1. Schizophrenia, Antipsychotic Medications and Birth Defects Jensea Chauvin, RNC, MN, BC-CNS Women’s and Children’s Clinical Nurse Specialist Salem Hospital 2013

2. Schizophrenia, Antipsychotic Medications, and Birth Defects Objectives: At the end of this course, the participant will be able to: 1.Identify signs and symptoms of schizophrenia 2.Discuss fetal develop and impact of medications 3.Identify common medications and side effects 4.Identify possible birth defects associated with schizophrenia 5.Identify nursing care during antepartum, intrapartum, and postpartum admissions

5. Case Presentation: Mother: 29 yr old G 3 P2, Spontaneous Vaginal Delivery at 39w 3d BMI 38.2,5’3, 215 lbs, Plans breast and formula feeding DSH Hold Social history: + for tobacco, alcohol and lV drug abuse Past Medical History: - Musculo-skeletal system disorder- Anxiety -STD- Migraines - Unspecified mental or behavioual disorder- Asthma - Postpartum depression- Schizophrenia - Scoliosis with spinal fusion

6. Case continued: Current Medications: Fluoxetine ( Prozac) Folic Acid Ibuprofen olanzapine(Zyprexa) perphanazine (Trilafon) quetiapine riseridone(Risperdal) acyclovir

7. Baby: Girl, 7’ 13”, APGARS 8 and 9 Failed hearing screening X 2 CMV ordered Head- shallow midfacies with somewhat frontal bossing Hands- simian crease on right, the left has a simian crease that is interrupted. Labs: Urine drug screen- negative Meconium drug screen-negative CMV- not detected Discharged to foster care on day 2.

8. Frontal BossingSimian Crease

9. Schizophrenia Is a chronic, disabling brain disorder Affects about 1% of Americans Is NOT dissociative identity disorder( multiple personality disorder). Symptoms: Hallucinations- Auditory or visual Delusions- Wildly false beliefs Paranoia

10. Schizophrenia Often have abnormal ways of thinking Have trouble organizing thoughts or making logical connections May feel like their mind is racing from one unrelated thought to another Sometimes experience “thought blocking”, a feeling that thoughts are removed form their head

11. Schizophrenia Causes a wide range of behaviors: May speak incoherently May make up words May act agitated or appear stone-faced May have trouble maintaining basic hygiene or order in homes May display repetitive behaviors, such as pacing

12. Schizophrenia Epidemiology Affects men at slightly greater rates than women (1.4 : 1) Crosses all ethnic groups Symptoms typically begin between ages 6 and 30 years Women tend to be diagnosed later in life than men Rarely begins in childhood or after age 45 Runs in families

13. Schizophrenia Etiologies Unknown Genes and environment may play a role… multifactorial? Levels of the chemical messengers dopamine and glutamate may be out of balance Brain structures may be abnormal

14. Schizophrenia Diagnosis Based on clinical history and symptoms In teenagers, a combination of family history and behaviors which might include withdrawing from social groups and expressing unusual suspicions.

15. Schizophrenia Treatments Long term medications Psychosocial therapies Rehabilitation

16. Schizophrenia Goals To help people with schizophrenia stay employed and maintain as much independence as possible Relapse prevention

17. Psychosis- A Psychiatric Emergency in Pregnancy Psychosis in Pregnancy: is a loss of contact with reality, presence of hallucinations, delusions, or thought disorganization Psychotic Disorders include: Primary thought disorders including schizophrenia or schizoaffective disorder Secondary disorders including mood disorders or substance induced

18. Schizophrenia Fertility and Pregnancy: Fertility is reduced, estimated to be 30% to 80% of the general population Factors contributing to decreased fertility Psychotropic medications/tranquillizers-suppress ovulation through the effects on the hypothalamus Untreated psychotic episodes may interfere with the menstrual cycle Lack of opportunity Difficulty forming relationships

19. Schizophrenia: Pregnancy Denial of pregnancy common Complications: Insufficient prenatal care Alcohol or substance abuse Prematurity Longer NICU stays Breech presentations Deliveries outside of hospitals Neonaticide

20. Schizophrenia: Pregnancy Other Risks: Intrauterine growth restriction increased twofold Stillbirth quadrupled Treatment: Antipsychotic medications No medications FDA approved for use during pregnancy

21. Schizophrenia: Pregnancy Placenta Anatomy

22. Fetal Development 4 Weeks Gestation Weeks 1 and 2 Getting Ready for fertilization. Weeks 3 Fertilization Week 4 Implantation- blastocyst. The inner group of cells will become the embryo and the outer upon contact with the uterus will burrow into the uterine wall and form the placenta.

23. Fetal Development 5 Weeks Gestation Week 5 Embryonic Period Formation begins for the: Ectoderm BrainSpinal Cord HeartOther Organs Skin Central and Peripheral Nervous System Eyes, Inner Ear, Connective Tissues Mesoderm Heart and Circulatory System Foundation of bones, muscles, kidneys, and reproductive system. Endoderm Lungs, Intestines, bladder

24. Fetal Development 8 Weeks Gestation Week 6 Period of rapid growth. Neural tube is closing Heart is beating Basic facial features appear. Week 7 Brain and face rapidly developing Baby is about the size of a pencil eraser. Week 8 Arms and Legs are getting longer Ears are forming. Eyes are visible Upper lip and nose have formed

25. Fetal Development 10-12 Weeks Gestation Week 9 Arms grow, develop bones and bends at the elbow. Toes form ¾ inch long Week 10 Baby’s head is rounding Neck begins to develop Eyelids begin to close Week 11 Officially now a fetus. RBC’s are beginning to form in the liver. External genital start developing. 2 inches long Week 12 Developing fingernails. 2 ½ inches long 14 grams

26. Schizophrenia Medications Antipsychotic medications Fetal exposure to antipsychotics may vary due to differences in placental permeability to these drugs. The placental passage ratios were as follows: Olanzapine – 72%(ZyPREXA) Olanzapine Haloperidol – 66% (Haldol) Haloperidol Risperidone – 49%(RisperDAL) Risperidone Quetiapine – 24%(SEROquel) Quetiapine

27. Schizophrenia Medications Olanzapine – pregnancy class C In breastfeeding infants, sedation has been seen but no short-term effects. Risperidone- pregnancy class C evidence of embryolethality but no teratogenicity Women should not breastfeed. Quetiapine- pregnancy class C In animal studies evidence of embryo, fetal and maternal toxicity. Breastfeeding not recommended. perphanazine (Trilafon)- has not been assigned a category Is excreted in breast milk. Monitor infant for excessive drowsiness and for developmental milestones.

28. Schizophrenia Medications Haloperidol- pregnancy class C Has the most data on safety in pregnancy Some cases of limb reduction malformations

29. Schizophrenia Medications Neonatal toxicity and withdrawal — Chronic administration of antipsychotics during the third trimester may cause symptoms of neonatal toxicity and withdrawal, including : Abnormal movements (dyskinesia) Abnormally increased or decreased muscle tone Motor restlessnessHyper-reflexiaAgitation HyperactivityTremorSedation IrritabilityCryingTachycardia HypotensionDifficulty breathingDifficulty feeding Gastrointestinal dysfunction (eg, functional bowel obstruction) May be mild or severe requiring intensive care support and prolonged hospitalization

30. Schizophrenia Medications Haloperidol: Neonatal Effects While Breastfeeding Limited Information: is found in low levels in breast milk does not seem to effect the infant in short or long term used in combination with other antipyschotic medications can negatively affect development.

31. Schizophrenia Medications Haloperidol Adverse Reactions in the Mother: - Cardiovascular: arrhythmia, hyper-/hypotension, sudden death, tachycardia, torsade de pointes - Endocrine & metabolic: hyper-/hypoglycemia,

32. Schizophrenia Common Side Effects of Antipsychotics 1.Extrapyramidal syndrome- psuedoparkinsonism, symptoms may present as bradykinesia, rigidity, tremor, and masked fascies. 2.Akathisia- a subjective sense of restlessness which can mimic worsening agiation. 3.Dystonias- can be severe, painful, dysfiguring and frightening. Laryngospasms can be life threatening Occulogyric can end in blindness due to retinal ischemia caused by kinking of the retinal artery that runs through the optic nerve when the eye is dramatically deviated beyond its typical range of motion. 4. Tardive dyskinsia- a permanent movement disorder associated with long term use. Typically seen in the muscle of the mouth and face.

33. Schizophrenia Interventions: In patients with history of neuroleptic use and presenting with symptoms: Supportive care- hydration, electrolyte stabilization, cooling, airway protection Immediate cessation of medications Transfer to ICU Electronic fetal monitoring Possible drug therapy Dantrolene Bromocriptine lorazopan

34. Schizophrenia Medications Benzodiazepines Useful in treating psychotic agitation Does not provide antipsychotic benefits May worsen psychosis through dis-inhibition and further disorganization of thoughts

35. Schizophrenia Medications Summary: We don't think schizophrenia itself causes birth defects but the medications have the potential to, and because the etiology of schizophrenia is likely multifactorial with some of the suspected causes (eg, maternal illness/infection like Toxo) having the potential for fetal effects independent of schizophrenia, we can't know the answer. There are no clear birth defects that are "classic" for schizophrenia. Dr Susan Tran Maternal Fetal Medicine

36. Schizophrenia Medications How to have a conversation with a patient with schizophrenia: 1. Know that many schizophrenics have a delay in processing information, so give them plenty of time to take in what is being said- the response is often delayed, sometimes significantly. 2. Know they often have auditory hallucinations in their head that compete with your conversation. Lori Kessler, RN Nurse Manager Psychiatric Patient Services

37. Antipsychotic Medications and Birth Defects Resources http://www.webmd.com/schizophrenia/ss/slideshow- schizophrenia-overview http://www.webmd.com/schizophrenia/ss/slideshow- schizophrenia-overview http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2153578/p df/canfamphys00221-0105.pdf http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2153578/p df/canfamphys00221-0105.pdf Foley,M., Strong, T., Garite,T. (2011). Obstetric intensive Care Manual. #rd Edition. McGraw Hill. Pg. 255-257. Hendrick, V. MD. (2012).Bipolar disorder in adults: Teratogenic and postnatal risks of pharmacotherapy. UptoDate Hendrick, V. MD