Antipsychotic therapy during early and late pregnancy. A systematic review

Olanzapine in pregnancy and breastfeeding: a review of data from global safety surveillance

Background

Olanzapine use has been reported during pregnancy and breastfeeding, but there are no controlled clinical trials assessing the safety of olanzapine exposure to infants and fetuses. The purpose of this report was to review and analyze prospective post-marketing cases of pregnancy and breastfeeding with olanzapine, in order to guide clinicians and women on the use of olanzapine therapy during pregnancy and/or breastfeeding.

Methods

A worldwide safety database maintained by Eli Lilly and Company was searched for all spontaneous-reported data regarding olanzapine use during pregnancy and/or breastfeeding. Cases reported prior to pregnancy outcome were considered to be prospective, and follow-up was pursued after the delivery date to assess outcome.

Results

Outcome data were available for 610 prospectively identified pregnancies during which olanzapine was used. The majority of women had normal births (66%), although premature births were reported in 9.8% and perinatal conditions in 8% of the pregnancies. A total of 102 pregnancies reported olanzapine treatment during breastfeeding. In these infants, the most commonly reported adverse events were somnolence (3.9%), irritability (2%), tremor (2%), and insomnia (2%), although the majority of pregnancies reported no adverse events (82.3%).

Conclusions

The frequency of fetal outcomes in these prospectively identified pregnancies exposed to olanzapine did not differ from rates of outcomes reported in the general population. These data may be useful to help guide clinicians and women decide to continue, or discontinue, olanzapine therapy during pregnancy and/or breastfeeding, but should be considered within the limitations associated with spontaneously reported data. Women should notify their clinicians if they become pregnant or intend to become pregnant while being treated with olanzapine. Because of limited experience in humans, olanzapine should be used in pregnancy only when potential benefit justifies potential risk to the fetus. Olanzapine should only be considered during breastfeeding when the potential benefit justifies the potential risk to the infant.

Fetal antipsychotic exposure in a changing landscape: seeing the future

Pregnant women and their fetuses are increasingly likely to be exposed to antipsychotics. However, safety data remain limited. This editorial suggests that, in future, well-designed observational pharmaco-epidemiology is our best chance of illuminating risk for exposed populations and of informing decision-making for women and clinicians.

Prevalence and trends in the use of antipsychotic medications during pregnancy in the U.S., 2001-2007: a population-based study of 585,615 deliveries

This study aims to estimate the prevalence of and temporal trends in prenatal antipsychotic medication use within a cohort of pregnant women in the U.S. We identified live born deliveries to women aged 15-45 years in 2001-2007 from 11 U.S. health plans participating in the Medication Exposure in Pregnancy Risk Evaluation Program. We ascertained prenatal exposure to antipsychotics from health plan pharmacy dispensing files, gestational age from linked infant birth certificate files, and ICD-9-CM diagnosis codes from health plan claims files. We calculated the prevalence of prenatal use of atypical and typical antipsychotics according to year of delivery, trimester of pregnancy, and mental health diagnosis. Among 585,615 qualifying deliveries, 4,223 (0.72%) were to women who received an atypical antipsychotic and 548 (0.09%) were to women receiving a typical antipsychotic any time from 60 days before pregnancy through delivery. There was a 2.5-fold increase in atypical antipsychotic use during the study period, from 0.33% (95% confidence interval: 0.29%, 0.37%) in 2001 to 0.82% (0.76%, 0.88%) in 2007, while the use of typical antipsychotics remained stable. Depression was the most common mental health diagnosis among deliveries to women with atypical antipsychotic use (63%), followed by bipolar disorder (43%) and schizophrenia (13%). The number and proportion of pregnancies exposed to atypical antipsychotics has increased dramatically in recent years. Studies are needed to examine the comparative safety and effectiveness of these medications relative to other therapeutic options in pregnancy.

Gynecologic and reproductive health concerns of adolescents using selected psychotropic medications

Psychiatric disorders are common in adolescent girls and may require chronic therapies with psychotropic medications. Antipsychotic medications and mood stabilizers have been increasingly prescribed to and widely used by adolescents for a variety of both "on" an "off" label indications. Studies on the safety and monitoring of these medications in adolescent girls have shown important potential for gynecologic and reproductive adverse effects. The objective of this article is to review the mechanisms for and management of menstrual disorders mediated by hyperprolactinemia associated with antipsychotic medications, hypothyroidism associated with lithium and quetiapine, and the independent association of polycystic ovary syndrome (PCOS) in girls using valproic acid. Beyond their susceptibility to these disruptions in the menstrual cycle, adolescent girls with psychiatric illness also have increased sexual risk behaviors. These behaviors makes it all the more important to review teratogenicity and clinically relevant contraceptive drug interactions in adolescent girls using these psychotropic medications.

Drug treatment developments in schizophrenia and bipolar mania: latest evidence and clinical usefulness

Schizophrenia and bipolar disorder are often highly debilitating with chronic courses, and psychotropic drugs represent cornerstones in the treatment. The primary aim of the review was to summarize the latest evidence with regards to the efficacy and effectiveness of drug treatment of schizophrenia and the manic phases of bipolar disorder. Schizophrenia systematic reviews conclude that antipsychotic drugs are effective in treating overall symptoms of psychosis and in preventing relapse. Some of the newer agents, the second-generation antipsychotics (SGAs), have demonstrated superiority compared with the older first-generation drugs and other SGAs but side-effect differences among the drugs are of a greater magnitude than effect differences. The pragmatic randomized trials of effectiveness have shown a longer time until treatment discontinuation for olanzapine compared with other antipsychotics. Cohort studies have found superiority for the long-acting injection formulations compared with the oral formulations of the drugs, and lower total mortality risk in users of antipsychotics compared with non-users. In bipolar mania SGAs have shown superior antimanic efficacy compared with other mood-stabilizing drugs. In conclusion antipsychotics, in particular some of the SGAs, seem to be drugs of first choice for both schizophrenia and bipolar mania. This perspective review focused on mean effects but the group means may not always be particularly useful as schizophrenia and bipolar mania are biologically heterogeneous disorders with large inter-individual variations in drug response and tolerance. In patients with a prior drug history the different pharmacological and clinical profiles may be exploited in subsequent choices of drugs.

Psychopharmacological treatment of mood and anxiety disorders during pregnancy

Many women with psychiatric disorders want to become mothers and only a minority seek advise prior to becoming pregnant. In those women, in whom pregnancy can be planned, the decision, if a medication is required for stabilisation and which one to choose if this is the case, is easier to make than in women in whom pregnancy occurs unplanned. The physician has to weigh the risk that a relapse of the psychiatric disorder during pregnancy poses to the foetus against the reproductive risk of psychotropic drugs. This presentation is intended to assist in understanding the general principles of pharmacotherapy during pregnancy as well as the morphological, perinatal and neurobehavioural toxicity of antidepressants, antipsychotics, benzodiazepines and mood stabilisers.

Clinical pharmacology of dopamine-modulating agents in Tourette's syndrome

Forty years of research and clinical practice have proved dopamine (DA) receptor antagonists to be effective agents in the treatment of Tourette's syndrome (TS), allowing a significant tic reduction of about 70%. Their main effect seems to be mediated by the blockade of the striatal DA-D2 receptors. Various typical and atypical agents are available and there is still discord between experts about which of them should be considered as first choice. In addition, there are suggestions to use DA receptor agonists such as pergolide or non-DA-modulating agents. The present chapter is focusing on the clinical pharmacology of DA-modulating agents in the treatment of TS. The introduction outlines their clinical relevance and touches on the hypotheses of the role of DA in the pathophysiology of TS. Subsequently, general information about the mechanisms of action and adverse effects are provided. The central part of the chapter forms a systematic review of all DA-modulating agents used in the treatment of TS, including an overview of studies on their effectiveness, and a critical discussion of their specific adverse effects. The present chapter closes with a summary of the body of evidence and a description of the resulting recommendations for the pharmacological treatment of TS.

The psychopharmacology algorithm project at the Harvard South Shore Program: an update on schizophrenia

This article is an update of the algorithm for schizophrenia from the Psychopharmacology Algorithm Project at the Harvard South Shore Program. A literature review was conducted focusing on new data since the last published version (1999-2001). The first-line treatment recommendation for new-onset schizophrenia is with amisulpride, aripiprazole, risperidone, or ziprasidone for four to six weeks. In some settings the trial could be shorter, considering that evidence of clear improvement with antipsychotics usually occurs within the first two weeks. If the trial of the first antipsychotic cannot be completed due to intolerance, try another until one of the four is tolerated and given an adequate trial. There should be evidence of bioavailability. If the response to this adequate trial is unsatisfactory, try a second monotherapy. If the response to this second adequate trial is also unsatisfactory, and if at least one of the first two trials was with risperidone, olanzapine, or a first-generation (typical) antipsychotic, then clozapine is recommended for the third trial. If neither trial was with any these three options, a third trial prior to clozapine should occur, using one of those three. If the response to monotherapy with clozapine (with dose adjusted by using plasma levels) is unsatisfactory, consider adding risperidone, lamotrigine, or ECT. Beyond that point, there is little solid evidence to support further psychopharmacological treatment choices, though we do review possible options.

Pregnancy outcomes following maternal exposure to second-generation antipsychotics given with other psychotropic drugs: a cohort study

OBJECTIVES

Second-generation antipsychotics (SGAs), in conjunction with other psychotropic medications, are increasingly used to treat psychiatric disorders in pregnancy. The few available studies investigating the reproductive safety of SGAs did not reach conclusive results, and none have compared monotherapy with polytherapy involving other psychotropic medications.

DESIGN

Descriptive cohort study using a prospectively collected database.

SETTING

Motherisk Program, The Hospital for Sick Children, Toronto, Canada.

PARTICIPANTS

133 women exposed to SGAs and other psychotropic drugs and 133 matched healthy controls were assessed and analysed. Outcomes of mother-child pairs exposed to SGAs in monotherapy (N=37) were compared with those exposed to SGAs with other psychotropic medications (in polytherapy; N=96).

MAIN OUTCOME MEASURES

Maternal, pregnancy, delivery and neonatal outcomes.

RESULTS

72% of exposed women received SGAs in polytherapy, and 101 women took their medications throughout pregnancy. These women had significantly higher pre-pregnancy weight, experienced more associated comorbidities and instrumental deliveries, and delivered a greater proportion of large for gestational age neonates. There were no differences in maternal weight gain in pregnancy between the exposed and comparison groups and between the monotherapy-exposed and polytherapy-exposed subgroups. The exposed neonates were more likely to be born premature, were admitted more often to the neonatal intensive care unit, presented with poor neonatal adaptation signs and had higher rates of congenital malformations. All the aforementioned neonatal outcomes were found mainly in the polytherapy subgroup.

CONCLUSIONS

The use of SGAs in polytherapy was prevalent in the assessed cohort and was associated with adverse pregnancy outcomes for both the mother and the child. In utero exposure to SGA monotherapy appears to be associated with less risk to the fetus. Future research should focus on polytherapy in pregnancy in order to define its reproductive safety and to separate the effects of medication exposure, underlying psychopathology and associated comorbidities.

Clinical interventions for women with schizophrenia: pregnancy

OBJECTIVE

A comprehensive treatment program for schizophrenia needs to include services to women of childbearing age that address contraception, pregnancy, and postpartum issues, as well as safe and effective parenting. To update knowledge in these areas, a summary of the recent qualitative and quantitative literature was undertaken.

METHOD

The search terms 'sexuality,''contraception,''pregnancy,''postpartum,''custody,' and 'parenting' were entered into PubMed, PsycINFO, and SOCINDEX along with the terms 'schizophrenia' and 'antipsychotic.' Publications in English for all years subsequent to 2000 were retrieved and their reference lists further searched in an attempt to arrive at a distillation of useful clinical recommendations.

RESULTS

The main recommendations to care providers are as follows: take a sexual history and initiate discussion about intimate relationships and contraception with all women diagnosed with schizophrenia. During pregnancy, adjust antipsychotic dose to clinical status, link the patient with prenatal care services, and help her prepare for childbirth. There are pros and cons to breastfeeding while on medication, and these need thorough discussion. During the postpartum period, mental health home visits should be provided. Parenting support is critical.

CONCLUSION

The comprehensive treatment of schizophrenia in women means remembering that all women of childbearing age are potential new mothers.

Pharmacological treatment of schizophrenia

BACKGROUND

A lack of human and financial resources, as well as effective health systems, leads to a worldwide treatment gap for schizophrenia. The aim of this paper is to propose evidence-based antipsychotics interventions for people with schizophrenia with special focus in low and middle income countries (LAMIC) reality.

METHOD

A comprehensive search was conducted to locate the main clinical trials, reviews and relevant meta-analyses, and a number of the main recent international clinical practice guidelines.

RESULTS

First- and second-generation antipsychotics are similarly effective in the acute treatment of psychotic symptoms. In LAMIC, the treatment of choice for medical treatment of psychotic conditions is the group of so-called 'first generation antipsychotics' (FGAs) preferentially delivered in a community-based service model.

CONCLUSIONS

Although the symptomatic control is essential, it is not the ultimate goal of treatment. The main aim of treatment is to improve functional recovery and social reintegration of patients.

Neonatal complications after maternal concomitant use of SSRI and other central nervous system active drugs during the second or third trimester of pregnancy

Drugs acting on the central nervous system (CNS) and given to a pregnant woman during the latter part of pregnancy may affect neonatal morbidity of the infant. Little is known on the combined effects of different categories of such drugs. The redeeming of prescriptions for CNS-active drugs during the second or third trimester of pregnancy was studied by linkage between a register of prescribed drugs and the Swedish Medical Birth Register for the deliveries during 2006-2008 (n = 15,045 live-born infants). Neonatal morbidity was defined as the presence of neonatal diagnoses of respiratory problems, hypoglycemia, convulsions, or other CNS pathologic abnormalities including intraventricular hemorrhage, or low 5-minute Apgar score. The risk of such neonatal morbidity after maternal use of selective serotonin reuptake inhibitors (SSRIs) with or without other CNS-active drugs were evaluated as odds ratios or risk ratios, comparing with unexposed infants or infants only exposed to SSRI drugs. An increased risk for neonatal morbidity was seen for most studied groups of CNS-active drugs when used alone. Benzodiazepines seemed to have a stronger effect than other sedatives/hypnotics. The combination of SSRIs with 1 or more other CNS-active drug groups increased the risk for neonatal morbidity. This was seen for all types of sedatives/hypnotics, which may suggest a confounding by indication. Polypharmacy with CNS-active drugs during the later part of the pregnancy seems to increase the occurrence of neonatal morbidity but difference in nature or strength of underlying psychiatric pathology may confound the findings.

Temporal trends in general and age-specific fertility rates among women with schizophrenia (1996-2009): a population-based study in Ontario, Canada

PURPOSE

There is substantial evidence that women with schizophrenia in many parts of the world have fewer children than their peers. Our objective was to analyze recent trends in general and age-specific fertility rates among women with schizophrenia in Ontario, Canada.

METHODS

We conducted a repeated cross-sectional population-based study from 1996 to 2009 using population-based linked administrative databases for the entire province of Ontario. Women aged 15-49 years were classified into schizophrenia and non-schizophrenia groups in each successive 12-month period. Annual general and age-specific fertility rates were derived.

RESULTS

The general fertility rate (GFR) among women with schizophrenia was 1.16 times higher in 2007-2009 than in 1996-1998 (95% confidence interval [CI] 1.04-1.31). The annual GFR ratio of women with vs. without schizophrenia was 0.41 (95% CI 0.36-0.47) in 2009, which was slightly higher than the same ratio in 1996 of 0.30 (95% CI 0.25-0.35). Annual age-specific fertility rates (ASFR) increased over time among women with schizophrenia aged 20-24, 25-29, 35-39 and 40-44 years, but the increase was not always statistically significant. Among women aged 20-24 years, the ASFR ratio in women with vs. without schizophrenia was not significant by the end of the study period (0.93, 95% CI 0.70-1.22).

CONCLUSIONS

The general fertility rate among women with schizophrenia appears to have increased modestly over the past 13 years. Clinical care and health policy should consider new strategies that focus on the mental health of women with schizophrenia as new mothers, while optimizing healthy pregnancies and child rearing.

Prenatal antipsychotic exposure and neuromotor performance during infancy

CONTEXT

Despite the expanding clinical utility of antipsychotics beyond psychotic disorders to include depressive, bipolar, and anxiety disorders, reproductive safety data regarding the neurodevelopmental sequelae of fetal antipsychotic exposure are scarce.

OBJECTIVE

To examine whether intrauterine antipsychotic exposure is associated with deficits in neuromotor performance and habituation in 6-month-old infants.

DESIGN, SETTING, AND PARTICIPANTS

A prospective controlled study was conducted from December 1999 through June 2008 at the Infant Development Laboratory of the Emory Psychological Center examining maternal-infant dyads (N=309) at 6 months postpartum with pregnancy exposure to antipsychotics (n=22), antidepressants (n=202), or no psychotropic agents (n=85). Examiners masked to maternal-infant exposure status administered a standardized neuromotor examination (Infant Neurological International Battery [INFANIB]) that tests posture, tone, reflexes, and motor skills and a visual habituation paradigm using a neutral female face.

MAIN OUTCOME MEASURES

The INFANIB composite score; number of trials required to achieve a 50% decrease in infant fixation during a visual habituation task; and mean time looking at the stimulus across 10 trials.

RESULTS

Infants prenatally exposed to antipsychotics (mean=64.71) showed significantly lower INFANIB scores than those with antidepressant (mean=68.57) or no psychotropic (mean=71.19) exposure, after controlling for significant covariates (F(2,281)=4.51; P=.01; partial η(2)=0.033). The INFANIB scores were also significantly associated with maternal psychiatric history, including depression, psychosis, and overall severity/chronicity (P's.05) and maternal depression during pregnancy was associated with less efficient habituation (r(245)=0.16; P.02). There were no significant differences regarding habituation between medication exposure groups.

CONCLUSIONS

Among 6-month-old infants, a history of intrauterine antipsychotic exposure, compared with antidepressant or no psychotropic exposure, was associated with significantly lower scores on a standard test of neuromotor performance, highlighting the need for further scrutiny of the reproductive safety and neurodevelopmental sequelae of fetal antipsychotic exposure. Disentangling medication effects from maternal illness effects, which also contributed, remains a critical challenge.

Women and psychosis

BACKGROUND

There are subtle differences in the presentation of psychosis that depend on the biological sex of the person exhibiting the symptoms. Because much of the early research in the field was conducted on male animals and on men, several issues of importance to women have been relatively neglected until recently. Current research into psychotic illness is beginning to analyze results for men and women separately and greater emphasis on qualitative methods has allowed the experiences of women patients to be documented.

METHODS

The last decade of research into the many facets of psychosis in women were reviewed for this paper by introducing the relevant search terms into PubMed, PsycINFO and SOCINDEX.

RESULTS

Subtle differences are reported in several areas, with important ramifications for treatment.

CONCLUSIONS

It is important for service providers to devise treatment programs that address the different needs of the two sexes. Effective treatment of women with psychosis is especially important in that these women are often mothers, whose well being impacts on the health of the next generation.

Lithium in pregnancy: the need to treat, the duty to ensure safety

INTRODUCTION

Untreated bipolar disorder during pregnancy leads to detrimental repercussions on the mother-infant pair's health. Despite different drugs having been proposed as mood stabilizers, lithium remains the first-choice agent for preventing mood changes.

AREAS COVERED

Analyzing up-to-date information on the reproductive safety of lithium and providing practice guidelines to optimize its use during pregnancy.

EXPERT OPINION

Findings from prospective and case-control studies confirm an increased, specific risk of Ebstein's anomaly (4.45-7.6/1000 live births), although lower than that previously reported. A potential increase in the risk of neural tube defects should also be taken into consideration. Moreover, several perinatal complications may occur, and even in the presence of relatively low infant serum levels, in the case of drug exposure during late pregnancy. Despite such concerns, lithium should still be considered the first-choice agent for treating bipolar disorder in pregnancy. Indeed, the U.S. FDA recently issued a new warning regarding the reproductive safety of antipsychotics. Moreover, the risk of fetal valproate/carbamazepine syndrome (and the confirmed neurodevelopmental teratogenicity of valproate) contraindicates the use of both medications, whereas the use of lamotrigine is limited by efficacy concerns. However, women who need lithium treatment during pregnancy should be carefully monitored: a strict gynecologic and psychiatric surveillance and, probably, preconception folate supplementation is highly advisable. Moreover, delivery should be programmed in Neonatal Intensive Care Units to ensure optimal management of potential iatrogenic perinatal complications.

Treatment of psychosis during pregnancy - a case report and a mini-review

Nielsen RE. Treatment of psychosis during pregnancy - a case report and a mini-review.

OBJECTIVE

Describe clinical problems in treating a patient with psychotic symptoms during pregnancy by presenting a case report, and review the current evidence on antipsychotic drugs during pregnancy.

METHODS

The review consists of a non-systematic clinical review of current data on treatment with antipsychotics during pregnancy. The case, a 27 year old female initially diagnosed with posttraumatic stress disorder (PTSD) after a rape and emotionally unstable personality disorder, illustrates some of the common challenges a clinician meets. The patient initially discontinues all treatment as she is unsure if the drugs could have a teratogenic effect and is changed to a treatment that is regarded as safe during pregnancy.

RESULTS

The current data supports treatment with chlorpromazine although there is a risk of side effects, e.g. extrapyramidal symptoms and hypotension, but also treatment with olanzapine and risperidone. If the patient is currently treated with clozapine, this treatment should be continued, due to clozapines unique efficacy profile. Blood monitoring for six months after birth is recommended when the newborn has been exposed to clozapine treatment.

CONCLUSION

Current evidence on treatment with antipsychotics during pregnancy is sparse, but not treating is associated with increased risks compared to treatment.

Suicidal mothers

Background:

Epidemiological research has demonstrated that suicidal ideation is a relatively frequent complication of pregnancy in both developed and developing countries. Hence, the aims of this study are: to assess whether or not pregnancy may be considered a period highly susceptible to suicidal acts; to recognize potential contributing factors to suicidal behaviors; to describe the repercussions of suicide attempts on maternal, fetal, and neonatal outcome; to identify a typical profile of women at high risk of suicide during pregnancy.

Methods:

Medical literature information published in any language since 1950 was identified using MEDLINE/PubMed, Scopus, and Google Scholar databases. Search terms were: "pregnancy", (antenatal) "depression", "suicide". Searches were last updated on 28 September 2010. Forty-six articles assessing the suicidal risk during pregnancy and obstetrical outcome of pregnancies complicated by suicide attempts were analyzed, without methodological limitations.

Results:

Worldwide, frequency of suicidal attempts and the rate of death by suicidal acts are low. Although this clinical event is rare, the consequences of a suicidal attempt are medically and psychologically devastating for the mother-infant pair. We also found that common behaviors exist in women at high risk for suicide during pregnancy. Review data indeed suggest that a characteristic profile can prenatally identify those at highest risk for gestational suicide attempts.

Conclusions:

Social and health organizations should make all possible efforts to identify women at high suicidal risk, in order to establish specific programs to prevent this tragic event. The available data informs health policy makers with a typical profile to screen women at high risk of suicide during pregnancy. Those women who have a current or past history of psychiatric disorders, are young, unmarried, unemployed, have incurred an unplanned pregnancy (eventually terminated with an induced abortion), are addicted to illicit drugs and/or alcohol, lack effective psychosocial support, have suffered from episodes of sexual or physical violence are particularly vulnerable.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: recommendations from the British Association for Psychopharmacology

These guidelines from the British Association for Psychopharmacology address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting, involving experts in schizophrenia and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from the participants and interested parties, and cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. The practice recommendations presented are based on the available evidence to date, and seek to clarify which interventions are of proven benefit. It is hoped that the recommendations will help to inform clinical decision making for practitioners, and perhaps also serve as a source of information for patients and carers. They are accompanied by a more detailed qualitative review of the available evidence. The strength of supporting evidence for each recommendation is rated.

Selective serotonin reuptake inhibitor exposure during early pregnancy and the risk of birth defects

OBJECTIVE

To assess the methodological value of studies that signaled one or more selective serotonin reuptake inhibitors (SSRIs) as teratogenic agents.

METHOD

Medical literature, published in English (1980-November 2010), was searched using MEDLINE/PubMed, TOXNET, EMBASE, and The Cochrane Library to identify all articles, reporting primary data that suggested any increased rate of congenital malformations following prenatal exposure to SSRIs as a group or single SSRI agents.

RESULTS

Reviewed studies showed some severe methodological limitations, such as data coming from retrospective studies and incomplete information available with reference to timing of exposure and dosages. Further, data continue to be extrapolated from automated databases that do not declare whether the women reported actually used the prescribed medication. Further, it should be noted the distinct lack of research analysis available with reference to the potential impact of non-iatrogenic confounders on pregnancy.

CONCLUSION

In light of such considerations, the hypothesized teratogenicity of SSRIs remains undemonstrated. Hence, further, well-designed research is needed to differentiate definitively the detrimental impact of depression on pregnancy outcomes from potential iatrogenic events.

Drug treatment for mood disorders in pregnancy

PURPOSE OF REVIEW

During the last few years, several researches, often showing contradictory findings, have investigated the safety of psychotropic medications used for treating mood disorders in pregnancy. Hence, the necessity exists to update this information constantly in order to ensure the safest option for the mother-infant pair.

RECENT FINDINGS

The risk of fetal anomalies associated with early in-utero exposure to antidepressants seems to be increased after paroxetine and clorimipramine exposure, whereas prenatal exposure to nearly all antidepressants is linked to the potential onset of the Prenatal Antidepressant Exposure Syndrome. As regards classic mood stabilizers, the teratogenic risk historically reported with lithium should probably be softened, whereas valproate is the medication which shows the strongest association with fetal anomalies. An increased risk of autism-spectrum disorders and infant neurodevelopmental delay is also associated with valproate exposure through the placenta. No significant reproductive safety data are available on atypical antipsychotics, although such medications may indirectly increase the rate of fetal malformation by inducing gestational diabetes.

SUMMARY

Avoiding the use of clorimipramine, paroxetine, valproate, and atypical antipsychotics during pregnancy is advisable. However, when starting or continuing pharmacological treatment during pregnancy, clinicians should consider not only the intrinsic iatrogenic risk of birth defects or perinatal complications, but also the general safety profile for the expectant mother. Indeed, specific adverse reactions (such as nausea, vomiting, constipation, and excessive weight gain) may aggravate the classic clinical findings of pregnancy, thus indirectly facilitating the occurrence of pregnancy complications and fetal and neonatal problems.

Antipsychotics in pregnancy

Women who are pregnant and who have a history of psychosis are commonly managed with antipsychotic medications. The evidence regarding the use of antipsychotics in pregnancy has been insufficient to provide adequate support for this practice and is a concern for clinicians and women alike. This review presents literature surrounding the use of antipsychotic medications in pregnancy, providing an overview of the historical and contemporary perspectives which influence clinicians prescribing practices. Data were sourced from Medline, CINAHL, PsycINFo, using the terms antipsychotics with pregnancy and psychosis or schizophrenia. This was expanded to include the most common atypical antipsychotics: olanzapine, risperidone, clozapine, quetiapine, ziprasidone and aripiprazole. Literature was found reporting the use of antipsychotic medications in pregnancy since the introduction of antipsychotics in the 1950s, comprising mainly of authors' reviews of the literature, case studies, retrospective reports, drug company registries and more recently a prospective comparative study. This review identifies that the literature provides no clear answer for clinicians as to the risk associated with the use of antipsychotics in pregnancy. To this effect, recently in Australia, the National Register of Antipsychotic Medications in Pregnancy was established to prospectively collect information regarding outcomes for mother and baby, when antipsychotic medications have been used during pregnancy.

Use of antipsychotics during pregnancy and breastfeeding

There is growing acceptance that pregnancy itself is not a protective factor against mental disorders. Indeed, some mental disorders such as psychotic and bipolar disorders may become worse during pregnancy and the immediate postpartum period. In pregnant women with a mental disorder that can be treated with antipsychotics, the known risks -teratogenic, obstetric, neonatal and those affecting the mother- indicate that, in general, the risk of the non-treated disorder is higher than that resulting from the use of antipsychotics and that the reduction in psychoticism improves the overall prognosis of these women. All the antipsychotics marketed in Spain are included in category C of the US Food and Drug Administration, with the exception of clozapine and piperazine, which are included in category B. The use of all of these drugs should be avoided during breast feeding as far as possible. The most reliable current recommendations indicate that optimal control of severe mental disorders should be maintained during pregnancy, the postpartum and subsequent periods. These recommendations also indicate that women with mental disorders must be considered as high risk and that both these women and their pregnancies should be constantly monitored. The currently available scientific information does not allow more than relatively secure individually-tailored recommendations to be made. When taking the decision of whether or not to treat with antipsychotics, the use of a risk-benefit relationship is crucial, with the participation of the woman's partner or legal representative, other physicians and even the clinical pharmacist if necessary.