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E-Resource May 2014 PSYCHIATRIC MEDICATION USE DURING PREGNANCY AND BREASTFEEDING
Psychotropic medication use during pregnancy may have adverse effects, hypoglycemia, nephrogenic diabetes insipidus, polyhydramnios, and however, there is a growing body of evidence that some medications may premature delivery.9,10,11,12 Proper hydration can reduce the risk of lithium be acceptable for use during pregnancy. As with any medication, risks and toxicity and regular lithium level monitoring should be performed. Prenatal benefits must be considered for each individual. This resource provides exposure to valproate (Depakote) is associated with an increased risk of useful information and reviews existing research on risks and benefits of neural tube defects, craniofacial, limb and cardiovascular issues.13,14,15,16 psychotropic medication use during pregnancy. Other mood stabilizers should be considered, but if Depakote is taken during pregnancy, a dose of less than 1,000 mg/day should be taken in The presence of psychiatric disorders during pregnancy is not uncommon; divided doses. Carbamazepine (Tegretol) exposure during pregnancy is approximately 500,000 pregnancies each year involve women with an associated with facial dysmorphism and fingernail hypoplasia and should emerging or already present psychiatric illness and an estimated 30% of only be used during pregnancy if there are no other options.17,18 Vitamin K women take some form of psychotropic medication while pregnant.1 should be taken by women who are treated with both Depakote and Mental illness, especially untreated, may lead to poor health outcomes Tegretol to promote proper development of the infant's head and face. during and after pregnancy for both the baby and mother, including Typical antipsychotics and some atypical appear to be relatively safe for inadequate prenatal care, poor nutrition, alcohol/tobacco use, and deficits use during pregnancy, although both are associated with a slightly in mother-infant bonding; thus, it is important to consider whether increased risk of birth defects. Psychotherapy, regular exercise and stress patients with mental illness can be safely treated during pregnancy. While management are other non-pharmaceutical options to manage symptoms all psychotropic medications cross the placenta, are present in the amniotic of BPD and should be first line intervention in the treatment plan. fluid and can enter into breast milk, not all produce teratogenic effects. Anxiety Disorders Considering what stage of pregnancy psychotropic medications are taken is The course of anxiety disorders during pregnancy is not well known, helpful in predicting teratogenicity; most risk occurs during the period of however, relapse is common during pregnancy and postpartum if embryogenesis (weeks 3 - 8 of pregnancy). If medication use is necessary medication is discontinued. Anxiety and stress during pregnancy is during pregnancy, a single medication at a higher dose is recommended associated with poor outcomes including spontaneous abortions, preterm over the use of multiple medications and changing medications is not delivery and delivery complications including prolonged labor, precipitate recommended as it increases the level of exposure to the fetus. labor, and fetal distress. Use of BZD during pregnancy is discouraged due to a possible association Up to 70% of women experience symptoms of depression while pregnant. between BZD use and oral cleft development in infants.19 Further, neonatal Screening with the PHQ-9 is an appropriate method and useful tool to toxicity and withdrawal symptoms are probable with maternal use of BZD detect depression early in pregnancy. Depression occurring before just before delivery.20 Use of Buspirone (Buspar) which is pregnancy safe is conception often appears during pregnancy or reappears as postpartum an appropriate alternative medication option. Cognitive behavioral therapy depression. Untreated depression is associated with premature birth, low should be considered as an alternate treatment option birthweight, postnatal complications, poor maternal weight gain, smoking, Schizophrenia-spectrum Disorders and drug/alcohol use during pregnancy.2 Schizophrenia affects approximately 1-2% of women and onset commonly Medications such as tricyclic antidepressants (TCAs) and selective serotonin occurs during childbearing years. Schizophrenia is associated with negative reuptake inhibitor (SSRI) fluoxetine (Prozac) have been shown to be pregnancy outcomes including preterm delivery, low birth weight and small relatively safe for use during pregnancy; neither teratogenic effects nor for gestational age fetuses. behavioral teratogenicity have been reported.3, 4, 5 Use of SSRI paroxetine (Paxil) early in pregnancy is associated with birth defects, including heart Treatment of schizophrenia with typical antipsychotics poses minimal risk defects, craniosynostosis and omphalocele. SSRI use later in pregnancy of teratogenicity. Specifically, use of haloperidol (Haldol) is preferred may lead to transient infant withdrawal symptoms after birth. Limited data during pregnancy as extensive data suggests it is not associated with any on use of novel agents, such as venlafaxine (Effexor), nefazodone congenital malformations with first trimester exposure.21 Low dosage of (Serzone), or bupropion (Wellbutrin) during pregnancy do not suggest an these medications is preferred to reduce the risk of extrapyramidal side increased risk of fetal anomalies or adverse events. The use of monoamine effects as medications used to treat these symptoms are associated with oxidase inhibitors is not recommended during pregnancy.6 Alternate increased risk of oral clefts.19 Atypical antipsychotics have not been studied treatment approaches for depression during pregnancy include structured as extensively, so use of these agents can not be recommended during pregnancy or breastfeeding with the exception of Latuda which is considered safe for pregnancy. Bipolar Disorder (BPD) Pregnant and not currently on medication for depression BPD onset in women commonly occurs in the teens or early 20s. Though the course of BPD during pregnancy is not well known, the postpartum Psychotherapy may be beneficial in women who prefer to avoid relapse rate of BPD among untreated women is up to 50% but treatment antidepressant medication. initiation prior to delivery may reduce the risk of relapse.7 Treatment For women who prefer taking medication, risks and benefits of treatment should be provided in consultation with a psychiatrist and consider both choices should be evaluated and discussed, including factors such as stage patient history of mood disorder symptoms and treatment risks. of gestation, symptoms, history of depression, and other conditions and Many mood stabilizers used to treat BPD are known teratogens.8 Lithium is circumstances (e.g., a smoker, difficulty gaining weight). associated with a small increase in congenital cardiac malformations; first All pregnant women trimester exposure is associated with risk of Ebstein's anomaly and Regardless of circumstances, a woman with suicidal or psychotic symptoms exposure later in gestation is associated with cardiac arrhythmia, should immediately see a psychiatrist for treatment. Pregnancy Risk
Lactation Risk
Pregnancy Risk Lactation Risk
Generic Name
Trade Name
Generic Name
Trade Name
Category
Category
Category
Category
Typical Antipsychotics
Chlordiazepoxide Benzodiazepines for Insomnia
Atypical Antipsychotics
Stimulants
Dextroamphetamine Dexedrine Mood Stabilizers/AED
Medications for Side Effects
Eskalith, Lithotabs, Lithium carbonate N/A No t Available y Risk Categories22 Co ntrolled studies sho w no risk Sinequan, Adapin No evidence of risk in humans Ris k cannot be ruled o ut Po sitive evidence of ri sk Contraindicated in pregnancy Lactation Risk Categories23 Possibly hazardous Pamelor, Aventyl References 1. Doering PL, Stewart RB. The extent and character of drug consumption during pregnancy. JAMA 1978;239:843– 6. 2. Zuckerman B, Amaro H, Bauchner H, Cabral H. Depressive symptoms during pregnancy: relationship to poor health behaviors. Am J Obstet Gynecol 1989;160:1107–11. 3. Wisner KL, Gelenberg AJ, Leonard H, Zarin D, Frank E. Pharmacologic treatment of depression during pregnancy. JAMA 1999;282:1264 4. Chambers CD, Johnson KA, Dick LM, Felix RJ, Jones KL. Birth outcomes in pregnant women taking fluoxetine. N Engl J Med 1996;335:1010-5. 5. Ericson A, Kallen B, Wiholm B. Delivery outcome after the use of antidepressants in early pregnancy. Eur J Clin Pharmacol 1999;55:503 6. Cohen LS, Rosenbaum JF. Psychotropic drug use during pregnancy: weighing the risks. J Clin Psychiatry 1998;59(suppl 2):18-28. 7. Nonacs R, Cohen LS. Postpartum mood disorders: diagnosis and treatment guidelines. J Clin Psychiatry 1998;59(suppl 2):34-40. 8. Viguera AC, Cohen LS. The course and management of bipolar disorder during pregnancy. Psychopharmacol Bull 1998;34:339-46. 9. Wilson N, Forfar JC, Godman MJ. Atrial flutter in the newborn resulting from maternal lithium ingestion. Arch Dis Child 1983;58:538 – 10. Mizrahi EM, Hobbs JF, Goldsmith DI. Nephrogenic diabetes insipidus in transplacental lithium intoxication. J Pediatr 1979;94:493–5. 11. Karlsson K, Lindstedt G, Lundberg PA, Selstam U. Transplacental lithium poisoning: reversible inhibition of fetal thyroid [letter]. Lancet 12. Llewellyn A, Stowe ZN, Strader JR Jr. The use of lithium and management of women with bipolar disorder during pregnancy and lacta- tion. J Clin Psychiatry 1998;59(suppl 6):57– 64;discussion 65. 13. Jager-Roman E, Deichl A, Jakob S, Hartmann AM, Koch S, Rating D, et al. Fetal growth, major malformations, and minor anomalies in infants born to women receiving valproic acid. J Pediatr 1986;108:997–1004. 14. Paulson GW, Paulson RB. Teratogenic effects of anticonvulsants. Arch Neurol 1981;38:140 –3. 15. Rodriguez-Pinilla E, Arroyo I, Fondevilla J, Garcia MJ, Martinez-Frias ML. Prenatal exposure to valproic acid during pregnancy and limb deficiencies: a case-control study. Am J Med Genet 2000;90:376–81. 16. Dalens B, Raynaud EJ, Gaulme J. Teratogenicity of valproic acid. J Pediatr 1980:97:332–3. 17. Moore SJ, Turnpenny P, Quinn A, Glover S, Lloyd DJ, Montgomery T, et al. A clinical study of 57 children with fetal anticonvulsant syn- dromes. J Med Genet 2000;37:489 –97. 18. Jones KL, Lacro RV, Johnson KA, Adams J. Pattern of malformations in the children of women treated with carbamazepine during preg- nancy. N Engl J Med 1989; 320:1661– 6. 19. Saxen I. Cleft palate and maternal diphenhydramine intake [letter]. Lancet 1974;1:407– 8. 20. Haram K. "Floppy infant syndrome" and maternal diazepam. Lancet 1977;2:612–3. 21. Trixler M, Tenyi T. Antipsychotic use in pregnancy. What are the best treatment options? Drug Saf 1997;16:403-10. 22. Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. 7th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2005. 23. Hale TW. Medications in Mother's Milk. Amaraillo (TX): Pharmasoft Publishing, 2004. PATIENT EDUCATION MATERIAL Medications and Pregnancy
About this topic
Taking drugs while you are pregnant can harm your baby. Only take drugs that your doctor gives you. Talk to your doctor first before taking any other drugs. Taking certain drugs can cause: Problems with how your baby grows Harm to your womb which may put your baby's life at risk Loss of pregnancy before the baby is born (miscarriage) Early delivery (premature birth) Pregnant women are not involved in studies for drugs. So, we do not know very much about what taking drugs may do to your baby. You need to be very careful before taking any drugs. Talk with your doctor about the good and bad things before taking any drug. This will help you decide what to do. Drugs may affect your baby based on: When you take the drug during your pregnancy (the stage of your baby's growth) How much of the drug you take If the drug you are taking is mixed with other drugs If you have a health problem Taking drugs during pregnancy: Never take any drug unless your doctor says it is OK. This includes prescription, over-the-counter (like cough or cold) drugs, and herbals (like St. John's wort). Always check with your doctor before taking any kind of drugs. Take prenatal vitamins and supplements that have folic acid. Do not take normal vitamins. Talk with your doctor about the right vitamins and supplements to take. Get a flu shot if you are pregnant during flu season. This is safe for your baby. If you are taking drugs for a health problem, check with your doctor to make sure the drugs are safe for your baby. Your doctor will find drugs that are safe for you and your baby. If you took drugs before you knew you were pregnant, tell your doctor right away. Helpful tips
Instead of taking drugs: Treat hard stools by eating foods high in fiber like whole-grain breads and cereals, beans, peas, apples, berries, Stay away from foods and smells that may cause an upset stomach. Rest and drink lots of fluids to help with colds. Where can I learn more?
Centers for Disease Control and Prevention Women's Health Matters Disclaimer: This information is not specific medical advice and does not replace information you receive from your health care provider. This is only a brief summary of general information. It does NOT include all information about conditions, illnesses, injuries, tests, procedures, treatments, therapies, discharge instructions or life-style choices that may apply to you. You must talk with your health care provider for complete information about your health and treatment options. This information should not be used to decide whether or not to accept your health care provider's advice, instructions or recommendations. Only your health care provider has the knowledge and training to provide advice that is right for you.

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