Prescribing in Pregnancy Dr Ashleigh Macaulay MMHS Conference 13th May 2019

Take Home Messages “Happy Mums = Happy Babies” Untreated mental illness is more damaging to mums and unborn babies than certain medications Always a balance of risks; Mums v’s Babies A few medications should be avoided Preconception conversations where possible

Take Home Messages 50% of pregnancies are unplanned Not specific to specialist perinatal mental health teams There are lots of options for Mums Many people are misinformed – including professionals Internet searches can be alarming Lots of useful (and balanced) information is available

Baseline rates Spontaneous malformations = 2-4% without any medications 1 in 40 babies are born with a birth defect 1 in 5 pregnancies ends in spontaneous miscarriage

Prescribing Principles How do we balance the risk? Things to consider in pregnancy...... Past Hx Severity of illness, previous response and patient choice Mums ability to cope with illness Sx Impact of untreated mental illness Risk of stopping medications suddenly Consider non-pharmacological interventions if appropriate

Prescribing Principles Try to discuss before conception Avoid contraindicated medications Avoid first trimester prescribing if possible Consider switching to lower risk medication Lowest possible dose Frequent monitoring

Antipsychotics in pregnancy First Generation eg haloperidol, amisulpride, flupentixol…… Slight increase in congenital abnormalities – no clustering 20% early risk of neonatal jitteriness Neonatal jaundice Second Generation eg quetiapine, olanzapine Gestational Diabetes Olanzapine Has biggest evidence base Low risk of malformations- no clustering, cardiac septal defects No short or long-term effects on intelligence and language development in the child.

Antipsychotics in pregnancy Clozapine High risk patients by default Treatment resistant = ? What is the benefit of changing No risk of malformations. Neonatal seizures. No benefit to switching due to relapse risk Normal blood monitoring applies

Summary; Antipsychotics Risk Assessment – Ranges from mums health, safety and wellbeing to the child’s health safety and wellbeing Consider form of medication V’s Compliance Sedation levels – ability to look after self/children Ability to drive – child safety in the car

Summary; Antipsychotics 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

Antidepressants in pregnancy 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 No evidence of any short or long-term effects on intelligence and language development,

SSRI Counselling First line medication –during and out with pregnancy Frequently used Common side effects GI disturbance = nausea (different or additional to pregnancy sx) Headache Initial irritability/Worsening anxiety Self limiting for 7-10 days Not addictive May have discontinuation Sx – don’t suddenly stop

Antidepressants in pregnancy 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)

Antidepressants in pregnancy 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

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

Mood Stabilisers in pregnancy Lithium Previous risks are overestimated Known association to Ebsteins anomaly (absolute risk is 1;1000. Li increases 10-20x). Remains very small risk overall 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 Not safe in breastfeeding

Mood Stabilisers in pregnancy Lamotrigine Good evidence that lamotrigine is not a risk in pregnancy or afterwards No increase in malformation rate No evidence of developmental problems for the children Considerations Levels of sedation Development of a rash Slow titration of medication

Benzodiazepines Not linked to any teratogenic effects No increase in spontaneous abortions Risk of oral clefts is reported to be about 7 in 1000 births with diazepam. Trimesters 2 and 3: No associated damage. Birth: “floppy baby syndrome”. Mild withdrawal which is short-lived. Can reduce dose before delivery.. Milestones: There may be a slight slowing of the child’s development and weight gain over the first year or so but this seems to only last a couple of years. Then it goes back to normal.

Breastfeeding All psychotropics are excreted in breast milk Drugs with <10% Relative Infant Dose (RID) are regarded as “safe” Balance of risk to mums mental health and need to breastfeed/exposure risk to baby 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

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

Perinatal Considerations Sedation levels Medication compliance Where medication is stored Breastfeeding Ability to drive

Any questions? ashleighmacaulay@nhs.net