Screening for depression during and after pregnancy is an important part of prenatal care and can impact both short and long term maternal health and prenatal outcomes.  Most importantly it is easily accomplished in the clinic setting and is acceptable by most patients.  Treatment includes counseling and pharmacotherapy.

 

Depression occurs most frequently among reproductive women age 25 and 44.  Approximately 1 in 8 women can expect to develop clinical depression during their lifetime.  Postpartum depression can affect up to 20% of women.  Untreated prenatal depression has been positively associated with poor pregnancy outcomes and long term development problems in the offspring of affected mothers.  Screening can be easily accomplished using the Edinburg Postnatal Depression Scale (EPDS) which has been studied and validated for use for prenatally and postpartum.   It is available in 12 different languages for free on the world web (www.nelmh.org/downloads/other _info/edinburg_postnatal_depression_scale.pdf).

 

The range of scores on the 10 item scale is 0-30 (0 consistent with no depression and 30 consistent with major risk of depression).  A cut off score of >12 has been found to have a sensitivity of 67-95% and a specificity of 78-96%.  Any affirmative response to the question regarding thoughts of suicide deserves immediate referral.

 

Consider screening at the first prenatal appointment as well as at the 6 week postpartum appointment and at any time in which a patient’s symptoms suggest a change in baseline.  Scores > 12 or thoughts of suicide should be further evaluated by the practitioner and/or referred to a mental health professional/ER.

 

1.              Psychotherapy or counseling can be used as initial treatment for the drug naïve patient with mild symptoms

2.              Women with a prior history of medication use with good response and moderate to severe symptoms can often be restarted on the previously tried medication

3.              Goals of treatment include maintaining euthymia and preventing postpartum depression

4.              Overall risk of Saris during pregnancy is low but paroxentine has been associated with cardiovascular effects.  These women may be offered a fetal echo

5.              SSRIs have been associated with transient neonatal withdrawal systems.  Fluoxetine, paroxetine and sertraline have been associated with an increased risk of     persistent pulmonary hypertension of the newborn – risks of PPHTN

6.              Sertraline has been recommended as firs-line drug treatment of depression in pregnancy despite the above associated risks

7.              Fluoxetine, although the oldest and best studied drug in pregnancy, has a long half-life which can accumulate in the neonate and there is a higher risk for drug transfer during breastfeeding and therefore should be avoided as first-line

8.              Paroxetine should be avoided as first-line unless women have become pregnant on the medication or are counseled adequately and decide that they don’t want to stop a drug to which they have a good response.

9.              Buproprion can be used for patient’s with ADD, haven’t responded to other drugs or for patient’s who want help quitting smoking.  Avoid Buproprion in women with history of seizures

10.          Women who conceive on SSRIs should continue their medications until reviewed at their initial obstetric visit.  A second trimester anatomy scan should be offered.  Delivery should occur in a setting with pediatric resuscitation potential.

 

 

The Clinical Care Guidelines Development Committee of the Perinatal Improvement Board of Duke University Health System has developed a series of multi-disciplinary protocols to offer guidance to health care providers who are caring for pregnant women with high risk conditions.

 

These protocols are designed to assist health care providers in the management of a variety of problems that occur in pregnancy and the time of delivery. They should not be interpreted as standard of care, but instead represent only general guidelines for the care of pregnant women with high risk conditions.  We recognize that services offered by individual providers depend not only on their training, experience and institutional resources, but on the medical facts and circumstances of the specific care situation.

The protocols remain the intellectual property of the Duke University Health System.  They cannot be reproduced in whole or part without the expressed permission of the Health System.

 

These protocols are reviewed by the Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine, the Department of Pediatrics Division of Neonatology and the Department of Anesthesiology Division of Women’s Anesthesia.  Please contact Andra H. James (andra.james@duke.edu), Chair, Clinical Care Guidelines Development Committee of the Perinatal Improvement Board with ideas for additional protocols.