[Mortality in pregnant and newly delivered women due to psychiatric disorders]. / Sterfte bij zwangeren en kraamvrouwen door psychiatrische stoornissen.

Two women, aged 28 and 37 years, both suffering from a psychiatric disorder i.e. puerperal psychosis and mood-disorder respectively, violently ended their lives at 12 days and 5 months after delivery. Early identification of risk factors in a multidisciplinary setting can lead to effective early management of psychiatric disorders during pregnancy and the puerperium. Negative outcomes such as suicide and even infanticide may consequently be prevented. The most common risk factors for suicide during pregnancy and the puerperium are: a history of psychiatric disorders, a family history of psychiatric disorders and current psychiatric symptomatology. Important recommendations to reduce maternal mortality due to psychiatric disorders include improvement of communication between health professionals and systematic registration of maternal mortality.

[The placing of an unborn child under formal supervision where there is doubt about the safety of the home situation]. / De mogelijkheid van ondertoezichtstelling van het nog ongeboren kind bij twijfels over de veiligheid van de thuissituatie.

Requests to place an unborn child under formal supervision was made in the course of two pregnancies. The first woman was 27 years old, she had a history of schizophrenia, forensic psychiatric care, and a personality disorder with impulsive aggressive behaviour. The second patient was 36 years old. She had a bipolar disorder due to which her firstborn had been placed in foster care. In the first case, formal supervision for the unborn child ensued. In the second case the request was initially denied, but due to the disordered domestic situation was granted ten days after birth. Prior to birth, a relevant risk assessment based on maternal characteristics can be made. In the Netherlands it is possible to place a foetus under formal supervision after 24 weeks gestation. This may prevent hospitalization of a healthy newborn in an unhealthy environment which is poor in stimuli. It also prevents the stressful situation that may arise when parents threaten to take their newborn child from the hospital, pending the inquiry into the domestic situation.

[Psychiatric disorders in pregnant and puerperal women]. / Psychiatrische stoornissen bij zwangeren en kraamvrouwen.

The most frequently occurring pre- and postpartum psychiatric disorders are depression and, to a lesser degree, panic disorder and psychosis. Apart from the negative effects on the psychological well-being of the mother, these psychiatric disorders may also result in obstetric complications and an impaired mother-infant relationship. In order to prevent these negative effects, mothers who are at risk for major psychiatric disorders need to be identified early, preferably before or during pregnancy. The most important risk factor is a history of psychiatric disorders. Obstetric risk factors for depression are unplanned or unwanted pregnancy, pregnancy-related hypertension, emergency caesarean section and early discharge from the hospital. Other factors are low socioeconomic status, recent life event, negative self-image, little social support, immigration in the last 5 years, feelings of loss of control during pregnancy and feeding problems with the child. For treatment, pregnant or puerperal women with a possible psychiatric disorder based on the presence of a serious risk factor, such as a previously experienced psychiatric disorder (related to pregnancy or not), serious current psychiatric symptoms or long-time use of psychoactive drugs, should be referred preferably to a combined psychiatric/obstetric clinic or, if unavailable, to a psychiatrist in a general hospital.

[Involuntary admission of addict during early pregnancy]. / Wet BOPZ toegepast bij vroege zwangerschap van verslaafde.

A 30-year-old cocaine-dependent woman was 16 weeks pregnant. Because of possible endangerment of the fetus, an involuntary provisional admission was authorized. Of particular interest is the application of the Dutch Act on Formal Admissions to Psychiatric Hospitals for the primary diagnosis 'addiction' and the fact that the fetus was regarded as a legal 'other'. In severe cases of addiction combined with pregnancy an earlier intervention is needed and arrangement of accelerated legal custody of the newborn before birth should be considered. For the protection of the unborn, we advocate a stricter application of the United Nations Convention on the Rights of the Child. Information for addicted women with preconception counselling can help prevent a compulsory admission.

Maternal use of SSRIs, SNRIs and NaSSAs: practical recommendations during pregnancy and lactation.

Selective serotonin reuptake inhibitors (SSRIs) are increasingly used during pregnancy and lactation, with 1.8-2.8% exposed pregnancies. Given the risks of untreated maternal depression for both mother and child, adequate treatment is essential. If pharmacological treatment with SSRIs is indicated, the fetal and neonatal effects of SSRIs have to be considered, as SSRIs cross the placenta and are excreted into breast milk. The overall risk of major congenital malformations during SSRI exposure in the first trimester does not appear to be greatly increased. Depending on the variability in pharmacokinetic properties between the different SSRIs and the individual drug metabolism of mother and child, SSRI exposure during late pregnancy can lead to serotonin reuptake inhibitor-related symptoms in up to 30% of exposed infants postnatally. Symptoms are generally mild and self-limited, but need observation during at least 48 h as some infants develop severe symptoms needing intervention. Limited data are available about the long-term neurodevelopmental outcomes after SSRI exposure during pregnancy and lactation, but currently, cognitive development seems normal, while behavioural abnormalities may be increased. In this article, the available clinical data are reviewed. Additionally, the authors provide a multidisciplinary guideline for the monitoring and management of neonates exposed to SSRIs during pregnancy and lactation.

An audit of single drug (propofol) dental general anaesthesia in children.

AIM: The aim of this study was to evaluate and describe the (dis)advantages of intravenous single drug anaesthesia (IVA) using the target- controlled infusion of propofol in order to validate a protocol. The treatments were performed in two secondary dental care clinics in Amsterdam. METHODS: Retrospective study of the anaesthetic reports and medical history of 950 patients treated were screened for any irregularities and medical problems. RESULTS: Most children treated were in the age group 2-5 years, time needed to wake up decreased significantly with age. Fourteen children dropped out of the planned IVA treatment because of medical reasons, 12 of whom were treated under general anaesthesia (GA). A further 26 were treated under GA because of convenience reasons. Total number of medical problems prior to treatment was 45 and mild complications were 42. CONCLUSIONS: There was a low morbidity in patients treated. The method seems to be successful in young children and creates an increase of treatment capacity in the field of special dental care. Preoperative screening is necessary, on paper and after consultation of a specialist. However blood test screening for allergies seem to be questionable. The treatment method is not possible without the presence of the anaesthesiologist and his team.