5 Postpartum

The weeks following delivery are a time of vulnerability to psychiatric disorders for many women (22). Mood and anxiety disorders are particularly likely to recur or worsen during these weeks. These conditions not only cause significant distress to the mother but can disrupt family life and, if prolonged, can negatively impact the child's emotional and social development (23). Clinicians should encourage patients to identify family members or friends who can help with child-care responsibilities if the mother experiences a relapse of psychiatric illness in the postpartum. Women with severe mental illnesses may be deficient in parenting skills and need a referral to a parenting education class.

Women with a history of psychiatric disorder may benefit from the prophylactic use of psychiatric medication begun the day of delivery. However, data on this approach are limited and inconsistent (24).

Certain side effects can be especially problematic to new mothers. For example, several psychiatric medications produce significant sedation and can therefore impair a new mother's ability to attend adequately to her infant. Weight gain is another common side effect, and women who are trying to lose the weight they gained during pregnancy may be hesitant to take medications with such an effect. New mothers may be looking forward to the end ofthe pregnancy to resume their pregravid intimate relationships with their partners and may prefer to avoid medications that impair sexual functioning, a widespread side effect of many anti-depressants.

Many new mothers begin contraception following the birth of a child, and clinicians should consider the potential impact of hormonal contraceptives on psychiatric medications. Estrogen-containing hormonal contraceptives inhibit CYP3A4 and may therefore reduce clearance for medications that are metabolized by this enzyme, including diazepam and imipramine (25,26). On the other hand, estrogen-containing hormonal contraceptives can induce hepatic conjugative enzymes and may therefore increase the metabolism of medications that are conjugated before elimination by the kidney, such as lamotrigine (27).

Conversely, hormonal contraceptives can be rendered ineffective by the concomitant use of medications that increase their metabolism, including carbamazepine, oxcarbazepine, topiramate, modafinil, and St. John's wort (28). Women should be encouraged to use a high-potency oral contraceptive (i.e., containing at least 50 ^g/d of estra-diol) or an alternative method of contraception while taking these medications.

An additional consideration in evaluating new mothers with histories of psychiatric disorders is the possibility of premenstrual relapse of psychiatric symptoms. Once a new mother's menstrual cycles resume, she may experience an exacerbation or relapse of symptoms in the days prior to onset of menses. If this premenstrual relapse occurs repeatedly and the patient is taking a psychiatric medication, an increase of medication dose by 50% from midcycle to onset of menses may help.

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