ACOG Guidelines on Psychiatric Medication Use During Pregnancy and Lactation
Am Fam Physician. 2008 Sep 15;78(6):772-778.
An estimated 500,000 pregnancies in the United States each year involve women who have or who will develop psychiatric illness during the pregnancy.
The use of psychotropic medications in these women is a concern because of the risks of adverse perinatal and postnatal outcomes.
However, advising these women to discontinue medication presents new risks associated with untreated or inadequately treated mental illness, such as poor adherence to prenatal care, inadequate nutrition, and increased alcohol and tobacco use.
Ideally, decisions about psychiatric medication use during and after pregnancy should be made before conception.
The use of a single medication at a higher dosage is preferred over multiple medications, and those with fewer metabolites, higher protein binding, and fewer interactions with other medications are also preferred.
All psychotropic medications cross the placenta, are present in amniotic fluid, and can enter breast milk. The U.S. Food and Drug Administration has categorized medications according to risk during pregnancy (Table 1).
Ten to 16 percent of pregnant women meet diagnostic criteria for depression, and up to 70 percent of pregnant women have symptoms of depression. Studies have shown a relapse rate of 68 percent in women who discontinue antidepressant therapy during pregnancy.
Untreated maternal depression is associated with increased rates of adverse outcomes (e.g., premature birth, low birth weight, fetal growth restriction, postnatal complications), especially when depression occurs in the late second to early third trimesters.
There is limited evidence of teratogenic effects from the use of antidepressants in pregnancy and adverse effects from exposure during breastfeeding.
Exposure to selective serotonin reuptake inhibitors (SSRIs) late in pregnancy has been associated with transient neonatal complications; however, the potential risks associated with SSRI use must be weighed against the risk of relapse if treatment is discontinued.
Treatment with SSRIs or selective norepinephrine reuptake inhibitors during pregnancy should be individualized.
Paroxetine (Paxil) should be avoided by pregnant women and women who plan to become pregnant, and fetal echocardiography should be considered for women exposed to paroxetine during early pregnancy.
Because abrupt discontinuation of this drug is associated with withdrawal symptoms and a high rate of relapse, prescribing information about discontinuation of therapy should be followed carefully.
The combination of breastfeeding and SSRI use has not been studied extensively; however, medication exposure from breastfeeding is less than the exposure that occurs transplacentally.
Isolated adverse effects have been reported, the most notable of which was an infant who had transient apnea after being exposed to citalopram (Celexa). Generally, no long-term neurobehavioral studies have been done in infants exposed to SSRIs through breast milk.
Most tricyclic antidepressants seem to be safe during lactation except for doxepin (Sinequan), which reportedly led to an incident of infant respiratory depression.
Rates of postpartum relapse in women with bipolar disorder range from 32 to 67 percent. Perinatal episodes of the disorder tend to be depressive and are more ly to recur in subsequent pregnancies. The risk of postpartum psychosis is increased by as much as 46 percent in women with this disorder.
The use of lithium during pregnancy has been associated with congenital cardiac malformations, fetal and neonatal cardiac arrhythmias, hypoglycemia, premature delivery, and other adverse outcomes.
However, neurobehavioral sequelae were not found in a five-year follow-up of 60 school-age children exposed to lithium during gestation.
The decision to discontinue lithium therapy during pregnancy because of fetal risks should be weighed against the maternal risks of illness exacerbation.
The physiologic changes of pregnancy may affect the absorption, distribution, metabolism, and elimination of lithium, and close monitoring of lithium levels during pregnancy and the postpartum period is recommended.
The following guidelines have been suggested for women with bipolar disorder who are taking lithium and plan to conceive:
- Lithium therapy should be gradually tapered before conception in women who have mild, infrequent episodes.
- Lithium therapy should be tapered before conception, but gradually restarted after organogenesis in women who have more severe episodes and are at moderate risk of short-term relapse.
- Lithium therapy should be continued throughout the pregnancy in women who have severe, frequent episodes, and these patients should be counseled about the reproductive risks associated with therapy.
- Fetal echocardiography should be considered in women exposed to lithium in the first trimester.
The use of lithium during breastfeeding has been associated with a number of adverse effects; however, only 10 maternal-infant dyads have been studied. Effects included lethargy, hypotonia, hypothermia, cyanosis, and electrocardiography changes. No long-term studies have examined the neurobehavioral consequences of lithium therapy during breastfeeding.
ANTIEPILEPTIC THERAPY FOR BIPOLAR DISORDER
Several antiepileptic drugs are used in the treatment of bipolar disorder, including valproic acid (Depakene), carbamazepine (Tegretol), and lamotrigine (Lamictal).
However, data on the fetal effects of these drugs come primarily from studies of women with seizures.
It is not clear whether the underlying pathology of epilepsy contributes to the teratogenic effect of these drugs on the fetus.
Exposure to valproic acid during pregnancy is associated with an increased risk of neural tube defects, craniofacial and cardiovascular anomalies, fetal growth restriction, and cognitive impairment.
Carbamazepine exposure during pregnancy is associated with facial dysmorphism and fingernail hypoplasia. It is unclear whether carbamazepine use increases the risk of neural tube defects or developmental delay.
Although these drugs are superior to lithium in the treatment of patients with mixed episodes or rapid cycling, they should be avoided during pregnancy.
The use of lamotrigine during pregnancy has not been associated with any major fetal anomalies and is an option for maintenance therapy in women with bipolar disorder.
Valproic acid use during lactation has been studied in 41 maternal-infant dyads; only one infant was adversely affected with thrombocytopenia and anemia.
The American Academy of Pediatrics and the World Health Organization consider valproic acid safe in breastfeeding women.
Carbamazepine is ruled “probably safe”; rare side effects include transient cholestatic hepatitis and hyperbilirubinemia.
Anxiety disorders are the most common psychiatric disorders, and some (e.g.
, panic disorder, generalized anxiety disorder, posttraumatic stress disorder, agoraphobia) are twice as ly to be diagnosed in women than in men.
Anxiety and stress during pregnancy are associated with spontaneous abortion, preterm delivery, and delivery complications, although a direct causal relationship has not been established.
The use of benzodiazepines in women with anxiety disorders does not carry a significant teratogenic risk. Prenatal exposure to diazepam (Valium) increases the risk of oral cleft, but the absolute risk increases by only 0.01 percent (from six to seven in 10,000 infants).
Maternal use of benzodiazepines shortly before delivery is associated with floppy infant syndrome (i.e.
, hypothermia, lethargy, poor respiratory effort, and feeding difficulties), and withdrawal syndromes may persist for several months after delivery in infants whose mothers took alprazolam (Xanax), chlordiazepoxide (Librium), or diazepam.
In general, use of benzodiazepines during breastfeeding affects the infant only if he or she has an impaired ability to metabolize the drug. In this situation, the infant may demonstrate sedation and poor feeding.
Adverse outcomes have been reported in women with schizophrenia, including preterm delivery, low birth weight, placental abnormalities, increased rates of congenital malformation, and a higher incidence of postnatal death. If left untreated during pregnancy, schizophrenia can have devastating effects on the mother and child.
Atypical antipsychotics have replaced typical agents as first-line therapy for psychotic disorders because these drugs are better tolerated and may be more effective in managing the negative symptoms of schizophrenia.
The reproductive safety data on atypical antipsychotics are limited, but the use of olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), and clozapine (Clozaril) has been associated with increased rates of low birth weight and therapeutic abortion.
No long-term studies of children exposed to atypical antipsychotics during gestation have been conducted. Therefore, the routine use of these drugs during pregnancy and lactation is not recommended.
Typical antipsychotics have a larger reproductive safety profile; no significant teratogenic effect has been documented with chlorpromazine (Thorazine), haloperidol (Haldol), or perphenazine (Trilafon). Doses of typical antipsychotics should be minimized during the peri-partum period to limit the necessity of using additional medications to manage extrapyramidal side effects.
Data on antipsychotic use in breastfeeding women are limited. A small study of chlorpromazine use during breastfeeding showed no developmental deficits in children up to five years of age; however, a study of both chlorpromazine and haloperidol revealed developmental deficits in children 12 to 18 months of age.
Antidepressants and Pregnancy: Tips from an Expert
Fertility, Pregnancy and Childbirth Managing Mood and Stress Rare Pregnancy Complications Living with Depression
Most pregnant women want to do everything right for their baby, including eating right, exercising regularly and getting good prenatal care. But if you’re one of the many women who have a mood disorder, you might also be trying to manage your psychiatric symptoms as you prepare to welcome your new baby.
It’s common for doctors to tell women with mood disorders to stop taking drugs antidepressants during pregnancy, leaving many moms-to-be conflicted about giving up the medications that help keep them healthy.
Lauren Osborne, M.D., assistant director of the Johns Hopkins Women’s Mood Disorders Center, talks about why stopping your medication may not be the right approach. She explains how women can — and should — balance their mental health needs with a healthy pregnancy.
Antidepressants and Pregnancy
Women who take antidepressants, such as selective serotonin reuptake inhibitors (SSRIs), during pregnancy may worry about whether the medications can cause birth defects.
There is good news on this front. Osborne says that there is generally no need to taper off medications during pregnancy.
“We can say with strong confidence that antidepressants don’t cause birth defects,” says Osborne.
She adds that most studies finding a physical effect on babies from antidepressants taken during pregnancy fail to account for the effects of the mother’s psychiatric illness.
In fact, untreated mental illness itself poses risks to a developing fetus. A woman who is depressed is less ly to get good prenatal care and more ly to engage in unhealthy or dangerous behaviors, smoking and substance abuse. Osborne also says mental illness has direct effects on newborn babies.
“Untreated depression may increase preterm birth or cause low birth weight,” she says. “Babies of depressed moms have higher levels of a hormone called cortisol. This raises a baby’s risk of developing depression, anxiety and behavioral disorders later in life.”
Weighing the Risks
While doctors don’t believe antidepressants cause birth defects, it’s still possible for them to affect the baby. It’s important for a mother and her doctor to know the risks.
About 30 percent of babies whose mothers take SSRIs will experience neonatal adaptation syndrome, which can cause increased jitteriness, irritability and respiratory distress (difficulty breathing), among other symptoms. Doctors aren’t sure whether this effect is due to the baby’s withdrawal from the SSRI after birth or exposure to the drug itself before birth.
“It may be distressing and cause pediatricians to run tests, but it will go away,” says Osborne, pointing out that these symptoms also sometimes occur in babies whose mothers don’t take SSRIs.
Common medications women frequently ask about include:
- SSRIs: Some studies link SSRI use with a very rare defect called persistent pulmonary hypertension, which is a condition where babies’ lungs don’t inflate well. “The most recent study looked at 3.8 million women and showed there was no increase in risk to their babies,” says Osborne.
- Paroxetine: Early studies on a small number of patients connected the SSRI paroxetine with cardiac defects in babies. However, these studies didn’t account for smoking, obesity and other risk factors that are more common in women who have depression. Osborne says larger, more recent studies show no such link with cardiac defects. She doesn’t recommend switching medications if paroxetine is the only one that works for you.
- Benzodiazepines: Women should avoid using tranquilizers, such as diazepam, alprazolam and clonazepam, in high doses during pregnancy because they can lead to sedation and respiratory distress in the newborn. You can still use them in small doses for short periods of time. However, Osborne will typically try to get mothers on intermediate-acting options lorazepam. These medications don’t linger in the baby’s bloodstream longer-acting forms and aren’t associated with high rates of abuse shorter-acting forms.
- Valproic acid: This medication treats seizures and bipolar disorder, and does carry significant risk to a developing fetus. Taking valproic acid during pregnancy carries a 10 percent risk of neural tube defects — birth defects that affect the brain or spinal cord, such as spina bifida — as well as risks to the baby’s cognitive development, such as lower IQ. “Valproic acid is the only one I’d never prescribe for pregnant women unless all other treatment had failed,” says Osborne .
Seeing a Reproductive Psychiatrist
If you have a mood disorder, you may benefit from speaking with a reproductive psychiatrist when you are pregnant or thinking about becoming pregnant. Ideally, this should happen when you are planning for pregnancy, although this isn’t always possible. Meeting with a doctor after you become pregnant is not too late.
Osborne says her approach with patients is to limit the number of potentially harmful exposures to the baby. This means considering the number of medications a mother is on, as well as her psychiatric illness.
“If a woman takes a low dose of many medications and we have time to plan, we’ll try to get that down to a higher dose of fewer medications,” she says. “If a woman is on a low dose and it’s not controlling her illness, then her baby is exposed to both the medication and the illness. In that case, I would increase the medication dosage so her baby isn’t exposed to the illness.”
If your illness is mild, your doctor might recommend getting off medication and replacing it with treatments such as psychotherapy, prenatal yoga or acupuncture to improve your mood.
Ultimately, Osborne says women should weigh the risks of medication against the risk of untreated illness.
“If a particular side effect is extremely rare, it’s still a very rare event even if you double the risk,” she says. Medication risks are typically not greater than those of untreated mental illness. “Switching a woman’s medication is something I do very carefully and reluctantly.”