Psychiatric medications in

pregnancy and lactation

Dr Bavi Vythilingum
Division CL Psychiatry, Dept of
Psychiatry UCT
Rondebosch Medical Centre
Psychiatric disorders in pregnancy

 In SA 30 -40% of women have antenatal

depression
 Decision to treat – benefit to mother vs risk to
child
 More accurate – look at benefit to mother
and child vs risk to mother and child
 “Would a physician tell a pregnant woman
with epilepsy, ‘Stop your meds and ride out
the seizures until you deliver’? Are the
medications of pregnant women with mental
illness somehow more “optional”?”

Dr Helen Kim, MGH Center for Women’s

Mental Health
Psychiatric medications in
pregnancy and lactation
Prescribing principles in
pregnancy and lactation

 Monotherapy
 Lowest effective dose
SSRI’s

 First line pharmacotherapy

 Citalopram, sertraline appear best tolerated
 No long term behavioural effects
SSRI and PPHN

 Six published studies

– only three studies adequately powered.
 3 studies – increased risk
 Absolute risk cannot be determined,
 BUT probably less than 1%.
 Information does not support discontinuation
or lowering the dose of the antidepressant.
Antidepressants and
teratogenicity

 Several studies linking SSRI use to

– Cardiac defects
– AHDH
– Autism
 Large database studies
 No face to face interview
 Multiple confounders – adequate power?
 Qualitatively different cases vs control
– Other drug use, higher rates FAS, older
 No control for effect parenting
Tricylic Antidepressants (TCA’s)

 No increased teratogenic risk

 More adverse side effect profile
– particularly postural hypotension
– constipation
– lethality in overdose
 Generally used as second line agents.
Other antidepressants

 Venlafaxine, duloxetine, bupropion

– Less data
– Probably safe
 MAOI’s – no data, avoid due to dietary
restrictions, risk hypertension
Take Home Message

 Risk of teratogenecity
 Absolute risk is not clear but appears to be
small
 Psychotherapy treatment of choice for
perinatal depression
 Weigh risk benefit ratio
 Management of Bipolar Disorder
during Pregnancy

 Should be by a psychiatrist
 Teratogenic risk
– Lithium Ebstein’s anomaly 1-5% (vs 0.5 – 1%
risk)
– Na Valproate NTD, other anomalies, 3x vs other
antiepileptics, 4x general population
– Carbamazepine 1% risk neural tube defects (vs
0.1% risk)
– Lamotrigine limited evidence, cleft palate
Second generation antipsychotics

 Attractive
– No described teratogenicity
– Mood stabilisers
 Metabolic side effects
– Boden 2012
– gestational diabetes adjusted OR, 1.77 [95% CI,
1.04-3.03]
– Higher risk SGA infant - confounders
Medication Summary

 Lithium – safest
 Lamotrigine, atypicals – appears safe
 Individualise for patient
 Adequate risk counselling
Patient falls pregnant on
medication

 DO NOT STOP MEDICATION

 Minimal decrease in risk of defects vs high
risk relapse
 Continue meds at lowest effective dose
 Early US and anomaly scan
 FOLATE
Medication through pregnancy

 Changing maternal blood volumes

 Increase doses during pregnancy
– Lithium – levels monthly first 2 trimesters, every
fortnight thereafter
– Valproate, CBZ – guided clinically, checking
levels every 2 -3 months useful
Delivery

 Liaise closely with obstetrician

 Hospital
 Adequate pain control
 IV line up
 Stop lithium, benzo’s at onset labour,
recommence post delivery after checking
level
 High risk for post natal depression/psychosis
Benzodiazepines

 Small increased risk for cardiac/oral cleft

malformations with first-trimester exposure.
 Neonatal toxicity (“floppy infant syndrome”)
/withdrawal
 Avoid in the first trimester,late in the third trimester
Benzodiazepines II

 To minimize neonatal withdrawal, gradually taper the

mother’s benzodiazepine before delivery
– Taper 3 to 4 weeks before the due date and discontinue at
least 1 week before delivery.
– If benzodiazepines cannot be tapered
 use a short acting agent
 advise the mother to discontinue benzodiazepine use as soon
as she thinks she is going into labour.
Medication

 Generally SSRI’s and TCA’s safe in

pregnancy and breastfeeding
 Antipsychotics – reasonably safe
 Mood stabilisers – teratogenic risk
 ECT – option
Breastfeeding and Medication

 MOST WOMEN ON MEDS CAN

BREASTFEED!!!!!
 Risk of child dying from diarrhoea,
respiratory disease, malnutrition higher than
medication side effects
 Breastfeeding, bedsharing mothers get more
sleep
 Case by case basis
Breastfeeding and Medication

 Lowest effective maternal dose

 All meds excreted into breastmilk
 Watch baby
– Jaundice
– Excessive sleepiness
 Pre term – probably best not to breastfeed
Breastfeeding and medication II

 Antidepressants – generally safe

 Antipsychotics
– Infant sedation
– Neonatal EPSE
Breastfeeding and medication III

 Mood stabilisers
– All present problems
– Consider risk benefit carefully
 Lithium
– Maternal hydration important
 Anticonvulsant class
– Rashes
Eglonyl?

 Sulpiride
 Antipsychotic with theoretical mood elevation
properties at low doses
 Side effect of increasing milk supply
 Sedating
 NOT an effective antidepressant
Pregnancy and lactation summary

 All medications present risk – some higher

than others
 Weigh risk benefit ratio
 PNDSA www.pndsa.org
– 0828820072
– info@pndsa.org.za
 Otispregnancy.org
 www.infantrisk.com
 In general, women do not use psychotropic
medications during pregnancy without good
reason.

 They educate themselves, struggle with

treatment options, and in many cases stop
medication, relapse, and then restart it when
they become ill.

 Being pregnant and giving birth to a child is

an exhausting physical and emotional
experience. A woman is vulnerable and
deserves support, not shaming.