1. Psychiatric medications in pregnancy and lactation
Dr Bavi Vythilingum
Division CL Psychiatry, Dept of Psychiatry UCT
Rondebosch Medical Centre

2. Psychiatric disorders in pregnancy
In SA % of women have antenatal depression
Decision to treat – benefit to mother vs risk to child
More accurate – look at benefit to mother and child vs risk to mother and child

3. “Would a physician tell a pregnant woman with epilepsy, ‘Stop your meds and ride out the seizures until you deliver’? Are the medications of pregnant women with mental illness somehow more “optional”?”
Dr Helen Kim, MGH Center for Women’s Mental Health

4. Psychiatric medications in pregnancy and lactation

5. Prescribing principles in pregnancy and lactation
Monotherapy
Lowest effective dose

6. SSRI’s First line pharmacotherapy
Citalopram, sertraline appear best tolerated
No long term behavioural effects

7. SSRI and PPHN Six published studies 3 studies – increased risk
only three studies adequately powered.
3 studies – increased risk
Absolute risk cannot be determined,
BUT probably less than 1%.
Information does not support discontinuation or lowering the dose of the antidepressant.
RR 2.56; (95% CI, ) and OR 2.1 (95% CI, )

8. Antidepressants and teratogenicity
Several studies linking SSRI use to
Cardiac defects
AHDH
Autism
Large database studies
No face to face interview
Multiple confounders – adequate power?
Qualitatively different cases vs control
Other drug use, higher rates FAS, older
No control for effect parenting

9. Tricylic Antidepressants (TCA’s)
No increased teratogenic risk
More adverse side effect profile
particularly postural hypotension
constipation
lethality in overdose
Generally used as second line agents.

10. Other antidepressants
Venlafaxine, duloxetine, bupropion
Less data
Probably safe
MAOI’s – no data, avoid due to dietary restrictions, risk hypertension

11. Take Home Message Risk of teratogenecity
Absolute risk is not clear but appears to be small
Psychotherapy treatment of choice for perinatal depression
Weigh risk benefit ratio

12. Management of Bipolar Disorder during Pregnancy
Should be by a psychiatrist
Teratogenic risk
Lithium Ebstein’s anomaly 1-5% (vs 0.5 – 1% risk)
Na Valproate NTD, other anomalies, 3x vs other antiepileptics, 4x general population
Carbamazepine 1% risk neural tube defects (vs 0.1% risk)
Lamotrigine limited evidence, cleft palate

13. Second generation antipsychotics
Attractive
No described teratogenicity
Mood stabilisers
Metabolic side effects
Boden 2012
gestational diabetes adjusted OR, 1.77 [95% CI, ]
Higher risk SGA infant - confounders

14. Medication Summary Lithium – safest
Lamotrigine, atypicals – appears safe
Individualise for patient
Adequate risk counselling

15. Patient falls pregnant on medication
DO NOT STOP MEDICATION
Minimal decrease in risk of defects vs high risk relapse
Continue meds at lowest effective dose
Early US and anomaly scan
FOLATE

16. Medication through pregnancy
Changing maternal blood volumes
Increase doses during pregnancy
Lithium – levels monthly first 2 trimesters, every fortnight thereafter
Valproate, CBZ – guided clinically, checking levels every 2 -3 months useful

17. Delivery Liaise closely with obstetrician Hospital
Adequate pain control
IV line up
Stop lithium, benzo’s at onset labour, recommence post delivery after checking level
High risk for post natal depression/psychosis

18. Benzodiazepines
Small increased risk for cardiac/oral cleft malformations with first-trimester exposure.
Neonatal toxicity (“floppy infant syndrome”) /withdrawal
Avoid in the first trimester,late in the third trimester

19. Benzodiazepines II
To minimize neonatal withdrawal, gradually taper the mother’s benzodiazepine before delivery
Taper 3 to 4 weeks before the due date and discontinue at least 1 week before delivery.
If benzodiazepines cannot be tapered
use a short acting agent
advise the mother to discontinue benzodiazepine use as soon as she thinks she is going into labour.

20. Medication
Generally SSRI’s and TCA’s safe in pregnancy and breastfeeding
Antipsychotics – reasonably safe
Mood stabilisers – teratogenic risk
ECT – option

21. Breastfeeding and Medication
MOST WOMEN ON MEDS CAN BREASTFEED!!!!!
Risk of child dying from diarrhoea, respiratory disease, malnutrition higher than medication side effects
Breastfeeding, bedsharing mothers get more sleep
Case by case basis

22. Breastfeeding and Medication
Lowest effective maternal dose
All meds excreted into breastmilk
Watch baby
Jaundice
Excessive sleepiness
Pre term – probably best not to breastfeed

23. Breastfeeding and medication II
Antidepressants – generally safe
Antipsychotics
Infant sedation
Neonatal EPSE

24. Breastfeeding and medication III
Mood stabilisers
All present problems
Consider risk benefit carefully
Lithium
Maternal hydration important
Anticonvulsant class
Rashes

25. Eglonyl?
Sulpiride
Antipsychotic with theoretical mood elevation properties at low doses
Side effect of increasing milk supply
Sedating
NOT an effective antidepressant

26. Pregnancy and lactation summary
All medications present risk – some higher than others
Weigh risk benefit ratio
PNDSA
Otispregnancy.org

27. In general, women do not use psychotropic medications during pregnancy without good reason.
They educate themselves, struggle with treatment options, and in many cases stop medication, relapse, and then restart it when they become ill.
Being pregnant and giving birth to a child is an exhausting physical and emotional experience. A woman is vulnerable and deserves support, not shaming.