Mental Health, Substance Use, Hyperemesis gravidarum, Thyroid Disorders, Diabetes in Pregnancy W10 (my copy)

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ACES

adverse childhood experiences - impacts you later in life

How/who do mental health disorders impact the pregnancy?

• Pregnant person

• Gestational diabetes

• Preeclampsia​​

• Newborn - parent might neglect their child​

• Entire family - more likely to be depressed​

• Average cost untreated PMADS(pregnany mental health) = $31,800 per di-ad saved. Untreated people may go to jail or the baby could cost more to take care of and cost more. ​

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PMADS

• Perinatal mood and anxiety disorders

• Depression (PPD)

• Anxiety

• Obsessive compulsive disorder

• posttraumatic stress disorder PTSD

• Postpartum psychosis

How to prevent mental health disorders in pregnancy?

• Adequate treatment for mental health disorders before pregnancy​

• Access to safe, effective, affordable contraception ​

How often should you screen a pregnant client for mental health disorders?

• Every trimester

• 1,2,4,6 months after birth

• EDPS

• IVP screening

EPDS

Edinburgh Postnatal Depression Scale

“How are things going?” How much time do you spend crying?” “Many women feel depressed after having a baby. Some feel so badly that they think about hurting themselves or their baby. Do you ever have these thoughts?”​

How to treat PPD and other mental health disorders

• Combination of antidepressants and cognitive behavioral therapy (CBT)

• Holistic treatment – massage, rest, exercise, light, acupuncture, guided imagery, aromatherapy, community groups , accept help​

Kalamazoo baby cafe

Food for clients

Speaker talks

The group talks

How do we screen PP clients for mental health disorders?

• Edinburgh postnatal depression scale

• S/S - regular depression + irritability or guilt

Medications for mental health. Add some you should not take too:

• SSRI - prozac, zoloft, lexapro. Think puzzle or PZL

• *Zuranolone = ONLY pp​

• Mood stabilizers​

• Anti-psychotics​

• Most medications = stay on, may increase d/t metabolism with exception of valproic acid (Depakote), some research = carbamazepine ​can also be bad

Zuranalone

Med made specifically for postpartum depression. SSRIs usually take 4-6 weeks to take effect. This med works within 72 hours! If someone is already on an SSRI, you can start this med too. Makes you very drowsy! Cannot drive! Can only take for 2 weeks! Think Saran Wrap, quick fix.

Potential dangers of SSRI’s for mom and baby.

• Serotonin syndrome: brains gets too much serotonin. Sweaty, tachycardia, temp dysregulation.

• Baby can go through withdrawal: difficulty eating, sleeping, irritability. Resolves by a week.

• Know these!

• Rare: pulmonary HTN in babies

How much more likely are women to have anxiety than men? Give some anxiety example types

2x more likely

Examples:

• Obsessive-compulsive disorder (OCD)​: obsessive thoughts or actions

• PTSD​

• Generalized anxiety disorder​

• Panic disorder ​

• Agoraphobia and other phobias ​

How do we screen for anxiety in the PP client?

EDPS​: know this one

Sometimes use the: GAD-7 ​

• >15 = severe anxiety ​

PP Psychosis. What is it and symptoms?

• PP depression with psychotic features

• Rare

• Hallucinations, delusions, agitation, grandiosity (inflated sense of self)

Hallucinations and delusions definition

Not based in reality

Distortion of reality

What puts you MOST at risk for PP psychosis?

Bipolar or schizophrenia

• If you discontinue antipsychotic or mood stabilizer, it could be VERY bad. Keep pregnant people on their meds.

What other factors can put you at risk for PP psychosis?

• Infections​

• Electrolyte, nutritional deficiencies​

• Eclampsia​

• Sheehan syndrome​ - severe hemorrhage

• Severe thyroid disorder​

• Substance use induced​

• Lack of sleep ​

• Previous history ​

Resources for pregnant clients with mental issues - local and state/national

Local:

• Cradle Kalamazoo – baby café’s​

• Family Health Center – support group​

• WMED – perinatal psychiatrist​

• Perinatal mental health – Bronson​

State/national:

• Postpartum support international​: give healthcare providers education and training. Also has virtual services.

• Pine Rest – in and outpatient​: Outpatient: they take care of your babies and you get to spend time with them.

• University of Michigan - Women and infant mental health program

End of Mental Health Portion!!

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SLIDO: What is the most commonly abused substance during pregnancy?

Alcohol

SLIDO: Is methadone a substitute for other drug addictions?

No. Explained later.

Good and bad news in regard to substance use disorder:

Good:

• Most receptive time to change lifestyle​ around pregnancy

• Treatment works​

• Rx authority = expanded, more treatment available ​to prescribe and healthcare providers are more educated.

Bad:

• Healthcare providers are source of trauma, shame​

• Many healthcare providers do not utilize evidence-based healthcare ​

Commonly abused drugs and the harm that each of them do: Know these.

• Tobacco – Blood vessels spasm and shrink. Increased risk of Placenta previa, IUGR, IUFD, SIDS, ​

  Alcohol – brain development, behavior​

  Marijuana – preterm birth, low birth weight, cognitive delays ​

  Cocaine – IUGR, IUFD, ptb, ptl, placental abruption​

  Meth – preterm birth, abruption, lethargy, heart and brain abnormalities​

  Opioids – withdrawal ​

  Rx – Wide variety, including opioids, benzos, etc. ​

Screening for drug use

4P’s

• Parents

• Partner

• Past

• Pregnancy

• Include a questionnaire

Make sure to build up screening in a non-threatening way. Ask about OTC drugs, ask about amount, then ask about recreational drugs.

DAST

Drug abuse screening test

Biological testing:

Not recommended - biased against patients of color, low SES, not completely accurate.

What are the parts of biological testing?

• Urine – only detectable for days, false negatives common​

• Meconium – may not have for several days, may be discarded by parents ​

• Hair – detects for longer period of time (baby and PP person)​

• Umbilical cord tissue – need 6 inch sample​

Should you just stop using opioids?

NO! Prescribe MOUD

What is MOUD?

Medication for opioid disorder

• Do not recommend stopping opioids – withdrawal is risky, high risk of overdose when re-start​

• Suboxone (buprenorphine + Nalaxone) = sublingual, oral, IM – can get from most healthcare providers ​

• Methadone = OTPs (opioid treatment programs aka “methadone clinic”) = only allowed to give methadone, usually daily ​

• Prevents risky sex, STIs, crimes, soft tissue infection, overdose​ that they might otherwise do/get for drugs.

Methadone v suboxone

Methadone: full opioid agonist but in a measure dose to not deliver a high

Suboxone: partial agonist and antagonist. Has a “ceiling effect”

Difference between addiction and dependence?

Addiction: Behavioral - treatable

Dependence: Your body depends on it. Without it, you will go through withdrawal.

What is contingency management? Memorize

Clients get a gift card to come into the clinic. Reward system to promote change.

Are babies born addicted?

No, they are born dependent

Eat, sleep console modality

Treatment for mom and baby to help with substance use disorder that focuses on connection between mom and baby and non-pharm interventions.

• get down on their level

• be non-judgemental

Finnigan method:

Take the baby away from the mom. Shame the mom. Give babies morphine and admit them to the NICU.

End of Substance Use slides!!

Keep going!!

S/S of hyperemesis gravidarum: S/S of dehydration.

• Persistent nausea/vomiting​

• Signs of dehydration such as: dry mouth, lips, and eyes; feeling dizzy or tired; dark or strong-smelling urine; headaches; infrequent urination; rapid heart rate; and confusion​.

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What is the PUQE score? Don’t memorize levels just memorize the gist.

• PUQE Score: A scoring system based on client responses about nausea and vomiting.​

• Scores 4-6: Mild nausea and vomiting.​

• Scores 7-12: Moderate nausea and vomiting.​

• Scores 13+: Severe nausea and vomiting.​

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Causes:

• Hormonal changes – hCG, progesterone​

• Genetic predisposition​

• Helicobacter pylori (H. pylori) ​: give antibiotics and a proton pump inhibitor. Test for h pylori with a breath test.

• Ptyalism​: excessive salivation

Risks for hyperemeissi gravidarum:

• Nulliparous client​

• Previous history​

hyperemesis gravidarum etiology

• Elevated hCG due to molar or multiple gestation pregnancy​

• Estradiol increase due to elevated hCG​

• Nausea associated with motion​

Normal potassium levels: on test

3.5 to 5

Electrolyte imbalances of hyperemesis gravidarum: Don’t have to memorize exact number.

• Potassium 3.5 to 5 mEq/L​

• Sodium 136 to 145 mEq/L​

• Calcium 9 to 10.5 mg/dL​

• Glucose 74 to 106 mg/dL​

How to treat hyperemesis gravidarum. Pharm, non-pharm and assessment:

1. Give Vitamin B6. Regulates neurotransmitters and hormones to control nausea.

2. Antiemetics: Zofran

3. Antihistamines like Benadryl

4. IV fluids for hydration

5. TPN: total parenteral nutrition - IV nu

Non-pharm strategies:

• avoid triggers

• ginger!

• pressure points

Assess:

• H-Pylori​

• CBC​

• Electrolytes ​

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END!

Type 1 v type 2 diabetes:

• Type 1 DM

• Memorize: high risk of fetal abnormalities or death​

• Peak diagnosis in early adolescents​

• Highest risk for maternal and fetal morbidity and mortality ​

• Type 2 DM​

• Increasing number of pregnancies affected (1% to 2% of all pregnancies)​

Gestational diabetes

• increased insulin resistance

• more likely to deveop type 2 in future

Risk factors: memorize

• BMI>25​

• History of GDM, family history of diabetes. Wanna know how other pregnancies were and how big their babies were. ​

• History of A1C 5.7%-6.4%​. Below 5.7% is normal

• Previous LGA infant ( above 4.08 kilogram or 9 pound)​

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Table

3 Ps

• Polyphagia, polydipsia, polyuria​

• Slow wound healing, dry skin, visual disturbances, fatigue​

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Glucose tolerance test:

Do a 3 hour if 1 hour is unusual

What is a BPP

Looking at baby movement, tone, fluid (8-10 score is deal)

Considerations for the client and baby:

Psychosocial Impact​

Anxiety or depression​

Increased surveillance ​

Considerations​

Lab work, additional visits​

increased stress, employment, finances​

Congenital malformations​

Preterm birth​

Large for gestational age (LGA) measurement​

Birth Injury​

Hypoglycemia 40-45 is low. May have tremors​

Obesity​

Health promotion for DM clients

Education:​

• Nutrition ​

• Exercise ​

• Medication ​

• Office visits​

• Glucose monitoring​

DM 1 management: memorize

• Insulin dose decreased in 1st trimester, increased in 2nd and 3rd trimester​

• May add rapid acting insulin to regimen​

• IV infusion during labor ​

• Preconception Care ​

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DM 2 management:

• Continue pre-pregnancy insulin regimen​

• Oral hypoglycemic (glyburide) ​

• Insulin therapy​

• Exercise, Diet ​

• Preconception care​

• Risk reduction for later ​

Next slideshow

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Hypothyroidism definition and 2 types and what they mean:

Everything slows down. Diagnosed if there is elevated TSH and decreased T4 levels.

Types:

• Subclinical hypothyroidism: mildly elevated TSH with normal T4 levels. ​

• Overt hypothyroidism: Elevated TSH with low T4 levels. ​

How does the thyroid change in pregnancy?

Increases in size due to pregnancy demands, with hCG and estrogen influencing thyroid hormone levels. ​

How is the fetus impacted by hypothyroidism?

Relies on maternal thyroid hormones and iodine for growth and thyroid development until about 20 weeks. ​If not properly treated, there might be IUGR, neurological delays, preterm birth or loss.

Risk factors for hypothyroidism:

Risk Factors​

• Female gender​

• African American​

• Surgical procedures - thyroid surgery​

• History of autoimmune disorder​

• Age​

• BMI​

• Multiparous

• Iron deficiency​

Impacts of hypothyroidism: memorize

• Risk of pregnancy loss​

• Gestational diabetes​

• Preeclampsia ​

• Placental abruption​

• Preterm labor​

• Postpartum hemorrhage​

• Neurological development of fetus​

• Placental dysfunction​

• Development of goiter​(enlargement of thyroid gland)

• Maternal stress ​

S/S of hypothyroidism. Subclinical and overt:

• Subclinical hypothyroidism ​

• Increase in serum TSH but not T4​

• No subjective or objective manifestations​

• ​

• Overt hypothyroidism ​

• Fatigue ​

• Constipation​

• Confusion​

• Weight gain​

• Amenorrhea​

• Bradycardia ​

• Peripheral edema​

• Feeling cold​

Treatment: monitor, pharm intervention - what to keep in mind with pharm intervention?

Monitor and maintain levels (check every 4-6 weeks during pregnancy)​

• TSH ​

• T4

Thyroid replacement – levothyroxine ​

• Titration of dosage dependent upon timing of diagnosis​​

• Avoid prenatal vitamins 4 hours after dose, no food with medication. Know this!! ​

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Should you increase pre-pregnancy levothyroxine dose?

Yes, by 30-50%.

Do you have to titrate levothyroxine levels?

Yes, titrate them throughout pregnancy to maintain TSH levels below 2.5 mIU/L

When to take prenatal vitamins in relation to levothyroxine?

Avoid taking prenatal vitamins within 4 hours of taking levothyroxine.

What is hyperthyroidism?

Decreased serum TSH

Elevated serum T4

Oposite of hypothyroidism

Most common cause for hyperthyroidism:

Graves disease - leads to elevated/excessive thyroid stimulating immunoglobulin (TSI)

Other causes of hyperthyroidism:

Thyroiditis: inflammation leads to excessive T4 release

Thyroid nodules or goiter: Tissue overgrowth causing increased T4 production.

Risks for hyperthyroidism:

• MOLAR PEGNANCY - memorize

• Family or personal history or thyroid and/or autoimmune disorder​

• Pregnancy/recent postpartum​

• Adrenal insufficiency ​

• Pernicious anemia ​

• Iodine intake​

• Smoking ​

• White, Non-Hispanic​

• Chilbearing age women​

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Hyperthyroidsim symptoms

• Flushing ​

• Sweating ​

• Anxiety ​

• Change bowel habits​

• Sleep difficulty​

• Change in energy​

• Hand tremors​

• Racing heart​

• Nausea and vomiting​

• ​

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Impacts of hyperthyroidism on pregnancy

mom

• Preeclampsia​

• Preterm labor​

• Thyroid storm​: this is a hyper metabolic state that can cause death from cardiac arrest or organ failure

• Mood changes ​

Baby

• Preterm birth​

• Small for gestational age (SGA)​

• Fetal demise​

• Congenital malformations​

• Fetal tachycardia​

• Fetal hyperthyroidism​

• Fetal goiter development.​

  
  

Treatment for antithyroid medications - hyperthyroidism

• Propylthiouracil (PTU) can be given until the 16th week​

• Methimazole after 16th week with goal to maintain T4 levels at slightly elevated. ​

• Goal is to maintain T4 level in high to expected range​

Impacts of PTU and methimazole on baby

• Congenital disabilities and fetal thyroid function and growth restriction