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Perinatal Psychiatry

Eri Achmad

Tujuan Pembelajaran
Menjelaskan gangguan jiwa yang dapat timbul
pada ibu pasca melahirkan
Menjelaskan hubungan psikologis ibu dan

Sindrom Perilaku yang Berhubungan dengan
Gangguan Fisiologis dan Faktor Fisik (F50-F59)
Gangguan Mental dan Perilaku yang Berhubungan
dengan Masa Nifas YTK (F53)
Gangguan mental dan perilaku ringan yang
berhubungan dengan masa nifas YTK (F53.0)
Gangguan mental dan perilaku berat yang berhubungan
dengan masa nifas YTK (F53.1)
Gangguan mental dan perilaku lainnya yang
berhubungan dengan masa nifas YTK (F53.8)
Gangguan jiwa masa nifas YTT (F53.9)

Education, knowledge and

Guardian 29.9.08

Contoh Kasus
Ny. A 22 th, datang dengan keluhan sudah satu
minggu ini tampak bersedih terus. Ny. A tidak
mau makan, malas mandi, dan sering mengeluh
merasa bersalah. Sudah tiga hari ini tidak bisa
tidur malam. Pernah berobat ke puskesmas dan
diberi obat tidur. Tetapi merasa tidurnya tidak
pulas. Lima minggu yang lalu Ny. A baru
melahirkan anak pertamanya.

Penatalaksanaan Kasus
Identifikasi pasien
Identifikasi permasalahan
Medik (gejala, keluhan, riwayat terapi, RPD, RPK)
Non psikiatrik

Non medik

Pemeriksaan penunjang jika diperlukan

Diagnosis kerja dan diagnosis banding
Rencana penatalaksanaan
Non medik

Perinatal Psychiatry
Psychiatric problem in time surrounding pregnancy and
the postpartum period
Perinatal mental health is about the psychologic wellbeing of pregnant women and their child, partner and
mother, child, and social function

Mental health issues concerning women who are:

(able to get pregnant)
In the postnatal year

Concerning mental illnesses in women that:

Are likely to relapse

And impair the womans experience of motherhood

Determined by many factors including

biological/hormonal, social and psychological
Mental health problems are often associated
with times of stress or change in our lives

Facts in Perinatal Psychiatry

Research has shown women experience anxiety and
depression during pregnancy at the same rate as
postpartum 10-15% (Heron et al.,2004)
Prenatal maternal depression is significantly
associated with low birth weight, premature labor
and delivery, and pre-eclampsia & infant
Pregnant women with high levels of mood
disturbance and/or stress have double the risk of
preterm birth or fetal growth restriction compared to
those women reporting low levels of stress

Three-fold risk of having non-psychotic depressive

disorder in first month postpartum (Cox et al.,1993)
22-fold increased risk of affective psychosis following
childbirth (Kendell at al.,1987)
The chance of psychiatric admission during the first
four weeks postpartum is 18 times greater than
during pregnancy (Paffenbarger,1982)

Pre & Postpartum Prevalence of

Psychiatric Admissions among Women

Types of Perinatal Psychiatry

Classic triad
baby blues
Postnatal depression
Puerperal psychosis
Pre-existing active psychiatric disorder; schizophrenia,
bipolar, depression, anxiety, etc
New disorder during pregnancy ; antenatal depression
Substance abuse, personality disorder
Disorder associated with the relationship with the baby attachment disorder

Baby blues


Postpartum depression


Postpartum psychosis


Antenatal depression


Pre-existing disorder


Disorders of mother-infant attachment


Non-puerperal anxiety/depression


Baby Blues
Most common perinatal mood disturbance
Adjustment reaction with depressed mood
Exhibits depressed mood with physiologic abrupt
withdrawal of hormones, estrogen, progesterone,
and cortisol
Onset day 3 or 4
Mild, transient lasting hours to days
Resolve within 2 weeks
No treatment necessary

Baby Blues: signs and symptoms

Difficulty concentrating

Risk Factors for Baby Blues

Hormonal fluctuations- Decreased estrogen, progesterone,
and thyroid. Increased prolactin.
Sudden loss of circulating volume, weight, internal organ
Stress, isolation, lack of social support.
Sleep disruption.
Low self esteem, preterm birth, problems with newborn, hx
of infertility.
Feelings of loss identity, freedom, control.
Concurrent losses family death, job loss, relocation.

Postpartum Depression

Most common complication of childbirth

Onset after 2 weeks, usually up to 6-12 months
Duration: weeks to months
Treatment necessary
Psychological interventions or

Clinically no different from depression occurring at

other times
High risk of further episodes following childbirth is
Estimated risk of depression unrelated to childbirth is

Post-Partum Depression

Exact cause not known. Levels of estrogen,

progesterone, cortisol, and thyroid hormones
drop sharply after birth.

Diagnostic Problems
Differentiating between clinical symptoms of
depression and normal sequelae of childbirth
Symptoms include

Caused disability / disorder

Women can be reluctance to disclose symptoms or
to recognize them as pathological

Post-Partum Depression
Emotional Symptoms

Increased Crying
Uncontrollable mood swings
Feeling overwhelmed
Fear of hurting self or baby

Post-Partum Depression
Behavioral Symptoms

Lack of, or too much, interest in the baby

Poor self-care
Loss of interest in otherwise normally
stimulating activities
Social withdrawal and isolation
Poor concentration, confusion

Post-Partum Depression
Physical Symptoms
Exhaustion, fatigue

Sleeping problems (not related to screaming baby)
Appetite changes
Chest pain

Heart Palpitations

Risk Factors:
Postpartum Depression

Undesired/ unplanned pregnancy

Hx of depression or previous PPD
Lack of social support
Recent major life change: family death,
financial stress, job loss, relocation, marital
discord, homelessness.

Post-Partum Depression

The Edinburgh Postnatal Depression Scale

(EPDS) is a 10-item self-rated questionnaire
used extensively for detection of postpartum
depression. A score of 12 or more on EPDS or
an affirmative answer on question 10
(presence of suicidal thoughts) requires more
thorough evaluation.

Post-Partum Depression

Important to rule out medical causes of

depression, such as anemia or thyroid
Check medical history
Perform physical examination/lab tests

Medication and non medication
70-80% of women recover with treatment

Antidepressants (issues relating to breastfeeding)

Psychotherapy CBT
Supportive counseling, peer support groups

For mild to moderate symptoms, focus less on

pharmacological treatment and more on
counseling and group therapy.

Post-Partum Depression
First-line choices are SSRIs such as fluoxetine 10-60 mg/d,
sertraline 50-200 mg/d, or escitalopram 10-20 mg/d
SNRIs such as venlafaxine 75-300 mg/d or duloxetine 40-60
mg/d, are also highly effective for depression and anxiety.
ECT is effective for those with severe depression/psychosis

Post-Partum Depression
In addition to counseling or talk-therapy (individual or group
therapy), other steps can be taken by the mother to fight the
depressive symptoms:
Eat healthy
Use an outlet, such as a diary, a family member, or a
Try not to isolate ones self
Promote sleep
Take breaks, and make time to do the things you enjoy

Baby Blues vs. Post-Partum Depression


Baby Blues
Onset at 3rd or 4th day
post-delivery and can
last from a few days to a
few weeks

Onset can be anytime
one year after delivery

Baby Blues vs. Post-Partum Depression


Baby Blues
70-80% of women will
experience depressive
symptoms that
disappear within a few

10% experience some
degree of postpartum
depression which can
last a year.

Postpartum Psychosis
Most rare and severe form of postpartum mood
Onset: rapid, within 72 hours of birth, 95% of cases
within 2 weeks
Treatment: psychiatric emergency

Depressed or elated mood which can fluctuate

Disorganized behavior
Mood lability
Hallucinations and delusions (religious, visual,
Most cases are manic or mixed presentations

Most cases of PP meet criteria for mania,

schizoaffective disorders or depression with
psychotic features
Hospitalization nearly always required
Although rare, risk of suicide and infanticide suicide
is leading cause of maternal death in the UK (Oates,
Infanticide delusions or neglect

Risk of Postpartum Recurrence

54/103 (52%) women had further children
31/54 or 57% had a further episode of PP
Not significantly associated with previous history or
family history of illness
Robertson E et al., Risk of puerperal and non-puerperal recurrence of illness
following bipolar affective puerperal (post-partum) psychosis. British Journal of
Psychiatry, 2005, 186; 258-259.

Treatment in pregnancy
Risk/benefit balance shifts because of the fetus risk
of poor mental health vs risk of harm from a drug
Tends to favour psychological treatment, but access
must be timely within 1 month
Pharmacological interventions must be least toxic
and monotherapy where possible
Attend to associated social problems
Affective symptoms in pregnancy predict postnatal

Specialist services
access to specialist perinatal mental health advice
access to inpatient mother and baby facilities
a policy in the area about who the midwife or GP can
ask to assess the needs of vulnerable pregnant
that high risk women will have a robust care plan by
the last trimester
treatment for mental illnesses in the perinatal period

Drugs in Pregnancy/Lactation
Pregnant - limited info on safety of drugs in
some risky - valproate, clozapine, carbamazepine
some moderate paroxetine, lithium, diazepam
some lower risk stelazine, imipramine, chlorpromazine,

Breast feeding does the drug appear in the

milk? Avoid clozapine or fluoxetine.
Use paroxetine or sertraline

Contoh Kasus II
Ny X 37 th, G2P2A0 sepuluh hari yang lalu menjalani
persalinan kedua dengan kelahiran BBLR. Sudah dua
hari ini Ny X tampak tidak wajar, sesekali ia
menangis sambil diselingi tertawa tawa, tidak mau
makan dan sulit tidur malam. Ny X mempunyai
riwayat kontrol ke psikiater sejak kurang lebih
sepuluh tahun. Persalinan pertamanya 12 tahun
yang lalu disertai dengan depresi berat pasca
persalinan. Riwayat pengobatannya tidak teratur
sehingga beberapak kali mengalami kekambuhan

Ibu dan Anak

Other risk factors postnatally in terms of environment,

relationship and attachment thanks to Robin Balbernie

PET scan of healthy 2 year old

PET scan of 2 year old Romanian baby

institutionalised shortly after birth

Mother and Child Attachment

An enduring emotional tie to a special person,
characterized by a tendency to seek and
maintain closeness, especially during times of

Importance of Attachment
Implications for infant's sense of security
Freud, Erikson, Bowlby, behaviorists described its
impact on development
Attachment Theory predicts that the quality of the
attachment predicts subsequent development
Longitudinal study found that securely attached infants
were more competent at age-appropriate tasks
throughout adolescence (Sroufe, Egeland, Carlson, &
Collins, 2005)

An infants attachment style to a caregiver

Effective social functioning during childhood and
Sociability through early, middle, and late adulthood
School grades
Teenage sexual activity
Quality of attachment to their own children
Attitudes toward their own children

Attachment Styles
Securely Attached: Belief that the caregiver
will protect and provide for them
Explores the environment with the parent
Might protest separation from parent but smiles
more often when the parent is present
Shows pleasure at reunion with parent
65% of middle-class American infants

Insecure-Avoidant: Belief that the caregiver

will not protect or provide. The caregiver is
not a safe haven in stressful circumstances
Does not protest at parents departure
Responds the same to the stranger and the
parent, or more positively to the stranger
Avoid parent upon return
20% of middle-class American infants

Insecure-Resistant: Uncertainty about

whether the parent will protect or provide
safety in stressful circumstances
Remain close to parent. Refuse to explore the new
Distressed at separation of parent
Mixture of approach and avoidance when
10% of middle-class American infants

Disorganized or Disoriented: No consistent way

of dealing with the stress
Exhibits contradictory behavior at the strange
Typical attachment style when the infant is abused or
Less than 5% of middle-class American infants

The same four types of attachments have been

found in various cultures, but the proportion of
children in each category differ by culture

Factors which Affect Attachment

Opportunity for attachment
Quality of caregiving
respond promptly and consistently
interactional synchrony the sensitively tuned
emotional dance

Caregivers sensitivity to the infants needs

Children are less likely to develop a secure attachment if
they are raised in an orphanage
Parents living in poverty tend to provide less sensitive
Sensitivity to infants can be taught to mothers, that then
leads to a higher probability of secure attachment (Van
den Boom, 1994)

Infant characteristics
infant's temperament, special needs, prematurity, or

Family circumstances
Stress can undermine attachment
Infants exposed to verbally aggressive fighting among
their parents form more insecure attachments

Parents internal working models

Parental psychopathology
Depressed mothers tend to have lower quality
interactions with their infants

Parents own attachment experiences

Parents ability to accept their past

Implications of Attachment Theory

Parents need to be sensitive to their infants
Parents need to provide a stable home
environment for their children
If children are not functioning well in school,
the first problem to investigate is their home
Any caring, stable adult can provide a secure
attachment for a needy child