Obstetric outcomes for women with severe mental illness: 10 years of experience in a tertiary multidisciplinary antenatal clinic.

PURPOSE: This study aims to describe 10 years of antenatal care and outcomes for women with a severe mental illness (SMI). METHODS: A retrospective cohort study of 420 completed pregnancy records over the last 10 years (2007-2017). Findings were compared to the Western Australian (WA) pregnancy data. Antenatal attendance, demographic, obstetric, neonatal and psychosocial variables were analysed using t tests, χ2, ANOVA and odds ratio (OR). RESULTS: Overall, women with a SMI had high rates of comorbidity (47%), antenatal complications, and preterm birth at 12.6% compared to WA mothers (p < 0.001). Those with schizophrenia were at highest risk with increased risk of threatened preterm labour OR 8.25 (95% CI 4.64-14.65), gestational diabetes OR 3.59 (95% CI 2.18-5.91) and reduced likelihood of a spontaneous vaginal birth OR 0.46 (95% CI 0.29-0.71). Late presentation and antenatal attendance for women with SMI were significantly associated with maternal substance use, psychiatric admission during pregnancy, and child welfare involvement. Women with schizophrenia had significantly lower attendance rates at scheduled antenatal care (ANC) appointments than those with bipolar disease (87.1% vs 94%, p = 0.003). CONCLUSION: Obstetric outcomes are poorer for women with SMI compared to the general population. They have higher rates of medical comorbidities, lifestyle and psychosocial risks factors that are known to contribute to poor obstetric outcomes. Effective delivery of regular and appropriate ANC is essential in addressing these multifactorial risks. Targeted strategies addressing comprehensive medical management, preterm birth prevention, lifestyle modifications and increased psychosocial support could improve both short- and long-term outcomes for these women and their children.

Psychiatric admission during pregnancy in women with schizophrenia who attended a specialist antenatal clinic.

Objectives: The mental health and wellbeing of pregnant women with schizophrenia is an area of research interest. We aim to explore this relationship particularly in regards to psychiatric admission rates, timing and their associated contributing factors. Methods: A total of 98 pregnancies to women with schizophrenia, who attended a specialist antenatal clinic and delivered from July 2007 to February 2016, were retrospectively examined. The cohort was divided into two groups based on psychiatric admission. Descriptive data were analyzed using SPSS software. Results: Overall, 40.8% required psychiatric admission during pregnancy. A higher proportion of subjects had their initial psychiatric admission in the first trimester compared to the third trimester (p = .002). Of note, 10.2% were admitted within one month either side of conception. Women with admission also presented later for their first antenatal appointment (p = .04, 95% CI -2.1 to -1.9). Psychiatric admission was associated with substance (p = .014) and alcohol use (p = .001), child protective services involvement (p = .022) and infant being placed in out-of-home care (p = .01), but not with poorer obstetric or neonatal outcomes. Conclusion: High rates of psychiatric admission are evident throughout pregnancy for women with schizophrenia, with a high proportion of first presentations for admission occurring in the first trimester. Psychiatric admission is associated with poorer antenatal care attendance and adverse psychosocial outcomes, highlighting the need for enhanced multidisciplinary pregnancy care for this at risk group. Inpatient psychiatric services should consider pregnancy testing and contraception review for all women of childbearing age, admitted with schizophrenia.

The effects of gestational use of antidepressants and antipsychotics on neonatal outcomes for women with severe mental illness.

BACKGROUND: Psychotropic medication use occurs in 8% of pregnancies, with rates increasing, and often multiple medications prescribed. AIMS: This study aims to determine if the use of psychotropic medication, in a cohort of women with severe mental illness, increases rates of special care nursery admission and reports differences between antidepressant and antipsychotic medication use either alone or in combination. METHODS: A retrospective database analysis from a cohort with severe mental illness in pregnancy identified 268 pregnant women who were grouped according to medication type. Demographic, obstetric and neonatal variables were analysed using t-tests, χ2 , analysis of variance and logistic regression analysis for special care nursery admission. RESULTS: The medication groups consisted of: women taking no psychotropic medications (n = 67); those taking antipsychotics (n = 87); those taking antidepressants (n = 55); those taking and a combination of antidepressants/antipsychotics (n = 59). Rates of special care nursery admission in women who took psychotropic medication (41.3%) were elevated compared to those who did not (26.9%) (P = 0.035), and were significantly raised when compared to the general population (P < 0.000). No significant difference occurred between the medication groups. A significant adjusted odds ratio of 2.79 (95% CI 1.286-6.049) was found for special care nursery and psychiatric admission during pregnancy but not for psychotropic medication. CONCLUSION: Rates of special care nursery admission are elevated in neonates of women with severe mental illness taking psychotropic medication, but were not different for monotherapy or polytherapy when prescribing antidepressants or antipsychotic medication. Additional vulnerability occurs in the neonates of women with a mental illness and paediatric presence at delivery is recommended.

Characteristics of men accompanying their partners to a specialist antenatal clinic for women with severe mental illness.

PURPOSE: Partners are often enlisted in the care and management of pregnant women with severe mental illness (SMI); however their needs and capacity to provide support is not yet well understood. We aim to describe the psychosocial characteristics, health behaviours and appraisals of parenthood of men accompanying their partners with SMI to a specialist antenatal clinic. METHODS: A 36-question, study-specific cross sectional survey was completed by men whose partners with SMI were receiving antenatal care at a specialist multidisciplinary clinic over a 12-month period. RESULTS: A high percentage of eligible participants (40/41, 97.5%) completed the survey. Overall 25% depended for income on social security benefits; 60% reported smoking, alcohol and drug using behaviours that carried high health risks; 18% had a history of domestic violence order (DVO) being taken out against them, and 12.5% a documented history of bipolar or schizophrenic illnesses. Despite these risk factors they reported high satisfaction with their intimate partner relationships, and all anticipated the birth of the baby and impending fatherhood with enthusiasm, optimism and perhaps idealisation. CONCLUSIONS: Men who are the pregnancy partners of women with SMI, appear to be an especially vulnerable population, who report high rates of psychosocial difficulties, which are likely to have an adverse impact on their capacity for realistic planning and support of their partners in this critical period of adjustment to parenthood. We recommend enhanced models of clinical care in which assessment and provision of support for partners is incorporated in comprehensive care of the pregnant woman with SMI.

Severe mental illness and induction of labour: outcomes for women at a specialist antenatal clinic in Western Australia.

BACKGROUND: Limited evidence is available around induction of labour (IOL) and obstetric outcomes for pregnant women with severe mental illness (SMI). AIMS: Our study examined obstetric and neonatal outcomes for women attending a specialist childbirth and mental illness (CAMI) antenatal clinic in Perth, Western Australia (WA), who experienced or did not experience IOL. METHODS: A retrospective study was conducted between December 2007 and May 2012 (n = 222), using patient records and computerised perinatal data collected by the Obstetrics and Gynaecology Clinical Care Unit. Descriptive statistics and univariate comparisons using Mann-Whitney tests and X(2) tests were conducted using SPSS. RESULTS: The overall rate of IOL in this study group was 40%, which was significantly higher than the WA Mother Baby Statistics by 11.6% (95% CI 4.9-18.3%, P < 0.002). Of those induced, 30% (27 of 185) were induced for psychiatric reasons. Women with schizophrenia were more likely to have IOL for an obstetric/fetal reason than a psychiatric reason (45% vs. 15%, P = 0.051). Women who experienced an IOL were less likely to have a spontaneous vaginal delivery (SVD) and more likely to have an assisted vaginal birth or emergency caesarean section (P = 0.040). Irrespective of labour onset, special care nursery admission (SCN) rates were similar and high for both groups (36% vs. 32%, P = 0.599). CONCLUSION: Obstetric management for women with SMI is complex, and psychiatric factors as well as medical factors must be considered to ensure the best outcomes for mother and infant.

Pregnancy experiences of Western Australian women attending a specialist childbirth and mental illness antenatal clinic.

Our purpose was to explore the pregnancy experiences of Australian women attending a specialized childbirth and mental illness (CAMI) antenatal clinic. A qualitative exploratory design was selected to give voice to women with severe mental illness receiving antenatal care. Telephone interviews with 41 women, 24 primiparous and 17 multiparous, were analyzed using thematic analysis. Three themes emerged: "building relationships," "acknowledging me as a person with special needs," and "respecting and understanding without stigma." Findings offer insight into care experiences possible within a multidisciplinary model developed to address psychiatric and obstetric needs of pregnant women with severe mental illness.

Obstetric and neonatal outcomes of pregnant women with severe mental illness at a specialist antenatal clinic.

OBJECTIVE: To evaluate the obstetric and neonatal outcomes of pregnant women with severe mental illness (SMI) who attended a specialist multidisciplinary antenatal clinic in Perth, Western Australia. DESIGN, SETTING AND PARTICIPANTS: A retrospective case-note audit of outcomes from the Childbirth and Mental Illness Antenatal Clinic (CAMI clinic) at King Edward Memorial Hospital for pregnant women with severe mental illness (SMI), aged 18-41 years, who gave birth between December 2007 and April 2011, and their babies. MAIN OUTCOME MEASURES: Obstetric and neonatal outcomes for 138 women and newborns from singleton live births. Data were compared between three diagnostic groups (schizophrenia, bipolar and non-psychotic SMI), and with WA obstetric and perinatal statistics for 2008. RESULTS: 44 women with schizophrenia, 56 with bipolar disorder and 38 with non-psychotic SMI attended antenatal care for an average of 7.7 (SD, 3.3) visits. The proportion of women who smoked tobacco was significantly higher than that in the WA antenatal population (46% v 15%; P < 0.0001). Alcohol use, illicit substance use and psychotropic medication exposure during pregnancy were high. The women were at increased risk of developing gestational diabetes mellitus (15% v 4%; P < 0.0001) and pre-eclampsia (9% v 3%; P < 0.0001), and birth complications were more common. Babies born to CAMI clinic women were less likely to have Apgar scores ≥ 8 at 1 minute and 5 minutes. Pregnant women with schizophrenia had more psychiatric relapses during pregnancy, and had more statutory child welfare involvement. Gestational age at birth and infant birth weights were similar for the pregnant women with SMI and the WA population in 2008. CONCLUSIONS: Women attending our specialist clinic had increased rates of obstetric and neonatal complications compared with the general population, and were exposed to a cluster of risk factors. We report encouraging trends in antenatal attendance, gestational age at birth, and birth weights. Managing pregnant women with SMI will require a comprehensive approach aimed at early detection of obstetric complications and psychosocial difficulties, as well as neonatal monitoring. Optimising prepregnancy maternal health and welfare may also be of benefit.

Managing pregnant women with serious mental illness: using the Edinburgh Postnatal Depression Scale as a marker of anxiety and depressive symptoms.

OBJECTIVE: To examine the course of depressive and anxiety symptoms using serial measurements of the Edinburgh Postnatal Depression Scale (EPDS) in pregnant women with serious mental illness (SMI) attending a specialist multi-disciplinary antenatal clinic in Perth, Western Australia. METHOD: A retrospective review of case notes was undertaken for 48 Western Australian pregnant women with schizophrenia and related psychoses and bipolar affective disorders who attended the Childbirth and Mental Illness (CAMI) antenatal clinic between December 2007 and November 2009. Of these patients, 27 completed the EPDS at booking (first appointment) and at 32 weeks gestation. Additional variables collected were demographic data, gestation at booking, and attendance rates for these 27 women, and for comparison another 21 women who did not complete the EPDS for one or both screening periods. RESULTS: Mean total EPDS score decreased from 12.2 (SD 7.6) at booking to 8.5 (SD 6.4) at 32 weeks gestation (p = 0.007). Overall mean attendance rates and number of appointments were similar to the non-SMI population and in keeping with standard guidelines. CONCLUSIONS: We speculate from these preliminary findings that being managed by a consistent small multi-disciplinary team and knowing that they will be supported throughout their pregnancy could lead to improvement of anxiety and depressive symptoms in pregnant women with SMI, and has the potential to increase their attendance for antenatal care.

Motherhood and mental illness: Part 1 - toward a general understanding.

BACKGROUND: Mental illness is common among women of childbearing age, and fertility rates of women with mental illness are close to those of the general population. General practitioners will see most of the women who may be seeking advice and management of their mental illnesses before, during or after a pregnancy. OBJECTIVE: This article reviews the current approaches to the management of mental illness in and around pregnancy, and provides practical advice regarding pregnancy related issues in women with mental health disorders. DISCUSSION: The GP is ideally placed to give information and encourage appropriate treatment choices in women with mental illness. Given the multifaceted complexities, the optimal approach is holistic and collaborative. Specialist opinion must be sought early and a multidisciplinary approach with access to specialist care offered if possible. Continuity of care, especially in the context of a trusting therapeutic relationship, is considered optimal.

Motherhood and mental illness--part 2--management and medications.

BACKGROUND: General practitioners see many women who may be on medication for the management of their mental illness before, during, or after a pregnancy. OBJECTIVE: This article reviews the current evidence and gives practical advice on management and use of psychotropic medication in women with mental health disorders in pregnancy. DISCUSSION: The general practitioner is often the first point of contact, and is vital in giving timely and accurate information and encouraging appropriate treatment choices in women with mental illness in our community. The risk-benefit analysis of treatment needs to be considered in light of the evidence at hand. Specialist opinion in complex cases must be sought early.