1. Medication for Mummies
Dr Ashleigh Macaulay
Clinical Lead MMHS
Mummy

2. Questions?

3. 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

4. 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

5. 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

6. 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

7. 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)

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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)

15. 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

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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

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

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

26. Questions?
Any new questions?
Anything not covered

27. 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

29. Thank You