PharmaTherapy

The latest trends in mental-health medication management for consumers, professionals, and caregivers.

Psychotropic Medication Use During Pregnancy

The latest in psychotropic medication used during pregnancy.

Antidepressants: None of the antidepressants that have been studied in pregnancy have been found to increase the baseline rate of 1 percent to 3 percent for major fetal malformations. Some studies, however, report an increased rate of spontaneous abortions. The SSRIs are not associated with malformation of the fetus or fetal organs. The FDA has however, issued a public health advisory regarding first trimester exposure to Paxil (paroxetine) and cardiac malformations (1.5-2 percent vs. non-exposed 1 percent).

Lithium is generally not recommended during pregnancy. Its use has been linked to neonatal effects -- including impaired respiration, EKG and heart-rate abnormalities. Exposure in the first trimester is strongly associated with fetal cardiac irregularities. Lithium is also linked to Ebstein’s anomaly, a heart defect in which the tricuspid valve malfunctions. Lithium is highly concentrated in breast milk; therefore, nursing is contraindicated in women taking this drug.

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Antipsychotics: Of all of the antipsychotic medications, Haldol (haloperidol) is the drug that has been most studied with no congenital malformations reported during the first trimester. Therefore, it remains the preferred antipsychotic agent for use during pregnancy. The newer, second-generation antipsychotics have not been significantly studied so as to determine their safety during pregnancy. All second-generation antipsychotics carry some risk for metabolic syndrome but are associated with less risk for movement disorders.

Benzodiazepines: Although there is insufficient evidence to prove that benzodiazepines are teratogens, many believe that the use of this class of drugs should be avoided during the first trimester of pregnancy, due to a risk of orofacial clefts. A significant concern with benzodiazepine use during pregnancy is the emergence of neonatal CNS depression and withdrawal symptoms. Other symptoms of abrupt discontinuation syndrome include sedation, hypotonia (loss of muscle tonicity), apnea, reluctance to suck and cyanosis. Benzodiazepines are secreted in breast milk and can cause sedation and slowed heart rate in newborns.

Anticonvulsants: Tegretol (carbamazepine) and Depakote (divalproex sodium) are established human teratogens. They should both be avoided during pregnancy. Also, both are present in breast milk. These drugs are also linked to long-term neuro-developmental effects in offspring well into adolescence, such as EEG pattern changes, expressive language and developmental delays, and diminished intellectual performance. Information on newer anticonvulsants, such as Lamictal (lamotrigine) is more promising, but far from definitive, and therefore should be avoided during pregnancy pending further study.

It is important to assess pregnant women for mental health issues that may affect both mother-to-be and baby. Thorough medical and mental health histories should accompany a physical examination. The woman should be actively involved in the decision-making process and should be well informed about the safety, efficacy, benefits and risks of treatment options. The goal of treatment should be the amelioration of symptoms thereby affording the woman a safe and rewarding pregnancy and hopefully, a healthy newborn.

Joe Wegmann is a licensed pharmacist and clinical social worker, professional speaker and trainer, and the author of Psychopharmacology: Straight Talk on Mental Health Medications.

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