Antipsychotic medication during pregnancy and lactation in women with schizophrenia: evaluating the risk

Association of In Utero Antipsychotic Medication Exposure With Risk of Congenital Malformations in Nordic Countries and the US

Importance

Psychiatric disorders are common among female individuals of reproductive age. While antipsychotic medication use is increasing, the safety of such medications in pregnancy is an area with large evidence gaps.

Objective

To evaluate the risk of first-trimester antipsychotic exposure with respect to congenital malformations, focusing on individual drugs and specific malformation subtypes.

Design, Setting, and Participants

This cohort study used data from nationwide health registers from the 5 Nordic countries and the US and spanned 1996 to 2018. The Nordic cohort included all pregnancies resulting in singleton live-born infants, and the US cohort consisted of publicly insured mothers linked to their live-born infants nested in the nationwide Medicaid Analytic eXtract. Data were analyzed from November 2020 to April 2022.

Exposures

One or more first-trimester dispensing of any atypical, any typical, and individual antipsychotic drugs.

Main Outcomes and Measures

Any major congenital malformation and specific malformation subtypes previously suggested to be associated with antipsychotic exposure in utero: cardiovascular malformations, oral clefts, neural tube defects, hip dysplasia, limb reduction defects, anorectal atresia/stenosis, gastroschisis, hydrocephalus, other specific brain anomalies, and esophageal disorders. Propensity score stratification was used to control for potential confounders. Pooled adjusted estimates were calculated using indirect standardization.

Results

A total of 6 455 324 unexposed mothers (mean maternal age range across countries: 24-31 years), 21 751 mothers exposed to atypical antipsychotic drugs (mean age range, 26-31 years), and 6371 mothers exposed to typical antipsychotic drugs (mean age range, 27-32 years) were included in the study cohort. Prevalence of any major malformation was 2.7% (95% CI, 2.7%-2.8%) in unexposed infants, 4.3% (95% CI, 4.1%-4.6%) in infants with atypical antipsychotic drug exposure, and 3.1% (95% CI, 2.7%-3.5%) in infants with typical antipsychotic drug exposure in utero. Among the most prevalent exposure-outcome combinations, adjusted relative risks (aRR) were generally close to the null. One exception was olanzapine exposure and oral cleft (aRR, 2.1 [95% CI, 1.1-4.3]); however, estimates varied across sensitivity analyses. Among moderately prevalent combinations, increased risks were observed for gastroschisis and other specific brain anomalies after atypical antipsychotic exposure (aRR, 1.5 [95% CI, 0.8-2.6] and 1.9 [95% CI, 1.1-3.0]) and for cardiac malformations after chlorprothixene exposure (aRR, 1.6 [95% CI, 1.0-2.7]). While the association direction was consistent across sensitivity analyses, confidence intervals were wide, prohibiting firm conclusions.

Conclusions and Relevance

In this study, considering the evidence from primary and sensitivity analyses and inevitable statistical noise for very rare exposure-outcome combinations, in utero antipsychotic exposure generally was not meaningfully associated with an increased risk of malformations. The observed increased risks of oral clefts associated with olanzapine, gastroschisis, and other specific brain anomalies with atypical antipsychotics and cardiac malformations with chlorprothixene requires confirmation as evidence continues to accumulate.

Antipsychotic Use in Pregnancy: Patient Mental Health Challenges, Teratogenicity, Pregnancy Complications, and Postnatal Risks

Pregnant women constitute a vulnerable population, with 25.3% of pregnant women classified as suffering from a psychiatric disorder. Since childbearing age typically aligns with the onset of mental health disorders, it is of utmost importance to consider the effects that antipsychotic drugs have on pregnant women and their developing fetus. However, the induction of pharmacological treatment during pregnancy may pose significant risks to the developing fetus. Antipsychotics are typically introduced when the nonpharmacologic approaches fail to produce desired effects or when the risks outweigh the benefits from continuing without treatment or the risks from exposing the fetus to medication. Early studies of pregnant women with schizophrenia showed an increase in perinatal malformations and deaths among their newborns. Similar to schizophrenia, women with bipolar disorder have an increased risk of relapse in antepartum and postpartum periods. It is known that antipsychotic medications can readily cross the placenta, and exposure to antipsychotic medication during pregnancy is associated with potential teratogenicity. Potential risks associated with antipsychotic use in pregnant women include congenital abnormalities, preterm birth, and metabolic disturbance, which could potentially lead to abnormal fetal growth. The complex decision-making process for treating psychosis in pregnant women must evaluate the risks and benefits of antipsychotic drugs.

[Psychiatric Patients in Obstetrics in Germany - The Legal Basis and a Thematic Analysis of Case Reports]

The care of adult patients with particularly severe psychiatric illnesses in the daily routine of inpatient obstetrics is rare, but due to its complexity it represents a great challenge for all professions involved. The clinical pictures are very variable. There are a number of interlocking responsibilities in the provision of care. For planning of the birth, the medical-professional cooperation of psychiatry, obstetrics and pediatrics is necessary. Patients are often represented by legal guardians. The Youth Welfare Office is responsible for the welfare of the family and the children. The legal basis is essentially provided by the Civil Code, the Criminal Code and specific state laws, compliance with which is monitored by the courts. Typical psychiatric clinical pictures are presented by means of case reports. Legally defined applications such as accommodation, measures similar to deprivation of liberty, compulsory medical measures and justifiable necessity are explained. In the sense of a thematic analysis, these are applied to the case reports and peripartum management is discussed against the legal background. The precise knowledge of the legal background makes it easier for obstetricians to follow the procedures and interdisciplinary cooperation, especially at perinatalogical centres.

Parsing components of risk of premature mortality in the children of mothers with severe mental illness

INTRODUCTION

Children of mothers with severe mental illness are at increased risk of premature death including in infancy and early childhood. Importantly, these children are also more likely to be exposed to adverse socio-demographic risk factors and serious obstetric complications which, of themselves, may increase risk for childhood mortality. We examined mortality outcome at different ages up to 5 years taking account of these risks.

METHOD

We used linked data across Western Australian whole-population psychiatric, inpatient, death, and midwives' registers to identify 15,486 births to mothers with severe mental illness and 452,459 births to mothers with no mental illness. Multivariable models were adjusted for exposure to adverse socio-demographic risk factors and serious obstetric complications.

RESULTS

Overall risk of premature death was increased amongst children of mothers with severe mental illness (2.3%, 354 deaths) compared with children of mothers with no mental illness (1.4%, 6523 deaths); the same was true for specific risk of stillbirth, neonatal, post‑neonatal and early childhood deaths. Risk was substantially attenuated after adjustment for adverse socio-demographic exposures, and further still after adjustment for exposure to serious obstetric complications. We observed no effects for the timing of maternal illness diagnosis.

CONCLUSIONS

To minimise the risk of premature mortality in the children of mothers with severe mental illness, priority should be given to the prompt diagnosis of maternal mental illness with targeted delivery of high quality antenatal and psychiatric care, as well as social and structural supports for affected families that continue after birth.

Psychiatric admission during pregnancy in women with schizophrenia who attended a specialist antenatal clinic

Objectives: The mental health and wellbeing of pregnant women with schizophrenia is an area of research interest. We aim to explore this relationship particularly in regards to psychiatric admission rates, timing and their associated contributing factors. Methods: A total of 98 pregnancies to women with schizophrenia, who attended a specialist antenatal clinic and delivered from July 2007 to February 2016, were retrospectively examined. The cohort was divided into two groups based on psychiatric admission. Descriptive data were analyzed using SPSS software. Results: Overall, 40.8% required psychiatric admission during pregnancy. A higher proportion of subjects had their initial psychiatric admission in the first trimester compared to the third trimester (p = .002). Of note, 10.2% were admitted within one month either side of conception. Women with admission also presented later for their first antenatal appointment (p = .04, 95% CI -2.1 to -1.9). Psychiatric admission was associated with substance (p = .014) and alcohol use (p = .001), child protective services involvement (p = .022) and infant being placed in out-of-home care (p = .01), but not with poorer obstetric or neonatal outcomes. Conclusion: High rates of psychiatric admission are evident throughout pregnancy for women with schizophrenia, with a high proportion of first presentations for admission occurring in the first trimester. Psychiatric admission is associated with poorer antenatal care attendance and adverse psychosocial outcomes, highlighting the need for enhanced multidisciplinary pregnancy care for this at risk group. Inpatient psychiatric services should consider pregnancy testing and contraception review for all women of childbearing age, admitted with schizophrenia.

Adverse Effects in the Pharmacologic Management of Bipolar Disorder During Pregnancy

Management of bipolar disorder during pregnancy often involves medications with potential adverse effects, including risks to the mother and fetus. Although some specifics are known, many medications continue to have incompletely characterized reproductive safety profiles. Women with bipolar disorder who are planning pregnancy face challenging decisions about their treatment; careful risk-benefit discussions are necessary. With the goal of further informing these discussions, this article reviews the data currently available regarding medication safety in the management of bipolar disorder during pregnancy, with specific attention to lithium, valproic acid, lamotrigine, carbamazepine, and antipsychotic medications.

Atypical antipsychotic use and outcomes in an urban maternal mental health service

Objective Despite many women suffering from psychosis in their childbearing years, limited data exist about the use of atypical antipsychotic agents in pregnancy. Atypical antipsychotic agents are often used to treat bipolar disorder, instead of lithium or valproate because of the known teratogenicity of those agents. As well, atypical antipsychotics are often prescribed in anxiety disorders and depression. This study sought to describe pregnancy outcomes for women prescribed atypical antipsychotics during pregnancy. Methods This retrospective review included all cases treated by Auckland Maternal Mental Health services in which atypical antipsychotic agents were utilized during pregnancy over three years. Results Over the three years, 45 pregnant women were prescribed atypical antipsychotic agents, most commonly quetiapine or olanzapine. Two-fifths (40%) were diagnosed with bipolar disorder and almost one-third (31%) with a psychotic disorder. Two-thirds (64%) were prescribed multiple psychotropic medications during their pregnancy. Instrumental delivery rates were elevated at 38%. A minority (13%) of the women developed gestational diabetes mellitus. Although 7% of infants were born premature, all were born after 35 weeks. Two major malformations were noted, similar to baseline community rates. Conclusions This naturalistic study adds to the limited literature about treatment with atypical antipsychotic agents in pregnancy, though not adequately powered to detect small differences in malformations or obstetrical outcomes. It also highlights the myriad of indications for which pregnant women are prescribed atypical antipsychotics, and the multiple other risk factors seen in this population.

From cholesterogenesis to steroidogenesis: role of riboflavin and flavoenzymes in the biosynthesis of vitamin D

Flavin-dependent monooxygenases and oxidoreductases are located at critical branch points in the biosynthesis and metabolism of cholesterol and vitamin D. These flavoproteins function as obligatory intermediates that accept 2 electrons from NAD(P)H with subsequent 1-electron transfers to a variety of cytochrome P450 (CYP) heme proteins within the mitochondria matrix (type I) and the (microsomal) endoplasmic reticulum (type II). The mode of electron transfer in these systems differs slightly in the number and form of the flavin prosthetic moiety. In the type I mitochondrial system, FAD-adrenodoxin reductase interfaces with adrenodoxin before electron transfer to CYP heme proteins. In the microsomal type II system, a diflavin (FAD/FMN)-dependent cytochrome P450 oxidoreductase [NAD(P)H-cytochrome P450 reductase (CPR)] donates electrons to a multitude of heme oxygenases. Both flavoenzyme complexes exhibit a commonality of function with all CYP enzymes and are crucial for maintaining a balance of cholesterol and vitamin D metabolites. Deficits in riboflavin availability, imbalances in the intracellular ratio of FAD to FMN, and mutations that affect flavin binding domains and/or interactions with client proteins result in marked structural alterations within the skeletal and central nervous systems similar to those of disorders (inborn errors) in the biosynthetic pathways that lead to cholesterol, steroid hormones, and vitamin D and their metabolites. Studies of riboflavin deficiency during embryonic development demonstrate congenital malformations similar to those associated with genetic alterations of the flavoenzymes in these pathways. Overall, a deeper understanding of the role of riboflavin in these pathways may prove essential to targeted therapeutic designs aimed at cholesterol and vitamin D metabolism.

Unplanned pregnancies leading to psychotropic exposure in women with mental illness - Findings from a perinatal psychiatry clinic

OBJECTIVE

The aims of this study were (a) to describe the sociodemographic and clinical profile of women with unplanned pregnancies and consequent exposure to psychotropic drugs, (b) to describe the nature and timing of psychotropic exposure during pregnancy among these women, and (c) to examine the outcome of decisions related to pregnancy following consultation at a perinatal psychiatric service.

MATERIALS AND METHODS

WOMEN ATTENDING THE PERINATAL PSYCHIATRY SERVICES REFERRED FOR ACCIDENTAL EXPOSURE TO PSYCHOTROPICS WERE ASSESSED BY STRUCTURED INTERVIEWS FOR THE FOLLOWING DETAILS: sociodemographic details, clinical details, psychotropic drug use, advice given in the clinic, and outcome related to this advice.

RESULTS

Fifty-three women were referred for counseling related to unplanned pregnancies and consequential psychotropic exposure. Forty-two women (79%) sought consultation in the first trimester. More than a third of the women, 19 (36%), were taking more than one psychotropic medication during the first consultation. Only 11 (20%) women had received any form of prepregnancy counseling prior to becoming pregnant. Of the 37 women who came for follow-up in the clinic, 35 (94%) of them continued the pregnancy.

CONCLUSIONS

Unplanned pregnancies in women with mental illness are common and result in exposure to multiple psychotropic medications during the first trimester. Majority of women did not report of having prepregnancy counseling and which needs to be an integral part of treatment and education.

Midwives and assessment of perinatal mental health

Childbirth involves many psychological and emotional changes for women. The recent Commonwealth Government of Australia, National Perinatal Mental Health Action Plan (in 2008) recommends all pregnant and postnatal women have a psychosocial assessment including completion of the Edinburgh Postnatal Depression Scale. Midwives will assess all women at antenatal 'booking in' to maternity services. Currently, midwives receive little education regarding mental health assessment of women. This study explored the perceptions of midwives of their own mental health skills, knowledge and experiences, when working with women with mental illness in the perinatal period. An exploratory descriptive design was utilized to survey midwives across 19 maternity sites in Victoria, Australia. Clearly, midwives lack mental health skills and knowledge, describing their lack of confidence and feeling uncomfortable and unsafe when providing care for women with mental illness. They also report little knowledge of resources available to provide appropriate services for these women. The future direction for improving maternity care will require midwives to assess mental health needs of women, and refer them on, for timely intervention. It is critical midwives are prepared and able to make this kind of assessment.

Gender differences in antipsychotic prescribing

OBJECTIVE

Optimum outcome for those with psychosis will necessarily involve treatment with antipsychotic medication. Unfortunately this medication is associated with a high rate of adverse effects and as a consequence non-adherence. Maximizing symptomatic relief whilst minimizing side effects is the aim of treatment. In order to do this adequately prescribers need to be aware of the significant differences between men and women in response to antipsychotic treatment. These differences are not simply biologically mediated; both physiological and sociocultural factors contribute.

METHOD

Findings from a variety of sources were used to summarize gender differences in antipsychotic treatment.

RESULTS

Pharmacokinetic and pharmacodynamic factors, the impact of reproductive phases in women and gender differences in antipsychotic prescription across the lifespan (from children and adolescents to the elderly) are discussed. Important ethnic and racial differences are also mentioned.

CONCLUSION

Women require less antipsychotic medication than men to achieve a better symptom response, but this is at the expense of a higher side effect burden, in particular hormonal and metabolic side effects. Children, adolescents and the elderly are at especially high risk of adverse reactions with antipsychotics. In order to optimize outcome in people with psychosis, prescribers should ensure that gender differences are taken into account.

Antipsychotic therapy during early and late pregnancy. A systematic review

OBJECTIVE

Both first- (FGAs) and second-generation antipsychotics (SGAs) are routinely used in treating severe and persistent psychiatric disorders. However, until now no articles have analyzed systematically the safety of both classes of psychotropics during pregnancy. DATA SOURCES AND SEARCH STRATEGY: Medical literature information published in any language since 1950 was identified using MEDLINE/PubMed, TOXNET, EMBASE, and The Cochrane Library. Additional references were identified from the reference lists of published articles. Bibliographical information, including contributory unpublished data, was also requested from companies developing drugs. Search terms were pregnancy, psychotropic drugs, (a)typical-first-second-generation antipsychotics, and neuroleptics. A separate search was also conducted to complete the safety profile of each reviewed medication. Searches were last updated on July 2008.

DATA SELECTION

All articles reporting primary data on the outcome of pregnancies exposed to antipsychotics were acquired, without methodological limitations.

CONCLUSIONS

Reviewed information was too limited to draw definite conclusions on structural teratogenicity of FGAs and SGAs. Both classes of drugs seem to be associated with an increased risk of neonatal complications. However, most SGAs appear to increase risk of gestational metabolic complications and babies large for gestational age and with mean birth weight significantly heavier as compared with those exposed to FGAs. These risks have been reported rarely with FGAs. Hence, the choice of the less harmful option in pregnancy should be limited to FGAs in drug-naive patients. When pregnancy occurs during antipsychotic treatment, the choice to continue the previous therapy should be preferred.

The clinical content of preconception care: women with psychiatric conditions

For a substantial proportion of women, pregnancy can be complicated by the occurrence or reoccurrence of a psychiatric condition. Psychiatric disorders during pregnancy are associated with poor obstetric outcomes, higher risk of postpartum psychiatric illness, increased rates of substance abuse, lower participation in prenatal care, and adverse infant and family outcomes. As part of preconception care, providers should be vigilant and screen for psychiatric disorders among women of reproductive age, as the detection and appropriate management of these conditions can reduce the occurrence of adverse pregnancy and family outcomes. This manuscript reviews the treatment options and the risks and benefits of discontinuing, changing, or continuing psychotropic medications for women of reproductive age with common psychiatric disorders (depression and anxiety disorders, bipolar disorder, and schizophrenia) and offers recommendations for preconception care.

Prevention inherent in services for women with schizophrenia

OBJECTIVE

Effective care to women with serious mental illness provides an opportunity for prevention of mental health problems in their offspring. The objective of this study is to outline the preventive possibilities of a service targeted to women with schizophrenia.

METHOD

An analysis of recently published literature on women suffering from schizophrenia, focusing on intervention.

RESULTS

Genetic counselling, prenatal care, prevention of obstetrical complications, substance abuse reduction, appropriate antipsychotic treatment, parenting support, safety issues, quality of life, ethics, cultural competence, and advocacy are components of a comprehensive service to women with schizophrenia.

CONCLUSIONS

These components improve maternal health and, by also ensuring fetal and neonatal health, are potentially preventive against schizophrenia in the second generation.

Unexpected depletion in plasma choline and phosphatidylcholine concentrations in a pregnant woman with bipolar affective disorder being treated with lithuim, haloperidol and benztropine: a case report

Introduction

Patients with bipolar affective disorder can be effectively managed with pharmacological intervention. This case report describes a pregnant woman with a ten-year history of bipolar affective disorder that was being treated with lithium, haloperidol and benztropine.

Case presentation

The patient had a normal pregnancy, but developed an elevated blood pressure and started to lose weight at 36 weeks of gestation. During pregnancy, plasma concentrations of choline and phosphatidylcholine are increased to meet the demands of the foetus. However, our findings in this case included depletion of plasma choline and phosphatidylcholine concentrations. Other unusual outcomes included low placental weight and low infant birth weight.

Conclusion

This report suggests that the pharmacological management of this patient could possibly account for the findings.

Distinct neurobehavioral consequences of prenatal exposure to sulpiride (SUL) and risperidone (RIS) in rats

Antipsychotic treatment during pregnancy is indicated when risk of drug exposure to the fetus is outweighed by the untreated psychosis in the mother. Although increased risk of congenital malformation has not been associated with most available antipsychotic drugs, there is a paucity of knowledge on the subtle neurodevelopmental and behavioral consequences of prenatal receptor blockade by these drugs. In the present study, antipsychotic drugs, sulpiride (SUL, a selective D2 receptor antagonist) and risperidone (RIS, a D2/5HT2 receptor antagonist) were administered to pregnant Sprague-Dawley dams from gestational day 6 to 18. Both RIS and SUL prenatal exposed rats had lower birth body weights compared to controls. RIS exposure had a significant main effect to retard body weight growth in male offspring until postnatal day (PND) 60. Importantly, water maze tests revealed that SUL prenatal exposure impaired visual cue response in visual task performance (stimulus-response, S-R memory), but not place response as reflected in hidden platform task (spatial memory acquisition and retention). In addition, prenatal SUL treatment reduced spontaneous activity as measured in open field. Both behavioral deficits suggest that SUL prenatal exposure may lead to subtle disruption of striatum development and related learning and motor systems. RIS exposure failed to elicit deficits in both water maze tasks and increased rearing in open field test. These results suggest prenatal exposure to SUL and RIS may produce lasting effects on growth, locomotion and memory in rat offspring. And the differences may exist in the effects of antipsychotic drugs which selectively block dopamine D2 receptors (SUL) as compared to second generation drugs (RIS) that potently antagonize serotonin and dopamine receptors.

Cotard's syndrome and delayed diagnosis in Kashmir, India

Cotard's syndrome is a rare syndrome, characterized by the presence of nihilistic delusions. The syndrome is typically related to depression and is mostly found in middle-aged or older people. A few cases have been reported in young people with 90% of these being females. We present a case of a young pregnant woman suffering from Cotard's syndrome. This is the first report of this syndrome in a pregnant woman. The case was diagnosed late, due to lack of awareness of psychiatric problems in primary care physicians resulting in undue suffering, loss of precious time and resources for the patient. Besides highlighting the rare combination of pregnancy and Cotard's syndrome this report delineates the difficulties faced by patients with such symptoms in a low resource setting.

Preliminary findings from the National Register of Antipsychotic Medication in Pregnancy

OBJECTIVE

Following the presentation of a case study and an overview of current data highlighting the need for further research into the use of antipsychotic medication during pregnancy, the aim of the present paper was to outline the establishment of, and present preliminary data from, the National Register of Antipsychotic Medication in Pregnancy (NRAMP).

METHOD

Australian women with a history of psychosis, including schizophrenia, bipolar affective disorder with psychosis, schizoaffective disorder and first-episode psychosis, who are pregnant, are currently being invited to participate. The confluence of speculated national pregnancy rates and epidemiological data regarding child-bearing-age women with psychosis suggested an enrollment target of 100 women over a 24 month period. Details of antipsychotic medication are recorded throughout the pregnancy and for 1 year postnatally. Interviews with the mother are conducted 6 weekly antenatally, and then at 6 and 12 weeks, and 6 and 12 months postnatally, to assess symptoms of psychosis and depression, and attitudes towards parenting. In addition, consultations are conducted with the women's health-care providers to collate information regarding pharmacology and related side-effects, obstetric outcomes, psychiatric diagnoses and symptoms during pregnancy and for 1 year after delivery, and the provision of details on the baby's health and well-being.

RESULTS

NRAMP was launched in 2005. Ethics approvals have been gained at 14 sites nationally. Thirty women have consented, and 11 have completed. Data including demographics, health-care provision and medication for the first 30 participants are presented.

CONCLUSIONS

The establishment of NRAMP is an important strategy in improving the management of serious mental illness such as schizophrenia and related disorders, in women who are pregnant. This project involves extensive collaboration between many different clinical groups and industry, and shall culminate in an important resource to improve the quality of life for both patients and future generations.

The effects of genetic liability for schizophrenia and maternal smoking during pregnancy on obstetric complications

The purpose of this study was to determine whether a genetic vulnerability for schizophrenia and/or health-risk behaviors among schizophrenic pregnant women were associated with an increased incidence of obstetric complications (OCs).

METHOD

A high-risk birth cohort was formed by searching the Finnish Perinatal Register for all births from 1991-2000 with arterial cord pH values below 7.20, an indication of fetal asphyxia. This database was merged with national hospital discharge registries to determine psychiatric morbidity of the mothers and the mothers' first-degree relatives. Mothers were divided into 3 groups: women diagnosed with schizophrenia/schizoaffective disorder (n=53), mothers with a first-degree relative with schizophrenia/schizoaffective disorder (n=590) and healthy controls (n=36,895).

RESULT

Schizophrenic women had significantly more OCs than mothers with a first-degree schizophrenic relative and controls. These women had significantly increased rates of eclampsia, premature delivery, prenatal hospitalizations, and marginally significant increases in high blood pressure. Offspring of schizophrenic mothers had significantly decreased APGAR scores and birth weight and increased medical complications after birth. In contrast, women with a schizophrenic first-degree relative had no significant increases in OCs compared to controls. Schizophrenic mothers also smoked more than the other groups and smoking was found to mediate the relationship between maternal schizophrenic status and decreased birth weight among offspring.

CONCLUSIONS

Maternal schizophrenia during pregnancy leads to an increased risk of OCs, possibly due to engagement in health-risk behaviors during pregnancy, such as smoking, whereas genetic susceptibility to schizophrenia, by itself, does not appear to be related to incidence of OCs.

Use of long-acting injectable risperidone before and throughout pregnancy in schizophrenia

Data on the use of long-acting injectable (LAI) risperidone, the first atypical depot antipsychotic, during pregnancy are limited. A 35-year-old woman with schizophrenia was given LAI risperidone before and throughout her pregnancy. She gave birth to a female infant weighing 2230 g at 36 weeks and 6 days of pregnancy, following premature rupture of the membranes. The baby had no congenital malformation and was healthy 8 months postnatal. To our knowledge, this is the first reported use of LAI risperidone throughout an entire pregnancy. In this paper, we discuss the rationale and problems of LAI risperidone use in pregnancy, based on a literature review.

Emergency management of agitation in pregnancy

OBJECTIVE

This study aimed to better understand how agitated pregnant women are pharmacologically managed in a psychiatric emergency service (PES).

METHOD

A retrospective chart review was conducted on 80 women admitted to a PES with HCG-positive urine, from January 1, 2004, to June 30, 2005. Of these, 31 patients required medication for agitation. We describe the demographics (age, ethnicity, housing status, insurance status), chief complaint, medical status, drug use and medical management in the PES, as well as pregnancy awareness, prenatal care and trimester. Patient data were analyzed using simple frequency calculations and cross tabulations with SPSS.

RESULTS

Thirty-one (39%) patients received 34 doses of psychotropic medication. Haloperidol, alone or in combination with a benzodiazepine, was the most frequently administered psychotropic medication, while risperidone was the second most commonly administered medication. Two patients required brief restraint for assaultive behavior that was unresponsive to any other intervention.

CONCLUSION

There are algorithms that provide guidance to clinicians regarding the pharmacological management of aggression. However, there are no efficacy or safety studies that recommend strategies for the management of the agitated pregnant patient.

Prophylactic treatment of bipolar disorder in pregnancy and breastfeeding: focus on emerging mood stabilizers

OBJECTIVES

Bipolar disorders are reported to have a high incidence during childbearing years and the need may arise to start or continue a pharmacological treatment during pregnancy and the postpartum period. In the last few years several investigations have evaluated the efficacy of emerging mood-stabilizing agents in the treatment of bipolar disorders, such as lamotrigine, olanzapine, risperidone, quetiapine, aripiprazole and ziprasidone. A number of studies, which examined the use of oxcarbazepine, point to its potential usefulness in prophylactic treatment. The aim of this review is to compare information from the literature on the safety of lamotrigine, oxcarbazepine, risperidone, olanzapine, and quetiapine to the safety data on classic mood stabilizers during pregnancy and the postpartum period.

METHODS

A computerized search carried out from 1980 to April 5, 2006 led to the summarization of the results. (References were updated after acceptance and prior to publication.)

RESULTS

Emerging mood stabilizers show uncertain safety parameters in pregnancy and lactation. Limited information on lamotrigine and oxcarbazepine does not suggest a clear increase in teratogenicity, while olanzapine appears to be associated with a higher risk of metabolic complications in pregnant women. Data about risperidone and quetiapine are still inconclusive. Finally, the literature on the safety of these compounds in breastfeeding is anecdotal.

CONCLUSIONS

Untreated pregnant bipolar women are at an increased risk of poor obstetrical outcomes and relapse of affective symptoms. On the other hand, classic antiepileptic drugs are well-known human teratogens, whereas data on lithium are partially ambiguous. The safety of emerging mood stabilizers in pregnancy and breastfeeding has not been examined extensively. Therefore, when approaching bipolar disorder, if possible, each episode must be considered separately.

Psychotropic drugs in pregnancy and lactation

The management of psychotropic medications during pregnancy and lactation involves a difficult and complex decision for both patient and provider, particularly due to the many unknown effects medication may have on the infant. Available studies concerning use of psychotropic medications in pregnant and lactating women are limited and there are no universal guidelines. This article reviews the literature on the use of psychotropic drugs, including antidepressants, mood stabilizers, antipsychotics, and benzodiazepines, in pregnant and breast-feeding women and presents relevant data on teratogenic effects, neonatal toxicity, perinatal syndromes, and neurobehavioral sequelae.

Psychotropic drugs in pregnancy: a case-control study

Psychotropic drug exposure during pregnancy is a common problem. Among the 601 cases exposed to drugs during pregnancy, who were followed by our Toxicology Information and Follow-up Service, 124 cases had used psychotropic drugs for depression, anxiety, or psychotic disorders. As the control group, 248 women, who did not use any drugs were selected. Of the 124 cases, 80 (64.5%) had healthy babies, and 17 (13.7%) decided to terminate the pregnancy. Spontaneous abortions, intrauterine death (in the 38th week) and premature deliveries were observed in the 9 (7.3%), 1 (0.8%) and 3 (2.4%) cases, respectively, in the drug exposure group. Pregnancies of the 14 (11.3%) cases were continuing during the preparation of this manuscript. Of the 248 controls, 151 (60.9%) had healthy babies, 9 (3.6%) experienced spontaneous abortion and 3 (1.2%) decided to terminate their pregnancies, 3 (1.2%) had premature deliveries, and we observed one (0.4%) congenital abnormality, 81 (32.7%) cases were still pregnant. Odds Ratio (95% confidence interval) for spontaneous abortion was found to be 1.35 (1.27-11.82) in the cases exposed to psychotropic drugs (P=0.02). No developmental problems were observed in the babies followed for 12 months. These data may give information about the early- but not the late-term effects of psychotropic drugs used in pregnant women.

Use of Antipsychotics in the Management of Schizophrenia during Pregnancy

The rapid development of pharmacotherapy has resulted in a growing clinical importance for the treatment of the increasing number of women with schizophrenia during pregnancy. An evolving database on reproductive health safety factors for women with schizophrenia has begun to be of assistance in optimising clinical benefits for women with childbearing potential. Given the prevalence of antipsychotic use during pregnancy in women with schizophrenia, it is important for the clinician to have a prepared approach to the administration of these agents. In general, the use of psychotropic medication during pregnancy is indicated when risk to the fetus from exposure to this medication is outweighed by the risks of untreated psychiatric illness in the mother. The preponderance of evidence from registries to large health surveys indicate that treatment with antipsychotic medication confers either no or a small nonspecific risk for organ malformations. According to the relevant literature published on the safety of antipsychotic medication during pregnancy, the findings are encouraging; however, the currently available data are very limited. Until there are more controlled prospective data on the impact of drugs on fetal and later development, the clinician will continue to work in a state of potential uncertainty, weighing partially estimated risks against managing individual clinical problems. The aim for the clinician should be to provide the best information available regarding the scope of possible risks associated with the treatment of schizophrenia during pregnancy. On the basis of the available data, generalisation is impossible and recommendations should be made on a drug-by-drug basis. The risks and benefits must always be carefully weighed for each patient on an individual basis. Only a woman who is well enough to acknowledge her pregnancy and her mental illness can effectively weigh the relative and partially unknown risks of treatment with antipsychotic medication against the highly probable risks of illness exacerbation if untreated.

Drugs that affect the fetus and newborn infant via the placenta or breast milk

In general, drugs that are taken by a mother during pregnancy or after birth may be transferred to the fetus or the infant (through breast milk). Many factors are involved that determine the amount of drugs that are transferred and their potential effects on the fetus or infant. A careful assessment of the risk versus benefit is necessary and should be individualized. In the breastfed infant, many measures can be undertaken further so that the amount of drug transferred to the infant is minimized.

Clinical utilization of atypical antipsychotics in pregnancy and lactation

OBJECTIVE

To analyze the available literature regarding the safety of atypical antipsychotics in pregnancy and lactation in order to recommend evidence-based strategies for pharmacologic management of psychosis in these conditions.

DATA SOURCES

We summarized the results from articles identified via MEDLINE/PubMed/TOXNET (1993-January 31, 2004), using the key terms pregnancy, lactation, breast-feeding, human milk, psychotropic drugs, atypical antipsychotics, olanzapine, quetiapine, risperidone, clozapine, ziprasidone, and aripiprazole.

STUDY SELECTION AND DATA EXTRACTION

Retrospective studies, clinical observations, and case reports regarding the 6 atypical antipsychotics mentioned above were selected and analyzed. Extensive manual review of pertinent journals and textbooks was also performed.

DATA SYNTHESIS

Reviewed studies show that olanzapine and clozapine apparently do not increase the teratogenic risk if administered to pregnant women, while evidence on quetiapine, risperidone, aripiprazole, and ziprasidone is still limited. In contrast, available information is not able to exclude unwanted serious effects associated with the use of all atypical antipsychotics on mother-infant dyads. Furthermore, more than a few studies suggest increased hyperglycemic risk for pregnant women related to atypical antipsychotic therapy during gestation. Finally, published evidence about the effects on long-term infant neurodevelopment of drug exposure through both placenta and breast milk is represented only by sporadic case reports.

CONCLUSIONS

It is well known that potential consequences of an untreated psychotic episode may be severe and may lead to the mother attempting suicide and/or infanticide. For these reasons, clinicians need to help mothers weigh both fetal and neonatal risks of exposure to drugs against the potential risk they and their infant may incur if the psychiatric illness is not treated. On the other hand, atypical antipsychotics in pregnancy and breast-feeding do not show evident advantages in safety when compared with typical neuroleptic agents. Therefore, we suggest that the most relevant parameters for selecting the best clinical option for pregnant and breast-feeding women with schizophrenia and related disorders remain strongly related to 3 main points: (1). cautious evaluation of the risk/benefit ratio of fetal and neonatal drug exposure, (2). degree of severity of maternal psychiatric illness, and (3). careful preliminary choice of drugs characterized by a balanced safety/efficacy profile.

Psychiatric disorders during pregnancy

Treating women with psychiatric disorders during pregnancy is a challenge for numerous reasons. Balancing the risks and benefits of symptoms and treatments is particularly important during pregnancy because both medication and maternal illness may have adverse effects on the fetus. Communication of options in the management of psychiatric disorders in pregnancy is vital to optimal treatment. One barrier to effective communication has been a paucity of research from which clinicians can draw information, particularly in the area of pharmacological treatment. However, emerging evidence points to the low risk of many psychotropic medications during pregnancy. Uncertainty must not prevent frank risk-benefit discussions from occurring between treating physicians and their pregnant patients. Psychiatrists can prepare themselves for management decisions by reviewing the current literature.