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

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Presentation on theme: "Psychiatric medications in pregnancy and lactation Dr Bavi Vythilingum Division CL Psychiatry, Dept of Psychiatry UCT Rondebosch Medical Centre."— Presentation transcript:

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

2 Psychiatric disorders in pregnancy In SA % 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 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

13 Second generation antipsychotics Attractive – No described teratogenicity – Mood stabilisers Metabolic side effects – Boden 2012 – gestational diabetes adjusted OR, 1.77 [95% CI, ] – 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 – – Otispregnancy.org

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.


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