Antipsychotic Drugs in Pregnancy: A Review of Their Maternal and Fetal Effects:
There has been a significant increase in the prescription of antipsychotic medication in the community. While this increase is not specific to pregnancy it includes prescription to women across the fertile years. Despite antipsychotics being amongst the earliest of psychotropic medications to be introduced, the evidence for their effects secondary to pregnancy exposure is extremely limited. While this review does not identify clear evidence for a risk of malformation, there is evidence for risks associated with pregnancy and neonatal outcomes. Studies identified found risks that included prematurity, low and high birth weight, and gestational diabetes.
The lifetime prevalence for schizophrenia is approximately 1% and bipolar disorder is approximately 2%, making these conditions in pregnancy relatively low prevalence. The trend in wider utilization of antipsychotics in the community makes understanding the risk profile in pregnancy essential for clinicians managing women in their fertile years. This is particularly relevant when consideration is given to the nearly 49% rate of unplanned pregnancies in the community. Both schizophrenia and bipolar disorder have been associated with an increased risk of pregnancy complications such as placental abnormalities, antepartum hemorrhage, prematurity, pre-eclampsia, low birth-weight, intrauterine growth retardation, fetal distress, neonatal hypoglycemia, low Apgar score, stillbirth and congenital defects, as well as the potential for adverse neurodevelopmental outcomes independent of any risk associated with exposure to antipsychotic medication.
The uses of antipsychotic medications have increasingly extended beyond their use in schizophrenia and bipolar disorder, and are frequently being prescribed for mood and anxiety disorders, self-harming behaviors, trauma-related conditions and even insomnia. Thus, it is essential that an adequate risk benefit analysis be performed whenever any medication is being prescribed in the perinatal setting, or if there is a potential for pregnancy, and a process of obtaining informed consent adhered to. Consideration needs to be given to the risks of teratogenesis, obstetric complications, impairment of neonatal adaption and negative neurodevelopmental outcome. Once decisions are made and enacted a comprehensive plan for obstetric, pediatric and psychiatric monitoring needs to be put in place.
There is some evidence to suggest that the overall risk for obstetric complications is increased in women with severe mental illness independent of any associated antipsychotic exposure.
While this review is limited to antipsychotic treatments in pregnancy, particularly for bipolar disorder, there are other psychopharmacological treatments that are prescribed either alone or in combination with antipsychotic medications. These include antiepileptic drugs such as sodium valproate, carbamazepine and lamotrigine, and also the mood stabilizer lithium carbonate. A systematic review was published in 2010 outlining the risks from pregnancy exposure. The literature on antiepileptic drugs (AEDs) is now substantial with comprehensive follow up of children. There is clear evidence of an association between certain AEDs, such as sodium valproate, and malformation risk. There is also an association with sodium valproate, particularly at doses above 1000 g, with lower cognitive outcomes in children exposed. The literature on lithium carbonate is far more limited, but there is evidence of an increased risk of Ebstein's anomaly, a cardiac malformation.
While pharmacological treatment is often important in both the treatment and prevention of relapse for schizophrenia and bipolar disorder (particularly in pregnancy and the postpartum), ensuring there is adequate support for women and their families cannot be underestimated as part of management..
Clear recommendations about breastfeeding and sleep are also helpful for women and their families. These recommendations will depend on a discussion of the risk and benefits of breastfeeding according to the profile of the specific medication prescribed and the role of sleep in increasing vulnerability to relapse for an individual woman. Given the lack of data regarding longer term outcomes for children exposed to antipsychotic medication in pregnancy, ensuring there is appropriate ongoing monitoring of infant and child development is optimal.
There is evidence to suggest that maternal mental illness is associated with not only increased morbidity for mother and baby but also maternal mortality. In addition, mothers who are unwell with these illnesses are less sensitive in their parenting and this may increase the risk of abuse and neglect.
However, this current review has also raised the issue of wider use of antipsychotic medications for indications beyond schizophrenia and bipolar, and given the paucity of data regarding safety of these medications in pregnancy, this is an area of use where a careful risk benefit analysis needs to be made.
Quazi Imam, M.D.
Board Certified in Psychiatry.
Board Certified in Addiction Psychiatry.
Board Certified in Geriatric Psychiatry.
Board Certified in Forensic Psychiatry.
Former Assistant Professor of Psychiatry,Mount Sinai School of Medicine, NY.
Child & Adolescent Psychiatrist,Harvard Medical School Trained.
1833 W. Pioneer Parkway Tel: 682-323-4566
Arlington, Texas 76013
Websites: WWW.takemetomydoctor.com
WWW.adhdclinictx.com
There has been a significant increase in the prescription of antipsychotic medication in the community. While this increase is not specific to pregnancy it includes prescription to women across the fertile years. Despite antipsychotics being amongst the earliest of psychotropic medications to be introduced, the evidence for their effects secondary to pregnancy exposure is extremely limited. While this review does not identify clear evidence for a risk of malformation, there is evidence for risks associated with pregnancy and neonatal outcomes. Studies identified found risks that included prematurity, low and high birth weight, and gestational diabetes.
The lifetime prevalence for schizophrenia is approximately 1% and bipolar disorder is approximately 2%, making these conditions in pregnancy relatively low prevalence. The trend in wider utilization of antipsychotics in the community makes understanding the risk profile in pregnancy essential for clinicians managing women in their fertile years. This is particularly relevant when consideration is given to the nearly 49% rate of unplanned pregnancies in the community. Both schizophrenia and bipolar disorder have been associated with an increased risk of pregnancy complications such as placental abnormalities, antepartum hemorrhage, prematurity, pre-eclampsia, low birth-weight, intrauterine growth retardation, fetal distress, neonatal hypoglycemia, low Apgar score, stillbirth and congenital defects, as well as the potential for adverse neurodevelopmental outcomes independent of any risk associated with exposure to antipsychotic medication.
The uses of antipsychotic medications have increasingly extended beyond their use in schizophrenia and bipolar disorder, and are frequently being prescribed for mood and anxiety disorders, self-harming behaviors, trauma-related conditions and even insomnia. Thus, it is essential that an adequate risk benefit analysis be performed whenever any medication is being prescribed in the perinatal setting, or if there is a potential for pregnancy, and a process of obtaining informed consent adhered to. Consideration needs to be given to the risks of teratogenesis, obstetric complications, impairment of neonatal adaption and negative neurodevelopmental outcome. Once decisions are made and enacted a comprehensive plan for obstetric, pediatric and psychiatric monitoring needs to be put in place.
There is some evidence to suggest that the overall risk for obstetric complications is increased in women with severe mental illness independent of any associated antipsychotic exposure.
While this review is limited to antipsychotic treatments in pregnancy, particularly for bipolar disorder, there are other psychopharmacological treatments that are prescribed either alone or in combination with antipsychotic medications. These include antiepileptic drugs such as sodium valproate, carbamazepine and lamotrigine, and also the mood stabilizer lithium carbonate. A systematic review was published in 2010 outlining the risks from pregnancy exposure. The literature on antiepileptic drugs (AEDs) is now substantial with comprehensive follow up of children. There is clear evidence of an association between certain AEDs, such as sodium valproate, and malformation risk. There is also an association with sodium valproate, particularly at doses above 1000 g, with lower cognitive outcomes in children exposed. The literature on lithium carbonate is far more limited, but there is evidence of an increased risk of Ebstein's anomaly, a cardiac malformation.
While pharmacological treatment is often important in both the treatment and prevention of relapse for schizophrenia and bipolar disorder (particularly in pregnancy and the postpartum), ensuring there is adequate support for women and their families cannot be underestimated as part of management..
Clear recommendations about breastfeeding and sleep are also helpful for women and their families. These recommendations will depend on a discussion of the risk and benefits of breastfeeding according to the profile of the specific medication prescribed and the role of sleep in increasing vulnerability to relapse for an individual woman. Given the lack of data regarding longer term outcomes for children exposed to antipsychotic medication in pregnancy, ensuring there is appropriate ongoing monitoring of infant and child development is optimal.
There is evidence to suggest that maternal mental illness is associated with not only increased morbidity for mother and baby but also maternal mortality. In addition, mothers who are unwell with these illnesses are less sensitive in their parenting and this may increase the risk of abuse and neglect.
However, this current review has also raised the issue of wider use of antipsychotic medications for indications beyond schizophrenia and bipolar, and given the paucity of data regarding safety of these medications in pregnancy, this is an area of use where a careful risk benefit analysis needs to be made.
Quazi Imam, M.D.
Board Certified in Psychiatry.
Board Certified in Addiction Psychiatry.
Board Certified in Geriatric Psychiatry.
Board Certified in Forensic Psychiatry.
Former Assistant Professor of Psychiatry,Mount Sinai School of Medicine, NY.
Child & Adolescent Psychiatrist,Harvard Medical School Trained.
1833 W. Pioneer Parkway Tel: 682-323-4566
Arlington, Texas 76013
Websites: WWW.takemetomydoctor.com
WWW.adhdclinictx.com
