Prescribing in Pregnancy and Breastfeeding Dr Cat Hinds Perinatal Psychiatrist 25th April 2019

Objectives Presentation (10 mins) Interactive session (15 mins) Croydon Community Perinatal Mental Health Service Referrals: Who, how and when? What we offer General principles of prescribing in Perinatal patients Interactive session (15 mins) Prescribing in Pregnancy and Breastfeeding 4 Clinical cases Objectives

Bethlem Royal Hospital

Who to refer Moderate to severe mental illness Pregnancy and 12 months of the baby’s life As early as possible in pregnancy Who to refer

Who to refer Diagnosis of Bipolar Affective Disorder Active suicidal thoughts or deliberate self-harm History of psychosis Accept most mental health diagnoses, including: Personality disorders Eating Disorders Exclusion criteria: Learning disability Primary diagnosis of substance abuse Who to refer

Telephone advice 020 3228 0304 Monday to Friday 9am-5pm Prescribing and referral advice For professionals and patients Telephone advice

Perinatal Mental Health Care Pathways Specialist assessment and care planning Emergency assessments while awaiting MBU placement Urgent admission to MBU Psychological interventions Pre-conception advice Perinatal Mental Health Care Pathways

Referrals Most referrals from GPs Next commonest group: Midwives Single referral form for all Perinatal services in SLaM Daily referral screening and response Referrals

Prescribing in Pregnancy

Prescribing in Pregnancy 90% of women stop psychotropic medication on discovering they are pregnant Prescribing in Pregnancy

Risk-benefit analysis

Risk-benefit analysis Risk of taking medication Risk-benefit analysis Teratogenicity Obstetric complications Neonatal toxicity/withdrawal Neonatal complications Neuro-developmental disorders Child psychopathology

Risk-benefit analysis Risk of taking medication Risk of untreated mental illness Risk-benefit analysis Relapse of mental illness Readmission Worse long-term prognosis Parent-infant bonding Suicide (+ extended suicide) Depression Anorexia Bulimia Nervosa/BED Schizophrenia All diagnoses Teratogenicity Obstetric complications Neonatal toxicity/withdrawal Neonatal complications Neuro-developmental disorders Child psychopathology

Risk of withdrawal of treatment A woman with a previous history of anxiety and depression, including postnatal depression Effectively treated with venlafaxine prior to the pregnancy Venlafaxine was stopped on discovering the pregnancy, either by the woman or her GP No alternative was suggested No specialist perinatal service in her area Risk of withdrawal of treatment

Risk of withdrawal of treatment Increasing anxiety, then depressed mood, with physical complaints, poor coping and suicidal ideation Referred for low intensity psychology Patient went to the GP to request to restarting venlafaxine Risk of withdrawal of treatment

Risk of withdrawal of treatment GP was reluctant to prescribe Placed the responsibility for the decision entirely on the woman Documented explanation of the risks but not the benefits of taking medication Risk of withdrawal of treatment

Risk of withdrawal of treatment She died violently by suicide a week later, in her third trimester On the day she was due to undergo a mental health assessment Risk of withdrawal of treatment

2014-16 data Recurrent depression Commonest diagnosis for maternal suicide: Recurrent depression Not puerperal psychosis 2014-16 data

Red Flags

Recent significant change in mental state or emergence of new symptoms New thoughts or acts of violent self-harm New and persistent expressions of incompetency as a mother Estrangement from the infant Red Flags

Case vignette

Case vignette 27 year-old woman Attends your surgery 5 weeks pregnant She is taking Epilim 800mg BD for Bipolar Affective Disorder What should you do? Case vignette

Sodium valproate Do not stop valproate abruptly Urgently specialist perinatal review Should be seen within two days Urgent referral to fetal medicine specialist for counselling and scanning for women with valproate-exposed pregnancy Patient to continue taking the medication until they are seen by the psychiatrist Sodium valproate

Withdraw valproate over at least 4 weeks to prevent relapse Does not remove the risk of malformations and neurodevelopmental problems May need to replace valproate with an antipsychotic Sodium valproate

Sodium Valproate High risk (~10 in 100) of congenital malformations Very high risk (30-40 in every 100) of neurodevelopmental problems Sodium Valproate

Valproate preparations must not be used in pregnant women Must not be used in women of child-bearing potential Unless they meet the conditions of a ‘pregnancy prevention programme’ Sodium valproate

Case vignette

Case vignette 35 year-old woman presents 10 weeks pregnant She has a diagnosis of OCD She is on 40mg fluoxetine daily What are the risks of the medication? What are the risks of changing it? Case vignette

Risks of SSRI Teratogenicity Adverse obstetric outcomes Neonatal adaptation syndrome Risks of SSRI

Risk of changing medication OCD tends to get worse as pregnancy goes on 40% of women say their OCD started in pregnancy Tend to use higher doses of SSRI in OCD Serious mental illness that can severely affect function if mental state deteriorates Risk of changing medication

Case vignette

Case vignette 30 year-old woman presents 6 weeks pregnant Diagnosis of recurrent depression She is on 20mg citalopram Has tried multiple SSRIs over the years and this one is working well What would you do? Case vignette

SSRI Continue citalopram Common for doctors to change to sertraline Risk of relapse if changed Discuss risks and benefits SSRI

Case vignette

39 year old woman with a diagnosis of Bipolar Affective Disorder Past suicide attempt while psychotically depressed Unwell with poor function for many years, but stabilised over the last few years on 15mg aripiprazole Presents 15 weeks pregnant Self-ceased her aripiprazole on discovering her pregnancy Currently irritable, intrusive with pressure of speech What would you advise her with respect to medication? Case vignette

Case vignette Restart aripiprazole Low dose initially Increase dose post-delivery Case vignette

Objectives

Objectives Croydon Community Perinatal Mental Health Service Principles of Prescribing in Perinatal Period Specific examples Sodium valproate Fluoxetine Aripiprazole Objectives

Useful prescribing resources Beware of patients accessing outdated information Reprotox Motherisk website – need a license for the department LactMed – breastfeeding information www.medicinesinpregnancy.org from UKTIS – print off patient information sheets British Assocation of Psychophamacology Consensus paper 2017 NICE Perinatal Mental Health Guidelines 2014 Useful prescribing resources