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

2. 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

3. Bethlem Royal Hospital

4. 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

5. 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

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

7. 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

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

10. Prescribing in Pregnancy

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

12. Risk-benefit analysis

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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 2014-16 data Recurrent depression
Commonest diagnosis for maternal suicide:
Recurrent depression
Not puerperal psychosis
data

20. Red Flags

21. 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

23. Case vignette

24. 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

25. 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

26. 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

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

28. 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

29. Case vignette

30. 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

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

32. 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

33. Case vignette

34. 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

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

36. Case vignette

37. 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

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

39. Objectives

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

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