Post on 22-Feb-2016
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Psychiatric medications in pregnancy and lactation
Dr Bavi VythilingumDivision CL Psychiatry, Dept of Psychiatry UCTRondebosch 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.