December 12, 2017

Psychopharmacology in Pregnant & Lactating Women

There is a gap between what experts recommend/current evidence suggests and what we as providers sometimes intuitively practice when it comes to psychotropics in pregnant and lactating women. It is crucial to understand that the primary goal of treatment in pregnancy is to minimize the number of exposures a fetus experiences. We should limit exposure to medication but also illness. Exposure to chemically imbalanced environment of illness has negative impacts on fetus as well. When we discontinue/reduce/ switch an antidepressant or mood stabilizer just before or during pregnancy, we are dramatically increasing a woman’s chances of relapse (60-70% MDD: 80-100% bipolar disorder) and thereby increase the number of times a fetus is exposed to medication and/or illness.

Overall, antidepressant use in pregnancy and lactation appears to be relatively safe for mother and fetus/newborn. Most studies demonstrate low or undetectable blood levels of antidepressant in infant during breastfeeding. Generally we don’t need to discontinue or decrease antidepressants use in women who are attempting to conceive or pregnant as evidence has shown high rates of relapse due to discontinuation and antidepressants have been shown to be relatively safe for use during pregnancy and breastfeeding.

With regards to mood stabilizers, it is recommended not to use valproic acid and carbamazepine during pregnancy, though they are considered safe for breastfeeding. If pregnant women are prescribed these medications, they should be supplemented with high-dose folate. If a pregnant woman is prescribed Lamotrigine, she should keep taking it as prescribed and serum drug levels should be monitored. Pregnant women who have severe Bipolar Disorder and are prescribed Lithium should strongly consider continuing to take it as discontinuation is associated with high risk of relapse. However, for women with significant euthymia and few past mood episodes, the prescriber could consider slowly tapering Lithium and reintroducing after the first trimester. Any pregnant woman kept on Lithium should have her levels closely monitored during pregnancy, though, to avoid perinatal toxicity.

Antipsychotics can be safe to use in pregnancy as long as it is monitored. Patients should be considered to continue on antipsychotics, particularly those with severe mental illness. For pregnant patients on atypicals, monitor glucose and obtain U/S of fetal size in late pregnancy. The one antipsychotic that should be avoided during pregnancy and breastfeeding is Clozapine.
When treating anxiety for pregnant women, benzodiazepines may be prescribed for those with overwhelming anxiety or sleep disturbances as benefits outweigh the risks. It is important to avoid prescribing benzodiazepines before delivery, however. Some alternatives that may be considered are gabapentin and pregabalin.

Reference Articles:
Cohen LS. (2017) Evolving practice in perinatal psychopharmacology: Lessons learned. Clinical Psychiatry News. .

Payne JL., (2017). Psychopharmacology in Pregnancy and Breastfeeding. Psychiatr Clin North Am, 40(2):217-238. doi: 10.1016/j.psc.2017.01.001.

Lingford-Hughes A., Welch S., Peters L., & Nutt D. (2012). BAP updated guidelines: Evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: Recommendations from BAP. Journal of Psychopharmacology, 26(7), 899–952. pmid:22628390.