Medication for Mummies Dr Ashleigh Macaulay Clinical Lead MMHS Mummy

Questions?

Key Messages Happy Mums = Happy Babies Untreated mental illness is more damaging to mums and unborn babies than certain medications There are plenty of options A few medications are “no-no’s” Preconception conversations where possible

Pregnancy Spontaneous abortion rate is 10-20% Spontaneous congenital malformations 2-3% Risk factors Lifestyle factors (diet, weight, drugs, alcohol) Psychiatric illness Medications Limited trials available

Prescribing Principles Things to consider in woman; Her ability to cope with illness symptoms Impact of untreated mental illness Risk of stopping medications suddenly Severity of illness, previous response and patient choice

Prescribing Principles Try to discuss before conception Avoid contraindicated medications Consider non-pharmacological interventions if appropriate Avoid first trimester prescribing if possible Consider switching to lower risk medications Lowest possible dose Frequent monitoring

Psychosis Pregnancy does not protect against psychosis Maternal mental health influences foetal well being Risk of untreated illness Harm to the mum (indirect or direct) Harm to the growing baby (indirect or direct)

Antipsychotics First Generation e.g. chlorpromazine, haloperidol, trifluperazine Slight increase in congenital abnormalities – no clustering 20% early risk of neonatal jitteriness Neonatal jaundice

Antipsychotics Second Generation Gestational Diabetes Olanzapine, quetiapine, clozapine Gestational Diabetes Olanzapine has biggest evidence base Low risk of malformations- no clustering, cardiac septal defects Clozapine No risk of malformations. Neonatal seizures. No benefit to switching due to relapse risk

Woman with repeated relapses are best maintained on medication Woman with repeated relapses are best maintained on medication. Changing may not always be the best. Avoid rapid discontinuation Most experience with Chlorpromazine, trifluperazine, haloperidol, olanzapine, quetiapine and clozapine Seek specialist advice

Depression 10% of pregnant woman develop depression Increased risk in first 3 months post delivery Further risk if there is a past history, particularly bipolar Risks of untreated; Mum - poor self care, lack of obstetric care Baby – neglect to infanticide Relapse rates are higher with discontinuation during pregnancy

Antidepressants Use is increasingly common worldwide SSRI’s are the first line and most evidence based “Reasonably certain” that antidepressants are not major teratogens Balance of risk

SSRI’s Sertraline has least placental exposure Fluoxetine is thought to be the safest Risks Persistent hypertension of the newborn Lower birth weight Increased early birth (days) Post partum haemorrhage Paroxetine – increased congenital cardiac malformations. Less safe than other SSRI’s

Tricyclic’s Most experience with amitriptyline and imipramine Foetal exposure is high but widely used with no apparent detriment to the foetus No effects on later child development Risk of pre-term delivery Third trimester use can cause neonatal withdrawal (mild and self limiting)

Other Treatments Venlafaxine – may increase cardiac defects, withdrawal and cleft palate Trazodone, bupropion and mirtazapine – not recommended MOAI’s are not recommended – high risk of congenital malformations ECT – anaesthetic risk

Anxiety Antidepressants first line medication Benzodiazepines Not teratogenic 3rd trimester risk of “floppy baby” Consider promethazine

Woman with high risk of relapse should be maintained on medication during and after pregnancy Moderate – Severe depression should be treated with antidepressants Several antidepressants have lots of evidence related to safety profiles

Bipolar High risk of relapse after delivery if mood stabilising medications are discontinued, particularly in the 1st month Bipolar risks Induction or C-section Pre-term delivery Small babies No increase in malformations

Mood Stabilisers Conversations pre-conception! No mood stabiliser is completely safe Carbamazepine and Valproate (most teratogenic) increase neural tube defects and should be avoided Switch to antipsychotics Acute mania – commence antipsychotics

Lithium Previous risks are overestimated but advice is still to avoid lithium Known association to Ebsteins anomaly (absolute risk is 1;1000. Li increases 10-20x) Ideally reduce slowly preconception Relapse rates are up to 70% after discontinuation so may have to be restarted Regular ECHO and enhanced US Alterations to dose in 3rd trimester

High relapse rates in woman with Bipolar if medications reduced abruptly Aim to switch to a safer antipsychotic Carbamazepine and valproate should be avoided in woman of child bearing age Increased monitoring if lithium is required May need to consider ECT

Breastfeeding Limited studies Short tern infant data only All psychotropics are excreted in breast milk Drugs with <10% Relative Infant Dose (RDI) are regarded as safe Balance of risk to mums mental health and need to breastfeed/exposure risk to baby

Breastfeeding Treatment of mental health is the highest priority, especially if relapse risk is high Lowest possible dose Avoid combinations of medications Timing doses to feeds

Recommendations Antidepressants Antipsychotics Mood stabilisers Sertraline 1st line Paroxetine, notriptyline, imipramine. Lots of options Antipsychotics Olanzapine Mood stabilisers Valproate (must protect against further pregnancy)

Lots more options with breastfeeding Consider feeding options before delivery where possible Patient choice and balance of risk

Questions? Any new questions? Anything not covered

Key Messages Happy Mums = Happy Babies Untreated mental illness is more damaging to mums and unborn babies than certain medications There are plenty of options A few medications are “no-no’s” Preconception conversations where possible

Thank You