Pregnancy and the perinatal period

Guidance in the UK has been developed by the Royal College of Psychiatrists, Royal College of Obstetricians and Gynaecologists and NHS England and Improvement:

• General levels of anxiety, worry or distress:
  • The pandemic will result in an increased amount of anxiety in the general population, and this is likely to be even more so for pregnant women.
  • These anxieties are likely to revolve around COVID-19 itself, the impact of social isolation resulting in reduced support from wider family and friends, the potential of reduced household finances and major changes in antenatal and other NHS care.
  • Often, simply acknowledging these difficulties can help to contain some of these anxieties.
  • This can be facilitated by maintaining access to midwifery (or maternity) services, accessing sources of self-help for anxiety and stress and when necessary self-referral to local IAPT (Improving Access to Psychological Therapies) Services in England (or equivalents in other nations).
• Mental illness:
  • Episodes of mental illness during pregnancy are common and affect up to 1 in 5 pregnant women.
  • Mental illness covers a full range of symptoms from mild anxiety and depression to severe mood disorders and psychosis.
  • Episodes of illness are more likely to be precipitated by periods of social stress.

Assessment and management:

• For mild symptoms of anxiety or low mood, utilise interventions (e.g. lifestyle and behavioural), which may have helped with previous mild symptoms in the past,  or are evidence-based strategies for mental wellness (for example maintaining a daily routine, meeting up with friends, attending antenatal groups).
• Consider how these interventions or strategies can be adapted e.g. by technology to contact friends and family and attend virtual groups.
• See general advice from: https://www.nhs.uk/pregnancy/keeping-well/mental-health/
• Continue to inform maternity services of any concerns so that advice and additional support can be offered.
• Be aware that the change in appointment style will also make assessment for women experiencing domestic violence, women with safeguarding concerns and women who are misusing substances more difficult (see section 1f).
• Usual specialised antenatal and perinatal mental health services are running, albeit in a different form (see section 1b), and can offer additional assessment, advice and support.
• Postpartum psychosis is directly associated with a diagnosis of bipolar affective disorder or women who have had previous episodes of postpartum psychosis. Continue to identify this group of women, with robust plans in place for labour and the immediate postpartum period.
• In the same way, also identify and formulate robust plans for women with previous psychotic illness, severe early postnatal depressive disorder or severe enduring mental illness.

Maternal mental illnesses remain one of the leading causes of maternal death. The MBRRACE-UK reports (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK, https://www.npeu.ox.ac.uk/mbrrace-uk/reports) identified key red flags which should prompt immediate referral to specialist perinatal mental health services:

• Recent significant changes in mental state or emergence of new symptoms
• New thoughts or acts of violent self-harm
• New and persistent expressions of incompetency as a mother or estrangement from the infant
• Referral with mental health concerns on more than one occasion should prompt clinical review, irrespective of usual access thresholds or practice.

In addition, the rapid report from MBBRACE-UK highlighted the critical importance of face to face assessments for high risk cases, with the following recommendations:

• Establish triage processes to ensure that women with mental health concerns can be appropriately assessed, including face-to-face if necessary, and access specialist perinatal mental health services in the context of changes to the normal processes of care due to COVID-19.
• Perinatal mental health services are essential and face to face contact will be necessary in some circumstances. There is a clear role for involvement of the lead mental health obstetrician or midwife in triage and clinical review.
• Ensure that referral with mental health concerns on more than one occasion is considered a ‘red flag’, which should prompt a clinical review irrespective of usual access thresholds or practice.
• Update guidance to reflect that safeguarding actions, including removal to a place of safety if necessary, should be followed in the context of public health measures such as lockdown.

An update in 2021 provided updated guidance and data, based on the period between June 2020-March 2021.

Whilst mental health care was not identified as a specific factor, there are recommendations which may be particularly relevant to mental health care from this report:

• Remote consultation guidance (see section 1d for further details)
• Measures should be taken to reduce risks, as women are reluctant to attend face to face visits and may delay accessing care:
  • Women should be advised to continue their routine antenatal care, although it may be modified, unless they meet self-isolation criteria for COVID-19.
  • Maternity units (and other services) should develop triage tools to assess the severity of illness for women who telephone with suspected or confirmed COVID-19, including assessment of symptoms, clinical and social risk factors, escalation pathways and ‘safety netting advice’.

Maternity units (and other services) should develop triage tools to assess the severity of illness for women who telephone with suspected or confirmed COVID-19, including assessment of symptoms, clinical and social risk factors, escalation pathways and ‘safety netting advice’.

The Italian National Institute of Health issued a report: Rapporti ISS COVID-19 n. 44/2020 – Indicazioni di un programma di intervento per la gestione dell’ansia e della depressione perinatale nell’emergenza e post emergenza COVID-19. Versione del 31 maggio 2020 – ISS which presents an intervention programme to provide evidence-based treatments to treat perinatal mental health problems in the context of COVID-19, and in particular, highlights adaptations to offer some of these screening methods and treatments remotely.

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Maternity services should continue to:

• Identify those women who are most at risk of maternal death or high morbidity in the postpartum period.
• Develop comprehensive management plans for women at risk of postpartum psychosis (including those with a past history of postpartum psychosis and or bipolar disorder) and/or those women with a high degree of complexity.
• Identify all women with this elevated risk (including those with a previous diagnosis of a psychotic illness, severe early postnatal depressive order or severe enduring mental illness) so that additional support can be offered during the pregnancy, labour and in the high-risk postpartum period.

Antenatal Mental Health Liaison clinics continue to be an important route for women with mental illness to access joint care between maternity and mental health services.

• These are now often being delivered via virtual clinics
• Working with maternity services they should continue to identify women most at risk of maternal death or high morbidity, develop comprehensive management plans and identify all women with elevated risk as outlined above.

Perinatal mental health services

• should give careful consideration of how pregnant women are assessed in community perinatal mental health teams following guidelines for community services. These services should continue to operate given perinatal morbidity.
• should undertake a careful risk assessment on a case by case basis before planning a psychiatric assessment of a patient on a maternity ward prior to discharge, and only proceed if women show symptoms of acute deterioration in mental state, or if there are significant safeguarding concerns that warrant a pre-discharge meeting requested by social care.
• Women who are well and on a stable treatment plan should be discharged as soon as fit to leave hospital with their baby and be reviewed by their clinician or allocated perinatal care coordinator the following working day via phone or by virtual review.
• Perinatal services will continue to work closely with families to ensure that partners and families are aware of the importance of early detection and seeking advice.
• Women who are under community perinatal services and who need a psychiatric review post-delivery should be reviewed as quickly as possible on the postnatal ward.

Advice for midwives on perinatal healthcare in the context of COVID-19 can be found at: perinatal-mental-health-care-during-covid-19-v4-march-2021-final.pdf (rcm.org.uk)

Guidance for midwives in supporting women with multiple disadvantage, including mental illness, during COVID-19 is at: Supporting women facing multiple disadvantage during COVID-19 | Birth Companions

Advice for nursery nurses in perinatal care can be found at https://www.rcpsych.ac.uk/improving-care/ccqi/quality-networks-accreditation/perinatal-quality-network/pqn-webinars

Advice for health visitors can be found at  https://ihv.org.uk/for-health-visitors/resources/resource-library-a-z/covid-19-coronavirus-guidance/ and at https://www.unicef.org.uk/babyfriendly/guidance-documents/

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Mother and Baby Units (MBUs) are psychiatric inpatient units which accept women in the later stages of pregnancy or with their baby up to 12 months of age.

UK advice for MBUs:

Decisions about admission

• Psychiatric illnesses remain amongst the leading causes of maternal deaths. It is important that women continue to have access to inpatient mother and baby units.
• The benefits of joint admission with mother and baby, for physically well mothers, outweigh the risks. This decision can be reviewed on a case by case basis should the mother become physically unwell. 
• Therefore, MBUs need to continue admitting mothers with babies with the usual protocols for admission applying.
• Appropriate country specific guidance on minimising COVID-19 infection risk should be followed also by those admitted to an MBU and this needs to be considered at the time of admission.
• All women on the MBU will be helped to develop a COVID-19 management plan outlining what they would like to happen if they develop symptoms of COVID-19. To make this plan they need to have access to the latest advice (e.g. from RCOG Coronavirus (COVID-19), infection in pregnancy | RCOG).
• Discharge from MBUs must be planned safely, as it is less likely women will receive face-to-face home visits during this time of crisis.

Involvement of family, friends, and significant others

• Partners, co-parents and significant others should be involved in this plan.  The needs of co-parents will be respected and contact should be facilitated within service protocols and making full use of technology.
• Visitors to MBUs should be in line with national and local guidance.
• Services will continue to maintain links with Social Services, Health Visiting and community services as needed.
• Where appropriate, professional contacts and meetings can happen virtually with exception of Mental Health Act assessments in line with guidance and the coronavirus bill.

Discharge from MBUs

• Discharge from MBUs must be planned safely, as it is may be less likely women will receive face to face home visits during this time of crisis.
• If the mother has suspected COVID-19 infection, she should be isolated in the MBU isolation area as arranged by local infection control procedures. A decision should be made about whether the mother and baby remain on the unit based on the mother’s wishes and case by case review.

VTE (venous thromboembolism) prevention and aftercare should follow current country specific guidance (for example Coronavirus (COVID-19), infection in pregnancy | RCOG)

General guidelines on contact with baby and breastfeeding are as per the latest country specific guidance (e.g. latest RCOG guidelines).

COVID-19 vaccination in pregnancy is strongly recommended for pregnant and breastfeeding women. Please consult the lasted country specific guidance for details. Examples of resources are given below:

• COVID-19 vaccination: a guide on pregnancy and breastfeeding – GOV.UK (www.gov.uk)
• Pregnancy, breastfeeding, fertility and coronavirus (COVID-19) vaccination – NHS (www.nhs.uk)
• COVID-19 vaccines, pregnancy and breastfeeding FAQs | RCOG
• COVID-19 Vaccines While Pregnant or Breastfeeding (cdc.gov)
• Vaccination and pregnancy: COVID-19 – Canada.ca
• Pregnancy, breastfeeding and COVID-19 vaccines | Australian Government Department of Health and Aged Care
• COVID-19 vaccine: Pregnancy and breastfeeding | Ministry of Health NZ

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(For general guidance on telepsychiatry during COVID-19, please see the separate table on Digital Technologies and Telepsychiatry).

There is currently little specific published guidance on the use of telepsychiatry in perinatal mental health. However, there are examples of primary papers reporting its use, one of which can be found at  https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201900143.

UK guidance:

Pre-COVID-19 NICE guidance on antenatal and postnatal mental health (CG192) suggests:

• remote consultation as an option for milder symptoms of anxiety
• clinicians should consider the setting in which they will be providing assessment and treatment (e.g. remote consultations by phone or video).

RCOG guidance during the COVID-19 pandemic

• care providers should employ teleconferencing and videoconferencing where possible
• consider which appointments can be most appropriately conducted remotely
• supporting women at risk of or currently experiencing mental health problems is included as a category where remote appointments will generally be appropriate.

Additional guidance:

• The National Institute for Health and Care Excellence recommended schedule of antenatal care Overview | Antenatal and postnatal mental health: clinical management and service guidance | Guidance | NICE
• National Perinatal Mental Health Guideline – COPE should be offered in full wherever possible.
• Healthcare providers should be aware of the increased risk of domestic abuse in pregnancy, which has escalated during the pandemic.
• There is evidence that the pandemic has resulted in a greater level of anxiety and other mental health problems in pregnant women compared to the overall population. Women should be asked about their mental health at every contact.
• Clinicians will need to weigh up the level and intensity of care the mother and baby require against the potential risk of infection involved in face to face assessment and treatment (see for example Overview | Antenatal and postnatal mental health: clinical management and service guidance | Guidance | NICE for details).
• Perinatal mental health services are essential and face to face contact will be necessary in some circumstances. There is a clear role for involvement of the lead mental health obstetrician or midwife in triage and clinical review.
• The MBRRACE updated report on perinatal deaths during the early part of the COVID-19 pandemic up to 31/3/2021 identified important areas to consider. Face to face treatment may be preferable when:
  • The patient has complex clinical needs
  • You need to examine the patient
  • It’s hard to ensure, by remote means, that patients have all the information they want and need about treatment options.
• Doctors should follow the GMC guidance on remote consultations (Remote consultations – ethical topic – GMC (gmc-uk.org)).

Possible limitations of virtual consultations:

• some women will not have sufficient remote access
• there may be challenges in relationship-building remotely especially among vulnerable groups, in women for whom English is not their first language
• women may have additional queries regarding their care with less face-to-face contact.

(Refer to the table on telepsychiatry for other potential limitations of remote consultation, including in this situation, difficulties which pregnant women may face in accessing a sufficiently private location for consultation)

The British Psychological Society and Division of Clinical Psychology (Faculty of Perinatal Psychology) have provided best practice guidelines for working therapeutically with parents and their infants during pregnancy and postpartum using remote delivery platforms available at Working therapeutically with parents and their infants during pregnancy and postpartum using remote delivery platforms – The British Psychological Society (bps.org.uk)

(The Oxford Centre for Anxiety Disorders and Trauma (OxCADAT) have provided guidance in how to remotely deliver the NICE recommended cognitive therapies for PTSD, Social Anxiety Disorder and Panic Disorder.)

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There is currently little specific guidance on modifying prescribing during pregnancy/the perinatal period in the context of COVID-19.

(For advice on prescribing lithium, benzodiazepines, and long-acting antipsychotics in general during COVID-19, please see the linked tables).

Prescribers should continue to follow general (pre-COVID-19) prescribing advice in pregnancy:

• The decision to start, stop, continue or change a medicine before or during pregnancy should be made together with the patient and prescribing clinician.
• When deciding whether to use a medicine in pregnancy, weigh up how the medicine might improve the patient’s and/or their unborn baby’s health against any possible problems that the drug may cause.
• Reproductive toxicity is governed by a dose-effect relationship therefore it is recommended at all times to use the lowest effective dose.
• There exists a sensitive period for different drug-related effects therefore always consider the stage of pregnancy and the known stage-specific risks for the drug in question.
  • During the first trimester, drugs can produce congenital malformations (teratogenesis), and the period of greatest risk is from the third to the eleventh week of pregnancy.
  • During the second and third trimesters, drugs can affect the growth or functional development of the foetus, or they can have toxic effects on foetal tissues.
  • Drugs given shortly before term or during labour can have adverse effects on labour or the neonate after delivery.
• Changes in pharmacokinetics must also be considered when using medicines in pregnancy: drug absorption, distribution, metabolism and excretion may all be affected.
• Medicines may vary in their ability to transfer across the placental barrier.  Fat soluble drugs cross more easily than water soluble drugs. All oral medicines that are well-absorbed will eventually pass the placental membrane.

General advice from the National Institutes of Health (NIH) in the US:
Pregnancy | COVID-19 Treatment Guidelines (nih.gov):

• Potentially effective treatment for COVID-19 should not be withheld from pregnant women because of theoretical concerns related to the safety of therapeutic agents in pregnancy.
• Decisions regarding the use of drugs approved for other indications or investigational agents for the treatment of COVID-19 in pregnant patients must be made with shared decision-making between the patient and the clinical team, considering the safety of the medication for the woman and the fetus and the severity of maternal disease, and Involving the multidisciplinary team in these discussions.
• For detailed guidance on the use of COVID-19 therapeutic agents in pregnancy, please refer to Antiviral Therapy and Immune-Based Therapy guidelines.

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Assessment of safeguarding may be more challenging, but usual referrals should not be delayed.

The change in appointment style will also make assessment of women experiencing domestic violence, women with safeguarding concerns and women who are misusing substances more difficult.

Domestic abuse

(For issues related to domestic abuse and remote assessment, please refer to the tables on telepsychiatry (section 4e) and domestic abuse)

For UK advice on domestic abuse in the context of COVID-19:

• https://www.gov.uk/government/publications/coronavirus-covid-19-and-domestic-abuse
• https://www.vamhn.co.uk/covid-19-resources.html (webinar facilitated by NHSE/I’s Perinatal Mental Health Programme Team on responding to domestic violence and abuse and associated safeguarding concerns in perinatal women in the context of COVID-19).

Risk of harm to children

If there is a risk of, or there are concerns about, suspected child maltreatment in the context of antenatal or postpartum care, follow local safeguarding protocols (https://www.nice.org.uk/guidance/cg192).

For UK advice on safeguarding children in the context of COVID-19:

• https://learning.nspcc.org.uk/safeguarding-child-protection/coronavirus
• https://www.scie.org.uk/care-providers/coronavirus-covid-19/safeguarding/children

Suicidality

General advice (pre-COVID-19) for assessing suicide risk in antenatal or postnatal care:

• Carry out a risk assessment in conjunction with the woman and, if she agrees, her partner, family or significant other, and focus on areas that are likely to present possible risk, e.g.:
  • self‑neglect, self‑harm, suicidal thoughts and intent
  • risks to others including the baby
  • smoking, drug or alcohol misuse
  • domestic violence and abuse
• If there is a risk of self-harm or suicide:
  • assess whether the woman has adequate social support and is aware of sources of help
  • arrange help appropriate to the level of risk, including specialist mental healthcare where appropriate
  • inform all relevant healthcare professionals, including GP and those identified in the care plan
  • advise the woman and her partner, family or significant other, to seek further help if the situation deteriorates.

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UK:

• Action of Postpartum Psychosis
• Anxiety UK
• Association for Post Natal Illness
• Beat Eating Disorders
• Best Beginnings
• Bipolar UK
• Birth Trauma Association
• Maternal OCD
• Maternal Mental Health Alliance (MMHA)
• Maternal Mental Health Scotland
• MIND (2020). Postnatal depression and Perinatal mental health
• MIND Cymru
• NHS.UK. Mental health problems and pregnancy
• OCD and coronavirus
• PANDAS Foundation.
• Rethink
• Royal College of Psychiatrists. Mental health in pregnancy and COVID-19. Perinatal care | Royal College of Psychiatrists (rcpsych.ac.uk).
• Young Minds.
• In 2021, the charity Tommy’s partnered with KCL, NHSE and PHE to produce a suite of resources to support women with a severe mental illness (SMI) to make informed decisions around when to get pregnant, what to watch out for and how to treat their condition during and after pregnancy. The resources include a new online information and support hub for anyone with SMI planning a pregnancy, as well as practical guidance for the frontline healthcare professionals who support them. Tommy’s also updated their Planning for Pregnancy tool so that users with severe mental illness get specific tailored advice.

Support for fathers:

• https://dadmatters.org.uk/
• https://thedadpad.co.uk/ – also comes as an app
• https://www.fatherhoodinstitute.org/

UK general information on COVID-19 and pregnancy:

• https://www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/perinatal-care-and-covid-19
• Coronavirus (COVID-19), infection and pregnancy FAQs | RCOG
• https://www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/covid-19-virus-infection-and-pregnancy/
• https://www.nhsinform.scot/illnesses-and-conditions/infections-and-poisoning/coronavirus-covid-19/parents-and-families/coronavirus-covid-19-pregnancy-and-newborn-babies
• Postpartum Psychosis & Covid-19 | Action on Postpartum Psychosis (app-network.org)
• Coronavirus (COVID-19) information for children, families and professionals, edpsy.org.uk
• Parenting through Coronavirus, Institute of Health Visiting
• Families Under Pressure
• Coronavirus | Parent Club

Best Beginnings have collated charities within the UK which are providing online and remoted support in pregnancy and maternity (Charities offering remote support to pregnant families and new parents | Best Beginnings).

United States:

• https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/pregnancy-breastfeeding.html
• https://www.acog.org/patient-resources/faqs
• COVID-19: Questions Your Patients May Have, American Society for Reproductive Medicine
• Breastfeeding and Caring for Newborns if You Have COVID-19 | CDC
• Supporting Families During COVID-19, Child Mind Institute
• Resources for Supporting Children’s Emotional Well-being during the COVID-19 Pandemic, Child Trends
• COVID-19 Fact Sheet / COVID-19 in Pregnancy and Breast-feeding: Podcast Mother to Baby, US
• Parent/Caregiver Guide to Helping Families Cope with the Coronavirus Disease 2019, The National Child Traumatic Stress Network
• COVID Resources for Families, Wisconsin Alliance for Infant Mental Health
• Coronavirus Resources for Early Childhood Professionals • ZERO TO THREE
• Helping Families in Time of Crisis, Zero to Thrive

Canada:

• https://www.canada.ca/en/public-health/services/publications/diseases-conditions/pregnancy-advise-mothers.html
• University of Toronto, Canada have created a ‘pandemic pregnancy guide’. Follow at Instagram (@pandemicpregnancyguide) or Twitter (@PandemicPreg) as a setting for pregnant women to ask questions about COVID-19 and its effects on them and their baby.

Australia:

• Resources for coping during COVID-19, Antenatal & Postnatal Psychology Network
• COVID-19 Resources, Centre for Perinatal Psychology
• Birdie and the Virus, Children’s Health Queensland Hospital and Health Service
• COVID-19 support, Gidget Foundation
• Perinatal Mental Health Guide During COVID-19 Outbreak – WSLHD (nsw.gov.au)

Italy:

The Italian Section of the Marcè Society has issued a concise guide for mothers and families on different mental health symptoms and illness in the perinatal period in the context of COVID-19: inglese pdf 10 sett (marcesociety.com) (available in English, Italian, Spanish at COVID-19 Perinatal Mental Health Resources | The International Marce Society for Perinatal Mental Health).

International:

• https://www.unicef.org/serbia/en/coronavirus-disease-covid-19-what-parents-should-know
• https://www.unicef.org/serbia/en/pregnancy-breastfeeding-and-coronavirus
• How to talk to your child about coronavirus disease 2019, Unicef
• Coronavirus disease (COVID-19) advice for the public: Advocacy, World Health Organization
• faqs-breastfeeding-and-covid-19_805d4ce8-2329-4227-9261-695afa68b32c.pdf (who.int) World Health Organization
• WCCBT_e-News_March-2020.pdf World Confederation of Cognitive and Behavioral Therapies
• Advocacy (who.int) World Health Organization

The International Marcé Society for Perinatal Mental Health has further resources those including from non-English speaking countries.

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