Page 754 - ACCCN's Critical Care Nursing

Pregnancy and Postpartum Considerations 731

MENTAL HEALTH DISORDERS Postpartum depression
Mental health disorders during pregnancy and the post- Postnatal depression (PND) is defined as a non-psychotic
partum consist of women with preexisting disease and depressive illness; most definitions specify occurrence
women who develop signs and symptoms of mental within three months postpartum although some specify
health disease for the first time. The mental health disor- a shorter period of only one month. 173,174 Risk factors
der may be separate from the pregnancy or there may be include prior mental illness, poor social supports, rela-
173
a relationship between the pregnancy and the develop- tionship disharmony and recent life events. Depression
ment of the disorder, such as postnatal depression. in the postpartum period raises treatment issues for the
nursing mother and the developing infant. 173
Preexisting Mental Health Disorders Early diagnosis and effective treatment, just like for any
The underlying principles of management of pregnant other person with depression, is indicated. Self-harm in
the first 12 months postpartum is a severe concern for
women with a preexisting mental health disorder are the women with serious depression. Care in the ICU is no
same as for non-pregnant women: safety of the woman, different to that provided to other patients admitted with
stabilisation of the mental illness and empowerment of, severe depression. PND is not a contraindication to lacta-
and support for, the woman to make her own choices. A tion, although some medication may be contraindicated.
considerable additional challenge is maintaining stability Medication should be prescribed as warranted on clinical
of the mental health disorder if changes to medication grounds and may include antidepressants, hormonal
are required due to potential teratogenesis or contraindi- treatment and psychological treatments.
cation for use during pregnancy. Generally speaking, if
the indication for treatment is unchanged, then treatment CARING FOR PREGNANT
should be continued during pregnancy. 167 WOMEN IN ICU
Pregnant women with preexisting mental health disor-
ders may require admission to ICU due to acute deterio- Any pregnant woman in ICU is considered to be carry-
ration in their mental health. This is most likely to be as ing an ‘at-risk’ fetus. This means that fetal wellbeing
a result of cessation or alteration of their regular medica- may be compromised and that he/she is at risk of sus-
tions. 168,169 Most relapses occur in the first trimester and taining injury/suboptimal growth and development or
many women who initially stop their medication, recom- death in utero. There are circumstances when the
mence it during the pregnancy. Routine care should be woman’s clinical status would improve by delivery of
168
provided as clinically indicated, keeping in mind the the fetus, and times when the fetus needs to be delivered
additional requirements to monitor fetal wellbeing, to increase the likelihood of its’ own survival. Consid-
conduct standard antenatal assessment and consider the eration of both the maternal condition and fetal wellbe-
impact of the physiological adaptations on treatments. ing contribute to the decision on when to deliver a fetus.
Delivery prior to 24 weeks’ gestation is only an option
if the maternal condition is very critical and considered
Mental Health Disorders Related necessary to potentially save the woman’s life; it is likely
to Pregnancy that the neonate’s care in this instance would be pallia-

Suicide related to unwanted pregnancy remains a cause tive, even though babies have been know to survive when
of maternal death in countries like Australia and New born as early as 22 weeks. 175 Once gestation reaches
Zealand, especially in adolescents and in women from 28 weeks, the neonate has more than a 90% chance
cultures where childbirth outside of marriage is unaccept- of survival when cared for in a neonatal intensive
able. Depression may arise during pregnancy (antenatal care unit. 175
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depression) although is more likely to present during the
postpartum (postpartum depression). The most severe MECHANICAL VENTILATION OF
mental health disorder related to pregnancy is puerperal THE PREGNANT WOMAN
psychosis. The provision of mechanical ventilation to a pregnant
woman occurs rarely and there is very little evidence to
guide practice. Pregnancy is considered a ‘high risk airway’
Puerperal psychosis with the reported ‘failure to intubate’ ranging from 1 in
Puerperal psychosis is a rare mental health complication 250 to 1 in 750, or approximately eight times more likely
of pregnancy, said to occur in 1/1000 births, though the than in the non-pregnant population. 176 Physiological
incidence seems to be reducing with a modern incidence changes of pregnancy that contribute to the increased
of 0.19/1000 deliveries reported. 170,171 The majority of difficulty in intubation include generalised vasodilatation
cases occur in women with preexisting mental illness, of pregnancy, increased fat deposition around the neck
such as bipolar disorder, with just 0.03/1000 deliveries and an increase in mucosal oedema. The vasodilation
occurring in women with no preexisting mental health increases the vascularisation of the upper airways in
171
disorder. It usually presents within two weeks postpar- pregnancy, increasing the likelihood of bleeding with
tum and is associated with an increased risk of suicide any instrumentation. Consequently, nasal intubation is
and infanticide. 172 Women with puerperal psychosis are not usually an option for pregnant women. Women with
frequently delusional, suffer hallucinations and require preeclampsia may also have substantial pharyngeal
acute hospitalisation for treatment. oedema.