Perinatal psychiatry 2 Flashcards
What are the main risks you are worried about in terms of prescribing a drug in each of the different stages of pregnancy and breastfeeding ?
In 1st trimester - mainly worried about teratogenicity
In 3rd trimester - mainly worried about neonatal withdrawl
When breastfeeding - mainly worried about the risk of the drug passing into breast milk (note tho exposure would be less than in utero if it did so drugs used in pregnancy are ok for in breast feeding)
In the 1st trimester are antidepressants safe to use ?
Yes generally, no ↑ major malformations or spontaneous abortion
What is the one anti-depressant associated with an increased risk of major malformations ?
Paroxetine (SSRI) - associated with increased risk of fetal heart defects
What are the risks of antidepressant use in the 3rd trimester ?
- Risk of neonatal withdrawal – usually mild & self-limiting
- ↑ risk of neonatal persistent pulmonary hypertension with SSRIs taken after 20 weeks (& Venlafaxine - SNRI)
- ↑ risk of low birth weight / prematurity (also happens in untreated depression) (for all classes of anti-depressants)
Which SSRI drugs carry the lowest risk of these complications in the 3rd timester?
SERTRALINE / fluoxetine
Which drugs of the TCA class carry the lowest risk in the 3rd trimester ?
imipramine / amitriptyline
Which anti-depressant class - SSRI’s or TCA’s carry the lowest risk in the 3rd trimester ?
TCA’s
Do SSRI’s or TCA’s when given durign breast feeding affect neonatal development ?
No
What are the best anti-depressant drugs to prescribe for each class in breast feeding period ?
- SSRI - Sertraline or paroxetine
- TCA - imipramine
Which 2 anti-depressant drugs should you avoid in the breast-feeding period ?
citalopram (SSRI) / doxepin (TCA)
Are you able to give benzodiazepines in the 1st, 3rd trimester or breast feeding period ?
No avoid in 1st and 3rd trimester but avoid regualar use in breast feeding
Why is the use of benzodiazepines avoided in 1st, 3rd trimester and avoided in regular use in breast feeding ?
1st trimester - possible ↑ risk of fetal malformation, e.g. cleft palate
3rd trimester - ↑ risk of floppy baby syndrome (hypothermia, hypotonia, respiratory depression, withdrawal effects)
Breast feeding - risks of lethargy & weight loss + accumulation of long acting drugs
Generally when are benzodiazepines used in pregnancy and the postnatal period ?
Treatment of severe anxiety and agitation. Otherwise avoid them
What may anti-psychotics do which reduces the chance of conception ?
Cause increase prolactin levels
If this is the case use a prolactin sparing anti-psychotic
Which class of anti-psychotics are safer in pregnancy ?
The typicals, as limited info on the newer atypicals
Are anti-psychotics safe to take during breast feeding ?
Yes even though they are all excreted in milk there is no evidence of fetal toxicity or altered development but monitor for signs of sedation / lethargy
What anti-psychotic drugs and mode of use should be avoided in pregnancy and breast feeding and why ?
- Avoid Clozapine at all time points due to risk of agranulocytosis
- Olanzapine causes - ↑ risk of gestational diabetes & weight gain
- Avoid depot antipsychotics due to prolonged effects e.g. EPSE in neonates
- Avoid anticholinergics for EPSE (extrapyramidal syndrome in newborns) in pregnancy
The 2 drugs mentioned are both atypicals
What are the recommendations for lithium useage in planning a pregnancy and in someone who is pregnant ?
Do not offer lithium to women who are planning a pregnancy or pregnant, unless antipsychotic medication has not been effective.
What do you need to remember if stopping someone on lithium ?
To gradually take them off it, do not take them off it suddenly
What are the recommendations for use of lithium in the:
- 1st trimester
- 3rd trimester
- During breast feeding
- Postnatally (not breast feeding)
And why are these recommendations in place ?
- Can increase fetal abnormalities in 1st trimester
- Okay in 3rd trimester
- Avoid in breast feeding
- Can restart it postnatally (not breast feeding)
What are the recommendations of sodium valproate usage prior to pregnancy, during pregnancy and then in breast feeding ?
Do not offer valproate for acute or long‑term treatment of a mental health problem in women who are planning a pregnancy, pregnant or considering breastfeeding.
1st trimester:
- ↑ risk of neural tube defects craniofacial defects + effects on child’s intellectual development
- Also longer term effects on neurological development - increased risk of autism
Avoid in women of child bearing age or use if necessary with risks explained & adequate contraception
Stop if possible before planned pregnancy
Use folate supplements to help prevent neural tube defects
What are the recommendations for Carbamazepine use and the risks associated with it being used
Risks:
- ↑ risk of neural tube defects, possibly GI and cardiac abnormalities also
- facial dysmorphism, fingernail hypoplasia
Recommendations for use:
- Do not offer carbamazepine to treat a mental health problem in women who are planning a pregnancy, pregnant or considering breastfeeding.
- if already taking it then discuss stopping
What are the recommendations for Lamotrigine use and the risks associated with it being used ?
Risks:
- ↑ risk of oral cleft – avoid in 1st trimester or withdraw before planned pregnancy
- risk of Stevens-Johnson Syndrome etc in infant if breast feeding
Recommendations for use:
- avoid in 1st trimester or withdraw before planned pregnancy
What are the rates of alcohol dependace and ilict drug dependance for women of child bearing age in the UK ?
- 4.7% for alcohol
- 2.2% for ilict drug dependance
==> something you need to be wary of in pregnant women
What health problem factors are associated with substance abuse in pregnancy i.e. what are they at risk of and may already have which complicates the pregnancy ?
- Associated with other mental illnesses- personality, depression and anxiety *3
- Nutritional deficiency
- HIV, Hep C, Hep B
- VTE
- STIs
- Endocarditis/ Sepsis
- Poor venous access
- Opiate tolerance/ withdrawal
- Drug overdose/ death
- At risk of domestic abuse and suicide
- IUGR, Stillbirth, SIDs, pre-term labour
What are the alcohol intake recommendations for pregnant women ?
RCOG suggests abstinence best but no evidence that 2 units/ week detrimental
What should be done if If harmful or dependent drug or alcohol misuse is identified in pregnancy or the postnatal period?
Refer the woman to a specialist substance misuse service for advice and treatment.
Antenatal care:
- Consider methadone programme
- Child protection and social work referral
- Smear History
- Breastfeeding (not if alcohol >8 , HIV, cocaine)
- Labour plan re analgesia and labour ward delivery
- Early IV access
- Postnatal contraception plan
What are the risks of alcoholism/usage above 2 unit/week?
- Risks of miscarriage
- Foetal Alcohol Syndrome - facial deformities, lower IQ, neurodevelopmental delay, epilepsy, hearing, heart and kidney defects
- Withdrawal
- Risk of Wernicke’s encephalopathy- 20% die (B1 deficiency)
- Korsakoff Syndrome – permanent
What are the risks of Cocaine, amphetamine, ecstasy use in pregnancy ?
- Death via stroke and arrhythmias
- Teratogenic (microcephaly, cardiac, genitourinary, limb defects)
- Pre-eclampsia
- Abruption
- IUGR
- Pre-term labour
- Miscarriage
- Developmental delay, SIDS, withdrawal
What are the risks associated with opiate or nitoctine use in pregnancy?
Opiates cause maternal deaths (1-2%), neonatal withdrawal, IUGR, SIDS, stillbirth
Nicotine causes miscarriages, abruption, IUGR, stillbirths and SIDS
