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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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.

8. 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

9. 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

10. 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

11. 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,

12. 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

13. 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)

14. 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

15. 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

16. 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

17. 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

18. Benzodiazepines Not linked to any teratogenic effects
No increase in spontaneous abortions
Risk of oral clefts is reported to be about 7 in 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.

19. 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

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

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

22. Any questions?