Perinatal Mood Disorders (Zechowy, 8/28/2024)

Many thanks to Dr. Jill Zechowy for an excellent presentation this week on Perinatal Mood Disorders. A link to the recording is available HERE. 

My notes:

• PPD: perinatal/post partum depression
• PPA: perinatal/post partum anxiety
• PMADs: perinatal mood disorders (including depression, bipolar, anxiety including panic, OCD, GAD)

PPD is persistent low mood lasting >2 weeks, occurring in pregnancy or in first year postpartum, dx'd the same as other forms of depression with the SIGECAPS pneumonic:

• Sleep
• Reduced Interest
• Guilt
• Low Energy
• Impaired Concentration (may be criteria for extending disability)
• Appetite (crave carbs, have low appetite)
• Psychomotor agitation or slowing
• Suicidality

In the first YEAR of life, maternal mental health diagnoses are the number 1 cause of maternal mortality (death from suicidality and/or drug overdose)

PPD differs from major depression in a few ways: more anxiety, changed sleep/lifestyle, parenting responsibilities

Costs for moms/women: PPD affects 1/7 women, PMADs in 1/5 women, 1/10 partners/adoptive parents (roughly 1 million people/year). Depression impairs women's ability to bond with baby, delays/impairs attachment. Depressed moms are less responsive to their babies -- children born to women with untreated PPD are more likely to have externalized behaviors (e.g. conduct issues, fights in school, shouting, hitting, aggressive behaviors). PMADs major cause of divorce, suicide.

Costs to infant: if a person with a uterus is pregnant with depression, more likely to have pre-term birth, SGA, impaired brain growth, developmental delay, behavioral disorders, attachment disorders. Untreated PPD is an ACE for the child.

Who is at risk? People with prior history of depression/anxiety is at increased risk, family history depression/anxiety (even  in a male relative) increases risk of PPD. Trouble sleeping in pregnancy has the strongest correlation with PPD in perinatal time. 

PPD is caused, in part, by hormone changes (e.g. allopregnanolone levels plummet at birth, women with a genetic issue with pregnanolone receptors have severe PPD). But hormones are only part of the explanation. There are other biological issues. Right now, our awareness of mental health of children is so acute that it is a particularly difficult time to mother/parent. The demands of parenting are also an extreme stress.

Screening

All pregnant people should be screened for PPD, positive Edinburgh screening is 9-12 (out of total 30). ACOG recommends in first trimester, again at "later trimester" and every postpartum visit. AAP recommends "mothers be screened for PPD at 1, 2, 4 and 6 month visits". 

• Assess for suicidality: pay particular attention to the suicide question on your screening tool.
• Ask how women are sleeping.
• Screen for bipolar disorder: history of bipolar disorder, family with bpd, ever a time they were agitated/impulsive/didn't sleep/more sexual
• bipolar disorder most often diagnosed postpartum
• Look for evidence of psychosis

Intrusive thoughts vs. Postpartum psychosis

Intrusive thoughts are common in perinatal period (common in PPA, OCD flare). Intrusive thoughts are scary, harsh images of harm coming to the baby (e.g. tripping on baby, imagining pot of hot water burning the baby). These intrusive thoughts make women scared of holding the baby. These get better with time away from baby, more sleep, more support, or OCD/anxiety is treated. They are NOT at risk of harming their baby because the idea is abhorrent.

In psychosis, it is more ego-syntonic. It feels okay, comfortable. People hear voices to kill their baby. This is VERY different. Women with psychosis have very high risk of infanticide (1/1000 risk of killing baby). They need urgent assessment and should not be left alone with their baby. Need ER assist. There is a mother-baby unit in Stanford. 

Principles of treatment

Therapy, medications are both first line. Medication may be more accessible in resource-poor settings.

Also, try not to allow breastfeeding to impair sleep: 5 hours in a row is better than 8 hours with three interruptions due to 3 REM cycles in a row, which is more replenishing for our brain biochemistry.

Don't be shaming when talking about breastfeeding. If a bottle of formula (or pumped milk) allows mom to get 5 hours of sleep, no shame and no blame. Can use power pumping, which is better than pumping in the middle of the night (don't set your alarm q3 hours to pump in the middle of the night).

Medication prescribing: weigh risks of treating vs. risk of untreated depression.

Don't change medication just because a woman is pregnant. 

Don't treat someone halfway (e.g. the lowest dose, but not effective dose, increase sertraline from 25 mg (too low) to more effective/therapeutic dose). When you do this, you are exposing infant to both the medication AND the depression.

Sertraline (Zoloft) has the most safety data, but that doesn't mean it's the safest medication. There isn't enough data to know which SSRI is safer. Sertraline does work for a wide range of diagnoses, so if a woman isn't on medication, sertraline is a good first start. BUT if a person has tried multiple anti-depressants, it's okay to continue that medication; don't switch to sertraline, especially if it didn't work for them in the past.

Perinatal psychiatrists use Reprotox.net (has every study on any medication in pregnancy) or MothertoBaby.org (patient handouts Eng/Spanish)

5 Risks of SSRI:

• poor neonatal adaptation (akin to SSRI withdrawal), occasionally NICU for monitoring and blood sugar
• pulmonary hypertension of newborn: very low risk
• cardiac defects ?some studies show yes, others no (cardiac side effects documented in paroxetine, fluoxetine (rx'd often for PMDD)
• bipolar disorder: do not want to precipitate mania, consider quetiapine QHS for someone who have postpartum bipolar disorder. Get psychiatrist help
• suicidality (always recheck 2 weeks after starting SSRI). Agitation can happen without warning, can be result of agitation that an SSRI can cause, unknown element of BPD. National Suicide Hotline 9-8-8. If they have thoughts of hurting themselves, should stop the med and let you know. 

For Insomnia/Post Partum Anxiety: can use very very very low doses of quetiapine (1/4-1//8 of a 25mg tablet of quetiapine): undetectable in breastmilk. May be safer than sleeping meds (less likely to roll over baby). Consider as adjunct for anxious patients who do not meet criteria for mania but for whom you are worried about starting sertraline. 

The newest treatment option for PPD is Zuranolone: synthetic analog of allopregnanolone. Works very quickly (within 3 days). Only 2 week course (14 pills), Can be done on top of SSRI, anti-psychotic, lithium. Causes profound sedation (no driving). No safety information in breastmilk. Very costly: $1000+/pill, $15,000 for a course. 

Preventing PPD

With specific techniques, up to 50% of PPD can be prevented. Lots of studies that we can prevent a good percentage of PPD: self care, support, sleep. Needs to be included in prenatal classes. We need policy change (paid maternity leave in the US!). Need to address partner treatment (male/female).

Oxygen Delivery and BiPAP (Manjuck, 8/14/2024)

Many thanks to Dr. Janice Manjuck, our SSRRH ICU Director, for an excellent Grand Rounds  this week on Oxygen Delivery and BiPAP for hospitalized patients. Dr. Manjuck gave us a nitty gritty review of when/how/why we might select one of many oxygen delivery devices. She combines humor, basic science, and evidence in just the right blend to bring us clinically relevant learning. We are so grateful!

A recording of her presentation is HERE. Feel free to check it out.

My notes:

First, off, when should we be using oxygen?

• if patient is acutely ill, oxygen is not indicated unless saturation is <96% (this excludes sickle cell crisis, CO poisoning, profound anemia (Hb <3) and pneumothorax
• in ACS/CAD aim for 93% saturation

Hypoxemia is a theoretical concern.

Pulse oximetry is not always reliable. SQ1 of 1 on the monitor tells us if the signal is reliable We should be suspicious about pulse oximetry -- it is not reliable in cases of poor perfusion, nail polish/artificial nails (think Olympic runners), tremor/movement disorder/seizure, anemia and CO poisoning (e.g. HB<5, bilirubin>30), bright lights (can falsely lower readings).

Of note, patients of color are MUCH less likely to have reliable reading from a pulse oximeter.

In a 2022 NEJM study of patients comparing ABG results to pulse oximeter readings, 11% of black patients had falsely elevated pulse ox readings (compared to 3% of white patients). This means a normal pulse oximeter reading may be falsely reassuring in BIPOC patients. 

ABG vs. VBG: For patients NOT in shock, a VBG is a relatively good alternative to an ABG,  particularly if you are getting the VBG to trend PCO2 in hypercapnic patients. VBGs are easier to get and less painful for patients. However, please note, if a patient is in shock, an ABG may be needed. Do not be offended if the intensivist asks for an ABG for an unstable floor patient!

Okay, when patients need oxygen, what kind of oxygen should I give them? It is important to take into account their clinical status, their comorbidities, and why they need oxygen. Low flow systems, which can deliver 0-15LPM of oxygen, are good for patients with a stable respiratory rate and pattern. High flow systems -- which can deliver 50-60 LPM-- may be better for patients who are more tachypneic. 

Dr. Manjuck reviewed the concepts of anatomical dead space and entrainment

• Anatomical dead space  is the internal volumes of the upper airways, in which no gas exchange takes place -- on average about 150 ML in a 70 kg person. Air is warmed, filtered and humidified in this space, but no gas exchange occurs. So it is essentially "wasted space". 
• Entrainment is when room air mixes with oxygen due to a negative pressure gradient. In other words, it is the air that leaks around the oxygen delivery device. This is more common in nasal cannula<<face mask<<HFNC.

Which oxygen device is indicated? Depending on this oxygen needs of the patient, these two concepts may be important in which oxygen delivery device you choose. Other questions include: what interface is more desirable (e.g. nasal cannula vs. face mask)? how precise does the FiO2 need to be titrated? Does the air need to be humidified? Are other therapies (e.g. bronchodilator) needed? Low flow delivery tends to be more comfortable.

Low flow oxygen delivery systems include nasal cannula (NC), simple face mask, non-rebreather face mask, and venturi face masks. They can  deliver 0-15 LPM of oxygen. 

• Nasal cannula coming from wall is always delivering 100% oxygen, each 1L/min is equivalent to 3-4% FiO2, remembering that room air contains approximately 21% oxygen, SO
• 1 LPM=24% oxygen
• 2LPM=28% oxygen
• 3LPM=32% oxygen
• 4LPM=36% oxygen
• 5LPM=40% oxygen
• And so on. . .This means that 10 LPM on a nasal cannula gets you about 60% FiO2. See chart .
• A (simple) low flow mask can delivers upwards of 60-70% FiO2 IF the patient is breathing normally (essentially maxed out at 15LPM)
• A non-rebreather mask ALSO gives about 15LPM max of oxygen, which is ~60-70%. It does not flood the face, but rather floods the bag, which is a means to effectively deliver high levels of oxygen anywhere in the hospital. It can deliver 75-90% FiO2, but100% non-rebreather should be considered a fast track to something else (i.e. BiPAP, HFNC or intubation)
  
  

High flow systems include HFNC, CPAP, BiPAP, and mechanical ventilators; these are all positive-pressure systems and can deliver 15-60 LPM. This level of oxygen delievery is indicated in profound hypoxemia, hypercapnia AND/OR both. 

Positive pressure systems can recruit alveoli, assist mechanical work of breathing, may ensure better oxygen delivery and increase functional residual capacity. Disadvantages include being confining/claustrophobia-inducing, may increase the need for sedation, increase risk of infection, increase in aerophagia, and they may reduce cardiac output (especially if patient is dry). 

HFNC, which delivers 50-60 LPM, must ALWAYS be humidified and warmed. It offers "a little PEEP" for patients who need it. Good for elevated respiratory rate.  Continuous high flow oxygen literally washes out the upper airways, leaving a reservoir of oxygen in the upper airway (pharynx) available for ongoing oxygen exchange. It also avoids rebreathing CO2, thereby decreasing anatomical dead space. 

EPAP=CPAP=PEEP

Home CPAP has variable oxygen delivery, is not titratable, and not always humidified. Do NOT use home CPAP if patient hospitalized for respiratory reason. Hospital CPAP, on the other hand, is more titratable in terms of PEEP. 

The worse the hypercapnia, the better to use BiPAP. Think of BiPAP as a non-invasive ventilator. It has different interfaces, can be humidified, you can titrate the oxygen more precisely, and you get feedback on its efficacy. 

Tradition to Transition: Dietary Shifts in Immigrant Patients (Rayas, 8/7/2024)

Muchas gracias to Dr. Lourdes "Lulu" Rayas for a wonderful presentation this week on food customs and Habits in our Mexican immigrant patient population. She titled the presentation, From Traditional to Transitional: Dietary Shifts with Immigration.  

A recording of her wonderful (and tasty) presentation is available HERE. 

***

My notes:

16% of our population in Sonoma County is foreign born.

Chronic disease is more prevalent  in the Latinx population. In fact, compared to non-Hispanic whites,

• Hispanic adults 70% more likely be diagnosed with DM2
• Hispanics are 1.3x more likely to die from diabetes 
• Hispanics have 2x risk of being hospitalized with ESRD

Of note, the immigrant paradox is a statistical pattern that shows first-generation immigrants may have better health outcomes than native-born people of the same age, race, and gender, even if they have lower socioeconomic status. This pattern has been observed for cardiovascular disease, mental health, and mortality. However, recent research suggests that immigrants may experience a decline in cardiovascular health over time. 

Some of this paradox may be explained by dietary acculturation-- the notion that, over time, immigrants gradually abandon eating habits from their native countries, ultimately increasing fats, sugary beverages, and decreasing fruits and vegetables. 

Children of immigrants have also been noted to have less physical activity (than native born children) and less healthy diets. 

In a study of Latinx immigrants, people were asked to share the pros and cons of their eating habits and food access in their country of origin as compared to the USA. You can see these lists in the images below. I was most struck by the notion that many immigrants literally do not have the time to cook like they did when they lived in their country of origin -- this is likely due to long work hours and less flexible home schedules. Also note, that people report eating more legumes (and less meat) in their country of origin. 

So what can we do as primary care providers? 

Dr. Lulu encouraged us to adhere to three principles: 1) have a culturally competent approach to nutrition 2) help patients find a community that shares valued and traditions, and 3) connect patients to food access resources. 

Culturally competent nutrition

Traditional Mexican cooking, Dr. Rayas, pointed out, contains tons of fresh fruits and vegetables and very little processed foods. We can encourage our patients to carry forward traditional family  menus and discourage processed foods. Commonly used foods used in Mexican cooking have well-documented health benefits:

• tomato (jitomate) has evidence that it lowers lipids, decreases blood pressure and general inflammation
• peppers (chiles) help with glucose metabolism 
• avocado (aguacate) decreases CVD, cancer, and works on the GLP system
• corn (elote) has been shown to be anti-inflammatory, anti-angiogenesis properties, and anti-carciongenic. (And, btw, corn is the foundation of the Mexican diet). 
• cactus (nopales) also has anti-inflammatory properties, hypoglycemic (one study showed 85gm of nopales daily demonstrated a 20% reduction in glucose levels), and anti-microbial. 
• hibiscus (jamaica) can decrease blood pressure (in one study from 134 to 112 SBP it drunk BID x 1 month)
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Help patients find community

Many of our immigrants patients are isolated and need help accessing community services and opportunities. Don't forget about some of our amazing community resources, including:

• Bayer Farms: a community garden space, sponsored by Land Paths, they offer garden space, herbal medicine classes, and a great park/playground
• The Botanical Bus: featuring bilingual health promotoras bringing a mobile herb clinic all around Sonoma County
• Campeones de Salud, a 6 week program run by SRCH for families to improve healthy eating and exercise (SRCH referral SA260 Dutton)
• Center for Well-Being, which offers nutrition classes in English and Spanish (SRCH providers can refer via EpiC)

Connecting patients with food access resources, including:

• WIC, a food supplementation program for pregnant women, post partum and breastfeeding, and children up to age 5.  
• Ceres Community Project, free medically tailored meals for patients with chronic illness, including heart failure, cancer, and diabetes. 
• Redwood Empire Food Bank, which comes to Vista Clinic every Monday from 11am-12pm. 

Ovarian Cancer (Delic, 7/29/2024)

 A recording of this presentation is available HERE.

A written summary is forthcoming. Please check back later.