Speaker: Dr Surabhi Chhabra, Consultant Emergency Medicine, Pregnancy & Postpartum Coach

July 31, 2022, Sunday 

• Health is physical (free of disease), mental (able to face the situation) and social well-being (able to adapt to relationships). All these three dimensions of health have to be catered to.
• Mental health has been defined by the WHO as “a state of well-being in which the individual realizes his/her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make contribution to his or her community”. The WHO also stresses that mental health is “more than just the absence of mental disorders or disabilities”.
• Peak mental health is about not only avoiding active conditions but also looking after ongoing wellness and happiness.
• If the person is able to adjust to surroundings and cope with the changes, then the person is mentally healthy. Wellness, happiness and contentment are part of mental health.
• Pregnancy is a time when lot of changes occur in the body. And, motherhood is probably the most permanent life change in a woman’s life.
• It is a happy time, but for some, it can have mixed emotions or even negative, which may be overwhelming.
• Its just as important to look after mental health and well-being during pregnancy as physical health. A mentally healthy woman will be able to manage the challenges of pregnancy and life with a new baby.
• Several factors can affect how a woman feels during the pregnancy. These include physical symptoms (e.g., morning sickness), the support she has or does not have.
• It is normal to feel stressed or anxious at times.
• Many women are afraid of labor. This condition has been called ‘tocophobia’; 3 out of 10 women suffer from tocophobia.
• The pregnant woman may worry about the changes in the role (becoming a mother, stopping work), changes in relationships, fear of complications. She may also worry about whether  she will be a good parent.
• These problems are even more if the pregnancy is unplanned.
• Pregnancy may also bring a lot of stress and anxiety plus a rollercoaster of hormones, which can cause or worsen depression and is termed antepartum depression. It has also been called maternal depression, prenatal depression and perinatal depression.
• About 7% of pregnant women suffer antepartum depression and this rate may be as high as 15% in some countries.
• Many symptoms of antepartum depression and anxiety get masked with normal symptoms of pregnancy. A thorough history must be elicited and if any red flags show up, prompt assessment is necessary.
• Some of the warning signs and symptoms include lower energy levels, fatigue, changes in appetite/sleep/libido, anxiety, low self-esteem, loss of interest in activities, eating poorly, 
• feeling unmotivated, poor sleep and even smoking, alcohol consumption or use drugs.
• Antepartum depression may be idiopathic; other risk factors can be lack of social support, h/o depression/anxiety/mood disorders/sleep disturbances/smoking, unintended pregnancy, lack of pregnancy education. Low nutrient levels (deficiency of vitamin B, D and zinc) have been linked to depression.
• Antepartum depression not only affects the mental and emotional health, it affects physical health and also the baby’s well-being. It can lead to serious health risks during and after pregnancy such as pre-eclampsia, low birth weight, preterm delivery, cesarean delivery and postpartum depression.
• The ACOG recommends that all pregnant women should be screened for antepartum depression at least once during pregnancy.
• If any red flag, the screen regularly after every trimester.
• Treatment includes counseling, therapy alone or antidepressant drugs, lifestyle modification depending on the symptoms. Citalopram (SSRI), sertraline (SSRI), dulexetine (SNRI), venlafaxine (SNRI) are safe during pregnancy.
• Counseling takes care of baby and the mental well-being of the pregnant woman and prevents many complications during pregnancy and in the postpartum period.
• Every pregnant woman who has delivered should be screened for symptoms of depression in the postpartum period.
• As per the DSM-5, postpartum depression begins within 4 weeks after delivery. About 1 in 10 women develop a more severe and longer-lasting depression post-delivery. And, one in 1000 women develop postpartum psychosis, a more serious condition.
• Diagnosis of postpartum depression is based not only on the length of time between delivery and onset but on the severity of the depression.
• The chemical changes in the postpartum period involve rapid fall in hormones and by the third day after delivery, the levels have dropped to prepregnancy levels. Additionally, the social and psychological changes of having a baby also increase the risk of depression. Other causes of postpartum depression include depression/anxiety during pregnancy, experiencing stressful life events during pregnancy or early postpartum, traumatic birth experience, past history of depression, preterm birth or admission of infant to NICU.
• Signs and symptoms of postpartum depression include depressed mood or severe mood swings, excessive crying, withdrawing from family and friends, difficulty bonding with the baby, loss of appetite/eating too much, hopelessness, insomnia/excessive sleep, reduced interest in activities, irritability, anger, fear of not being a good mother.
• The Edinburgh Postnatal Depression Scale (EPDS) is used to screen for postpartum depression. The maximum score is 30. A score of ≥10 suggests possible depression. Always look at Q#10 about suicidal thoughts. 
• Postpartum depression sometimes resolves within 3 months of giving birth. However, if the symptoms interfere with everyday life or if “the blues” last longer than 2 weeks, then treatment should be sought.
• Treatment includes: lifestyle modifications, balanced diet (avoid alcohol and caffeine), yoga, meditation and holistic lifestyle, social support, foster the relationship with your partner, reduce screen time, sleep or rest when the baby sleeps, breastfeeding, seek help from pregnancy coach/counsellor.
• It can be treated successfully with medication or medication + psychotherapy.
• Two types of counseling interventions - Cognitive behavioral therapy and interpersonal therapy, can help to reduce the incidence of pregnancy during pregnancy.
• CBT helps to change negative and incorrect thoughts and includes increasing positive activities., while interpersonal therapy focuses on helping people resolve interpersonal conflicts and navigate role transitions.
• Postpartum psychosis is a rare condition that typically develops within the first week after delivery. Signs and symptoms include confusion, disorientation, obsessive thoughts about the baby, hallucinations, delusions, sleep disturbances, excessive energy and agitation, paranoia, attempts to harm oneself or the baby.
• A pregnancy coach helps to empower pregnant women so that they are better prepared, know what to expect in the labor room, what exercises they should do during pregnancy and in the postpartum period etc.

(Excerpts from a presentation by Dr Surabhi Chhabra)