Review Note

Psychiatric Disorders and Pregnancy:

• Psychiatric History: Women with a history of major psychiatric illness should receive counseling before pregnancy. They are at higher risk for postpartum psychoses and may pose risks to both mother and child.
  • Risks: These include increased risk to the fetus, potential for behavioral teratogenesis, and harm due to inadequately managed disease.
  • Antenatal Assessment: Psychiatric disorders should be assessed by a psychiatrist during pregnancy, and a management plan should be established.
  • Mental Health Stressors: Pregnancy and childbirth represent major life stresses, contributing to a 5x increased risk of mental illness in the year following childbirth.
  • Relapse/Development of New Disorders: Women may relapse or develop new disorders during pregnancy or after childbirth.
• Common Diagnoses Linked to Obstetric Inpatient Units:
  • Personality disorders (19%)
  • Mood disorders (17%)
  • Schizophrenic disorders (15%)
  • Adjustment disorders
• Reasons for Referral:
  • Coping issues
  • Depression
  • Anxiety
  • History of major psychiatric illness

Anaesthetic Implications:

• Obstetric anaesthetists may face challenges when managing women with personality disorders.
  • May exhibit rudeness or excessive complaints.
  • Poor impulse control, requiring firm professionalism.
  • Commonly not on medication, so interactions with anaesthetic agents are less likely.

• Women with poorly controlled schizophrenia may be uncooperative and hostile, complicating the management of labour pain.
• Non-compliance with medication can indicate a potential for difficult interactions.
• Informed Consent: Gaining informed consent can be difficult due to cognitive and psychiatric challenges.
• General Anaesthesia (GA): May be necessary for operative delivery if the patient is violent or uncooperative.

• Many women with psychiatric disorders take medications that can interact with anaesthetic agents.
  • Antipsychotics: Medications like risperidone and quetiapine may block alpha1 adrenergic receptors, leading to orthostatic hypotension, which can result in:
    • Pronounced hypotension
    • Heat loss
    • Inadequate compensation for blood loss
  • Tricyclic Antidepressants (TCAs):
    • Associated with anticholinergic side effects.
    • Overdose can result in anticholinergic poisoning (dilated pupils, agitation, delirium, convulsions, hyperpyrexia, prolonged QT & QRS).
    • TCAs lower seizure threshold; caution is needed with PET patients.
  • SSRIs: Commonly prescribed to women of childbearing age.
    • Not associated with increased risk of congenital malformations when taken during the first trimester.
    • Little evidence of clinically significant interactions with anaesthetic agents.
  • MAOIs: Use of monoamine oxidase inhibitors (MAOIs) can cause exaggerated hypertensive responses when indirect-acting pressor agents (e.g., ephedrine, metaraminol) are used.
    • Direct-acting agents should be preferred for maintaining blood pressure.

Further Reference: