PSYCHOSOMATIC DISORDERS IN PREGNANCY

Dr. Sunil Yadav, M.S. (Obst. & Gynaecology)

INTRODUCTION
Psychosomatic disorders are illnesses that manifest as physical symptoms but originate
from mental or emotional rather than physiological causes. It also includes the diseases
where no organic cause could be found out and which is related to anxiety, stress and
depression. Pregnancy and the post partum period are considered as high-risk times
for women with pre-existing psychiatric illnesses, especially for depressive episodes in
women. Pregnancy either induces or exacerbates pre-existing psychiatry illness hence
special consideration has to be given to psychosomatic disorders in pregnancy.
The psychosomatic disorders in pregnancy are antenatal and postnatal depression,
post traumatic stress disorder, postpartum psychosis and postpartum blues. .

Stress and pregnancy

Pregnancy either induces or exacerbates pre-existing stress and stress seems to have
a negative effect on pregnancy, mostly in the first trimester and also chances of the
period of the highest rate of pregnancy loss.
Pathophysiology: It is known that the hypothalamic-pituitary-adrenal axis (HPA) reacts
to sustained anxiety and depression. Stress factors may affect to uterine circulation, in
turn decreasing blood flow reaching the decidua and which affecting the implantation
site. Some women under stress use drugs, alcohol,cigarettes and tranquilisers,. It may
effects on placental function.
Grimm used many of psychological tests on 61 recent aborters and 35 controls. Simon
et al reported that with 20 out of 32 women with one or more abortions appeared to
have a psychiatric diagnosis after one or more years. Ten tests showed significant
psychopathology in the women who aborted compared to the control group.

Depression and pregnancy

DSM-IV uses the term within postpartum onset referring to depression that typically
begins within 4 weeks postpartum and occurs within 3 months after delivery. Many
cases of postpartum depression which have their onset before the delivery, and
antenatal depressive symptoms are not uncommon.
Risk factors for antenatal depression include past history of mood disorders marital
dissatisfaction, past history of depression, discontinuation of antidepressants, ,

inadequate psychosocial supports, recent adverse life events, lower socio-economic

status and unwanted pregnancy.
INCIDENCE: It is seen that major depression is twice as common in women than in
men and frequently clusters during the childbearing years. Although pregnancy has
traditionally been considered a time of emotional well-being for women conferring
protection against psychiatric disorders, at least one prospective study describes rates
of major and minor depression as approximating 10%.

Signs and symptoms: Pregnant women may have several clinical signs and
symptoms overlapping with those seen in major depression like sleep, appetite
disturbance, diminished libido, and low energy. Some medical disorders usually seen
during pregnancy, such as gestational diabetes , anemia, , and thyroid dysfunction, may
be associated with depressive symptoms and may complicate the diagnosis of
depression during pregnancy .Clinical features that may support the diagnosis of major
depression include anhedonia (loss of pleasure), feelings of guilt and hopelessness,
and suicidal thoughts.

TREATMENT AND MANAGEMENT

Antipsychotics and pregnancy :Psychotropic medications which readily cross the placenta. The following factors must
be considered before starting psychotropic medications 1. Teratogenesis 2. Toxicity to
the neonate sequelae 3. Risk of no treatment 4. Risk of medication discontinuation.
.Selective serotonin reuptake inhibitors (SSRIs) are the most commonly used class of
antidepressants to treat postpartum depression. SSRIs have the advantages of
achieving full therapeutic dose in the first day in contrast to tricyclic antidepressants.
SSRIs are associated with mild maternal side effects. Fluoxetine was comparable to
cognitive behavioural therapy in efficacy in improving symptoms after 4 weeks of
treatment, while both were significantly superior to placebo. A study by Misriet
al.reported that paroxetine was effective in reducing depressive and anxiety symptoms
when used alone or in combination with cognitive behavioral therapy.
Recent systematic review of pooled data on most SSRIs used during pregnancy over 15
years did not find any significant increase in major or minor fetal malformations, but
there was a significant increase in the risk of miscarriage. Population-based studies
have suggested an increased risk of preterm delivery, low birth weight, fetal death, and
fetal seizure. This information may have an impact on the continuation of ant depressive
treatment in mothers with a known history of depression prior to pregnancy.

Postpartum Psychosis
The onset of postpartum psychosis is usually rapid and it can be as early as 23 days
after delivery; the peak of the illness falls in the first 2 weeks after delivery. Women
usually develop grandiose, paranoid, , or bizarre delusions, mood swings, confused
thinking, and grossly disorganized behaviour that represents a dramatic change from
previous functioning . A careful neurologic examination is needed and other differential
diagnoses, including organic neurologic disease such as stroke, should be excluded.
Two of 1000 women with postpartum psychosis may commit suicide, and these women
often use more irreversible and aggressive means.. The possibility of postpartum
psychosis in future pregnancies should always be considered in women with a history of
bipolar disorder because of the very high rate of recurrence.
INCIDENCE :Postpartum psychosis affects about 1 in 1000 deliveries. Women with a
history of bipolar disorders are at greater risk of postpartum psychosis, with episodes
following 2550% of deliveries
Risk factors: Primiparity, older maternal age, and being a single mother .
Treatment: The main treatment is 1]Antipsycotics and
2]Mood stabilizers.

CONCLUSION:
Recent findings emphasizes the significance of correct analysis and awareness of
serious mental illness. Looking the higher rate of relapse, women should be counselled
carefully and cautiously regarding discontinuation of antidepressants during pregnancy.
Differentiation of posttraumatic stress disorders with comorbid anxiety and depression,
awareness of risk factors, and clinical features of psychosis are important in the
management of psychosomatic disorders in pregnancy . Many psychiatric disorders have
been found to be linked with pregnancy. In the above review some of the psychiatric
disorders in pregnancy have been described. More studies are required regarding
safety of psychotropic drugs in pregnancy and during breast feeding. However, if the
psychiatric disorder is of a severe intensity, then pharmacotherapy is a must and it
outweighs the small possibility of congenital malformation. Identification of risk factors
prior to pregnancy or prior to delivery, screening and exploring symptoms, and
appropriate and timely referral for psychiatric care are key issues in reducing risk
amongst women with psychosomatic disorders during pregnancy and post partum.

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