Psychotropics and perinatal period
Theme: Perinatal mental health
The question about the use and about correct and safe use of psychotropic medication during the pregnancy is crucial in care of mothers suffering mental disorders. The newest information and main recommendation about it in an article by the professor Maris Taube.
(Foreword by Ramunė Mazaliauskienė)
Pregnancy is normal part of life for everyone, including patients with very difficult mental problems and severe mental disorders. Decision about continuation and use of medicines always is difficult. We as psychiatrist must remember that no decision without risk. Pregnancy complications, e.g. low birth weight, prematurity are possible due to maternal stress. Irritation, agitation, lethargy, poverty of facial expressions will be result of mom’s distress. Also, we will take in to account that relapse can lead to the need for higher doses of medicines.
From other side use of psychotropic medicines during pregnancy can lead to physical malformations (hearth defects, cleft lip and cleft palate, spina bifida, Down syndrome), intrauterine fetal death, growth impairment, neonatal toxicity, behavioural and postnatal development delay.
No decision without risk. But we together with a patient must make right decision in a particular individual situation.
Every pregnancy starts out with a 3-5% chance of having a birth defect. This is called the background risk. Congenital malformations, hearth, neural tube defects, Down syndrome, spontaneous abortion, premature birth, low birth weight, hearth defects, persistent pulmonal hypertension, learning difficulties, development delay are some of them and we don’t link all problems only to medicines.
Better way to avoid unexpected problems afterward is discus the risks and benefits before pregnancy. Will be very good to avoid all drugs during first trimester of pregnancy. We can remember about a relapse risk and will be nice to lower dosages timely before pregnancy. It is recommended use low doses as possible. Consider the risk of pregnancy even if not currently planned, recommend make a test. Very important is to balance risks of medicines and risks of possible mental disorders episodes. Is the risk of disease new episode higher than fatal risk for a child?
When decision about medicines is made, next question is about medicines, dosages. The pharmacokinetics of some drugs change during pregnancy, e.g. lamotrigine, lithium doses needs to decrease, levetiracetam, SSRI class antidepressants doses needs to increase. If its possible, will be good to reduce doses or withdraw medicines in the 1-2 weeks before delivery.
What we can do in case of unexpected pregnancy? First of all – don’t panic! It is necessary to confirm pregnancy. Before day 17 of pregnancy consider immediate stopping of medicines or temporary discontinuation. After day 60 the major risks has passed. Nutritional supplements, e.g. folic acid are recommended. If its possible, try to reduce doses of medicines and also discontinue any non-essential drugs. This is time to discuss the risk of the possible consequences of relapse versus published risk to the fetus.
How big is risk when we decided to use medicines? Based on scientific evidence different organisations like FDA (US Food and Drug Administration), ADEC (The Australian Drug Evaluation Committee) etc. try to classified psychotropics and other drugs in risk categories. E.g. A class means that controlled human studies do not show a risk (FDA) or drug has been taken by a large number of pregnant women with no proven increase in malformations or other direct, or indirect harmful effects on the fetus (ADEC). In opposite X class means that fetal abnormalities have been shown in animals or humans, or both, and the risk outweighs any possible benefits (FDA) or high risk of causing permanent damage, so should not be used in pregnancy (ADEC).
If we looked on specific medicines, we don’t see class A or X because evidence usually is not so strong, pregnancy isn’t the best time for drug trials. Usually we see class B, C, D and it means that evidence is not so strong. From particular group of medicines we must pay attention to mood stabilisers/anticonvulsants, especially high risk medicine is valprate. Also, carbamazepine, lithium, topiromate request special attention. From antidepressants group we will try to avoid paroxetine during pregnancy. From antipsychotics clozapine will be more safety option compering to others. Benzodiazepines from anxiolytics/hypnotics during pregnancy will be substituted by buspirone or Z drugs.
No decision without risk!
Decision about medicines during pregnancy is always compromise and common decision with a patient.
Avoiding all medicines during first trimester is ideal.
Use low doses as possible.
The pharmacokinetics of some drugs changing during pregnancy (e.g. SSRI needs to use in higher doses).
Pay attention to every drug used in pregnancy, some of them are more risky (e.g. valproate). □