Psychiatric medications in pregnancy and lactation

1. Psychiatric medications in pregnancy and lactation Dr BaviVythilingum Division CL Psychiatry, Dept of Psychiatry UCT Rondebosch Medical Centre

2. 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

3. “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

4. Psychiatric medications in pregnancy and lactation

5. Prescribing principles in pregnancy and lactation • Monotherapy • Lowest effective dose

6. SSRI’s • First line pharmacotherapy • Citalopram, sertraline appear best tolerated • No long term behavioural effects

7. 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.

8. 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

9. 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.

10. Other antidepressants • Venlafaxine, duloxetine, bupropion • Less data • Probably safe • MAOI’s – no data, avoid due to dietary restrictions, risk hypertension

11. 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

12. Management of Bipolar Disorder during Pregnancy • Should be by a psychiatrist • Teratogenicrisk • 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

13. 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

14. Medication Summary Lithium – safest Lamotrigine, atypicals – appears safe Individualise for patient Adequate risk counselling

15. 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

16. 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

17. 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

18. 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

19. 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.

20. Medication • Generally SSRI’s and TCA’s safe in pregnancy and breastfeeding • Antipsychotics – reasonably safe • Mood stabilisers – teratogenic risk • ECT – option

21. 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

22. Breastfeeding and Medication • Lowest effective maternal dose • All meds excreted into breastmilk • Watch baby • Jaundice • Excessive sleepiness • Pre term – probably best not to breastfeed

23. Breastfeeding and medication II • Antidepressants – generally safe • Antipsychotics • Infant sedation • Neonatal EPSE

24. Breastfeeding and medication III • Mood stabilisers • All present problems • Consider risk benefit carefully • Lithium • Maternal hydration important • Anticonvulsant class • Rashes

25. Eglonyl? • Sulpiride • Antipsychotic with theoretical mood elevation properties at low doses • Side effect of increasing milk supply • Sedating • NOT an effective antidepressant

26. 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

27. 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.