Psychotropic Management in Pregnancy
Critical Phases in Normal Development
Risk of termination if toxicity occurs prior to implantation.
Prior to placenta formation, developing embryo likely not exposed to drugs.
Weeks 3 to 8 are critical for organ development.
Weeks 3 to 8—cardiovascular formation.
Weeks 4-5 up to 16-18—neurologic development.
Weeks 6 to 9—lip and palate development.
Drug exposure during later stages of pregnancy may result in decreased birth weight and poor neonatal functioning (e.g., respiratory distress).
General Principles
Incidence of congenital malformation, 3% to 4% in the United States.
Perform a thorough evaluation, including current mood state, maternal psychiatric history, comorbid medical disorders, obstetric history, substance use history, and prior treatment.
Perform risk-benefit analysis to determine need for medication, keeping in mind the pregnancy period is a high-risk time for onset or relapse of psychiatric illness.
As indicated, consider alternatives to medications, including frequent visits and psychotherapy (e.g., cognitive-behavioral).
Factors to consider in selecting a psychotropic medication include:
Staying apprised of ever-changing evidence-based data on safety of use during pregnancy, including FDA risk category.
Preferably use agents with the most available evidence-based safety data for pregnancy/lactation. Medications with conflicting data should be avoided.
Of note, safety data for psychotropic use during pregnancy is limited, often conflicting, and may not be controlled for confounding factors.
Properties such as fewer side effects, low drug-drug interactions, low risk of hypotensive and anticholinergic effects, and few or no metabolites.
Consideration to potential adverse interactions with obstetric, anesthetic, and analgesic agents.
Minimize exposure to fetus by:
Using the minimum dosage to achieve remission of maternal target symptoms.
Avoiding multiple medications.
Monitoring
Continuous monitoring of maternal psychiatric target symptoms with ongoing risk-benefit analysis.
Documentation to support improvement of symptoms with pharmacologic treatment.
Consultation and coordination with obstetrician.
Counseling and detailed informed consent including:
Incidence of congenital malformation 3% to 4% in the United States.
Risk of congenital malformation increased with psychotropic medications, particularly during weeks 6 to 10.
Discussion of available evidence about medication being considered, including documentation of conversation.
Encourage patient to involve significant other during discussion and decision making.
Antidepressants
Selective serotonin reuptake inhibitors (SSRIs)
Until recently, research supported safety of SSRI use during pregnancy.
Recent data indicate risks of SSRI use during pregnancy, including:
Data on paroxetine having increased risk of major malformation, including cardiac (e.g., ventricular septal defect).
Studies reporting prematurity, low birth weight, serotonergic withdrawal, seizure-like activity, and poor neonatal adaptation (e.g., respiratory distress, hypoglycemia, tremulousness, altered muscle tone, jitteriness).
Study indicating increased risk of persistent pulmonary hypertension of the newborn (unexposed risk ˜2/1000 live births).
One study reporting long-term effects of impairment in cognition and psychomotor skills (e.g., coordination, fine motor skills, body control).
Although fluoxetine has the most safety data available, its long halflife may result in neonatal complications (e.g., serotonergic withdrawal) and increased exposure to infant during breastfeeding.
Sertraline appears to have more favorable safety data compared to other SSRIs due to evidence indicating low transfer to fetus and favorable breastfeeding profile.
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