Other disorders

Personality disorders

Personality disorders are difficult to define and diagnose but can cause significant difficulties in pregnancy and the postpartum pe­riod. According to the American Psychiatric Association, they are characterized by ‘an enduring pattern of inner experience and be­haviour that deviates markedly from the expectations of the culture of the individual who exhibits it' (83).

Eating disorders

Although eating disorders may be associated with fertility problems (86), a clinical study has estimated the prevalence of some form of eating disorders during pregnancy at around 7.5%, compared to 9.2% prior to pregnancy (87). Some women symptomatically im­prove in pregnancy. A Norwegian survey reported remission rates between 29% and 78%, depending on the specific eating disorder (88). Over half of women with a history of a prepregnancy eating disorder have a continuation or recurrence in the postpartum (8). The continued presence of eating disorder symptoms increases the risk of postpartum depression compared to women whose symp­toms remit (8). Apart from binge-eating disorder, the incidence of other eating disorders in pregnancy is rare (8).

Substance abuse and dependence

The United States 2012 National Survey on Drug Use and Health es­timated that 9.0% of pregnant women aged 18-25 and 3.4% of those aged 26-44 use illicit drugs (including cannabis, stimulants, cocaine, heroin, hallucinogens, and inhalants) or misuse prescription-type drugs. These estimates are roughly half the rates observed in non­pregnant women in the same age group (89).

There are significant barriers to care for pregnant women with substance use disorders (89). Universal antenatal screening with val­idated questionnaires has been advocated and should be preferred to urine drug testing, that does not identify women with significant, but sporadic, use and may prevent women to seek prenatal care (89). Perinatal women with substance use disorders require intensive and multidisciplinary care. They often present comorbidity with other medical and psychiatric disorders and environmental stressors that need to be addressed. A harm reduction approach, aimed to extend periods of abstinence while recognizing the likelihood of relapse, should be adopted (89).

Opioid use in pregnancy is an increasing concern, with rates raised from 0.1% in 2000 to 0.6% in 2009 in the United States. Opioid­containing pain medications are ten times more commonly used than heroin during pregnancy (89). Opioid replacement therapy has specific benefits for pregnant women, including the prevention of in­toxication and withdrawal and the mitigations of the negative effects on fetal growth and length of gestation. Significant constipation is a common side effect of all opioids, including replacement therapy, and should be enquired about and addressed by clinicians (89).