Pregnancy in women with psychotic disorders

Clinical Effectiveness in Nursing (2006) 9S2, e201–e211

Clinical

Effectiveness

in Nursing

http://intl.elsevierhealth.com/journals/cein

Pregnancy in women with psychotic disorders Louise M. Howard

*

Health Services Research Department, PO29 Institute of Psychiatry, London SE5 8AF

KEYWORDS

Summary Objectives: To review the psychiatric and obstetric complications of pregnancy in women with psychotic disorders and discuss implications for prevention and treatment of these conditions. Design: Narrative review. Results: Many women with psychotic disorders have children but their pregnancies are at an increased risk of obstetric complications, stillbirths and neonatal deaths, and psychiatric complications. Women with a history of mood disorders (affective psychoses) are at high risk of postpartum relapse. A significant proportion of mothers with psychotic disorders have parenting difficulties and lose custody of their infant. Conclusions: Close liaison between all health professionals during pregnancy and postpartum is essential for optimal management of these high-risk pregnancies. c 2006 Elsevier Ltd. All rights reserved.

Obstetric complications; Schizophrenia; Psychotic disorders; Parenting; Pregnancy



Introduction The definition of psychosis The term ‘‘psychosis’’ is used as a descriptive term for mental disorders with hallucinations, delusions or severe abnormalities of behaviour (e.g. psychomotor retardation, catatonic behaviour) (WHO, 1992). Hallucinations can be defined as perceptions that occur in the absence of a corresponding stimulus. Delusions are fixed false beliefs which are out of keeping with the patient’s educational, cultural and social background and are held with extraordinary conviction and subjective certainty. The two main categories of psychosis are schizo* Tel.: +44 020 7848 0735; fax: +44 020 7277 1462. E-mail address: [email protected].



phrenia and related disorders and affective disorders (psychotic mood disorders) including bipolar disorder and psychotic depression (WHO, 1992). There is an equal prevalence of bipolar disorder in men and women but men are at a slightly higher risk of schizophrenia (Aleman et al., 2003); women with schizophrenia usually have a less severe form of the disorder (Usall et al., 2002), more mood symptoms (Castle et al., 1994) and fewer negative symptoms (Roy et al., 2001) and are more likely to spend time in remission and live independently (Angermeyer et al., 1990; Navarro et al., 1996).

Childbearing and psychosis Early studies reported consistently that women with psychotic disorders are subfertile (Howard, 2005). However, it is increasingly recognised that

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e202 although fertility may be lower than the general population (Howard et al., 2002), since the advent of community psychiatry the majority of women with psychotic disorders have children. (McGrath et al., 1999; Howard et al., 2001). Neuroleptics cause hyperprolactinaemia, which can lead to anovulatory cycles or amenorrhoea in women (Dickson et al., 2000), and would therefore be expected to be a cause of some of the reduction in fertility found. Newer drugs such as clozapine, olanzapine and quetiapine, which do not cause sustained increases in serum prolactin levels, may lead to higher birth rates in patients with psychotic disorders in the future. Women with psychoses who become pregnant are at high risk of obstetric and psychiatric complications. Many different health professionals, in particular midwives and health visitors, come into contact with patients with psychotic disorders during pregnancy and in the immediate postpartum period, providing many opportunities for intervention to prevent potentially serious consequences. Recent research has clarified the risk of complications and started to examine how they can be prevented. This review will critically summarise the literature, antenatal problems and perinatal complications of pregnancy and the postnatal period for women with psychosis.

Antenatal care Identification of psychiatric disorders Psychiatric disorders in pregnancy are under-recognised (Kelly et al., 2001) and even in those women in whom mental disorders are documented in their medical notes by delivery, there can be a twofold higher risk of inadequate prenatal care (Kelly et al., 1999). There is some evidence that women with psychotic disorders book in for antenatal care later than other women (Goodman and Emory, 1992), though this has not been a consistent finding (Howard et al., 2003a), and may attend less regularly (Wrede et al., 1980; Miller and Finnerty, 1996). However, these pregnancies are high-risk pregnancies which need optimal antenatal care. Patients with schizophrenia are at increased risk of impaired glucose tolerance and incident diabetes, particularly if they are taking atypical antipsychotic drugs (Kornegay et al., 2002; Lindenmayer et al., 2003); they are therefore at high risk of gestational diabetes. Women with psychoses may have neglected themselves and be malnourished as a result. They are also more likely to smoke and drink

L.M. Howard alcohol during pregnancy (Bennedsen et al., 1999; Howard et al., 2003a). A UK study using primary care data found that GPs were less likely to record alcohol and smoking consumption during pregnancy in women with psychotic disorders (Howard et al., 2003a), suggesting that when healthcare professionals have detected psychiatric disorders they may then attend to aspects of the mental illness during pregnancy to the neglect of important aspects of antenatal care. Midwives need to identify women with a history of severe mental illness by taking a detailed history of any previous postnatal illnesses and non pregnancy related chronic mental illness e.g. bipolar disorder or schizophrenia. Women with mental health problems are likely to experience homelessness and socio-economic difficulties and these should also be asked about sensitively. The Department of Health (1998) has highlighted the need to obtain a thorough psychiatric and social history at the first antenatal visit. Most NHS trusts now include screening questions in their protocols for midwives to ask at the booking appointment. The questions range widely from two questions such as: ‘‘Have you ever had any emotional or psychological problems?’’ ‘‘Have you ever had a problem with alcohol or used recreational drugs?’’ to over 10 more specific questions asking about diagnoses and suicidality. However these questions have not been validated by research, and most midwives do not have much training in probing for a history of mental health problems. At present training may consist of being asked to read the questions from the booking questionnaire or may include a specific training programme for maternity staff which will include learning about screening at booking to detect women at risk of severe postpartum disorders, current disorders and ongoing supervision sessions regarding the maternity care of women with mental health problems. These training programmes need evaluation with randomised controlled trials to detect which aspects of the training programme are helpful for midwives. It seems clear, however, that all women should be routinely asked at the beginning of their antenatal care about a past history of, or current, mental health problems or substance misuse.

Nursing care during pregnancy Subsequent antenatal care for women with psychotic disorders should include support for women

Pregnancy in women with psychotic disorders to reduce risk factors for poor perinatal outcome including tobacco use, alcohol and drug use and abuse and obesity. Educational material about treatment options should be provided and a collaborative review of illness history should include a risk-benefit assessment of treatment options. Nutritional supplements (including vitamins and folic acid) should be offered and vitamin K should be offered to patients taking valproate or carbamazepine. Protocols have been developed by many UK National Health Service (NHS) trusts (and it is recommended that they should be in place in every NHS trust providing maternity services) i.e. routine pathways for midwives to use after their routine antenatal assessment in women with mental health problems (see, for example, www.esussex.nhs.uk/clinicalaudit/#top). These protocols are based on expert opinion and reviews of the available research literature but have not yet been evaluated. The protocols need the support of a consultant psychiatrist with a special interest in perinatal psychiatry, and good liaison between community mental health teams, community drug and alcohol teams, liaison psychiatry, children family social services, primary care, and any relevant voluntary agencies. Women with a history of psychosis who become pregnant may be faced with difficult decisions to make regarding medication. They will be concerned about possible adverse effects of prescribed drugs on the foetus during pregnancy and in the past many women have had their medication stopped often abruptly during pregnancy (or stopped medication themselves) for this reason. However withholding antipsychotic treatment may produce more risks than benefits. Relapse of psychosis may put the mother and foetus at risk and worsening of symptoms could affect the woman’s job and ability to care for other children. A psychiatric emergency could lead to larger doses of medication and it is possible that physiological changes associated with psychosis (e.g. increase in arousal, higher anxiety levels) could impact on the development of the foetus. Untreated psychiatric disorder may effect foeto-placental integrity and foetal central nervous system development (Cohen and Rosenbaum, 1998). It may therefore be necessary to change the type of treatment or change the treatment regimen to stabilise the mental state while avoiding foetal damage (see below). Women should be informed of the evidence available to date so they can make an informed decision about this. The evidence to date is as follows:

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Psychotropic medication during pregnancy The only large controlled studies of antipsychotics in pregnancy have been conducted on women with hyperemesis gravidarum; much lower doses of medication (generally drugs such as phenothiazines) are used for these patients than in schizophrenia and residual confounding is commonplace so conclusions are limited. A meta-analysis reported that first trimester exposure to low potency antipsychotics was associated with a small additional risk of congenital anomalies (Altshuler et al., 1996). Neuroleptics can also produce toxic effects in newborn infants medicated in utero, including respiratory depression and neonatal behavioural abnormalities such as extrapyramidal movements and difficulty with oral feeding, though these effects usually resolve within days. The few small studies examining longer term effects in children exposed in utero to antipsychotics have found no motor, behavioural or intellectual abnormalities (e.g. Desmond et al., 1967; Slone et al., 1977) but larger, more methodological vigorous studies are needed to determine neurobehavioural effects in such children. Less is known about the effects of atypical antipsychotics. Normal rates of adverse effects with olanzapine during pregnancy have been reported comparing case registry data with historical controls (Goldstein et al., 2000). However, data from the UK National Teratology Information Service (NTIS) indicate an increased incidence of malformations of 10% (compared with an expected incidence of 2–3%), though as this was based on only three cases no clear relationship can be established. One survey of pregnant women taking clozapine reported a higher than expected rate of malformations (5 cases in 61 pregnancies) (Dev and Krupp, 1995). Case reports and NTIS data report no problems with quetiapine and risperidone during pregnancy but this partly reflects the low frequency of prescribing these drugs in pregnancy; there are no data available on newer drugs such as aripiprazole. Lithium is associated with cardiac malformations if exposure is in the first trimester, though this appears to be less of a problem than previously thought (Cohen et al., 1994; Jacobson et al., 1992); a pooled review has estimated the risk of Ebstein’s anomaly to be approximately 1 in 1000–2000 (Cohen et al., 1994). A five year follow up of 60 children exposed to lithium in the second and third trimesters did not reveal any developmental anomalies compared to their siblings (Schou, 1976). There are pregnancy complications (e.g. polyhydramnios, diabetes

e204 insipidus and foetal goitre), which can occur if lithium is used during the latter two trimesters. Women taking lithium through pregnancy should be offered detailed foetal ultrasonography and ediocardiography at sixteen to eighteen weeks to assess cardiac development. Lithium levels should be taken frequently during pregnancy (NICE, 2006). Sodium valproate is a human teratogen that causes serious neural tube defects in 1–2% of infants exposed prenatally to the drug and should not be used prenatally if possible (NICE, 2006). Carbamazepine is also associated with an increased risk of spina bifida and other congenital anomalies (Ornoy and Cohen, 1996) but the risk is smaller than with valproate. Lamotrigine is used as maintenance therapy in bipolar disorder but may also be associated with an increase in the risk of teratogenicity and is not recommended for use in pregnancy (NICE, 2006). There is still little known of the long-term effects of psychotropic drugs on the foetus. More research is needed using large datasets to investigate developmental effects in the growing child. In general, psychotropic medication has a place in the treatment of pregnant women with psychotic disorders, but without more data on the prevalence of prescriptions and adverse effects in the foetus an accurate risk: benefit analysis can be difficult. If women do decide to stop medication, they should be offered appropriate psychological interventions (e.g. cognitive-behavioural therapy) and social support. Although there has been no research on psychosocial interventions in pregnant women with psychotic disorders, there is some evidence from other patient groups that cognitive-behavioural therapy can be helpful for bipolar disorder and schizophrenia.

Domestic violence Women with severe mental health problems are at increased risk of domestic violence (Cascardi et al., 1996; Dienemann et al., 2000), and domestic violence often starts or increases in severity during pregnancy (Gazmararian et al., 1996; Bowen et al., 2005). The main health effect specific to domestic violence during pregnancy is the threat to health and risk of death of the mother, foetus, or both, from trauma (El Kady et al., 2005; Pearlman et al., 1990). Abuse in pregnancy is associated with sexually transmitted diseases including HIV, urinary tract infections, and mental health symptoms including depression and post-traumatic stress disorder (Amaro et al., 1990; Martin et al., 1998), though whether these conditions occur and exacer-

L.M. Howard bate pre-existing psychotic disorders has not been investigated. Domestic violence is also associated with anxiety, insomnia, alcohol and drug abuse, and suicide attempts (Campbell, 2002). The Department of Health recommends routine enquiry about domestic violence. However, less than half are routinely asked about domestic violence during pregnancy during antenatal care in the USA (Renker and Tonkin, 2006) a Scottish study found only 15% of midwives routinely inquired about domestic violence (Foy et al., 2000) and similar findings have been reported for maternity units in England and Wales. Many women need to be asked about violence several times before they feel sufficiently comfortable to discuss this and are more likely to disclose domestic violence to health professionals who are supportive, non-judgmental and to ask questions in a sensitive manner (Rodriguez et al., 1996; Bacchus et al., 2003). However there is good evidence to suggest that very few women are angry, embarrassed or offended when asked about domestic violence during pregnancy (e.g. 3%-Renker and Tonkin, 2006). When a woman discloses domestic violence, healthcare professionals need to know the appropriate responses including sources of local help, and local training is advised for all staff.

Services A clear protocol for the treatment and support of women with serious mental health problems should be provided (see Fig. 1). For example, if a midwife is told by a woman of a history of schizophrenia the first step in any protocol would be to decide whether there are any emergency concerns or not, and whether she needs specialist mental health care. If there are no emergency concerns but she needs specialist care and is currently ill, does she need inpatient care? Should she be admitted to a psychiatric ward or could she be admitted to a mother and baby unit (MBU)? Also the child protection risk should be assessed and a care plan agreed between the following: mother, carer (e.g partner, family), community mental health team, primary care, perinatal mental health service, maternity services. The woman’s case should be discussed with social services and drug and alcohol services where appropriate. As women with psychotic disorders clearly have complex healthcare needs perinatal psychiatric services have been developed in a number of countries. Appleby et al. (1989) audited one of the early UK psychiatric liaison services to a general hospital obstetric unit and found that although

Pregnancy in women with psychotic disorders

e205

Identification of a pregnant woman with psychotic disorder

Immediate Care

Longer term care

Consider psychiatric admission if necessary

During pregnancy

Following birth

Child protection

Treatment

Treatment

Care planning meeting

Support

Support

Professional network meeting

Child care support

Child care support

Provide emergency contact

Elective referral to

Planned admission to

MBU for assessment/

MBU

visit to MBU

Figure 1

Relapse prevention

Relapse prevention

Information, advice

Information, advice

Management protocol for pregnant women with severe mental illness.

the service was initially intended to predict antenatally those at risk of postnatal depression, a large proportion of referrals were of women currently unwell, including women with psychotic disorders. It is therefore clear that liaison services are needed antenatally for pregnant women with severe mental illness. They also emphasised the difficulties in postnatal follow-up in the community subsequently and the importance of strong community links. An obstetric liaison team in the UK usually includes a consultant psychiatrist with a special interest in perinatal psychiatry and a specialist multidisciplinary community team whose key members should be specialist community psychiatric nurses who have good links with primary care and maternity teams as well as their own community mental health team. Oates (2000) suggests that the perinatal team should provide general and liaison psychiatric services. The main functions of the team should include the offer of prenatal counselling to those women at high risk of developing a postpartum psychiatric disorder; assessing and monitoring high-risk women who are well and are referred from the antenatal clinic; advising to and managing distressed pregnant women, particularly those from vulnerable subgroups; assisting in the management of mentally ill pregnant women and liaison obstetricians and general adult psychiatrists; planning postnatal psychiatric care and intervention for women at high risk; providing a liaison consultation service to the postnatal wards; managing significant psychiatric disorder arising in the postnatal period in the community and on the

MBU; and contributing to the undergraduate and postgraduate education of general practitioners, obstetricians and midwives.

Mother and baby units Women needing acute admission during pregnancy e.g. an acute exacerbation of a schizophrenic illness, have traditionally been admitted to acute wards which until recently have usually been mixed sex wards. These have been inappropriate for inpatient care for pregnant women as these women often have not realised they are pregnant, or had delusions about their pregnancy, and men on the ward may be a risk to the pregnant woman. There are now alternatives for such admissions. UK national policy has led to a rapid increase in women only wards which are more suitable for pregnant women. However, potentially even more suitable, are MBUs where the mother can be admitted antenatally. Some pregnant women stay on the MBU and, if necessary are admitted to the labour ward from the MBU and return after labour on the obstetric ward to the MBU where psychiatric treatment can continue with her baby. However, mother and baby units are used mainly for mothers and babies in the postpartum period and were developed in the 1940s and 1950s (Howard, 2000). There is very little written in the literature about their use for treatment of pregnant women and it is probable that this has only been carried out on an ad hoc basis occasionally until recently, though this is now seen as good practice.

e206 Mother and baby units are not available in many countries, and even in the countries in which they have been developed their availability is patchy (Oluwatayo and Friedman, 2005). There has been no randomised controlled trial to evaluate joint mother and baby admission compared with separation of mother and baby postpartum or the admission of pregnant women into mother and baby units rather than traditional psychiatric wards. Research is clearly needed to evaluate the effectiveness and cost-effectiveness of these units. In addition to separate MBUs some hospitals have mother and baby facilities which consist of a few mother and baby beds, separate from a main ward, where mothers can be admitted with their babies. These may consist of only 3 to 5 beds and achieving optimal staffing issues may be difficult but in a relatively small catchment area they may be the best way to ensure mothers can be admitted with their babies and pregnant women can be admitted to a safer and specialist area, if there is no MBU available regionally.

Perinatal community services Perinatal specialist services also run specialist community services for pregnant women. Different services will differ in their provision of care depending on levels of funding and priorities. Most will use specialist nurses who will either see women in their own homes or in clinics for assessments and regular follow-ups, if needed, in close liaison with primary care and obstetric care, and supervision by another member of the perinatal mental health service. If child protection is a concern for the future the nurse will be able to plan for this antenatally and call for a pre-birth case conference. The nurse can offer psychiatric treatment for certain psychiatric disorders if appropriately trained e.g cognitive behavioural therapy and monitor the mental state around the birth in women at risk of relapse after delivery e.g in women with bipolar disorder. She can also liaise with the health visitor who will be visiting regularly in the postnatal period.

L.M. Howard the mother and OCs, in particular for low infant birthweight (Sacker et al., 1996). This increased risk was found in women with an onset of schizophrenia any time in her life including after the birth of the child, in addition to women who already had schizophrenia before or during the pregnancy. Bennedsen’s (1998) review similarly concluded that childbearing women with schizophrenia have an increased risk of intrauterine growth retardation and preterm birth, though commented that most studies were of small samples and did not control for confounders such as smoking and poor nutrition. There is also some evidence of an increased risk of OCs in women with bipolar disorder (eg. Jablensky et al., 2005). Other recent large studies have reported a small but significantly increased risk of OCs in mothers with psychotic illnesses (Dalman et al., 1999; Bennedsen et al., 1999), though this may be explained by the increase in smoking in women with schizophrenia. These studies have not controlled for socio-economic status so residual confounding is possible. This increase in OCs may be due to genetic susceptibility, poorer antenatal care or lifestyle factors (e.g. smoking, substance misuse, poor nutrition and socio-economic factors). Psychotropic drugs may also have an effect on OCs (in addition to the more common concern of teratogenicity) but no clinical controlled trials exist, with the few studies in the literature tending to be small with little information on confounders and drug dosage.

Labour There is a significantly increased risk of lack of detection of labour in women with schizophrenia compared with women with bipolar disorder (Spielvogel and Wile, 1992) which may contribute to OCs in women who do not get appropriate help during labour. In women taking lithium, care should be taken to monitor and maintain hydration during labour as the changes in mother’s blood volume can lead to lithium toxicity in the mother and/or infant. Lithium levels should be taken with 24 hours of delivery.

Obstetric complications (OCs) Perinatal conditions in the infant There have been over 30 studies published on obstetric complications in women with schizophrenia with conflicting results reported. However, a high quality meta-analysis of case-control studies found an association between schizophrenia in

Stillbirth and neonatal death There is evidence from a high quality recent metaanalysis of a two fold increased risk of stillbirth in

Pregnancy in women with psychotic disorders women with psychotic disorders (Webb et al., 2005) and there is also evidence of an increased risk of neonatal deaths (e.g. Howard et al., 2003a). This is likely to be due to lifestyle factors such as smoking and substance misuse and may also reflect the poor condition at birth of the infants of women with schizophrenia who tend to have a lower APGAR score (Bennedsen et al., 2001). Attempted suicide during pregnancy is also associated with neonatal and infant death (Gandhi et al., 2006).

e207 of any other age (Marks and Kumar, 1993). Severe mental illness is directly implicated in only a minority of cases, but there is a significant association between fatal child maltreatment and parental psychotic disorder (D’Orban, 1979; Falkov, 1996). Less is known about more widespread but non-fatal harm or neglect of infants. It is therefore very important for the mental state of women with a history of psychosis to be assessed regularly postpartum and maximum support to be given by an appropriate range of healthcare professionals (e.g. social services, CMHT, health visitor).

Sudden infant death syndrome A large study using data from the Danish Psychiatric Register and the Danish Medical Birth Register has reported a relative risk of 5 for Sudden Infant Death Syndrome (SIDS) (the commonest cause of infant death in the general population) in the children of women with schizophrenia after adjustment for birthweight and gestational age (Bennedsen et al., 2001). There was no adjustment for socio-economic status or smoking which the authors acknowledge may have led to residual confounding. This study linking SIDS and schizophrenia does not provide clear evidence for a causal association between SIDS and schizophrenia, and more research needs to be carried out to investigate this further. However, there are several possible reasons to believe that such an association is plausible as psychosis is associated with many of the risk factors for SIDS e.g. smoking, substance misuse and possibly psychotropic medications which are sedating. The literature discussed in the previous section suggests that the infants of women with schizophrenia can be in poorer condition at birth, which may also increase their risk of subsequent death. Women with psychosis may also find it hard to change child care practices associated with SIDS such as placing an irritable baby on his or her back to sleep when he or she is easier to settle in the prone position (Howard and Hannam, 2003). It is therefore important that childbearing women with psychotic disorders are helped to stop smoking in pregnancy, and if they cannot stop smoking, to subsequently reduce the infant’s smoke exposure. Mothers must also be informed of the importance of putting babies on their back to sleep.

Infanticide A child under one year of age is four times more likely to be the victim of homicide than is a person

Physical health outcomes There has been little research into the physical health outcomes of infants of mothers with severe mental illness. However, there is evidence from one study that babies of mothers with psychiatric disorders may receive routine immunisations later than matched controls (Howard et al., 2003a). Health visitors need to ensure these babies are followed up carefully to ensure they receive age appropriate interventions e.g. immunisations, developmental checks.

Psychiatric complications postpartum Women with bipolar disorder have a nearly 7-fold higher risk admission for a primary episode and nearly 2-fold increased risk for a recurrent episode in puerperal women, compared with non postpartum and non pregnant women (Terp and Mortensen, 1998). There is a further increase in risk if there is a history of a postpartum mood episode after a first pregnancy (Freeman et al., 2002). Women with paranoid schizophrenic illnesses may also be at higher risk of relapse (Davies et al., 1995). One study has reported that women with psychotic disorders are also at a 2 fold increased risk of postnatal depression compared with controls (Howard et al., 2004). Other studies have not investigated postnatal depression in women with schizophrenia and this needs to be re-examined by the other researchers. Prevention of these psychiatric complications involves careful screening for mental illness during pregnancy with close liaison between obstetrics and psychiatric services, and primary care. Many women will need psychotropic medicine during pregnancy and all women with a history of psychosis will need regular assessment during pregnancy and in the postpartum period. Postnatal psychiatric care should therefore focus on relapse prevention.

e208 Psychiatric disorders are the leading cause of maternal death in the first year postpartum (RCOG, 2001). Sixty eight percent of maternal suicides in the first year appear to be due to psychosis or severe depressive illness (Oates, 2000), and better management of acute postpartum illnesses may improve outcome (Oates, 2000). Postpartum psychosis often presents within the first few days postpartum while a mother may still be on the obstetric ward; obstetric staff therefore clearly have an important role in detecting early signs of illness and making an emergency referral to psychiatric services. Women with a history of bipolar disorder should be assessed daily for the first two weeks postpartum (NICE, 2006) and regularly for the next two weeks as postpartum relapse is most likely in this early postpartum period.

L.M. Howard (Diaz-Caneja and Johnson, 2004; McNeil et al., 1983; Savvidou et al., 2003). Women talk about feeling continually monitored and suspected of abusing their children (Nicholson et al., 1998). This perception of stigma may prevent women from seeking or receiving support with parenting. Fear of custody loss is a central issue in the lives of these mothers (Krumm and Becker, 2006) and when custody loss occurs women understandably suffer emotional distress (Dipple et al., 2002; Sands et al., 2004; Savvidou et al., 2003). Healthcare and social professionals should ensure women feel supported in their parenting role and if custody loss occurs support the woman where possible.

Management

Parenting outcomes Parenting abilities Many women are able to rear families successfully despite the presence of severe and enduring psychoses and motherhood is a very important role for women with severe mental illness (Krumm and Becker, 2006). However psychotic disorders may make it hard for women to parent for a number of reasons e.g. antipsychotic medications that control symptoms may reduce responsiveness to children; withdrawal, delusional thinking and inappropriate behaviour when they occur can impair daily living and consistent parenting and there is some research documenting problems of mother-infant attachment. Mothers admitted to a psychiatric MBU are more likely to have significant parenting difficulties if they have a diagnosis of schizophrenia, belong to a low social class or have a partner with a psychiatric illness (Howard et al., 2003b). Social and illness factors are therefore clearly important in parenting. Neonatal complications are also associated with problems in practical baby care and perceived risk of harm to child in women with psychosis (Howard et al., 2003b), though it should be noted that neonatal complications are associated with bonding problems in many parents (Feldman et al., 1999; Poehlmann and Fiese, 2001).

Stigma Many studies have found that women with severe mental disorders report negative reactions from other people to their pregnancy and motherhood

Health and social services are often asked to evaluate the parenting skills of women with psychotic disorders. In cases where there is strong concern about a pregnant woman’s potential parenting skills, social services should be contacted for a pre-birth case conference to plan parenting assessments postpartum. Parenting assessments can take place in the community but if there is serious concern about potential risks to the baby, such assessments can be carried out on an MBU. However, at present services do not always make assessments optimally- pre-birth planning in the form of a case conference and arrangements for residential assessment occurred in less than half of admissions to a MBU where there had been pre-birth concern in a study of mothers in a psychiatric MBU in South London (Seneviratne et al., 2001). It is therefore vital for midwives and other members of the primary healthcare team to remember that a pre-birth case conference may be appropriate and to liaise with other relevant professionals to discuss this and arrange one if necessary.

Postnatal care Contraception Women with psychotic disorders are less likely than controls to have a record of a discussion about contraception in the first year postpartum (Howard et al., 2003a; Rudolph et al., 1990) even though unplanned pregnancies are more common in women with severe mental illness (Buist et al., 1990; Coverdale and Aruffo, 1989). Obstetric services and

Pregnancy in women with psychotic disorders primary care should ensure contraceptive advice is provided.

Assessment of needs As can be seen from this review, pregnant women and mothers with severe mental illness have complex health and social care needs. A recently developed standardised instrument to assess the needs of these women may help healthcare professionals caring for them. The CAN-M (Camberwell Assessment of Need for mothers with severe mental illness) is a brief validated instrument designed to give professionals’ and service users’ perspectives on the needs of pregnant women and mothers with severe mental illness in 26 health and social care domains, (Howard et al., In Press). The instrument is available from the author on request (see www.iop.kcl.ac.uk/prism).

Conclusions Many women with psychotic disorders have children and their pregnancies are high-risk pregnancies for a number of reasons. Primary care, psychiatric and obstetric services therefore need to ensure they know when a woman with a psychotic disorder is pregnant and liaise throughout the pregnancy and postnatal period. Pregnant women with psychoses are more likely to smoke and drink than other childbearing women and they therefore need to be counselled on the risks to the baby, and given help to reduce their intake of these and other substances if possible. Optimal antenatal care may also include psychotropic medication, close monitoring of the patient’s mental state, obstetric intervention to prevent obstetric complications and psychiatric management of any psychiatric episodes during pregnancy and in the postpartum period. Health and social care needs should be assessed by healthcare professionals during pregnancy and postpartum. Close liaison between obstetric, psychiatric and primary care services is essential for optimal management of these high-risk pregnancies.

References Aleman, A., Kahn, R.S., Selten, J.P., 2003. Sex differences in the risk ofschizophrenia: evidence from meta-analysis. Archives of General Psychiatry 60 (6), 565–571. Altshuler, L.L., Cohen, L., Szuba, M.P., Burt, V.K., et al., 1996. Pharmacologic management of psychiatric illness during

e209 pregnancy: dilemmas and guidelines. American Journal of Psychiatry 153 (5), 592–606. Amaro, H., Fried, L.E., Cabral, H., Zuckerman, B., 1990. Violence during pregnancy and substance use. American Journal of Public Health 80 (5), 575–579. Angermeyer, M.C., Kuhn, L., Goldstein, J.M., 1990. Sex and the course of schizophrenia: differences in treated outcomes. Schizophrenia Bulletin 16, 293–307. Appleby, L., Fox, H., Shaw, M., Kumar, R., 1989. The psychiatrist in the obstetric unit. Establishing a liaison service. Br J Psychiatry 154, 510–515. Bacchus, L., Mezey, G., Bewley, S., 2003. Experiences of seeking help from health professionals in a sample of women who experienced domestic violence. Health and Social Care in the Community 11 (1), 10–18. Bennedsen, B.E., Mortensen, P.B., Olesen, A.V., Henriksen, T.B., 2001. Congenital malformations, stillbirths, and infant deaths among children of women with schizophrenia. Archives of General Psychiatry 58, 674–679. Bennedsen, R.E., 1998. Adverse pregnancy outcome in schizophrenic women: occurrence and risk factors. Schizophrenia Research 33, 1–26. Bennedsen, R.E., Mortensen, P.B., Olesen, A.V., 1999. Preterm birth and intra-uterine growth retardation among children of women with schizophrenia. British Journal of Psychiatry 175, 239–245. Bowen, E., Heron, J., Waylen, A., Wolke, D.ALSPAC Study Team, 2005. Domestic violence risk during and after pregnancy: findings from a British longitudinal study. British Journal of Gynaecology 112 (8), 1083–1089. Buist, A.E., Dennerstein, L., Burrows, G.D., 1990. Review of a mother-baby unit in a psychiatric hospital. Australian New Zealand Journal of Psychiatry 24 (1), 103–108. Campbell, J.C., 2002. Health consequences of intimate partner violence. Lancet 3;359(9314), 1331–1336. Cascardi, M., Mueser, K.T., De Giralomo, J., Marrin, M., 1996. Physical aggression against psychiatric inpatients by family members and partners. Psychiatric Services 47 (5), 531– 533. Castle, D.J., Sham, P.C., Wessely, S., et al., 1994. The subtyping of schizophrenia in men and women: a latent class analysis. Psychological Medicine 24, 41–51. Cohen, L.S., Friedman, J.M., Jefferson, J.W., Johnson, E.M., et al., 1994. A re-evaluation of risk of in utero exposure to lithium. JAMA 271, 146–150. Cohen, L.S., Rosenbaum, J.F., 1998. Psychotropic drug use during pregnancy: weighing the risks. Journal of Clinical Psychiatry 59 (Suppl 2), 18–28. Coverdale, J.H., Aruffo, J.A., 1989. Family planning needs of female chronic psychiatric patients. American Journal of Psychiatry 146, 1489–1491. D’Orban, P.T., 1979. Women who kill their children. British Journal of Psychiatry 134, 560–571. Dalman, C., Allebeck, P., Cullberg, J., Grunewald, C., et al., 1999. Obstetric complications and the risk of schizophrenia: a longitudinal study of a national birth cohort. Archives of General Psychiatry 56 (3), 234–240. Davies, A., McIvor, R., Kumar, R., 1995. Impact of childbirth on a series of schizophrenic mothers; possible influence of oestrogen on schizophrenia. Schizophrenia Research 16, 25– 31. Department of Health, 1998. Confidential enquiries into maternal deaths 1994–96 Health Service Circular 211. Desmond, M.M., Rudolph, A.J., Holl, R.M., 1967. Behavioural alterations in infants born to mothers in psychoactive medication during pregnancy. In: Farrall, G. (Ed.), Congenital Mental Retardation. University of Texas Press, Austin.

e210 Dev, V.J., Krupp, P., 1995. Adverse event profile and safety of clozapine. Rev Contemp Pharmacother 6, 197–208. Diaz-Caneja, A., Johnson, S., 2004. The views and experiences of severely mentally ill mothers–a qualitative study. Social psychiatry and psychiatric epidemiology 39 (6), 472–482. Dickson, R.A., Seeman, M.V., Corenblum, B., 2000. Hormonal side effects in women: typical versus atypical antipsychotic treatment. Journal of Clinical Psychiatry 61 (suppl 3), 10–15. Dienemann, J., Boyle, E., Baker, D., Resnick, W., et al., 2000. Intimate partner abuse among women diagnosed with depression. Issues in mental health nursing 21 (5), 499–513. Dipple, H., Smith, S., Andrews, H., Evans, B., 2002. The experience of motherhood in women with severe and enduring mental illness. Journal of Social Psychiatry and Psychiatric Epidemiology 37, 336–340. El Kady, D., Gilbert, W.M., Xing, G., Smith, L.H., 2005. Maternal and neonatal outcomes of assaults during pregnancy. Obstetric Gynaecology 105 (2), 357–363. Falkov, A., 1996. A Study of Working Together ‘Part 8 Reports’: Fatal Child Abuse and Parental Psychiatric Disorder. Department of Health, London. Feldman, R., Weller, A., Leckman, J.F., Kuint, J., Eidelman, A.I., 1999. The nature of the mother’s tie to her infant: maternal bonding under conditions of proximity, separation and potential loss. Journal of Reproductive and Infant Psychology 40 (6), 929–939. Foy, R., Nelson, F., Penney, G., McIlwaine, G., 2000. Antenatal detection of domestic violence. Lancet 27;355(9218), 1915. Freeman, M.P., Gracious, B.L., Wisner, K.L., 2002. Pregnancy outcomes in schizophrenia. American Journal of Psychiatry 159 (9), 609. Gandhi, S.G., Gilbert, W.M., McElyy, S.S., El Kady, D., et al., 2006. Maternal and neonatal outcomes after attempted suicide. Obstetric Gynaecology 107 (5), 984–990. Gazmararian, J.A., Lazorick, S., Spitz, A.M., Ballard, T.J., et al. 1996. Prevalence of violence against pregnant women. JAMA 26;275(24), 1915–1920. Goldstein, D.J., Corbin, L.A., Fung, M.C., 2000. Olanzapineexposed pregnancies and lactation: early experience. Journal of Clinical Psychopharmacology 20, 399–403. Goodman, S.H., Emory, E.K., 1992. Perinatal complications in births to low socio-economic status schizophrenic and depressed women. Journal of Abnormal Psychology 101, 225–229. Howard, L.M., 2000. The separation of mothers and babies in the treatment of postpartum disorders in Britain 1900–1960. Archives of Womens’ Mental Health 3, 1–5. Howard, L.M., 2005. Fertility and Pregnancy in Women with Psychotic Disorders. European Journal of Obstetrics & Gynecology and Reproductive Biology 119 (1), 3–10. Howard, L.M., Hunt, K., Slade, M., O’Keane, V., Seneviratne, G., Thornicroft, G. The CAN-M: Camberwell assessment of need – Mother’s version. A needs-based assessment for pregnant women and mothers with severe mental illness. Gaskell. in press. Howard, L.M., Kumar, C., Thornicroft, G., 2001. The psychosocial characteristics of mothers with psychotic disorders. British Journal of Psychiatry 178, 427–432. Howard, L.M., Leese, M., Kumar, C., Thornicroft, G., 2002. The general fertility rate in women with psychotic disorders. American Journal of Psychiatry 159, 991–997. Howard, L.M., Leese, M., Goss, C., Appleby, L., Thornicroft, G., 2004. The psychosocial outcome of pregnancy in women with psychotic disorders and for their infants in the first year postpartum. Schizophrenic Research 1; 71(1), 49–60. Howard, L.M., Goss, C., Leese, M., Thornicroft, G., 2003a. The medical outcome of pregnancy in women with psychotic

L.M. Howard disorders and their infants after birth. British Journal of Psychiatry 182, 63–67. Howard, L.M., Hannam, S., 2003. Sudden Infant Death Syndrome and Psychiatric Disorders. British Journal of Psychiatry 182, 379–380. Howard, L.M., Shah, N., Salmon, M., Appleby, L., 2003b. Predictors of parenting difficulties in women admitted to mother and baby units. Social Psychology Psychiatric Epidemiology 38 (8), 450–455. Jablensky, A.V., Morgan, V., Zubrick, S.R., Bower, C., Yellachich, L.A., 2005. Pregnancy, delivery, and neonatal complications in a population cohort of women with schizophrenia and major affective disorders. American Journal of Psychiatry 162 (1), 79–91. Jacobson, S.J., Jones, K., Johnson, K., Ceolin, L., et al. 1992. Prospective multicentre study of pregnancy outcome after lithium exposure during first trimester. Lancet 29;339(8792), 530–533. Kelly, R.H., Danielsen, B.H., Zatrick, D.F., et al., 1999. Chartrecorded psychiatric diagnoses in women giving birth in California in 1992. American Journal of Psychiatry 156, 955– 957. Kelly, R.H., Zatzick, D.F., Anders, T.F., 2001. The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in obstetrics. American Journal of Psychiatry 158, 213–219. Kornegay, C.J., Vasilakis-Scaramozza, C., Jick, H., 2002. Incident diabetes associated with antipsychotic use in the United Kingdom general practice research database. Journal of Clinical Psychiatry 63 (9), 758–762. Krumm, S., Becker, T., 2006. Subjective views of motherhood in women with mental illness – a sociological perspective. Journal of Mental Health. In Press. Lindenmayer, J.P., Czobor, P., Volavka, J., et al., 2003. Changes in glucose and cholesterol levels in patients with schizophrenia treated with typical or atypical antipsychotics. American Journal of Psychiatry 160 (2), 290–296. Marks, M.N., Kumar, R., 1993. Infanticide in England and Wales. Medicine Science and the Law 33, 329–339. Martin, S.L., Kilgallen, B., Dee, D.L., Dawson, S., Campbell, J., 1998. Women in a prenatal care/substance abuse treatment program: links between domestic violence and mental health. Maternal Child Health Journal 2 (2), 85–94. McGrath, J.J., Hearle, J., Jenner, L., Plant, K., Drummond, A., Barkla, J.M., 1999. The fertility and fecundity of patients with psychoses. Acta Psychiatrica Scandinavica. 99 (6), 441– 446. McNeil, T.F., Kaij, L., Malmquist-Larsson, A., 1983. Pregnant women with nonorganic psychosis : life situation and experience of pregnancy. Acta Psychiatrica Scandiavica 68 (6), 445–457. Miller, L.J., Finnerty, M., 1996. Sexuality, pregnancy, and childrearing among women with schizophrenia-spectrum disorders. Psychiatric Services 47 (5), 502–506. NICE, 2006. Antenatal and postnatal mental health. Draft guidelines for consultation. http://www.nice.org.uk/ download.aspx?o=340580. Navarro, F., van Os, J., Jones, P., Murray, R., 1996. Explaining sex differences in course and outcome in the functional psychoses. Schizophrenia Research 18;21(3), 161–170. Nicholson, J., Sweeney, E.M., Geller, J.L., 1998. Mothers with mental illness: I. The competing demands of parenting and living with mental illness. Psychiatric Services 49 (5), 635– 642. Oates, M., 2000. Liaison psychiatry in the maternity hospital. In: Peveler, R., Feldman, E., Friedman, T.Gaskell (Eds.), Liaison

Pregnancy in women with psychotic disorders Psychiatry: Planning Services for Specialist Settings. Gaskell, London, pp. 136–141. Oluwatayo, O., Friedman, T., 2005. A survey of specialist perinatal mental health services in England. Psychiatric Bulletin 29, 177–179. Ornoy, A., Cohen, E., 1996. Outcome of children born to epileptic mothers treated with carbamazepine during pregnancy. Archives of Diseases of Childhood 75, 517–520. Pearlman, M.D., Tintinalli, J.E., Lorenz, R.P., 1990. A prospective controlled study of outcome after trauma during pregnancy. American Journal of Obstetric Gynecology 162 (6), 1502–1507, discussion 1507-10. Poehlmann, J., Fiese, B.H., 2001. The interaction of maternal and infant vulnerabilities on developing attachment relationships. Development and psychopathology 13 (1), 1–11. RCOG, Oates M., 2001. Deaths from psychiatric causes. In: Why mothers die. The fifth report of the confidential enquiries into maternal deaths in the United Kingdom 1997–1999. London: RCOG Press; pp. 165–166. Renker, P.R., Tonkin, P., 2006. Women’s views of prenatal violence screening: acceptability and confidentiality issues. Obstetrics and Gynecology 107 (2 Pt 1), 348–354. Rodriguez, M.A., Ouiroga, S.S., Bauer, H.M., 1996. Breaking the silence.Battered women’s perspectives on medical care. Archives of Family Medicine 5 (3), 153–158. Roy, M.A., Mziade, M., Labbe, A., 2001. Male gender is associated with deficit schizophrenia: a meta-analysis. Schizophrenia Research 47, 141–147. Rudolph, B., Larson, G.L., Sweeney, S., Hough, E.E., Arorian, K., 1990. Hospitalised pregnant women: characteristics and treatment issues. Hospital & community psychiatry 41 (2), 159–163. Sacker, A., Done, D.J., Crow, T.J., 1996. Obstetric complications in children born to parents with schizophrenia: a metaanalysis of case-control studies. Psychological Medicine 26 (2), 279–287. Sands, R., Koppelman, N., Solomon, P., 2004. Maternal custody status and living arrangements of children of

e211 women with severe mental illness. Health and Social Work 29, 317–325. Savvidou, I., Vasilis, F., Hatzigeleki, S., Karavatos, A., 2003. Narratives about their children by mothers hospitalised on a psychiatric unit. Family Process, 391–402. Schou, M., 1976. What happened to all the lithium babies? A follow up study of children born without malformation. Acta Psychiatrica Scandinavica 54, 193–197. Seneviratne, G., Conroy, S., Marks, M., 2001. Parenting assessment in a psychiatric mother and baby unit. Journal of Reproductive and Infant Psychology 19, 274. Slone, D., Siskind, V., Heinonen, O.P., et al., 1977. Antenatal exposure to the phenothiazines in relation to congenital malformations, perinatal mortality rate birthweight and intelligence quotient score. American Journal of Obstetrics and Gynaecology 128, 486–488. Spielvogel, A., Wile, J., 1992. Treatment and outcomes of psychotic patients during pregnancy and childbirth. Birth 19 (3), 131–137. Terp, I.M., Mortensen, P.B., 1998. Post-partum psychoses. Clinical diagnoses and relative risk of admission after parturition. British Journal of Psychiatry 172, 521–526. Usall, J., Haro, J.M., Ochoa, S., Marquez, M., et al., 2002. Influence of gender on social outcome in schizophrenia. Acta Psychiatrica Scandinavica. 106 (5), 337–342. Webb, R., Abel, K., Pickles, A., Appleby, L., 2005. Mortality in offspring of parents with psychotic disorders: a critical review and meta-analysis. American Journal of Psychiatry 162 (6), 1045–1056. World Health Organisation, 1992. Tenth Revision of the International Classification of Diseases and Related Health Problems. Clinical Descriptions and Diagnostic Guidelines. WHO, Geneva. Wrede, G., Mednick, S.A., Huttunen, M.O., Nilsson, C.G., 1980. Pregnancy and delivery complications in the births of an unselected series of Finnish children with schizophrenic mothers. Acta Psychiatrica Scandanvica 62 (4), 369–381.