Pregnancy care for women with severe mental illness

This Chapter^[10] discusses considerations in providing antenatal care for women with low prevalence mental health conditions (bipolar disorder, schizophrenia and borderline personality disorder). Screening for high prevalence conditions (depression and anxiety) is discussed in Chapter 27. Resources to assist in management of serious mental health disorders in the antenatal period are included in Section 5.3 Resources.

5.1 Impact of severe mental illness in pregnancy

Mental health conditions in their more severe form are often associated with impaired functioning, especially in relation to a woman’s ability to care for her infant and the formation of secure infant attachment, which may in turn be associated with poorer social, cognitive, and behavioural outcomes in the child. 1st 1001 Days APPG 2015

5.1.1 Bipolar disorder and schizophrenia

Bipolar disorder is characterised by intense and sustained mood shifts usually between episodes of depression and mania. Schizophrenia is a complex condition of brain function with wide variation in symptoms and signs, and in the course of the illness. The experiential ‘core’ of schizophrenia has been described as a disturbance involving the most basic functions that give the person a feeling of individuality, uniqueness and self-direction (Galletly et al 2016). 

The prevalence of schizophrenia and bipolar disorder in the general population is around 1 in 100 Mitchell et al 2013, Galletly et al 2016. People with schizophrenia or bipolar disorder (in the general population) suffer from high rates of other mental health conditions, including depression and anxiety disorders Merikangas et al 2011, Galletly et al 2016. 

Relapse of these conditions during pregnancy is common, with 22.5% of diagnosed women in one study being admitted to a psychiatric hospital during pregnancy (38.6% of women with schizophrenia and 10.7% of women with bipolar disorder) (Nguyen et al 2013). 

Women with bipolar disorder or schizophrenia are more likely than women in the general pregnant population to experience pregnancy complications (pre-eclampsia, gestational diabetes) (Nguyen et al 2013) and women with bipolar disorder may also be more likely to experience gestational hypertension, antepartum haemorrhage, severe fetal growth restriction (<2nd–3rd centile) (although this may be related to smoking) and neonatal morbidity (Rusner et al 2016).

5.1.2 Borderline personality disorder

Borderline personality disorder is characterised by emotional dysregulation (poorly modulated emotional responses); efforts to overcome fear of abandonment; intense and unstable relationships; engaging in impulsive activities (eg substance use); talking about or engaging in self-harm and/or suicidal behaviours; inappropriate, intense anger or difficulty controlling anger; and transient, stress-related paranoid ideation or severe dissociative symptoms. Women who have borderline personality disorder have often experienced sexual, physical or emotional abuse or neglect in childhood. Estimated prevalence among women aged 25 years or more is 2.7% (95%CI 1.4 to 4.0) (Quirk et al 2016).

Women with borderline personality disorder during pregnancy have been found to be at increased risk of gestational diabetes, premature rupture of the membranes, chorioamnionitis, venous thromboembolism, caesarian section and preterm birth (Pare-Miron et al 2016). They may experience distress when touched, anticipate birth as traumatic and frequently request early delivery, comorbidity with substance abuse is common and rates of referral to child protective services high (Blankley et al 2015). Continuity of carer (the same person or small group of people) is likely to be helpful for women with this condition.

The label ‘borderline personality disorder’ should be used with caution as it often has negative connotations (especially for health professionals) and may be associated with substantial stigma. Conversely, it is important to identify women with such a condition, as they, their families and treating health professionals will need additional resources and support over the antenatal period and beyond.

5.2 Planning antenatal care for women with severe mental illness

While women with pre-existing severe mental illness may already be under the care of a GP and/or psychiatrist, specific consideration must be given to planning their antenatal care due to the complexity of these conditions and the substantial challenges for primary care professionals involved in their management. (Austin et al 2017)

When planning antenatal care for women with severe mental illness, priority needs to be given to ensuring that health professionals involved in their care consider the complexity of these conditions and the challenges of living with them. Where available, involvement of specialist perinatal mental health services is advisable.

Key considerations in providing antenatal care to women with severe mental illness include:

• monitoring for early signs of relapse, particularly as medication is often ceased before or during pregnancy
• education about nutrition and ceasing smoking, substance use and alcohol intake in pregnancy
• monitoring for excessive weight gain and gestational diabetes in women taking antipsychotics, with consideration given to referral to an appropriate health professional if excessive weight gain is identified
• referral for multi-dimensional care planning early enough in the pregnancy (particularly if the pregnancy is unplanned) to build trusting relationships and develop a safety net for mother, baby and significant others.

5.3 Resources

• Austin M-P, Highet N and the Expert Working Group (2017) Mental Health Care in the Perinatal Period: Australian Clinical Practice Guideline. Melbourne: Centre of Perinatal Excellence.

5.3.1 Consumer websites

• Centre of Perinatal Excellence (COPE)
• beyondblue
• Black Dog institute
• Children of Parents with a Mental Illness (COPMI)
• Mindhealthconnect
• Perinatal Anxiety and Depression Australia (PANDA)

5.3.2 Mental health referral and advice

• The beyondblue website includes a directory of health professionals in mental health, including psychologists, social workers and mental health nurses.
• The headspace Knowledge Centre provides information about treatment interventions and models of care for young people with mental health and substance use issues.
• The Black Dog Institute offers education and training programs, resources and online learning for health professionals with a focus on depression and bipolar disorder.
• square.org.au/">square (Suicide, Questions, Answers and Resources) is an integrated suicide prevention resource that is part of the National Suicide Prevention Strategy.
• The GP Psych Support service provides GPs with patient management advice from psychiatrists within 24 hours. Phone: 1800 200 588; Fax: 1800 012 422.
• Government funding to receive treatment from psychiatrists, psychologists and GPs, social workers is available through the Better Access initiative (Medicare items).