#92 Use Of Psychiatric Meds In Pregnancy And Breastfeeding

Question 1

What are used to treat anxiety (broad categories)?

Answer 1

Benzodiazepines
Antidepressants
Psychotherapy

Question 2

What are used to treat major depressive disorder (broad categories)?

Answer 2

Antidepressants
ECT
Therapy

Question 3

What are used to treat bipolar disorder (broad categories)?

Answer 3

Lithium
Anticonvulsants
Antipsychotics
ECT

Question 4

What are used to treat schizophrenia (broad categories)?

Answer 4

Antipsychotics

Question 5

For pregnant patients on psychiatric medication is it better to do high dose of one medication or low doses of multiple medications?

Answer 5

Better to have higher dose of one medication

Question 6

What is the prevalence rate of depression in adults in the US?

Answer 6

17%

Question 7

Are women more or less likely to suffer depression than men? By how much?

Answer 7

2x as likely to have depression

Question 8

What percentage of pregnant women fulfill diagnostic criteria for depression?

Answer 8

10-16%

Question 9

What are the lactation risk categories?

Answer 9

L1, safest; L2, safer; L3, moderately safe; L4, possibly hazardous; L5, contraindicated.

Question 10

What psychiatric med is contraindicated for breastfeeding?

Answer 10

Doxepin [tricyclic antidepressant] (case reports of respiratory depression)

Question 11

Does continuation of antidepressant in women with a history of depression decrease the risk of relapse?

Answer 11

Yes. Risk of 68% vs 25%

Question 12

What survey tools are designed to help detect postpartum depression?

Answer 12

Edinburgh Postnatal Depression Scale, Beck Depression Inventory, and the Postpartum Depression Screening Scale

Question 13

What birth defects are associated with benzodiazepines?

Answer 13

Basically none. Possible increased incidence of cleft lip/palate (from 6 in 10k to 7 in 10k)

Question 14

What birth defects are associated with SNRIs and SSRIs?

Answer 14

None

Question 15

What birth defects are associated with tricyclic antidepressants?

Answer 15

None

Question 16

What birth defects are associated with early lithium use?

Answer 16

Heart defects - ebstein’s anomaly.

Question 17

What birth defects are associated with antipsychotic medications?

Answer 17

None confirmed

Question 18

What is the prevalence of bipolar disorder in America?

Answer 18

3.9 to 6.4%

Question 19

What is the typical age of onset of bipolar disorder in women?

Answer 19

Teens to early 20s

Question 20

What are rates of postpartum relapse in patients with bipolar disorder?

Answer 20

32% to 67%

Question 21

What is the risk of postpartum psychosis in patients with bipolar disorder?

Answer 21

As high as 46%

Question 22

Does OCD get better or worse during the postpartum period?

Answer 22

Worse

Question 23

What is the prevalence of schizophrenia in women?

Answer 23

1-2%

Question 24

What adverse pregnancy outcomes have been associated with schizophrenia?

Answer 24

preterm delivery, low birth weight infants, small for gestational age fetuses, placental abnormalities and antenatal hemorrhage, increased rates of congenital malformations, especially of the cardiovascular system, and a higher incidence of postnatal death

Question 25

Which SSRI is Category D and associated with birth defects?

Answer 25

Paroxetine. Congenital cardiac malformations, anencephaly, craniosynostosis, and omphalocele. But the data for this is weak, and likely clinically insignificant.

Question 26

What can be seen at birth with infants exposed to SSRIs close to delivery?

Answer 26

Withdrawal. including jitteriness, mild respiratory distress, transient tachypnea of the newborn, weak cry, poor tone, and neonatal intensive care unit admission

Question 27

Is electroconvulsive therapy safe to use during pregnancy?

Answer 27

Yes

Question 28

What is associated with lithium use later in pregnancy?

Answer 28

Fetal and neonatal cardiac arrhythmias, hypoglycemia, nephrogenic diabetes insipidus, polyhydramnios, reversible changes in thyroid function, premature delivery, and floppy infant syndrome

Question 29

What are symptoms of neonatal lithium toxicity?

Answer 29

flaccidity, lethargy, and poor suck reflexes, which may persist for more than 7 days

Question 30

What are the treatment guidelines for women with bipolar disorder being treated with lithium who want to conceive?

Answer 30

1) If mild and infrequent episodes of illness, taper lithium gradually before conception;
2) If more severe episodes but only moderate risk for relapse in the short term, treatment with lithium should be tapered before conception but reinstituted after organogenesis;
3) If especially severe and frequent episodes of illness, treatment with lithium should be continued throughout gestation and the patient counseled regarding reproductive risks

Question 31

In addition to routine prenatal care, what should be considered for patients with lithium exposure during first trimester?

Answer 31

Fetal echocardiogram

Question 32

What is the concern with prenatal exposure of valproate?

Answer 32

Neural tube defects (1-3.8% risk). Craniofacial anomalies. Limb anomalies. Cardiovascular anomalies.

Question 33

What is the concern with carbamazepine exposure during pregnany?

Answer 33

facial dysmorphism and fingernail hypoplasia

Question 34

What is the risk of fetal exposure to lamotrigine?

Answer 34

May have risk of midline facial clefts, but overall good reproductive safety

Question 35

What is floppy infant syndrome?

Answer 35

Characterized by hypothermia, lethargy, poor respiratory effort, and feeding difficulties, is associated with maternal use of benzodiazepines shortly before delivery

Question 36

What are fetal and neonatal toxicity from typical antipsychotics?

Answer 36

Neuroleptic malignant syndrome, dyskinesia, extrapyramidal side effects manifested by heightened muscle tone and increased rooting and tendon reflexes persisting for several months, neonatal jaundice, and postnatal intestinal obstruction

Question 37

What is the risk ratio of congenital heart abnormalities in fetus’s of mothers taking lithium?

Answer 37

1.2 - 7.7