Triple Board Morning Report

Allie R. Shapiro MD PGY2 August 19, 2013

CASE REPORT
A patient you followed in the WBN presents for the 2 week well child check. The baby has surpassed birth weight, his stools have transitioned, and he is feeding q2-3hours. On Edinburgh Postnatal Depression Scale mom scored a 21 with the question about self harm or to others being never.

Postpartum Mood Reactivity

Maternal

blues or postpartum mood reactivity is considered a normal emotional experience in the immediate postpartum period. 50-80% of women experience transient symptoms of depressed mood, at times alternating with elated moods, irritability, increased crying spells, and a sense of unreality during the first 10 days after birth.

Postpartum Psychosis
Rare

(1/1000), serious event that occurs within 2 weeks postpartum, considered a psychiatric emergency

Postpartum Depression

50% of PPD cases are continuations of depressive episodes that occur during or before pregnancy New-onset cases of depression during postpartum period is estimated around 15% (peak prevalence 10-14 wks post-delivery) Some studies show that depressive episodes resolve more quickly than a generalized major depressive episode (really not known)

Signs and Symptoms

Depressed or sad mood Anhedonia Irritability Anxiety Insomnia Difficulty Concentrating Complaints of poor memory

Crying Poor

appetite Feeling overwhelmed Feeling hopeless or worthless Thoughts of death (own or childs) Suicidal Ideation

At risk

Younger maternal age Lower education Single marital status Lower SES Personal or family history of mood disorder Depression during pregnancy Psychosocial stress Lack of Social Support Marital Discord

Possible effects of maternal depression on Childrens behavior

Infant Behavioral Problem
Sleep

Delayed Cognitive Development

disruption Feeding/eating disruption Temper tantrums Fussy/Crying Withdrawn

Lag

in developing concept of object permanence Lower scores on the McCarthy Scale of Childrens Abilities

Cont.
Impaired Social Development
Less

Insecure Attachment Patterns

socialable with strangers Less engagement in sharing No fear of strangers

Difficulties with emotions regulation Difficulties being comforted Lack of interest in age-appropriate objects

Effects of Maternal Depression on Parental Attitudes and Behavior

Guilt/anxiety

Loss

of love Negative attributions Thoughts of harm Bizarre beliefs about the baby Extreme disappointment about the gender Inflated expectations about the infants developmental abilities

Effects on Mother-Infant Interactions

Mother

Baby

Difficulty enjoying the baby Disinterest or negative toward the baby Less active interactions Inability or lack of attempt to sooth the baby Refusal to look at/hold the baby Hostile expressions toward the baby

Decreased eye gaze toward the mother Less reciprocity in interactions More drowsy or fussy Greater reactivity

Depression Screening Tools

Edinburgh

Postnatal Depression Scale Postpartum Checklist Postpartum Depression Screening Scale

 Maximum

30 Possible depression 10 or greater Always look at item 10

Score

Case Cont.
Your

patients mom scored a 21! questions do you ask next?

What

Questions to ask
How

are you feeling about being a new mother? How are you coping with the additional stress of a new baby? Are you able to sleep when the baby is sleeping? Do you have enough energy to do the things you need to do for yourself, your baby, your work?

 Have

you been feeling sad or depressed over the past week? Have you been feeling anxious, worried, or irritable over the past week? Have you had difficulty concentrating or remembering things? Do you find yourself crying for no reason? Have you been having thoughts of hurting yourself? Anyone else? Your baby?

REMEMBER SIGECAPS
S

I
G E C A P S

REMEMBER SIGECAPS
Sleep

Interest
Guilt Energy Concentration Appetite Psychomotor Suicidal

agitation/retardation

 Mom

says she is not suicidal and is not thinking of harming her baby, but is feeling very overwhelmed. She begins to cry in the office. do you tell her next?

What

Resources if really worried

211

Crisis

number/evaluation Try to get mom an appointment with PCP/OBGYN

Most moms dont seen there OB until 6 weeks post partum

Follow

up in 1 week www.postpartum.net

Repeat Screening

Track changes in symptom severity to determine the need for referral and intervention Identify women at risk as well as affected women Identify women who have suicidal ideations Provide mothers a nonverbal venue to express their emotions Provide an opening for discussion of other sensitive issues.