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

Effect of aripiprazole on neural tube development in early chick embryos

INTRODUCTION

Aripiprazole (ARI) is a recently developed antipsychotic medication that belongs to the second generation of antipsychotics. The literature has contradictory information regarding ARI, which has been classified as pregnant use category C by the FDA.

METHODS

125 pathogen-free fertilized eggs were incubated for 28 h and divided into five groups of 25 eggs each (including the control group), and 18 eggs with intact integrity were selected from each group. After the experimental groups were divided, ARI was administered subblastodermally with a Hamilton micro-injector at 4 different doses (1 mg/kg, 5 mg/kg, 10 mg/kg, 20 mg/kg). At the 48th hour of incubation, all eggs were hatched and embryos were removed from the embryonic membranes. And then morphologic (position of the neural tube (open or closed), crown-rump length, number of somites, embryological development status), histopathologic (apoptosis (caspase 3), cell proliferation (PCNA), in situ recognition of DNA breaks (tunnel)), genetic (BRE gene expression) analyzes were performed.

RESULTS

According to the results of the morphological analysis, when the frequency of neural tube patency was evaluated among the experimental groups, a statistically significant difference was determined between the control group and all groups (p < 0.001). In addition, the mean crown-rump length and somite number of the embryos decreased in a dose-dependent manner compared to the control group. It was determined that mRNA levels of the BRE gene decreased in embryos exposed to ARI compared to the control group (p < 0.001).

CONCLUSION

Morphologically, histopathologically, and genetically, aripiprazole exposure delayed neurogenesis and development in early chick embryos. These findings suggest its use in pregnant women may be teratogenic. We note that these results are preliminary for pregnant women, but they should be expanded and studied with additional and other samples.

Prescription medication use during pregnancy in the United States from 2011 to 2020: trends and safety evidence

BACKGROUND

Medication use during pregnancy has increased in the United States despite the lack of safety data for many medications.

OBJECTIVE

This study aimed to inform research priorities by examining trends in medication use during pregnancy and identifying gaps in safety information on the most commonly prescribed medications.

STUDY DESIGN

We identified population-based cohorts of commercially (MarketScan 2011-2020) and publicly (Medicaid Analytic eXtract/Transformed Medicaid Statistical Information System Analytic Files 2011-2018) insured pregnancies ending in live birth from 2 health care utilization databases. Medication use was based on filled prescriptions between the date of last menstrual period through delivery, as well as the period before the last menstrual period and during specific trimesters. We also included a cross-sectional representative sample of pregnancies ascertained by the National Health and Nutrition Examination Survey (2011-2020), with information on prescription medication use during the preceding month obtained through maternal interviews. Teratogen Information System was used to classify the available evidence on teratogenic risk.

RESULTS

Among over 3 million pregnancies, the medications most commonly dispensed at any time during pregnancy were analgesics, antibiotics, and antiemetics. The top medications were ondansetron (16.8%), amoxicillin (13.5%), and azithromycin (12.4%) in MarketScan, nitrofurantoin (22.2%), acetaminophen (21.3%; mostly as part of acetaminophen-hydrocodone products), and ondansetron (19.5%) in Medicaid Analytic eXtract/Transformed Medicaid Statistical Information System Analytic Files, and levothyroxine (5.0%), sertraline (2.9%), and insulin (2.9%) in the National Health and Nutrition Examination Survey group. The most commonly dispensed suspected teratogens during the first trimester were antithyroid medications. The use of antidiabetic and psychotropic medications has continued to increase in the United States during the last decade, opioid dispensation has decreased by half, and antibiotics and antiemetics continue to be common. For one-quarter of medications, there is insufficient evidence available to characterize their safety profile in pregnancy.

CONCLUSION

There is a need for more drug research in pregnant patients. Future research should focus on anti-infectives with high utilization and limited level of evidence on safety for use during pregnancy. Although lack of evidence is not evidence of safety concerns, it does not indicate risk either. In many instances, the benefits outweigh the risks when these medications are used clinically, and some of the medications with no proven safety may be necessary to treat patients.

Pearls for Caring for the Boarding Psychiatric Patient in the Emergency Department

BACKGROUND

Emergency department (ED) boarding of psychiatric patients is a national issue that continues to worsen at a disturbing rate. Implementing strategies in the ED to provide continuous care for patients can help secure patient safety.

OBJECTIVE

The objective of this review is to discuss the boarding of psychiatric patients and its implications. It will focus on executing best clinical practices in managing boarding psychiatric patients in the ED. It will not focus on the treatment of substance use disorders.

DISCUSSION

This article will address the pearls for management plans that can be implemented in the ED, alongside discussing pregnant and elderly patients. Risk factors, complications, and treatments for boarding psychiatric patients are discussed.

CONCLUSIONS

Patients with psychiatric disorders boarding in the ED need careful consideration of management plans to mitigate patient safety events.

Pregnancy related complications in women with hypertrophic cardiomyopathy: a nationwide population-based cohort study

BACKGROUND

The impact of hypertrophic cardiomyopathy (HCM) on cardiovascular and obstetrical outcomes in pregnant women remains unclear, particularly in Asian populations. This study aimed to evaluate the maternal cardiovascular and obstetrical outcomes in Korean women with HCM.

METHODS

Using data from the Korean National Health Insurance Service database, we identified women who gave birth via cesarean section or vaginal delivery after being diagnosed with HCM between 2006 and 2019. Maternal cardiovascular and obstetrical outcomes were assessed based on the trimester of pregnancy.

RESULTS

This study included 122 women and 158 pregnancies. No maternal deaths were noted; however, 21 cardiovascular events, such as hospital admission for cardiac problems, including heart failure and atrial fibrillation (AF), new-onset AF or ventricular tachycardia (VT) occurred in 14 pregnancies (8.8%). Cardiac events occurred throughout pregnancy with a higher occurrence in the third trimester. Cesarean sections were performed in 49.3% of the cases, and all cardiovascular outcomes occurring after delivery were observed in patients who had undergone cesarean sections. Seven cases involved preterm delivery, and two of these cases were accompanied by cardiac events, specifically AF. Pre-existing arrhythmia (AF: odds ratio (OR): 7.44, 95% confidence interval (CI): 2.61-21.21, P < 0.001; VT: OR: 31.61, 95% CI: 5.85-172.77, P < 0.001) was identified as a predictor for composite outcomes of cardiovascular events or preterm delivery.

CONCLUSIONS

Most pregnant women with HCM were well-tolerated. However, cardiovascular complications could occur in some patients. Therefore, planned delivery may be necessary for selected patients, especially the women with pre-existing arrhythmias.

Inpatient antipsychotic medication switching and rehospitalization risk among patients with schizophrenia-spectrum disorders

OBJECTIVE

To describe patterns of antipsychotic switching among patients hospitalized for schizophrenia and to correlate antipsychotic switching with hospital readmission risk.

METHODS

We identified 3295 patients with index hospitalizations for schizophrenia or schizoaffective disorder from New York State Medicaid claims 2017-2018 who had filled at least one prescription for an antipsychotic in both the 44 days (one month +14 day grace period) prior to and after their admission. We identified patients who had kept or switched any of their antipsychotic medication between the pre- and post-periods surrounding their index hospitalization. We compared the kept and switched any groups, adjusting for patient characteristics.

RESULTS

Of patients who had filled antipsychotic prescriptions in both the 44 days prior to and after their hospitalization, 1599 (48.6 %) had switched at least one antipsychotic and 1215 (36.8 %) had switched their primary antipsychotic. Switching any antipsychotic was associated with increased hazards of readmission, HR = 1.21, 95%CI 1.09-1.35, which was slightly concentrated during the first 90 days after hospital discharge.

CONCLUSIONS

Switching antipsychotic medications during hospitalization occurs commonly and is associated with higher rehospitalization risk following hospital discharge.

Association between prenatal antipsychotic exposure and the risk of attention-deficit/hyperactivity disorder and autism spectrum disorder: a systematic review and meta-analysis

The paucity of evidence regarding the safety of gestational antipsychotic exposure has led to treatment discontinuation in pregnant women with severe mental health conditions. This systematic review and meta-analysis aimed to summarise the current evidence on the association between gestational antipsychotic exposure and attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in children (Study protocol registered in PROSPERO:CRD42022311354). Five studies included in our meta-analysis with around 8.6 million pregnancy episodes in nine different countries/regions. Results from our meta-analysis indicate that the heightened risks of ASD and ADHD in children gestationally exposed to antipsychotics appear to be attributable to maternal characteristics, rather than having a causal relationship with the antipsychotic exposure during pregnancy. The results underscore the importance of meticulously monitoring the neurodevelopment of children born to mothers with mental illnesses, which can facilitate early interventions and provide requisite support.

Antipsychotic-induced weight gain: exploring the role of psychiatrists in managing patients' physical health - challenges, current options and direction for future care

Antipsychotics and severe mental illness (SMI) are associated with weight gain, and obesity increases the risks of cardiometabolic disease and premature death. These present management and liability issues for psychiatrists. Physical healthcare for people with SMI is poor, and this may partly be owing to training limitations and lack of proactiveness by psychiatrists. Ethically and legally, psychiatrists have a duty to avoid unnecessary harm and to maintain an acceptable standard of care. This would apply particularly to patients receiving compulsory treatment for their SMI owing to their vulnerability. Discrepancy between psychiatric and non-psychiatric approaches to pharmacological treatment creates ambiguity, and weight gain could demotivate antipsychotic adherence. This article explores how the Mental Health Act could be used to address these issues, and the ethical considerations, and proposes how long-acting glucagon-like peptide-1 receptor agonists could be introduced into existing psychiatric practice as a treatment option for antipsychotic-induced weight gain and obesity in SMI.

Prenatal exposition to haloperidol: A preclinical narrative review

Pre-existing maternal mental disorders may affect the early interactions between mother and baby, impacting the child's psychoemotional development. The typical antipsychotic haloperidol can be used during pregnancy, even with some restrictions. Its prescription is not limited to psychotic disorders, but also to other psychiatric conditions of high incidence and prevalence in the woman's fertile period. The present review focused on the preclinical available data regarding the biological and behavioral implications of embryonic exposure to haloperidol. The understanding of the effects of psychotropic drugs during neurodevelopment is important for its clinical aspect since there is limited evidence regarding the risks of antipsychotic drug treatment in pregnant women and their children. Moreover, a better comprehension of the mechanistic events that can be affected by antipsychotic treatment during the critical period of neurodevelopment may offer insights into the pathophysiology of neurodevelopmental disorders. The findings presented in this review converge to the existence of several risks associated with prenatal exposure to such medication and emphasize the need for further studies regarding its dimensions.

Quetiapine and other antipsychotic medications during pregnancy: a 15-year follow-up of a university hospital birth register

PURPOSE

To survey trends of antipsychotic use during pregnancy and examine the associations between the use of quetiapine or any antipsychotic and adverse obstetric and neonatal outcomes.

METHODS

Birth register study of 36,083 women who gave birth at Kuopio University Hospital, Finland, between 2002 and 2016. Obstetric and neonatal outcomes between women using quetiapine (N = 152) or any antipsychotic (N = 227) were compared to controls (N = 35,133).

RESULTS

Altogether 246 (0.7%) women used antipsychotic medications during pregnancy and 153 (62,2%) of these women used quetiapine. Antipsychotic usage increased from 0.4% to 1.0% during the 15-year follow-up. Women using antipsychotics were more likely to smoke, drink alcohol, use illicit drugs, use other psychotropic medications, and have higher pre-pregnancy body mass index. Quetiapine use was associated with higher risk of increased postpartum bleeding in vaginal delivery (aOR 1.65; 95%CI 1.13-2.42), prolonged neonatal hospitalization (≥5 days) (aOR 1.54; 95%CI 1.10-2.15), and higher placental to birth weight ratio (PBW ratio) (aB 0.009; 95%CI 0.002-0.016). Use of any antipsychotic was associated with a higher risk of gestational diabetes mellitus (aOR 1.64; 95%CI 1.19-2.27), increased postpartum bleeding in vaginal delivery (aOR 1.50; 95%CI 1.09-2.07), prolonged neonatal hospitalization (≥5 days) (aOR 2.07; 95%CI 1.57-2.73), and higher PBW ratio (aB 0.007; 95%CI 0.001-0.012).

CONCLUSION

The use of antipsychotic medications increased among Finnish pregnant women from 2002 to 2016. Pregnant women using antipsychotics appear to have a higher risk for some adverse pregnancy and birth outcomes and may benefit from more frequent maternity care follow-ups.

The Association of Perceived Labor Agentry and Depression and/or Anxiety

OBJECTIVE

Pregnancies complicated by perinatal mood disorders or a history of mental health disorder are at increased risk for complications including postpartum depression/anxiety. Patients' perceived control over childbirth is known to be an important factor for development of postpartum depression/anxiety. It is unclear whether women with preexisting and/or current depression and/or anxiety have different perceptions of control during childbirth compared with those without these comorbidities. This study aimed to evaluate the association between a current and/or prior diagnosis of depression and/or anxiety and scores on the Labour Agentry Scale (LAS), a validated tool evaluating patient's experience of control over their labor and delivery.

STUDY DESIGN

This is a cross-sectional study of nulliparous patients admitted at term to a single center. Participants completed the LAS after delivery. A trained researcher performed detailed chart reviews for all participants. Participants were identified as having a current or historical diagnosis of depression/anxiety by self-report confirmed by chart review. Scores on the LAS were compared between those with versus without a diagnosis of depression/anxiety prior to admission for delivery.

RESULTS

A total of 73 (44.8%) of the 149 participants held a current and/or prior diagnosis of depression and/or anxiety. Baseline demographics were similar between those with and without depression/anxiety. Mean scores on the LAS (range: 91-201) were significantly lower for those with depression/anxiety than those without a prior diagnosis (150.0 vs. 160.5, p < 0.01). Even after controlling for mode of delivery, admission indication, anesthesia, and Foley balloon usage, participants with anxiety and depression had scores that were on average 10.4 points lower on the LAS (95% confidence interval: -19.25, -1.62).

CONCLUSION

Participants with a current and/or prior diagnosis of depression and/or anxiety scored lower on the LAS as compared with those without psychiatric diagnoses. Patients with psychiatric diagnoses may benefit from increased education and support during childbirth.

KEY POINTS

· Control over childbirth is an important factor in the development of postpartum depression/anxiety.. · Patients with a prior or current diagnosis of anxiety and depression have lower labor agentry scores.. · These differences remained significant even when controlling for confounders such as delivery mode..

Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 5

PURPOSE

To assess the evidence regarding safety and efficacy of psychiatric medications to treat mental health conditions during pregnancy and lactation. The conditions reviewed include depression, anxiety and anxiety-related disorders, bipolar disorder, and acute psychosis. For information on screening and diagnosis, refer to American College of Obstetricians and Gynecologists (ACOG) Clinical Practice Guideline Number 4, "Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum" (1).

TARGET POPULATION

Pregnant or postpartum individuals with mental health conditions with onset that may have predated the perinatal period or may have occurred for the first time in pregnancy or the first year postpartum or may have been exacerbated in that time.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of one specialist in obstetrics and gynecology and one maternal-fetal medicine subspecialist appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and two external subject matter experts. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes recommendations on treatment and management of perinatal mental health conditions including depression, anxiety, bipolar disorders, and acute postpartum psychosis, with a focus on psychopharmacotherapy. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

Maternal antipsychotic use during pregnancy and congenital malformations

BACKGROUND

Existing data may underestimate the potential teratogenic effects of prenatal antipsychotic exposure because of lacking data on miscarriages and induced abortions.

OBJECTIVE

This study aimed to present a comprehensive analysis based on information on pregnancies ending in termination, miscarriage, stillbirth, and live birth.

STUDY DESIGN

We conducted a population-based cohort study in Denmark of clinically recognized singleton pregnancies with the first-trimester scan performed from 2008 to 2017. We compared the risk of major malformations between pregnancies exposed to antipsychotics in the first trimester and unexposed pregnancies. In secondary analyses, the comparison was made with pregnancies of women who used antipsychotics before but not during pregnancy (discontinuers). We used weighted log-binomial regression to estimate adjusted prevalence ratios and propensity score fine stratifications for confounding control. We performed 4 sensitivity analyses, including a sibling-controlled analysis.

RESULTS

Of the 503,158 pregnancies, 1252 (0.2%) were of women who filled an antipsychotic prescription in the first trimester. Major malformations were present in 7.3% of antipsychotic-exposed pregnancies, 5.1% of unexposed pregnancies, and 6.0% of discontinuers' pregnancies. The adjusted prevalence ratio was 1.23 (95% confidence interval, 1.01-1.50) among exposed pregnancies compared with unexposed pregnancies. The prevalence ratio was attenuated to 1.14 (95% confidence interval, 0.88-1.48) compared with discontinuers and 1.08 (95% confidence interval, 0.47-2.49) in the sibling analysis. Similar findings were observed with cardiac malformations. Results were consistent for classes and individual antipsychotics, and remained robust across the 4 sensitivity analyses.

CONCLUSION

Our findings suggest limited or no overall teratogenic effect of first-trimester antipsychotic exposure. For individual antipsychotics, with estimations based on very few cases, further studies with sufficient sample sizes are warranted.

Optimizing Therapeutic Drug Monitoring in Pregnant Women: A Critical Literature Review

BACKGROUND

More than 90% of pregnant women take at least one drug during pregnancy. Drug dose adjustments during pregnancy are sometimes necessary due to various pregnancy-induced physiological alterations frequently associated with lower plasma concentrations. However, the clinical relevance or benefits of therapeutic drug monitoring (TDM) in pregnant women have not been specifically studied. Clinical pharmacokinetic studies in pregnant women are incredibly challenging for many reasons. Despite this, regulatory agencies have made efforts to encourage the inclusion of this population in clinical trials to achieve more information on the pharmacotherapy of pregnant women. This review aims to provide support for TDM recommendations and dose adjustments in pregnant women.

METHODS

The search was conducted after a predetermined strategy on PubMed and Scopus databases using the MeSH term "pregnancy" alongside other terms such as "Pregnancy and dose adjustment," "Pregnancy and therapeutic drug monitoring," "Pregnancy and PBPK," "Pregnancy and pharmacokinetics," and "Pregnancy and physiological changes."

RESULTS

The main information on TDM in pregnant women is available for antiepileptics, antipsychotics, antidepressants, antibiotics, antimalarials, and oncologic and immunosuppressive drugs.

CONCLUSIONS

More data are needed to support informed benefit-risk decision making for the administration of drugs to pregnant women. TDM and/or pharmacokinetic studies could ensure that pregnant women receive an adequate dosage of an active drug. Mechanistic modeling approaches potentially could increase our knowledge about the pharmacotherapy of this special population, and they could be used to better design dosage regimens.

A Clinical Review of the Use of Common Psychiatric Medications in Pregnancy: Guidelines for Obstetrical Providers

Psychotropic medications are commonly prescribed in pregnancy, and obstetrical providers should be informed about how and when to use them. The current narrative review addresses the use of some of the most commonly prescribed psychotropic medications-antidepressants, sedatives and hypnotics, and antipsychotic drugs. The aim is neither a complete review of psychiatric disorders in pregnancy nor all possible psychological and pharmacological treatments for mental illness around the time of pregnancy. Rather, the focus is on therapeutic considerations for general obstetrical providers.

Physiologically-based pharmacokinetic model to investigate the effect of pregnancy on risperidone and paliperidone pharmacokinetics: Application to a pregnant woman and her neonate

This study aimed to determine the effects of pregnancy and ontogeny on risperidone and paliperidone pharmacokinetics by assessing their serum concentrations in two subjects and constructing a customized physiologically-based pharmacokinetic (PBPK) model. Risperidone and paliperidone serum concentrations were determined in a pregnant woman and her newborn. PBPK models for risperidone and paliperidone in adults, pediatric, and pregnant populations were developed and verified using the Simcyp simulator. These models were then applied to our two subjects, generating their "virtual twins." Effects of pregnancy on both drugs were examined using models with fixed pharmacokinetic parameters. In the neonatal PBPK simulation, 10 different models for estimating the renal function of neonates were evaluated. Risperidone was not detected in the serum of both pregnant woman and her newborn. Maternal and neonatal serum paliperidone concentrations were between 2.05-3.80 and 0.82-1.03 ng/ml, respectively. Developed PBPK models accurately predicted paliperidone's pharmacokinetics, as shown by minimal bias and acceptable precision across populations. The individualized maternal model predicted all observed paliperidone concentrations within the 90% prediction interval. Fixed-parameter simulations showed that CYP2D6 activity largely affects risperidone and paliperidone pharmacokinetics during pregnancy. The Flanders metadata equation showed the lowest absolute bias (mean error: 22.3% ± 6.0%) and the greatest precision (root mean square error: 23.8%) in predicting paliperidone plasma concentration in the neonatal population. Our constructed PBPK model can predict risperidone and paliperidone pharmacokinetics in pregnant and neonatal populations, which could help with precision dosing using the PBPK model-informed approach in special populations.

A Review: Integrative Perspectives on the Features and Clinical Management of Psychotic Episodes in Pregnancy

Psychotic episodes represent one of the most complex manifestations of various mental illnesses, and these encompass a wide variety of clinical manifestations that together lead to high morbidity in the general population. Various mental illnesses are associated with psychotic episodes; in addition, although their incidence and prevalence rates have been widely described in the general population, their correct identification and treatment is a challenge for health professionals in relation to pregnancy. In pregnant women, psychotic episodes can be the consequence of the manifestation of a previous psychiatric illness or may begin during the pregnancy itself, placing not only the mother, but also the fetus at risk during the psychotic episode. In addition, we cannot forget that both pharmacological and nonpharmacological management are complex given the different teratogenic effects of various neuroleptic drugs or mood stabilizers; moreover, the recommendation is that patients should be followed together with different specialists to maintain close contact during puerperium given the high incidence of recurrence of psychotic episodes. In addition, we cannot forget that a large portion of these patients for whom the onset times of such episodes are during pregnancy have a greater probability of an unpredictable psychiatric illness that requires a postpartum follow up, in addition to the postpartum psychotic episodes, at some point in their lives. Therefore, the purpose of this review is to summarize the epidemiology of psychotic breaks during pregnancy related to the main mental illnesses that affect this population and to summarize the main pharmacological treatments available for their clinical management.

The maternal health of American Indian and Alaska Native people: A scoping review

Indigenous people in the United States experience disadvantage in multiple domains of health. Yet, their maternal health receives limited research attention. With a focus on empirical research findings, we conduct a scoping review to address two questions: 1) what does the literature tell us about the patterns and prevalence of maternal mortality and morbidity of American Indian and Alaska Native (AI/AN) people? and 2) how do existing studies explain these patterns? A search of CINAHL, Embase and Medline yielded 4757 English-language articles, with 66 eligible for close review. Of these, few focused specifically on AI/AN people's maternal health. AI/AN people experience higher levels of maternal mortality and morbidity than non-Hispanic White people, with estimates that vary substantially across samples and geography. Explanations for the maternal health of AI/AN people focused on individual factors such as poverty, cultural beliefs, and access to healthcare (e.g. lack of insurance). Studies rarely addressed the varied historical and structural contexts of AI/AN tribal nations, such as harms associated with colonization and economic marginalization. Research for and by Indigenous communities and nations is needed to redress the effective erasure of AI/AN people's maternal health experiences and to advance solutions that will promote their health and well-being.

Antipsychotic Use in Early Pregnancy and the Risk of Maternal and Neonatal Complications

OBJECTIVE

To assess the association between antipsychotic use in early pregnancy and the risk of maternal and neonatal metabolic complications.

METHODS

We conducted a population-based retrospective cohort study (January 1, 2010, to December 31, 2016) using the Health and Welfare Database in Taiwan. Pregnant women (18 to 49 years of age) were grouped as antipsychotic users (ie, received oral antipsychotic monotherapy during the first 20 weeks of pregnancy) and nonusers. Antipsychotic users were further categorized into first-generation antipsychotic and second-generation antipsychotic users. Propensity score methods, including matching and inverse probability of treatment weighting, were used to balance covariates. Conditional logistic regression and Cox proportional hazards models were used to compare risks of maternal (gestational diabetes mellitus, preterm birth) and neonatal (low birth weight [LBW], macrosomia) outcomes.

RESULTS

Antipsychotic users had a notably higher risk of preterm birth compared with nonusers (adjusted HR, 1.29; 95% CI, 1.04 to 1.60), but the risk of gestational diabetes mellitus (HR, 1.21; 95% CI, 0.94 to 1.56), LBW (odds ratio [OR], 1.07; 95% CI, 0.84 to 1.37), and macrosomia (OR, 1.36; 95% CI, 0.63 to 2.92) did not differ between the two groups. Among women who received antipsychotics, the odds of LBW were significantly higher in second-generation antipsychotic users compared with first-generation antipsychotic users (adjusted OR, 1.32; 95% CI, 1.04 to 1.68).

CONCLUSION

This study found that using antipsychotics in early pregnancy did not result in a greater risk of metabolic complications both for mothers and newborns. For women requiring treatment with antipsychotics during pregnancy, they should be monitored for the risk of preterm birth and low infant birth weight.

The Influence of Prenatal Exposure to Quetiapine Fumarate on the Development of Dopaminergic Neurons in the Ventral Midbrain of Mouse Embryos

The effects of second-generation antipsychotics on prenatal neurodevelopment, apoptotic neurodegeneration, and postnatal developmental delays have been poorly investigated. Even at standard doses, the use of quetiapine fumarate (QEPF) in pregnant women might be detrimental to fetal development. We used primary mouse embryonic neurons to evaluate the disruption of morphogenesis and differentiation of ventral midbrain (VM) neurons after exposure to QEPF. The dopaminergic VM neurons were deliberately targeted due to their roles in cognition, motor activity, and behavior. The results revealed that exposure to QEPF during early brain development decreased the effects of the dopaminergic lineage-related genes Tyrosine hydroxylase(Th), Dopamine receptor D1 (Drd1), Dopamine transporter (Dat), LIM homeobox transcription factor 1 alfa (Lmx1a), and Cell adhesion molecule L1 (Chl1), and the senescent dopaminergic gene Pituitary homeobox 3 (Pitx3). In contrast, Brain derived neurotrophic factor (Bdnf) and Nuclear receptor-related 1 (Nurr1) expressions were significantly upregulated. Interestingly, QEPF had variable effects on the development of non-dopaminergic neurons in VM. An optimal dose of QEPF (10 µM) was found to insignificantly affect the viability of neurons isolated from the VM. It also instigated a non-significant reduction in adenosine triphosphate formation in these neuronal populations. Exposure to QEPF during the early stages of brain development could also hinder the formation of VM and their structural phenotypes. These findings could aid therapeutic decision-making when prescribing 2nd generation antipsychotics in pregnant populations.

Association of Maternal Antipsychotic Prescription During Pregnancy With Standardized Test Scores of Schoolchildren in Denmark

Importance

An increasing number of individuals fill antipsychotic prescriptions during pregnancy, and concerns have been raised about prenatal antipsychotic exposure on neurodevelopmental outcomes.

Objective

To examine whether maternal prescription fill for antipsychotics during pregnancy was associated with performance in standardized tests among schoolchildren.

Design, Setting, and Participants

This register-based cohort study included 667 517 children born in Denmark from January 1, 1997, to December 31, 2009, and who were attending public primary and lower secondary school. All children had completed at least 1 language (Danish) or mathematics test as part of the Danish National School Test Program between 2010 and 2018. Data were analyzed from November 1, 2021, to March 31, 2022.

Exposures

Antipsychotic prescriptions filled by pregnant individuals were obtained from the Danish National Prescription Register.

Main Outcomes and Measures

Differences in standardized test scores (range, 1-100; higher scores indicate better test results) in language and mathematics between children of mothers with and without antipsychotic prescription fills during pregnancy were estimated using linear regression models. Seven sensitivity analyses, including a sibling-controlled analysis, were performed.

Results

Of the 667 517 children included (51.2% males), 1442 (0.2%) children were born to mothers filling an antipsychotic prescription during pregnancy. The mean (SD) age of children at the time of testing spanned from 8.9 (0.4) years in grade 2 to 14.9 (0.4) years in grade 8. Maternal prescription fill for antipsychotics was not associated with performance in language (crude mean test score: 50.0 [95% CI, 49.1-50.9] for the exposed children vs 55.4 [95% CI, 55.4-55.5] for the unexposed children; adjusted difference, 0.5 [95% CI, -0.8 to 1.7]) or in mathematics (crude mean test score: 48.1 [95% CI, 47.0-49.3] for the exposed children vs 56.1 [95% CI, 56.1-56.2] for the unexposed children; adjusted difference, 0.4 [95% CI, -1.0 to 1.8]). There was no evidence that results were modified by the timing of filling prescriptions, classes (first-generation and second-generation) of antipsychotics, or the most commonly prescribed antipsychotic monotherapies, including chlorprotixene, flupentixol, olanzapine, zuclopenthixol, quetiapine, perphenazine, and methotrimeprazine. The results remained robust across sensitivity analyses, including sibling-controlled analyses, negative control exposures analyses, and probabilistic bias analyses.

Conclusions and Relevance

In this register-based cohort study, maternal prescription fill for antipsychotics during pregnancy did not appear to be associated with standardized test scores in the offspring. The findings provide further reassuring data on offspring neurodevelopmental outcomes associated with antipsychotic treatment during pregnancy.

Antipsychotic utilization patterns in pregnant women with psychotic disorders: a 16-year population-based cohort study

Despite growing concern about reproductive safety of antipsychotics, there is a paucity of research specifically assessing prenatal antipsychotic prescribing practices for psychotic disorders. This population-based cohort study identified women aged 15-50 years with diagnosis of psychotic disorders, who delivered their first and singleton child between 2003-2018 in Hong Kong, with an aim to examine temporal trends and predictors of prenatal antipsychotic use as well as antipsychotic utilization patterns before and during pregnancy. Data were retrieved from territory-wide medical-record database of public healthcare services. Of 804 women, 519 (65%) redeemed at least one prescription for antipsychotics during pregnancy. Older age at conception (25-34 years: OR 2.12 [95% CI 1.22-3.67]; 35-50 years: 2.52 [1.38-4.61]; 15-24 years as reference category) and antipsychotic treatment within 12 months pre-pregnancy (24.22 [16.23-36.16]) were significantly associated with prenatal antipsychotic use. Second-generation-antipsychotic (SGA) use during pregnancy increased over 16-year study period, while prenatal first-generation-antipsychotic (FGA) use showed declining trend. Overall antipsychotic and SGA use progressively decreased across pre-pregnancy and trimesters of pregnancy. Further analyses on antipsychotic use trajectories revealed that 87.4% (n = 459) of 529 women receiving antipsychotics in 12-month pre-pregnancy redeemed antipsychotic prescription during pregnancy, and 63.4% (n = 333) continued antipsychotic treatment throughout pregnancy. Only 7.5% of the cohort (n = 60) commenced antipsychotics in pregnancy. This is one of the few studies evaluating real-world prenatal antipsychotic utilization among women with psychotic disorders. Future research delineating risk conferred by illness-related factors and antipsychotic exposure on adverse maternal and fetal outcomes is warranted to facilitate treatment guideline development.

Neonatal morbidity after fetal exposure to antipsychotics: a national register-based study

OBJECTIVE

To investigate the admission rate to neonatal care and neonatal morbidity after maternal use of antipsychotics during pregnancy.

DESIGN

A population-based register study.

SETTING

Information on all singleton births between July 2006 and December 2017 in Sweden including data on prescription drugs, deliveries and infants' health was obtained from the Swedish Medical Birth Register, the Prescribed Drug Register and the Swedish Neonatal Quality Register. Exposed infants were compared with unexposed infants and with infants to mothers treated with antipsychotics before or after but not during pregnancy.

PARTICIPANTS

The cohort comprised a total of 1 307 487 infants, of whom 2677 (0.2%) were exposed to antipsychotics during pregnancy and 34 492 (2.6%) had mothers who were treated before/after the pregnancy.

OUTCOME MEASURES

The primary outcome was admission rate to neonatal care. Secondary outcomes were the separate neonatal morbidities.

RESULTS

Of the exposed infants, 516 (19.3%) were admitted to neonatal care compared with 98 976 (7.8%) of the unexposed infants (adjusted risk ratio (aRR): 1.7; 95% CI: 1.6 to 1.8), with a further increased risk after exposure in late pregnancy. The highest relative risks were seen for withdrawal symptoms (aRR: 17.7; 95% CI: 9.6 to 32.6), neurological disorders (aRR: 3.4; 95% CI: 2.4 to 5.7) and persistent pulmonary hypertension (aRR: 2.1; 95% CI: 1.4 to 3.1) when compared with unexposed infants. The absolute risks for these outcomes were however low among the exposed infants, 1.3%, 1.8% and 1.0%, respectively, and the relative risks were lower when compared with infants to mothers treated before/after the pregnancy.

CONCLUSION

Fetal exposure to antipsychotics was associated with an increased risk of neonatal morbidity. The effects in the exposed infants seem transient and predominantly mild, and these findings do not warrant discontinuation of a necessary treatment but rather increased monitoring of these infants. The increased risk of persistent pulmonary hypertension requires further studies.

Association of Antipsychotic Drug Exposure in Pregnancy With Risk of Neurodevelopmental Disorders: A National Birth Cohort Study

IMPORTANCE

Although antipsychotic drugs cross the placenta and animal data suggest potential neurotoxic effects, information regarding human neurodevelopmental teratogenicity is limited.

OBJECTIVE

To evaluate whether children prenatally exposed to antipsychotic medication are at an increased risk of neurodevelopmental disorders (NDD).

DESIGN, SETTINGS, AND PARTICIPANTS

This birth cohort study used data from the Medicaid Analytic eXtract (MAX, 2000-2014) and the IBM Health MarketScan Research Database (MarketScan, 2003-2015) for a nationwide sample of publicly (MAX) and privately (MarketScan) insured mother-child dyads with up to 14 years of follow-up. The MAX cohort consisted of 2 034 883 children who were not prenatally exposed and 9551 who were prenatally exposed to antipsychotic medications; the MarketScan consisted of 1 306 408 and 1221 children, respectively. Hazard ratios were estimated through Cox proportional hazards regression, using propensity score overlap weights for confounding control. Estimates from both cohorts were combined through meta-analysis.

EXPOSURES

At least 1 dispensing of a medication during the second half of pregnancy (period of synaptogenesis), assessed for any antipsychotic drug, at the class level (atypical and typical), and for the most commonly used drugs (aripiprazole, olanzapine, quetiapine, risperidone, and haloperidol).

MAIN OUTCOMES AND MEASURES

Autism spectrum disorder, attention-deficit/hyperactivity disorder, learning disability, speech or language disorder, developmental coordination disorder, intellectual disability, and behavioral disorder, identified using validated algorithms, and the composite outcome of any NDD. Data were analyzed from April 2020 to January 2022.

RESULTS

The MAX cohort consisted of 2 034 883 unexposed pregnancies and 9551 pregnancies with 1 or more antipsychotic drug dispensings among women with a mean (SD) age of 26.8 (6.1) years, 204 (2.1%) of whom identified as Asian/Pacific Islander, 2720 (28.5%) as Black, 500 (5.2%) as Hispanic/Latino, and 5356 (56.1%) as White. The MarketScan cohort consisted of 1 306 408 unexposed and 1221 exposed pregnancies among women with a mean (SD) age of 33.1 (5.0) years; race and ethnicity data were not available. Although the unadjusted results were consistent with an approximate 2-fold increased risk for most exposure-outcome contrasts, risks were no longer meaningfully increased after adjustment (eg, pooled unadjusted vs adjusted hazard ratios [95% CI] for any NDD after any antipsychotic exposure: 1.91 [1.79-2.03] vs 1.08 [1.01-1.17]), with the possible exception of aripiprazole (1.36 [1.14-1.63]). Results were consistent across sensitivity analyses.

CONCLUSIONS AND RELEVANCE

The findings of this birth cohort study suggest that the increased risk of NDD seen in children born to women who took antipsychotic drugs late in pregnancy seems to be explained by maternal characteristics and is not causally related with prenatal antipsychotic exposure. This finding highlights the importance of closely monitoring the neurodevelopment of the offspring of women with mental illness to ensure early intervention and support. The potential signal for aripiprazole requires replication in other data before causality can be assumed.

Complex chronic conditions among children born to women with schizophrenia

PURPOSE

Maternal schizophrenia is linked to complications in offspring near the time of birth. Whether there is also a higher future risk of the child having a complex chronic condition (CCC) - a pediatric condition affecting any bodily system expected to last at least 12 months that is severe enough to require specialty care and/or a period of hospitalization - is not known.

METHODS

In this population-based health administrative data cohort study (Ontario, Canada, 1995-2018), the risk for CCC was compared in 5066 children of women with schizophrenia (the exposed) vs. 2,939,320 unexposed children. Adjusted hazard ratios (aHR) were generated for occurrence of any CCC, by CCC category, and stratified by child sex, and child prematurity.

RESULTS

CCC was more frequent in the exposed (7.7 per 1000 person-years [268 children]) than unexposed (4.2 per 100 person-years [124,452 children]) - an aHR of 1.25 (95% CI 1.10-1.41). aHRs were notably higher in 5 of 9 CCC categories: neuromuscular (1.73, 1.28-2.33), cardiovascular (1.94, 1.64-2.29), respiratory (1.83, 1.32-2.54), hematology/immunodeficiency (2.24, 1.24-4.05) and other congenital or genetic defect (1.59, 1.16-2.17). The aHR for CCC was more pronounced among boys (1.32, 1.13-1.55) than girls (1.16, 0.96-1.40), and of similar magnitude in term (1.22, 1.05-1.42) and preterm infants (1.18, 0.95-1.46).

CONCLUSIONS

The risk for a CCC appears to be higher in children born to women with schizophrenia. This finding introduces opportunities for targeted preconception counselling, optimization of maternal risk factors, and intervention to support a vulnerable parent population who will experience unique challenges caring for a child with CCCs.

In utero exposure to antipsychotic medication and psychiatric outcomes in the offspring

Information on neurodevelopmental effects of antenatal exposure to antipsychotics is limited to 10 studies, all examining children up to 5 years of age or less. The paper aimed to investigate the association between in utero exposure to antipsychotics and psychiatric outcomes in children using Danish nationwide registers. In total, 9011 liveborn singletons born 1998-2015 in Denmark whose mothers took antipsychotic medication before pregnancy were identified. Children whose mothers continued to take antipsychotics during pregnancy were compared with children of mothers who discontinued antipsychotics before pregnancy. As a negative control, paternal antipsychotic use in the same window was investigated. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression for the primary outcome of psychiatric disorders, as well for subcategories of psychiatric disorders. In total, 9.9% of children in the discontinuation group and 11.0% of children in the continuation group received a psychiatric disorder diagnosis during follow-up. The adjusted HR for psychiatric disorders among offspring in the continuation group compared to the discontinuation group was 1.10 (95% CI 0.93-1.30). For antipsychotic use in the fathers, the HR was 1.05 (95% CI 0.89-1.24). The study does not provide evidence of increased risk of psychiatric disorders among children of women who continue antipsychotic treatment during pregnancy. This was observed after accounting for the underlying risk conferred by maternal psychiatric disorders. This suggests women who need to continue antipsychotic medications during pregnancy can do so without adverse psychiatric outcomes for offspring.

Antipsychotic Use During Pregnancy and Risk for Gestational Diabetes: A National Register-Based Cohort Study in Sweden

OBJECTIVE

We aimed to study whether antipsychotic use during pregnancy is associated with gestational diabetes.

METHODS

This was a Swedish national register-based cohort study on the Medical Birth Register and the Prescribed Drug Register including all 1,307,487 singleton births between July 2006 and December 2017. Antipsychotics were divided into first-generation antipsychotics (n = 728), high-risk metabolic second-generation antipsychotics including olanzapine, clozapine and quetiapine (n = 1710), and other second-generation antipsychotics (n = 541). The risks for gestational diabetes, foetal growth disturbances, pre-eclampsia, caesarean section and preterm labour were assessed. Women treated during pregnancy were compared to women not treated during pregnancy and to women who used antipsychotics before/after but not during pregnancy.

RESULTS

The crude risk ratio for gestational diabetes for women treated with high-risk metabolic second-generation antipsychotics during pregnancy was 2.2 (95% confidence interval [CI] 1.6-2.9) compared to untreated pregnant women (n = 1,296,539) and 1.8 (95% CI 1.4-2.5) compared to women treated before/after pregnancy (n = 34,492). After adjustment for maternal factors including body mass index, the risk ratios were 1.8 (95% CI 1.3-2.4) and 1.6 (95% CI 1.2-2.1). Exposed infants had an increased risk of being large for gestational age: adjusted risk ratios 1.6 (95% CI 1.3-1.9) and 1.3 (95% CI 1.1-1.6) compared to no maternal antipsychotic use during pregnancy and maternal use before/after the pregnancy. Other antipsychotics were not associated with metabolic risks.

CONCLUSIONS

Olanzapine, clozapine and quetiapine used during pregnancy were associated with increased risks for gestational diabetes and the infant being large for gestational age. Enhanced metabolic monitoring should be considered for pregnant women using these drugs.

Antidepressants Are the Most Commonly Discontinued Psychotherapeutic Medications in Pregnancy

BACKGROUND

Psychiatric illnesses are common during the perinatal period. The use of antipsychotic medication during pregnancy has increased over the past two decades. In many instances, clinicians agree that untreated psychiatric illness during the perinatal period is more dangerous than the risks imposed by continuing psychotherapeutic medication. We describe patterns of psychotherapeutic medication continuation and discontinuation during pregnancy in a large U.S. cohort.

METHODS

We assessed the relationship between the demographic and clinical characteristics of women who continued or discontinued psychotherapeutic medications-antidepressants, anxiolytics/sedatives, anticonvulsants, antipsychotics, mood stabilizers, and stimulants-during pregnancy. This study used data from 2008 to 2015 from the Medical Expenditure Panel Survey. We used t tests and Medical Expenditure Panel Survey Household Component longitudinal sampling weights in the analysis of this data.

RESULTS

There were few significant differences noted in clinical and demographic characteristics between women who continued and discontinued medications during pregnancy. Those who continued were less likely to be employed (46.95% of continuers were employed vs. 80.55% of discontinuers; p = .0053). Women taking antipsychotics were more likely to continue medications during pregnancy (64.60% continually used antipsychotics vs. 35.40% discontinued antipsychotics; p = .008), whereas women taking antidepressants were more likely to discontinue their use (19.62% continually used antidepressants vs. 80.38% discontinued antidepressants; p = .032). For each medication category, women resumed medication after pregnancy.

CONCLUSIONS

Antidepressants are the most commonly discontinued psychotherapeutic medication during pregnancy. We recommend further research examining factors that may influence this observed difference.

Drug-Induced QTc Prolongation: What We Know and Where We Are Going

Drug-induced QTc prolongation is a concerning electrocardiogram (ECG) abnormality. This cardiac disturbance carries a 10% risk of sudden cardiac death due to the malignant arrhythmia, Torsades de Pointes. The Arizona Center for Education and Research on Therapeutics (AzCERT) has classified QTc prolonging therapeutic classes such as antiarrhythmics, antipsychotics, anti-infectives, and others. AzCERT criteria categorizes medications into three risk categories: "known," "possible," and "conditional risk" of QTc prolongation and Torsades de Pointes. The list of QTc prolonging medications continues to expand as new drug classes are approved and studied. Risk factors for QTc prolongation can be delineated into modifiable or non-modifiable. A validated risk scoring tool may be utilized to predict the likelihood of prolongation in patients receiving AzCERT classified medication. The resultant risk score may be applied to a clinical decision support system which offers mitigation strategies. Mitigation strategies including discontinuation of possible offending agents with selection of an alternative agent, assessment of potential drug interactions or dose adjustments through pharmacokinetic and pharmacodynamic monitoring, and initiation of both ECG and electrolyte monitoring are essential to prevent a drug-induced arrhythmia. The challenges presented by the COVID-19 pandemic have led to the development of innovative continuous monitoring technology, increasing protection for both patients and healthcare workers. Early intervention strategies may reduce adverse events and improve clinical outcomes in patients identified to be at risk of QTc prolongation.

Associations between inpatient psychiatric admissions during pregnancy and adverse obstetrical and birth outcomes

BACKGROUND

Previous research supports an association between psychiatric diagnoses and adverse obstetrical and neonatal outcomes including low birthweight, preterm birth, and preeclampsia. Women who are admitted for inpatient psychiatric care are regarded as having more acute illnesses than those who are able to be managed as outpatients. Previous research has not yet investigated how the severity of psychiatric illness, as indicated by type of antenatal psychiatric care received, is associated with adverse obstetrical outcomes.

OBJECTIVE

This study examines whether the rates of adverse birth and obstetrical outcomes vary with the type of antenatal psychiatric care received when psychiatric care is indicated.

STUDY DESIGN

Using a retrospective, observational design, information about women who gave birth between January 1, 2006, and December 31, 2016 was captured from electronic medical records. Women were grouped as follows: (1) those who received antepartum inpatient psychiatric treatment (n=148), (2) those with documented psychiatric history without antepartum inpatient treatment (n=301), and (3) those with no documented psychiatric history or antepartum treatment (n=301). Linear and logistic regression predicted the odds of birth and obstetrical outcomes including gestational age at birth, birthweight, mode of delivery, time to delivery, preterm premature rupture of membranes, meconium-stained amniotic fluid, and 5-minute Apgar score. Measured covariates included maternal age, race, parity, body mass index, maternal medical comorbidities, smoking tobacco, gestational age at first prenatal visit, and psychotropic medication use during pregnancy.

RESULTS

Women with a psychiatric history, despite receiving any type of antepartum psychiatric care, had higher rates of adverse outcomes than women without documented psychiatric history. However, women who received antepartum inpatient psychiatric care had longer gestational lengths (38.05±3.0 vs 37.19±4.23 weeks [P<.05]) and gave birth to heavier babies (3047.84±591.99 vs 2906.48±851.85 g [P<.01]) than women with a psychiatric history who did not receive antepartum inpatient care even when adjusting for measured covariates.

CONCLUSION

Receiving antepartum inpatient psychiatric care may promote positive birth outcomes for women with acutely severe psychiatric conditions.

The use of antipsychotic agents during pregnancy and the risk of gestational diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Previous studies have found contradicting results with regard to the use of antipsychotics during pregnancy and the risk of gestational diabetes mellitus (GDM). We aimed to evaluate the association between antipsychotic use in pregnancy and GDM.

METHODS

A systematic literature search was conducted in PubMed, EMBASE, PsycINFO and Cochrane Library databases up to March 2019, for data from observational studies assessing the association between gestational antipsychotic use and GDM. Non-English studies, animal studies, case reports, conference abstracts, book chapters, reviews and summaries were excluded. The primary outcome was GDM. Estimates were pooled using a random effect model, with the I2 statistic used to estimate heterogeneity of results. Our study protocol was registered with PROSPERO number: CRD42018095014.

RESULTS

In total 10 cohort studies met the inclusion criteria in our systematic review with 6642 exposed and 1 860 290 unexposed pregnancies. Six studies were included in the meta-analysis with a pooled adjusted relative risk of 1.24 overall [95% confidence interval (CI) 1.09-1.42]. The I2 result suggested low heterogeneity between studies (I2 = 6.7%, p = 0.373).

CONCLUSION

We found that the use of antipsychotic medications during pregnancy is associated with an increased risk of GDM in mothers. However, the evidence is still insufficient, especially for specific drug classes. We recommend more studies to investigate this association for specific drug classes, dosages and comorbidities to help clinicians to manage the risk of GDM if initiation or continuation of antipsychotic prescriptions during pregnancy is needed.

[Antipsychotics during pregnancy: a systematic review]

BACKGROUND

The benefits and risks of treatment with antipsychotics during pregnancy must be weighed up carefully and individually because antipsychotics can penetrate the placental barrier and prescription is off-label.

OBJECTIVE

Evaluation of the risks and benefits of administering antipsychotics during pregnancy or for women who wish to become pregnant regarding teratogenic effects, risk of fetal death and stillbirths, perinatal complications, persisting postnatal impairments or disorders and gestational diabetes.

METHODS

A systematic review of the literature is provided to aid the selection of psychotropic drugs during pregnancy and in determining whether to begin, continue or switch an antipsychotic treatment during pregnancy.

RESULTS

Large, well-designed and controlled studies are missing; however, most studies suggest that the group of antipsychotics seem to be safe in terms of teratogenicity during pregnancy, at least in monotherapy.

CONCLUSION

Treating mental illnesses during pregnancy requires an individual assessment of the benefits and risks. The risk of an untreated mental illness versus the benefit of a suitable treatment with antipsychotics and the potential harm to the infant must be evaluated. If certain rules are observed and a suitable antipsychotic is selected the risk to the newborn child and/or mother during pregnancy can be minimized, however, a decision about subsequent medication can only be indirectly made from the results of this study.

Antipsychotic drug use in pregnancy: A multinational study from ten countries

AIM

To compare the prevalence and trends of antipsychotic drug use during pregnancy between countries across four continents.

METHODS

Individually linked health data in Denmark (2000-2012), Finland (2005-2014), Iceland (2004-2017), Norway (2005-2015), Sweden (2006-2015), Germany (2006-2015), Australia (New South Wales, 2004-2012), Hong Kong (2001-2015), UK (2006-2016), and the US (Medicaid, 2000-2013, and IBM MarketScan, 2012-2015) were used. Using a uniformed approach, we estimated the prevalence of antipsychotic use as the proportion of pregnancies where a woman filled at least one antipsychotic prescription within three months before pregnancy until birth. For the Nordic countries, data were meta-analyzed to investigate maternal characteristics associated with the use of antipsychotics.

RESULTS

We included 8,394,343 pregnancies. Typical antipsychotic use was highest in the UK (4.4%) whereas atypical antipsychotic use was highest in the US Medicaid (1.5%). Atypical antipsychotic use increased over time in most populations, reaching 2% in Australia (2012) and US Medicaid (2013). In most countries, prochlorperazine was the most commonly used typical antipsychotic and quetiapine the most commonly used atypical antipsychotic. Use of antipsychotics decreased across the trimesters of pregnancy in all populations except Finland. Antipsychotic use was elevated among smokers and those with parity ≥4 in the Nordic countries.

CONCLUSION

Antipsychotic use during pregnancy varied considerably between populations, partly explained by varying use of the typical antipsychotic prochlorperazine, which is often used for nausea and vomiting in early pregnancy. Increasing usage of atypical antipsychotics among pregnant women reflects the pattern that was previously reported for the general population.

Psychotropic drug use in perinatal women with bipolar disorder

Optimal dose management of psychotropic drugs during the perinatal period reduces the risk for recurrence of mood episodes in women with Bipolar Disorder. Physiological changes during pregnancy are associated with decreases in the plasma concentrations of the majority of mood stabilizing medications. Regular symptom and drug concentration monitoring for lithium and anticonvulsants with reflexive dose adjustment improves the probability of sustained symptom remission across pregnancy. The elimination clearance trajectory across pregnancy for psychotropics dictates the frequency of laboratory monitoring and dose adjustment. The literature on the pharmacokinetics of lithium, lamotrigine, carbamazepine and atypical antipsychotics during pregnancy and postpartum are reviewed, recommendations for symptom and laboratory monitoring are proposed and recommendations for dose adjustments are presented.

Antipsychotic Exposure in Pregnancy and the Risk of Gestational Diabetes: A Systematic Review and Meta-analysis

BACKGROUND

We have limited knowledge about the effects of antipsychotic exposure on the development of gestational diabetes mellitus (GDM). Aim of this study is to perform a systematic review and meta-analysis to assess GDM risk associated with antipsychotic exposure in pregnancy.

METHODS

Systematic literature search was performed using PubMed, Science Direct, Scopus, and Web of Science databases up to August 22, 2018. No restrictions to language or date were applied. Randomized, controlled trials, case-control, or cohort studies reporting GDM risk in antipsychotic-exposed, healthy controls or antipsychotic-ceased patients were included in the meta-analysis. The primary outcomes were study defined GDM, including number of events, odds ratios, and/or risk ratios (RR) with confidence intervals (CI).

RESULTS

Ten studies were included in the meta-analysis. The total number of subjects was 6213 for the antipsychotic-exposed group, 6836 for antipsychotic-ceased control group, and 1 677 087 for the healthy control group. Compared with the healthy controls, the unadjusted cumulative RR for GDM associated with antipsychotic use was 1.63 (95% CI = 1.20-2.22). Adjusted risk for GDM was significantly higher in antipsychotic exposure group than in healthy controls (RR = 1.30, 95% CI = 1.023-1.660). The adjusted RR for GDM was similar between the antipsychotic-exposed group and the antipsychotic-ceased group (RR = 0.78, 95% CI = 0.281-2.164). No significant association was found between study quality, smoking, alcohol use, gestational age, and cumulative GDM risk.

DISCUSSION

Our results indicate an increased risk of GDM with antipsychotic exposure in pregnant women, who may benefit from close pregnancy monitoring, early testing for GDM, targeting modifiable risk factors, and lifestyle modifications.

Advances in Epidemiological Methods and Utilisation of Large Databases: A Methodological Review of Observational Studies on Central Nervous System Drug Use in Pregnancy and Central Nervous System Outcomes in Children

INTRODUCTION

Studies have used various epidemiological approaches to study associations between central nervous system (CNS) drug use in pregnancy and CNS outcomes in children. Studies have generally focused on clinical adverse effects, whereas variations in methodologies have not received sufficient attention.

OBJECTIVE

Our objective was to review the methodological characteristics of existing studies to identify any limitations and recommend further research.

METHODS

A systematic literature search was conducted on observational studies listed in PubMed from 1 January 1946 to 21 September 2017. Following independent screening and data extraction, we conducted a review addressing the trends of relevant studies, differences between various data sources, and methods used to address bias and confounders; we also conducted statistical analyses.

RESULTS

In total, 111 observational studies, 25 case-control studies, and 86 cohort studies were included in the review. Publications dating from 1978 to 2006 mainly focused on antiepileptic drugs, but research on antidepressants increased from 2007 onwards. Only one study focused on antipsychotic use during pregnancy. A total of 46 studies obtained data from an administrative database/registry, 20 from ad hoc disease registries, and 41 from ad hoc clinical samples. Most studies (58%) adjusted the confounding factors using general adjustment, whereas only a few studies used advanced methods such as sibling-matched models and propensity score methods; 42 articles used univariate analyses and 69 conducted multivariable regression analyses.

CONCLUSION

Multiple factors, including different study designs and data sources, have led to inconsistent findings in associations between CNS drug use in pregnancy and CNS outcomes in children. Researchers should allow for study designs with clearly defined exposure periods, at the very least in trimesters, and use advanced confounding adjustment methodology to increase the accuracy of the findings.

Atypical antipsychotic use during pregnancy and birth defect risk: National Birth Defects Prevention Study, 1997-2011

PURPOSE

To examine the prevalence of, and factors associated with, atypical antipsychotic use among U.S. pregnant women, and potential associations between early pregnancy atypical antipsychotic use and risk for 14 birth defects.

METHODS

We analyzed data from the National Birth Defects Prevention Study (1997-2011), a U.S. population-based case-control study examining risk factors for major structural birth defects.

RESULTS

Atypical antipsychotic use during pregnancy was more common among women with pre-pregnancy obesity, and women who reported illicit drug use before and during pregnancy, smoking during pregnancy, alcohol use during pregnancy, or use of other psychiatric medications during pregnancy. We observed elevated associations (defined as a crude odds ratio [cOR] ≥2.0) between early pregnancy atypical antipsychotic use and conotruncal heart defects (6 exposed cases; cOR: 2.3, 95% confidence interval [CI]: 0.9-6.1), and more specifically Tetralogy of Fallot (3 exposed cases; cOR: 2.5, 95% CI: 0.7-8.8), cleft palate (4 exposed cases, cOR: 2.5, 95% CI: 0.8-7.6), anorectal atresia/stenosis (3 exposed cases, cOR: 2.8, 95% CI: 0.8-9.9), and gastroschisis (3 exposed cases, cOR: 2.1, 95% CI: 0.6-7.3).

CONCLUSIONS

Our findings support the close clinical monitoring of pregnant women using atypical antipsychotics. Women treated with atypical antipsychotics generally access healthcare services before pregnancy; efforts to reduce correlates of atypical antipsychotic use might improve maternal and infant health in this population.

Psychotropic Treatment During Pregnancy: Research Synthesis and Clinical Care Principles

Background: Psychiatric illnesses are common in women of childbearing age. The perinatal period is a particularly high-risk time for depression, bipolar, and anxiety disorders. Methods: The scope of the public health problem of perinatal mental disorders is discussed followed by an examination of the specific research methods utilized for the study of birth and developmental outcomes associated with maternal mental illness and its treatment. The evidence on exposure to common psychotropics during pregnancy and breastfeeding is reviewed. Results: Selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitor medications are not associated with higher rates of birth defects or long-term changes in mental development after adjustment for confounding factors associated with underlying psychiatric illness. Lithium exposure is associated with an increased risk for fetal cardiac malformations, but this risk is lower than previously thought (absolute risk of Ebstein's anomaly 6/1,000). Antipsychotics, other than risperidone and potentially paliperidone, have not been associated with an increase in birth defects; olanzapine and quetiapine have been linked with an elevated risk of gestational diabetes. Due to the dramatic physiological changes of pregnancy and enhanced hepatic metabolism, drug doses may need to be adjusted during pregnancy to sustain efficacy. Untreated maternal psychiatric illness also carries substantial risks for the mother, fetus, infant, and family. Conclusions: The goal of perinatal mental health treatment is to optimally provide pharmacotherapy to mitigate the somatic and psychosocial burdens of maternal psychiatric disorders. Regular symptom monitoring during pregnancy and postpartum and medication dose adjustments to sustain efficacy constitutes good practice.

Trajectories of antipsychotic use before and during pregnancy and associated maternal and birth characteristics

OBJECTIVE

To identify distinct trajectories of antipsychotic use prior to and during pregnancy and describe the associated maternal and birth characteristics.

METHODS

We conducted a population-based cohort study of births (2005-2012) using linked administrative data in New South Wales, Australia. We used group-based trajectory modelling to classify trajectories of antipsychotic use in the 450 days prior to pregnancy and during pregnancy. We characterised women with different trajectories according to maternal sociodemographic characteristics, mental health diagnoses and hospitalisations, use of psychotropic medicines and birth outcomes.

RESULTS

Of 137,993 women who gave birth, 2741 (2.0%) were exposed to antipsychotics prior to or during pregnancy. We identified six trajectories of antipsychotic use: two involved short-term use of low daily doses prior to pregnancy (51.1%), while three involved long-term use of low (20.9%), moderate (11.0%) and high (2.0%) daily doses throughout pregnancy. One trajectory (15.0%) involved increasing use during pregnancy. Women with long-term use were more likely to have a schizophrenia or bipolar disorder diagnosis, to have used multiple psychotropics and to have a mental health hospitalisation during pregnancy. Overall, women using antipsychotics had elevated rates of adverse birth outcomes compared to unexposed women. Women with the greatest antipsychotic exposure had the highest rates of gestational diabetes and gestational hypertension.

CONCLUSION

Women using antipsychotics around pregnancy are heterogeneous, with varying patterns of use and associated birth outcomes, reflecting underlying differences in the indications for treatment and/or severity of illness. This diversity should be considered when developing clinical guidelines and designing safety studies.

Expert advice on the management of valproate in women with bipolar disorder at childbearing age

INTRODUCTION

The perinatal period is associated with up to 2/3 relapses in untreated bipolar disorder (BD), with important consequences on the clinical BD outcome and on fetal and child development. Valproate (VPA), one of the most effective treatments in BD, is associated with the highest risk of serious neurodevelopmental disorders in exposed children. This has brought to tightened restrictions to its use by regulatory agencies and clinical guidelines.

METHODS

A panel of experts on the pharmacological treatment of BD conducted a non-systematic review of the scientific literature and clinical guidelines until March 2019, and provided specific evidence-based and experience-based clinical recommendations for VPA switching/discontinuation in BD women of childbearing potential.

RESULTS

After the review of the evidence in a face-to-face meeting, the panel concluded that several clinical criteria need to be considered to make a clinical decision about VPA discontinuation and switch. The plateau cross-taper switch may be preferred. Abrupt switching may bear augmented risk of relapse CONCLUSIONS: BD childbearing women treated with VPA must be managed on a personalized basis according to the clinical situation. It is mandatory to stop VPA during pregnancy. The duration of the discontinuation/switch process depends on different clinical variables. Lithium, lamotrigine, quetiapine, olanzapine or aripiprazole are good options for switch in stable BD patients in planned/unplanned pregnancy. In unstable BD patients planning pregnancy, stability is paramount. Prevention of post-partum episodes requires reinstatement of effective treatment before or after birth (in the case of VPA). VPA is still an option in the post-partum period and beyond.

Safety of acupuncture during pregnancy: a retrospective cohort study in Korea

OBJECTIVE

The present study aimed to analyse the Korean National Health Insurance Service (NHIS) cohort data to examine the safety of acupuncture therapy during pregnancy.

DESIGN

Retrospective cohort.

SETTING

Korea.

POPULATION OR SAMPLE

Women with confirmed pregnancy between 2003 and 2012 from the 2002-13 NHIS sample cohort (n = 20 799).

METHODS

Women with confirmed pregnancy were identified and divided into acupuncture or control group for comparison of their outcomes. Differences in other factors such as age, and rate of high-risk pregnancy and multiple pregnancy were examined. In the acupuncture group, the most frequent acupuncture diagnosis codes and the timing of treatment were also investigated.

MAIN OUTCOME MEASURES

Incidence of full-term delivery, preterm delivery and stillbirth by pregnancy duration and among the high-risk and multiple pregnancy groups.

RESULTS

Of 20 799 pregnant women analysed, 1030 (4.95%) and 19 749 were in the acupuncture and control groups, respectively. Both overall (odds ratio [OR] 1.23; 95% CI 0.98-1.54), and in the stratified analysis of high-risk pregnancies (OR 1.09; 95% CI 0.73-1.64), there was no significant difference between acupuncture and control groups in preterm deliveries. No stillbirths occurred in the acupuncture group and 0.035% of pregnancies resulted in stillbirths in the control group.

CONCLUSION

No significant difference in delivery outcomes (preterm delivery and stillbirth) was observed between confirmed pregnancies in the acupuncture and control groups. Therefore, in pregnancy, acupuncture therapy may be a safe therapeutic modality for relieving discomfort without an adverse delivery outcome.

TWEETABLE ABSTRACT

In pregnancy, acupuncture therapy may be a safe therapeutic modality for relieving discomfort without an adverse outcome.

Use of Antipsychotic Drugs During Pregnancy

Purpose of review

Antipsychotics are frequently prescribed to women of childbearing age and are increasingly prescribed during pregnancy. A small, but growing, body of research on implications for pregnancy and infant outcomes is available to inform the risks and benefits of in utero exposure to antipsychotics. This review examines the existing published research on the use of common typical and atypical antipsychotics in pregnancy and the implications for pregnancy and infant outcomes.

Recent findings

The majority of studies do not show associations with major malformations and antipsychotic use in pregnancy, with the possible exception of risperidone. There is concern that atypical antipsychotics may be associated with gestational diabetes. Metabolic changes during pregnancy may necessitate dose adjustments.

Summary

In general, it is recommended that women who need to take an antipsychotic during pregnancy continue the antipsychotic that has been most effective for symptom remission. Further study on risperidone is needed to better understand its association with malformations and it is not considered a first-line agent for use during pregnancy.

Treatment of Peripartum Bipolar Disorder

Bipolar disorder affects women throughout their childbearing years. During the perinatal period, women with bipolar disorder are vulnerable to depressive episode recurrences and have an increased risk for postpartum psychosis. Perinatal screening is critical to identify women at risk. Although medications are the mainstay of treatment, the choice of pharmacotherapy must be made by the patient based on a risk-benefit discussion with her physician. For optimal dosing in pregnancy, therapeutic drug monitoring may be required to maintain effective drug concentrations. Residual symptoms of bipolar depression are treatable with bright light therapy as an alternative to medication augmentation.

An analysis of online pregnancy message boards: Mother-to-mother advice on medication use

PROBLEM AND BACKGROUND

Psychotropic medication use is increasingly common among pregnant women. Many women solicit information from other mothers about the safety of these medications for use during pregnancy, yet little is known about the specific advice they receive.

AIM

The purpose of the current study was to examine the type of feedback women receive on a popular internet message board about psychotropic medication use during pregnancy.

METHODS

A modified Consensual Qualitative Research approach was used to analyze 1728 comments posted by Babycenter.com users about the safety of the use of six common psychotropic medications during pregnancy. Researchers analyzed the comments for overall themes and core ideas.

FINDINGS

Results found that comments were comprised of six themes: (1) Personal Anecdotes, (2) Suggesting Alternative Solutions, (3) Directives, (4) Judgement, (5) Social Support, (6) Skepticism & Mistrust, and (7) Risks vs. Benefits. While many comments conveyed emotional support, or encouraged women to seek professional advice, others contained inaccurate and/or contradictory information, or harsh criticism.

CONCLUSION

Given that the decision about the use of medication during pregnancy has implications for the health of the mother and fetus, it is important for care providers to be aware of what feedback women may receive from this source. Providers should address questions and concerns that women have about safety of these medications and recognize how the social context of the internet impacts the emotional health of pregnant women faced with these decisions.

Pregnancy-Associated Cancer: A U.S. Population-Based Study

BACKGROUND

The incidence of pregnancy-associated cancer (PAC) is expected to increase as more women delay childbearing until later ages. However, information on frequency and incidence of PAC is scarce in the United States.

METHODS

We identified pregnancies among women aged 10-54 years during 2001-2013 from five U.S. health plans participating in the Cancer Research Network (CRN) and the Medication Exposure in Pregnancy Risk Evaluation Program (MEPREP). We extracted information from the health plans' administrative claims and electronic health record databases, tumor registries, and infants' birth certificate files to estimate the frequency and incidence of PAC, defined as cancer diagnosed during pregnancy and up to 1 year postpartum.

RESULTS

We identified 846 PAC events among 775,709 pregnancies from 2001 to 2013. The overall incidence estimate was 109.1 (95% confidence interval [CI] = 101.8-116.7) per 100,000 pregnancies. There was an increase in the incidence between 2002 and 2012 (the period during which complete data were available), from 75.0 (95% CI = 54.9-100.0) per 100,000 pregnancies in 2002 to 138.5 (95% CI = 109.1-173.3) per 100,000 pregnancies in 2012. The most common invasive cancers diagnosed were breast (n = 208, 24.6%), thyroid (n = 168, 19.9%), melanoma (n = 93, 11.0%), hematologic (n = 87, 10.3%), and cervix/uterus (n = 74, 8.7%).

CONCLUSIONS

Our study provides contemporary incidence estimates of PAC from a population-based cohort of U.S. women. These estimates provide the data needed to help develop clinical and public health policies aimed at diagnosing PAC at an early stage and initiating appropriate therapeutic interventions in a timely manner.

Patterns and predictors for prescription of psychotropics and mood-stabilizing antiepileptics during pregnancy in Denmark 2000-2016

AIMS

To analyse prescribing patterns during pregnancy for antipsychotics (APs), antidepressants (ADs) and mood-stabilizing antiepileptics (AEDs) in Denmark from 2000 to 2016.

METHODS

Data were obtained from the Danish Medical Birth Register, the Register for Legally Induced Abortions, the Danish National Patient Register and the Register of Medicinal Product Statistics. Data were linked through a unique personal identifier by Statistics Denmark.

RESULTS

The use of APs increased 2.5-fold from a prevalence of 1.5 per 1000 pregnancies to 3.8 for pregnancies ending in a delivery. Use of mood-stabilizing AEDs increased from a prevalence of 0.1 to 2.1 during the study period. The prevalence for APs and mood-stabilizing AEDs was nearly twice as high for pregnancies ending in miscarriage or termination compared to pregnancies ending in delivery. A marked increase in the prevalence of ADs use during pregnancy was seen from 2000-2011 (from 6 to 41 per 1000 pregnancies ending in a delivery) but appears slightly in decline. Age, smoking, obesity and social status were generally associated with increased use of psychotropic drugs.

CONCLUSIONS

The use of APs, ADs and mood-stabilizing AEDs during pregnancy has increased substantially in Denmark from 2000-2016. The use of ADs appears to be slightly in decline since 2011.

Prenatal Exposure to Antipsychotics Disrupts the Plasticity of Dentate Neurons and Memory in Adult Male Mice

BACKGROUND

With the growing use of second-generation antipsychotics for the treatment of a spectrum of psychiatric illnesses in pregnancy, concerns have been raised about the long-term impact of these medications on offspring neurodevelopment. However, preclinical and clinical evidence on the lasting effects of prenatal antipsychotic exposure is still sparse.

METHODS

Risperidone, a widely used second-generation antipsychotic, and haloperidol, a representative first-generation antipsychotic, were administered to pregnant C57BL/6N mice from embryonic day 6 to 16. Behavioral tests, immunohistochemical staining, Golgi-Cox technique, and western blot were used to determine the effects of prenatal antipsychotic exposure on the plasticity of the dentate gyrus and related behavior in adult male mice.

RESULTS

Both prenatal haloperidol- and risperidone-exposed mice showed recognition memory deficits but had no anxiety-related behavior. In addition, both prenatal haloperidol and risperidone exposure impaired the proliferation and maturation of adult-born dentate granule cells. We found that haloperidol exposure decreased dendritic length of dentate granule cells, while risperidone had no effect. However, both drugs inhibited dendrite branching in granule cells. Haloperidol exposure also significantly reduced total spine density in the middle dendritic segment of dentate gyrus. Prenatally risperidone-exposed mice only displayed a loss in thin and mushroom spines of infrapyramidal blade of dentate gyrus. Collectively, prenatal haloperidol exposure exerted more robust negative effects than risperidone.

CONCLUSION

These data provide evidence for the long-term programming effects of early-life exposure to antipsychotics on hippocampal plasticity and behavior.

Continuation of Atypical Antipsychotic Medication During Early Pregnancy and the Risk of Gestational Diabetes

OBJECTIVE

Some atypical antipsychotics are associated with metabolic side effects, which are risk factors for gestational diabetes. The authors examined the risk of developing gestational diabetes associated with the continuation of treatment with aripiprazole, ziprasidone, quetiapine, risperidone, and olanzapine during pregnancy compared with discontinuation of these antipsychotic drugs.

METHOD

Nondiabetic pregnant women who were linked to a live-born infant and enrolled in Medicaid (2000-2010) and who received one or more prescriptions dispensed for an antipsychotic drug during the 3 months before pregnancy were included in the analyses. Among 1,543,334 pregnancies, some expectant mothers at baseline were receiving treatment with aripiprazole (N=1,924), ziprasidone (N=673), quetiapine (N=4,533), risperidone (N=1,824), or olanzapine (N=1,425). For each antipsychotic drug, women with two or more dispensings ("continuers") were compared with women with no dispensings ("discontinuers") during the first half of pregnancy. A generalized linear model and propensity-score stratification were used to obtain absolute and relative risks of developing gestational diabetes, with adjustment for confounders.

RESULTS

Women who continued antipsychotic treatment during pregnancy generally had higher comorbidity and longer baseline antipsychotic use. The crude risk of developing gestational diabetes among continuers compared with discontinuers, respectively, was 4.8% and 4.5% for aripiprazole, 4.2% and 3.8% for ziprasidone, 7.1% and 4.1% for quetiapine, 6.4% and 4.1% for risperidone, and 12.0% and 4.7% for olanzapine. The adjusted relative risks were 0.82 (95% CI=0.50-1.33) for aripiprazole, 0.76 (95% CI=0.29-2.00) for ziprasidone, 1.28 (95% CI=1.01-1.62) for quetiapine, 1.09 (95% CI=0.70-1.70) for risperidone, and 1.61 (95% CI=1.13-2.29) for olanzapine.

CONCLUSIONS

Compared with women who discontinued use of an atypical antipsychotic medication before the start of pregnancy, women who continued treatment with olanzapine or quetiapine had an increased risk of gestational diabetes that may be explained by the metabolic effects associated with these two drugs.

Pregnancy exposure to quetiapine - Therapeutic drug monitoring in maternal blood, amniotic fluid and cord blood and obstetrical outcomes

RATIONALE

This prospective study is the first to measure and correlate quetiapine concentrations in maternal blood, amniotic fluid and umbilical cord blood to account for the distribution of quetiapine.

METHODS

Concentrations of quetiapine are quantified in seven mother infant pairs at the time of delivery. Data are provided as median values, first (Q1) and third (Q3) quartiles and ranges. To account for the penetration ratio, the concentration of quetiapine in amniotic fluid and cord blood was divided by maternal concentrations. Correlations between daily dosage, maternal serum and umbilical cord blood concentrations were computed for seven patients while calculations for amniotic fluid were only available for six mother-infant pairs.

RESULTS

The median daily dosage of quetiapine was 300mg (Q1: 300mg, Q3: 600mg, range 200-800mg). There was a strong and significant correlation between maternal serum and cord blood concentrations (r=0.893, p=0.007). The median penetration ratio into fetal circulation was 0.18 (Q1: 0.16, Q3: 0.32; range 0.13-0.42), suggesting a low penetration. The median penetration ratio into amniotic fluid was 0.44 (Q1: 0.15, Q3: 0.96; range 0.09-1.70).

CONCLUSIONS

Quetiapine concentrations in amniotic fluid and cord blood give evidence that quetiapine is constantly accessible to the fetus with a relatively low penetration ratio. A high correlation between maternal serum and umbilical cord blood concentrations highlights a predictive role of quantifying drug concentrations in maternal serum for assessing drug concentrations in fetal circulation. Findings support the important role of therapeutic drug monitoring in supporting the efficacy and safety of psychopharmacological treatment strategies in highly vulnerable populations.