rapid-acting antacid before the procedure, and their airway is protected to decrease the likelihood of aspiration. Ater midpregnancy, a wedge is placed under the right hip to prevent sudden maternal hypotension from aortocaval compression. Other important preparatory steps include assessment of the cervix, discontinuation of nonessential anticholinergic medication, uterine and fetal heart rate monitoring, and intravenous hydration. During the procedure, excessive hyperventilation is avoided. In most cases, maternal and fetal heart rate and maternal blood pressure and oxygen saturation remain normal throughout the procedure.


Obstentrics_Williams

Obstentrics_Williams. With proper preparation, the risks to both mother and fetus appear to be reasonable (Pinette, 2007). hat said, adverse maternal and perinatal outcomes have followed ECT. Balki and associates (2006) reported a pregnancy in which fetal brain damage likely was caused by sustained maternal hypotension associated with treatment of status epilepticus stimulated by ECT.


Obstentrics_Williams

Obstentrics_Williams. At least two extensive reviews have evaluated ECT outcomes in pregnancy. In the earlier one, Miller (1994) found 300 cases and reported complications in 10 percent. These included fetal arrhythmias, vaginal bleeding, abdominal pain, and self-limited contractions. Women not adequately prepared had increased risks for aspiration, aortocaval compression, and respiratory alkalosis. In the more recent review, Andersen and Ryan (2009) described 339 cases, undoubtedly with some homology with the earlier study. In most cases, ECT therapy was done to treat depression, and it was 78-percent efective. hey reported a 5-percent maternal ECT -related complication rate. here was a 3-percent associated perinatal complication rate, which included two fetal deaths. For all of these reasons, we agree with Richards (2007) that ECT in pregnancy is not "low risk" and that it should be reserved for women whose severe depression is resistant to intensive pharmacotherapy.


Obstentrics_Williams

Obstentrics_Williams. According to the National Institute of Mental Health (2010), the lifetime prevalence for manic-depression illness is 3.9 percent. he prevalence of bipolar disorder does not vary between gravidas and nonpregnant reproductive-aged women (Yonkers, 2011). It has a strong genetic component and has been linked to possible mutations on chromosomes 16 and 8 (Jones, 2007). The risk that monozygotic twins are both afected is 40 to 70 percent, and the risk for first-degree relatives is 5 to 10 percent (Muller-Oerlinghausen, 2002). Periods of depression last at least 2 weeks. At other times, patients are manic, in which mood is abnormally raised, expan sive, or irritable. Potential organic causes of mania include substance abuse, hyperthyroidism, and central nervous system (CNS) tumors. hese are all excluded during an acute event.


Obstentrics_Williams

Obstentrics_Williams. Importantly, pregnancy frequently prompts medication dis continuation, which poses a twofold increased risk for relapse (Viguera, 2007). Afected women are considered high risk, and as many as 20 percent of patients with manic-depression illness commit suicide. his has also been associated with adverse perinatal outcomes, for example, preterm birth (Mei-Dan, 2015). Di Florio and associates (2013) found that those women who experience pregnancy complications are more likely to exhibit periods of mania or depression. Women who tend to be manic present with exacerbations earlier in the postpartum period.


Obstentrics_Williams

Obstentrics_Williams. Typical therapy for bipolar disorder includes mood stabilizers such as lithium, valproic acid, and carbamazepine, as well as antipsychotic medications (see Table 61-3). Treatment of bipolar disorder in pregnancy is complex and is ideally managed concurrently with a psychiatrist. Decisions include risks versus benefits of using mood stabilizers, some of which are teratogenic. For example, lithium has been linked to Ebstein anomaly in exposed fetuses. More recent data, however, suggest a lower risk of cardiac malformations than previously indicated (Micromedex, 2016; Patomo, 2017) . Nevertheless, many recommend fetal echocardiography for lithium-exposed fetuses. Some limited evidence suggests that lithium in breast milk, when its elimination is impaired as in dehydration or immaturity, can adversely afect the infant (Davanzo, 2011). However, lithium use in mothers with a healthy, term fetus is considered moderately safe. A more detailed discussion of other mood stabilizers and


Obstentrics_Williams

Obstentrics_Williams. can adversely afect the infant (Davanzo, 2011). However, lithium use in mothers with a healthy, term fetus is considered moderately safe. A more detailed discussion of other mood stabilizers and antipsychotic medications side efects can be found in Chapter 12 (p. 244).


Obstentrics_Williams

Obstentrics_Williams. This severe mental disorder is usually a bipolar disorder, but it may be due to major depression (American Psychiatric Association, 2013). Its incidence is estimated to be 1 in every 1000 deliveries, and it is more common in nulliparas, especially those with obstetrical complications (Bergink, 2011; Blackmore, 2006). In most cases, illness manifests within 2 weeks of delivery. In one study of postpartum women with their first lifetime episode of psychosis, the median onset of psychiatric symptoms was 8 days after delivery, and the median duration of the episode was 40 days (Bergink, 2011). Because those with underlying psychiatric disease have a 10-to 15-fold risk for recurrence postpartum, close monitoring is imperative.


Obstentrics_Williams

Obstentrics_Williams. The most important risk for postpartum psychosis is a history of bipolar disease. These women typically exhibit symptoms within 1 to 2 days after delivery (Heron, 2007, 2008). Manic symptoms include feeling excited or elated, being active or energetic, feeling "chatty," and sufering insomnia. Afected women have signs of confusion and disorientation but may also have lucid episodes. Postpartum psychosis has a 50-percent recurrence risk in the next pregnancy. As a result, Bergink and associates (2012) rec in women with a history of postpartum psychosis. The clinical course of bipolar illness with postpartum psycho sis is comparable with that for nonpregnant women. Patients usually require hospitalization, pharmacological treatment, and long-term psychiatric care. Psychotic women may have delu sions leading to thoughts of self-harm or harm to their infants.


Obstentrics_Williams

Obstentrics_Williams. Unlike women with nonpsychotic depression, these women commit infanticide, albeit uncommonly (Kim, 2008). In most instances, women with postpartum psychosis ultimately develop relapsing, chronic psychotic manic-depression. These relatively common disorders-18 percent prevalence overall-include panic attack, panic disorder, social anxiety disorder, specific phobia, separation anxiety disorder, and generalized anxiety disorder. All are characterized by irrational fear, tension, and worry, which are accompanied by physiological changes such as trembling, nausea, hot or cold lashes, dizziness, dyspnea, insomnia, and frequent urination (Schneier, 2006). They are treated with psychotherapy and medication, including SSRIs, tricyclic antidepressants, monoamine oxide inhibitors, or others.


Obstentrics_Williams

Obstentrics_Williams. Despite the relative high prevalence in childbearing-aged women, little speciic attention has been directed to anxiety disorders in pregnancy. Most reports conclude that rates between pregnant and nonpregnant women do not difer. One recent analysis of 268 gravidas with generalized anxiety disorder demonstrated that both symptoms and severity of anxiety decline across pregnancy (Buist, 2011).


Obstentrics_Williams

Obstentrics_Williams. From their review, Ross and McLean (2006) concluded that some of the anxiety disorders may have important matemalfetal implications. Some have been linked to preterm birth, fetal-growth restriction, and poor neurobehavioral development (Van den Bergh, 2005). Children with a history of in utero exposure to maternal anxiety are felt to be at increased risk for various neuropsychiatric conditions such as attention-deicit/ hyperactivity disorder (ADHD). Hunter and coworkers (2012) analyzed infants of 60 mothers with an anxiety disorder and found that auditory sensory gating-a relection of inhibitory neurotransmission-was impaired, particularly in ofspring of untreated women. Conversely, Littleton and associates (2007) found no excessive adverse pregnancy outcomes with "anxiety symptoms." One important exception is their link with postpartum depression (Vythilingum, 2008).


Obstentrics_Williams

Obstentrics_Williams. Anxiety disorders can be efectively treated during pregnancy with psychotherapy, cognitive-behavioral therapy, or medications. vlood and anxiety disorders coexist in more than half of women identified with either diagnosis (Frieder, 2008). hus, antidepressants listed in Table 61-3 are often the first line of pharmacotherapy. Benzodiazepines are also commonly used to treat anxiety or panic disorders before and during pregnancy. Earlier casecontrol studies linked use of these CNS depressants to a possible increased risk for cleft lip and palate. A metaanalysis of more than 1 million exposed pregnancies, however, did not identiY a teratogenic risk (Enato, 2011). Benzodiazepines, especially when taken during the third trimester, can cause neonatal withdrawal syndrome, which persists for days to weeks after delivery.


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Obstentrics_Williams. his major form of mental illness afects 1.1 percent of adults (National Institute of Mental Health, 2016). Schizophrenia spectrum disorders are defined by abnormalities in one or more of the following domains: delusions, hallucinations, disorganized thinking, grossly disorganized or abnormal motor behavior, and negative symptoms. Brain-scanning techniques such as positron emission tomography (PET) and functional magnetic resonance imaging (MRI) show that schizophrenia is a degenerative brain disorder. Subtle anatomical abnormalities are present early in life and worsen with time.


Obstentrics_Williams

Obstentrics_Williams. Schizophrenia has a major genetic component, and there is a 50-percent concordance in monozygotic twins. If one parent has schizophrenia, the risk to ofspring is 5 to 10 percent. Some data, including a strong association between schizophrenia and the velocardiofacial syndrome, suggest that associated genes are located on chromosome 22q 11 (Murphy, 2002). But sophisticated gene mapping studies clearly show that schizophrenia is not related to a single gene or mutation. Instead, multiple DNA variants likely interact to lead to schizophrenia (Kukshal, 2012). Other putative risks for subsequent schizophrenia in an exposed fetus include maternal iron-deiciency anemia, diabetes, and acute maternal stress (Insel, 2008; Malaspina, 2008; Van Lieshout, 2008). hese remain unproven, as does the association with maternal inluenza A infection.


Obstentrics_Williams

Obstentrics_Williams. Signs of illness begin approximately at age 20 years, and commonly, work and psychosocial functioning deteriorate over time. Women have a slightly later onset than men and are less susceptible to autism and other neurodevelopmental abnormalities. hus, many investigators theorize that estrogen is protective. Afected women may become pregnant before symptoms manifest. With appropriate treatment, patients can experience a decrease or cessation of symptoms. Within 5 years from the irst signs of illness, 60 percent have social recovery, 50 percent are employed, 30 percent are mentally handicapped, and 10 percent require continued hospitalization (American Psychiatric Association, 2013).


Obstentrics_Williams

Obstentrics_Williams. vlost studies have not found adverse maternal outcomes, although researchers in a Swedish study noted increased rates of low birthweight, fetal-growth restriction, and preterm delivery (Bennedsen, 1999). In a study of more than 3000 pregnancies in schizophrenic women, Jablensky and coworkers (2005) reported that placental abruption was increased threefold and "fetal distress" -vaguely deined-was increased l.4-fold.


Obstentrics_Williams

Obstentrics_Williams. Because schizophrenia has a high recurrence if medications are discontinued, continued therapy during pregnancy is advised. Ater 40 years of use, no evidence links the conventional or "typical" antipsychotic drugs listed in Table 61-3 and adverse fetal or maternal sequelae (McKenna, 2005; Robinson, 2012; Yaeger, 2006). Because less is known about "atypical" antipsychotics, the American College of Obstetricians and Gynecologists (2016b) recommends against their routine use in pregnant and breastfeeding women. In response to adverse event reports, the Food and Drug Administration (2011) issued a safety communication alerting health-care providers concerning some antipsychotic medications. hese have been associated with neonatal extrapyramidal and withdrawal symptoms similar to the neonatal behavioral syndrome seen in those exposed to SSRIs.


Obstentrics_Williams

Obstentrics_Williams. hese include anorexia nervosa, in which the patient refuses to maintain minimally normal body weight, and bulimia nervosa, in which binge eating is usually followed by purging or excessive fasting to maintain normal body weight (Zerbe, 2008). Eating behavior disturbances largely afect adolescent females and young adults. With anorexia and bulimia, the lifetime prevalence for each is 2 to 3 percent (National Institute of Mental Health, 2016).


Obstentrics_Williams

Obstentrics_Williams. Bulik and coworkers (2009) studied pregnancy outcomes in almost 36,000 Norwegian women screened for eating disorders. Approximately 0.1 percent had anorexia nervosa, 0.85 percent had bulimia nervosa, and 5.1 percent reported a binge-eating disorder. This 6-percent pregnancy prevalence is similar to the 6-month prevalence for nonpregnant individuals (National Institute of Mental Health, 2016). he last subtype had a higher risk for large-for-gestational age neonates with a concomitantly increased cesarean delivery rate. All eating disorders begin with the desire to be slim, and women with chronic eating disorders may migrate between subtypes (Andersen, 2009).


Obstentrics_Williams

Obstentrics_Williams. Early pregnancy complication rates are increased with both eating disorders, but especially in women with bulimia nervosa (Andersen, 2009; Hofman, 2011). Generally, eating disorder symptoms improve during pregnancy, and remission rates may reach 75 percent. In contrast, typical cases of hyperemesis gravidarum may actually be a new or relapsing case of bulimia nervosa or of binge-purge type anorexia nervosa (Torgerson, 2008). As perhaps expected, anorexia is associated with low-birthweight neonates (Micali, 2007). Additional risks associated with eating disorders include poor wound healing and diiculties with breastfeeding (Andersen, 2009). At a minimum, closely monitoring gestational weight gain in women with a suspected history of an eating disorder seems prudent. Care for these women involves a multidisciplinary team that includes an obstetrician, mental health provider, and either dietician or nutritionist (American Dietetic Association, 2006).


Obstentrics_Williams

Obstentrics_Williams. Care for these women involves a multidisciplinary team that includes an obstetrician, mental health provider, and either dietician or nutritionist (American Dietetic Association, 2006). Psychological treatment is the cornerstone for treatment in women with eating disorders and frequently includes cognitivebehavioral therapy. Anorexia nervosa oten responds to motivational interactions with meal planning (Cardwell, 2013). After delivery, women with eating disorders are more prone to postpartum depression. Women with bulimia are at particular risk for disease rebound ater delivery because of body image concerns. hese disorders are characterized by the chronic use of certain coping mechanisms in an inappropriate, stereotyped, and maladaptive manner. hey are rigid and unyielding personality traits. The American Psychiatric Association (2013) recognizes three clusters of personality disorders: 1.


Obstentrics_Williams

Obstentrics_Williams. Paranoid, schizoid, and schizotypal personality disorders, which are characterized by oddness or eccentricity. 2. Histrionic, narcissistic, antisocial, and borderline disorders, which are all characterized by dramatic presentations along with self-centeredness and erratic behavior. 3. Avoidant, dependent, compulsive, and passive-aggressive personalities, which are characterized by underlying fear and anxiety. Genetic and environmental factors are important in the genesis of these disorders, whose prevalence may be as high as 20 percent. lthough management is through psychotherapy, most afected individuals do not recognize their problem, and thus only 20 percent seek help. In an observational study of 202 women with borderline personality disorder, De Genna during the most severe trajectory of their illness. hey are at increased risk for teen and unintended pregnancies.


Obstentrics_Williams

Obstentrics_Williams. Personality disorders during pregnancy are probably no diferent than in nonpregnant women. Akman and colleagues (2007) reported that avoidant, dependent, and obsessive-compulsive disorders are associated with an excessive prevalence of postpartum major depression. Magnusson and associates (2007) found a link between some personaliy traits-not disordersand excessive alcohol consumption, but not necessarily addiction or dependence. Conroy and coworkers (2010) found that a mother's ability to care for her newborn was impaired only when a personality disorder was coupled with depression. Ahokas A, Kaukorantat], Aito M: Efect of oestradiol on postpartum depres sion. Psychopharmacology 146: 108, 1999 Akman C, Uguz F, Kaya N: Postpartum-onset major depression is associated with personality disorders. Compr Psychiatry 48:343, 2007


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Obstentrics_Williams. Alder ], Fink N, Bitzer ], et al: Depression and anxiety during pregnancy: a risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. ] Matern Fetal Neonatal Med 20: 189, 2007 American College of Obstetricians and Gynecologists: Screening for perinatal depression. Committee Opinion No. 630. May 2015, Reairmed 2016a American College of Obstetricians and Gynecologists: Use of psychiatric medication during pregnancy and lactation. Practice Bulletin No. 92. April 2008, Reairmed 2016b American Dietetic Association: Position of the American Dietetic Association: nutritional intervention in the treatment of anorexia nervosa, bulimia ner vosa, and other eating disorder. ] Am Diet Assoc 106:2073Y2082, 2006 American Psychiatric Association: Guidelines for the treatment of patients with major depressive disorder (revision). Am] Psychiatry 157:1,2000


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Obstentrics_Williams. American Psychiatric Association: Guidelines for the treatment of patients with major depressive disorder (revision). Am] Psychiatry 157:1,2000 American Psychiatric Association: The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5). rlington, American Psychiatric Publishing, 2013 Andersen E, Ryan GL: Eating disorders in the obstetric and gynecologic patient population. Obstet Gynecol 114: 1353, 2009 Andersen ]T, Andersen NL, Horwitz H, et al: Exposure to selective serotonin reuptake inhibitors in early pregnancy and the risk of miscarriage. Obstet Gynecol 124(4):655,t2014 Avalos A, Raine-Bennett T, Chen H, et al: Improved perinatal depression screening, treatment, and outcomes with a universal obstetric program. Obstet GynecoIt127(5):917, 2016 Babbitt E, Bailey K], Coverdale ]H, et al: Professionally responsible intrapartum management of patients with major mental disorders. Am ] Obstet Gynecol 210:27, 2014


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Obstentrics_Williams. Babbitt E, Bailey K], Coverdale ]H, et al: Professionally responsible intrapartum management of patients with major mental disorders. Am ] Obstet Gynecol 210:27, 2014 Balki M, Castro C, Ananthanarayan C: Status epilepticus after electroconvulsive therapy in a pregnant patient. Int] Obstet Anest 15:325,2006 Bennedsen BE, Mortensen PB, Olesen Av, et al: Preterm birth and intra-uterine growth retardation among children of women with schizophrenia. Br] Psychiatry 175:239, 1999 Bergink V, Bouvy PF, Vervoort ]S, et al: Prevention of postpartum psychosis and mania in women at high risk. Amt] Psychiatry 169:609, 2012 Bergink V, van den Berg L, Koorengevel KM, et al: First-onset psychosis occurring in the postpartum period: a prospective cohort study. ] Clin Psychiatry 72(1t1):1531,t2011 Blackmore ER, Jones I, Doshi M, et al: Obstetric variables associated with bipolar afective puerperal psychosis. Br] Psychiatry 188:32, 2006


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Obstentrics_Williams. Blackmore ER, Jones I, Doshi M, et al: Obstetric variables associated with bipolar afective puerperal psychosis. Br] Psychiatry 188:32, 2006 Briggs GG, Freeman RK: Drugs in Pregnancy and Lactation, 10th ed. Philadelphia, Wolters Kluwer, 2015 Buist A, Gotman N, Yonkers A: Generalized anxiety disorder: course and risk factors in pregnancy.] Afective Dis 131(1-3):277,t2011 Bulik CM, Von Holle A, Siega-Riz AM, et al: Birth outcomes in women with eating disorders in the Norwegian mother and child cohort (MoBa). Int ] Eat Disord 42(1):9, 2009 Cardwell MS: Eating disorder during pregnancy. Obstet Gynecol Surv 68(4):312,t2013 Center for Behavioral Health Statistics and Quality: Behavioral health trends in the United States: results from the 2014 National Survey on Drug Use and Health. HHS Publication No. SMA 15-4927, NSDUH Series H-50, 2015


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Obstentrics_Williams. Cerimele ]M, Vanderlip ER, Croicu CA, et al: Presenting symptoms of women with depression in an obstetrics and gynecology setting. Obstet Gynecol 122(2 Pt 1):313,t2013 Chambers CD, Hernandez-Diaz S, Van Martin L], et al: Selective serotoninreuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl ] Med 354(6):579, 2006 Comtois A, SchifMA, Grossman DC: Psychiatric risk factors associated with postpartum suicide attempt in Washington state, 1992-2001. Amt] Obstet Gynecol 199:120.e1, 2008 Conroy S, Marks MN, Schacht R, et al: The impact of maternal depression and personality disorder on early infant care. Soc Psychiatry Epidemiol 45(3):285,t2010 Davanzo R, Copertino M, De Cunto A, et al: Antidepressant drugs and breastfeeding: a review of the literature. Breastfeeding Med 6(2):89, 2011


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Obstentrics_Williams. Davanzo R, Copertino M, De Cunto A, et al: Antidepressant drugs and breastfeeding: a review of the literature. Breastfeeding Med 6(2):89, 2011 Deecher D, Andree TH, Sloan D, et al: From menarche to menopause: exploring the underlying biology of depression in women experiencing hormonal changes. Psychoneuroendocrinology 33:3, 2008 De Genna NM, Feske U, Larkby C, et al: Pregnancies, abortions, and births among women with and without borderline personality disorder. Women's Health Issues 22(4):e371, 2012 Dennis CL, Dowswell T: Psychological interventions for preventing postpartum depression. Cochrane Database Syst Rev 2:CD001134, 2013 Dennis CL, Ross LE, Grigoriadis S: Psychosocial and psychological interventions for treating antenatal depression. Cochrane Database Syst Rev 3:CD006309,t2007 Di Florio A, Forty L, Gordon-Smith K, et al: Perinatal episodes across the mood disorder spectrum.t]AMA Psychiatry 70(2):168,t2013


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Obstentrics_Williams. Di Florio A, Forty L, Gordon-Smith K, et al: Perinatal episodes across the mood disorder spectrum.t]AMA Psychiatry 70(2):168,t2013 Enato E: he fetal safety of benzodiazepines: an updated meta-analysis. ] Obstet Gynaecol Can 33(4):319,t2011 Flnagan T, Avalos A: Perinatal obstetric oice depression screening and treatment: implementation in a health care system. Obstet GynecoIt127(5):911, 2016 Flynn A, Henshaw E, O'Mahen H, et al: Patient perspectives on improving the depression referral processes in obstetrics settings: a qualitative study. Gen Hosp Psychiatry 32:9,t2010 Food and Drug Administration: Antipsychotic drug labels updated on use during pregnancy and risk of abnormal muscle movements and withdrawal symptoms in newborns, 201t1. Available at: http://www.fda.gov/Drugs/ DrugSafety/ucm243903.htm. Accessed July 12,t2016 Frieder A, Dunlop AI, Culpepper L, et al: The clinical content of preconception care: women with psychiatric conditions. Am ] Obstet Gynecol 199:S328,t2008


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Obstentrics_Williams. Frieder A, Dunlop AI, Culpepper L, et al: The clinical content of preconception care: women with psychiatric conditions. Am ] Obstet Gynecol 199:S328,t2008 Gavin NI, Gaynes BN, Lohr N, et al: Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecolt106:1071, 2005 Gold K], Dalton VK, Schwenk TL: Hospital care for parents after perinatal death. Obstet Gynecol 109: 1156, 2007 Goodwin RD, Keyes K, Simuro N: Mental disorders and nicotine dependence among pregnant women in the United States. Obstet Gynecolt1 09:875, 2007 Grigoriadis S, VonderPorten EH, Mamisashvili L, et al: he impact of maternal depression during pregnancy on perinatal outcomes: a systematic review and meta-analysis.] Clin Psychiatry 74(4):e321, 2013 Grzeskowiak LE, Morrison ]L, Henriksen TB, et al: Prenatal antidepressant exposure and child behavioural outcomes at years of age: a study within the Danish National Birth Cohort. B]OG 123(12):1919,t2016


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Obstentrics_Williams. Hayes RM, Wu P, Shelton RC, et al: Maternal antidepressant use and adverse outcomes: a cohort study of 228,876 pregnancies. Am ] Obstet Gynecol 207:49.e1,t2012 Heron], Blackmore ER, McGuinnes M, et al: No "latent period" in the onset of bipolar afective puerperal psychosis. Arch Womens Ment Health 10:79, 2007 Heront], McGuinness M, Blackmore ER, et al: Early postpartum symptoms in puerperal psychosis. B]OG 115(3):348,2008 Hippman C, Oberlander TG, Honer WG, et al: Depression during pregnancy: the potential impact of increased risk for fetal aneuploidy on maternal mood. Clin Genet 75(1):30, 2009 Hofman ER, Zerwas SC, Bulik CM: Reproductive issues in anorexia nervosa. Obstet Gynecol 6:403, 2011 Houston A, Kaimal A], Nakagawa S, et al: Mode of delivery and postpartum depression: the role of patient preferences. Am ] Obstet Gynecol 212(2):229.e1,2015


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Obstentrics_Williams. Obstet Gynecol 6:403, 2011 Houston A, Kaimal A], Nakagawa S, et al: Mode of delivery and postpartum depression: the role of patient preferences. Am ] Obstet Gynecol 212(2):229.e1,2015 Huang H, Coleman S, Bridge ]A, et al: A meta-analysis of the relationship berween antidepressant use in pregnancy and the risk of preterm birth and low birth weight. Gen Hosp Psychiatry 36(1):13,t2014 Hunter SK, Mendoza], D'Anna K: Antidepressants may mitigate the efects of prenatal maternal anxiety on infant auditory sensory gating. Amt] Psychiatry 169:616,t2012 Huybrechts F, Bateman BT, Palmsten K, et al: Antidepressant use late in pregnancy and risk of persistent pulmonary hypertension of the newborn. ]AMA 313(21):2142,t2015


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Obstentrics_Williams. Huybrechts F, Bateman BT, Palmsten K, et al: Antidepressant use late in pregnancy and risk of persistent pulmonary hypertension of the newborn. ]AMA 313(21):2142,t2015 Insel B], Schaefer CA, McKeague IW, et al: Maternal iron deficiency and the risk of schizophrenia in ofspring. Arch Gen Psychiatry 65(10):1136,t2008 ] ablensky A V, vlorgan V, Zubrick SR, et al: Pregnancy, delivery, and neonatal complications in a population cohort of women with schizophrenia and major afective disorders. Amt] Psychiatry 162:79,t2005 Janssen PA, Heaman MI, Urquia ML, et al: Risk factors for postpartum depression among abused and nonabused women. Am] Obstet GynecoI207:489.e1, 2012 Jimenez-Solem E, Andersen ]T, Petersen M, et al: SSRI use during pregnancy and risk of stillbirth and neonatl mortality. Am] Psychiatry 170(3):299, 2013


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Obstentrics_Williams. Jimenez-Solem E, Andersen ]T, Petersen M, et al: SSRI use during pregnancy and risk of stillbirth and neonatl mortality. Am] Psychiatry 170(3):299, 2013 Jones I, Hamshere M, Nangle ]M, et al: Bipolar afective puerperal psychosis: genome-wide significant evidence for linkage to chromosome 16. Amt] Psychiatry 164:999, 2007 ]uulia Paavonen E, Saarenpaa-Heikkila 0, Polkki P, et al: Maternal and paternal sleep during pregnancy in the Child-sleep birth cohort. Sleep Med , 2017 Kanotra S, D'Angelo 0, Phares TM, et al: Challenges faced by new mothers in the early postpartum period: an analysis of comment data from the 2000 Pregnancy Risk Assessment Monitoring System (PMS) Survey. Matern Child Health] 11(6):549,t2007 Keenan K, Hipwell E, Bortner ], et al: Association berween fatty acid supplementation and prenatal stress in African Americans: a randomized controlled trial. Obstet Gynecol 124(6):1080,2014


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Obstentrics_Williams. Keenan K, Hipwell E, Bortner ], et al: Association berween fatty acid supplementation and prenatal stress in African Americans: a randomized controlled trial. Obstet Gynecol 124(6):1080,2014 Kieler H, Artama M, Engeland A, et al: Selective serotonin reuptake inhibitors during pregnancy and risk of persistent pulmonary hypertension in the newborn: population based cohort study from the ive Nordic countries. BM] 344:d8012, 2012 Kim ]H, Choi SS, Ha K: A closer look at depression in mothers who kill their children: is it unipolar or bipolar depression? ] Clin Psychiatry 69(10):1625, 2008 Kim J], La Porte LM, Saleh MP, et al: Suicide risk among perinatal women who report thoughts of self-harm on depression screens. Obstet Gynecol 125(4):885,t2015 Ko ]Y, Rockhill KM, Tong T, et al: Trends in Postpartum Depressive Symptoms-27 States, 2004, 2008, and 2012. MMx'R 66(6):153,t2017


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Obstentrics_Williams. Ko ]Y, Rockhill KM, Tong T, et al: Trends in Postpartum Depressive Symptoms-27 States, 2004, 2008, and 2012. MMx'R 66(6):153,t2017 Koren G, Finkelstein Y, Matsui 0, et al: Diagnosis and management of poor neonatal adaptation syndrome in newborns exposed in utero to selective serotonin/norepinephrine reuptake inhibitors. ] Obstet Gynaecol Can 31(4):348,2009 Koren G, Nordeng H: Antidepressant use during pregnancy: the beneit-risk ratio. Amt] Obstet ,t2012 Kukshal P, Thelma BK, Nimgaonkar VL, et al: Genetics of schizophrenia from a clinical perspective. Int Rev Psychiatry 24(5):393, 2012 Lavender T, Richens Y, Milan S], et al: Telephone support for women during pregnancy and the irst six weeks postpartum. Cochrane Database Syst Rev 7:CD009338,t2013 Lee M, Lam SK, Lau SM, et al: Prevalence, course, and risk factors for antenatal anxiety and depression. Obstet Gynecol 110: 11 02, 200


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