113b - Psychopharmacology of Pregnancy

Question 1

What is neonatal adapatation syndrome?

Which medications is it associated with?

Answer 1

Uncomfortable infant: fussy, gittery, stiff, tremulous, feeding/breathing concerns

Generally does not require a higher level of care or delay discharge post-partum

• SSRIs
• Benzos
• Antipsychotics

In gneral, it is best to treat maternal depression, anxiety, and/or psychosis and accept risk of neonatal adaptation syndrome

Question 2

Which antipsychotic is associated with fetal malformations?

Answer 2

Risperidone (at ≥ 2mg/day) (a second generation/atypical antipsychotic)

cardiac malformations

Question 3

Which concerns for benzos in pregnancy are supported by evidence?

Answer 3

• Increased risk of neonatal adaptation syndrome
• Behavioral development may be delayed at first, but caught up by 2 years
• Withdrawal symptoms
  
  • But no seizures
• Risk for sedation due to transfer to breast milk (has a long half life so consider using a short acting benzo)

Question 4

Which concerns for SSRIs in pregnancy are supported by evidence?

Answer 4

• Neonatal adaptation syndrome
  
  • Known association with SSRI, but generally does not require a higher level of care or delay discharge post-partum
• *Slight* increase in mild persistent pulmonary hypertension in babies exposed to SSRIs during 3rd trimester

No evidence for association with cardiac malformation, autism, pre-term delivery

In general, risks of untreated maternal depression are much higher than those associated with SSRIs

Question 5

Which concerns for Lithium in pregnancy are supported by evidence?

Answer 5

• Increased risk of cardiac malformation (Ebstein’s anomaly)
  
  • But lower than perviously thought
  • Can continue at lowest effective dose, supplement with folate

Question 6

Which concerns for antipsychotics in pregnancy are supported by evidence?

Answer 6

• Maternal weight gain, metabolic changes
  
  • Increased risk of gestational diabetes
• Neonatal adaptation syndrome
• Slower neuromotor development at first, but catch up by 2 years

Exception: risperidone has a higher risk of cardiac malformation; not first line in pregnancy

Question 7

How would you advise mothers who are breastfeeding and taking psychotropic medications?

Answer 7

• Most do transfer to breast milk, but relative infant dose is much lower than maternal dose
• If taking Li, monitor breast milk levels
• Monitor babies for weight concerns, agitation, sleep issues
• Milk supply will not be impacted

Question 8

Levels of which psychotropic medication should be monitored in breastmilk, if breastfeeding?

Answer 8

Lithium

Others do not need to be monitored unless concern for weight, agitation, sleep issues in the infant

Question 9

What effect does lamotrigine have if taken during pregnancy?

Answer 9

• Lamotrigine does not increase the risk of cardiac malformations of neural tube defects
  
  • an increased dose of lamotrigine shows up in the breast milk compared to other antiepileptic drugs