Psychiatric medications in pregnancy and lactation

Dr Bavi VythilingumDivision CL Psychiatry, Dept of Psychiatry UCT

Rondebosch Medical Centre

Psychiatric disorders in pregnancy

In SA 30 -40% of women have antenatal depression

Decision to treat – benefit to mother vs risk to child

More accurate – look at benefit to mother and child vs risk to mother and child

“Would a physician tell a pregnant woman with epilepsy, ‘Stop your meds and ride out the seizures until you deliver’? Are the medications of pregnant women with mental illness somehow more “optional”?”

Dr Helen Kim, MGH Center for Women’s Mental Health

Psychiatric medications in pregnancy and lactation

Prescribing principles in pregnancy and lactation

Monotherapy Lowest effective dose

SSRI’s

First line pharmacotherapy Citalopram, sertraline appear best tolerated No long term behavioural effects

SSRI and PPHN

Six published studies– only three studies adequately powered.

3 studies – increased risk Absolute risk cannot be determined, BUT probably less than 1%. Information does not support discontinuation

or lowering the dose of the antidepressant.

Antidepressants and teratogenicity

Several studies linking SSRI use to – Cardiac defects– AHDH– Autism

Large database studies No face to face interview Multiple confounders – adequate power? Qualitatively different cases vs control

– Other drug use, higher rates FAS, older No control for effect parenting

Tricylic Antidepressants (TCA’s)

No increased teratogenic risk More adverse side effect profile

– particularly postural hypotension– constipation– lethality in overdose

Generally used as second line agents.

Other antidepressants

Venlafaxine, duloxetine, bupropion– Less data– Probably safe

MAOI’s – no data, avoid due to dietary restrictions, risk hypertension

Take Home Message

Risk of teratogenecity Absolute risk is not clear but appears to be

small Psychotherapy treatment of choice for

perinatal depression Weigh risk benefit ratio

Management of Bipolar Disorder during Pregnancy

Should be by a psychiatrist Teratogenic risk

– Lithium Ebstein’s anomaly 1-5% (vs 0.5 – 1% risk)

– Na Valproate NTD, other anomalies, 3x vs other antiepileptics, 4x general population

– Carbamazepine 1% risk neural tube defects (vs 0.1% risk)

– Lamotrigine limited evidence, cleft palate

Second generation antipsychotics

Attractive– No described teratogenicity– Mood stabilisers

Metabolic side effects– Boden 2012– gestational diabetes adjusted OR, 1.77 [95% CI,

1.04-3.03]– Higher risk SGA infant - confounders

Medication Summary

Lithium – safest Lamotrigine, atypicals – appears safe Individualise for patient Adequate risk counselling

Patient falls pregnant on medication

DO NOT STOP MEDICATION Minimal decrease in risk of defects vs high

risk relapse Continue meds at lowest effective dose Early US and anomaly scan FOLATE

Medication through pregnancy

Changing maternal blood volumes Increase doses during pregnancy

– Lithium – levels monthly first 2 trimesters, every fortnight thereafter

– Valproate, CBZ – guided clinically, checking levels every 2 -3 months useful

Delivery

Liaise closely with obstetrician Hospital Adequate pain control IV line up Stop lithium, benzo’s at onset labour,

recommence post delivery after checking level

High risk for post natal depression/psychosis

Benzodiazepines

Small increased risk for cardiac/oral cleft malformations with first-trimester exposure.

Neonatal toxicity (“floppy infant syndrome”) /withdrawal

Avoid in the first trimester,late in the third trimester

Benzodiazepines II

To minimize neonatal withdrawal, gradually taper the mother’s benzodiazepine before delivery – Taper 3 to 4 weeks before the due date and discontinue at

least 1 week before delivery.– If benzodiazepines cannot be tapered

use a short acting agent advise the mother to discontinue benzodiazepine use as soon

as she thinks she is going into labour.

Medication

Generally SSRI’s and TCA’s safe in pregnancy and breastfeeding

Antipsychotics – reasonably safe Mood stabilisers – teratogenic risk ECT – option

Breastfeeding and Medication

MOST WOMEN ON MEDS CAN BREASTFEED!!!!!

Risk of child dying from diarrhoea, respiratory disease, malnutrition higher than medication side effects

Breastfeeding, bedsharing mothers get more sleep

Case by case basis

Breastfeeding and Medication

Lowest effective maternal dose All meds excreted into breastmilk Watch baby

– Jaundice– Excessive sleepiness

Pre term – probably best not to breastfeed

Breastfeeding and medication II

Antidepressants – generally safe Antipsychotics

– Infant sedation– Neonatal EPSE

Breastfeeding and medication III

Mood stabilisers– All present problems– Consider risk benefit carefully

Lithium– Maternal hydration important

Anticonvulsant class– Rashes

Eglonyl?

Sulpiride Antipsychotic with theoretical mood elevation

properties at low doses Side effect of increasing milk supply Sedating NOT an effective antidepressant

Pregnancy and lactation summary

All medications present risk – some higher than others

Weigh risk benefit ratio PNDSA www.pndsa.org

– 0828820072– info@pndsa.org.za

Otispregnancy.org www.infantrisk.com

In general, women do not use psychotropic medications during pregnancy without good reason.

They educate themselves, struggle with treatment options, and in many cases stop medication, relapse, and then restart it when they become ill.

Being pregnant and giving birth to a child is an exhausting physical and emotional experience. A woman is vulnerable and deserves support, not shaming.