Pharmacological treatment in pregnancy Flashcards
Most vulnerable period for major infant malformations in relation to medication taken during pregnancy
6-10 weeks
Trimester in which drug doses may need to be increased
3rd trimester
General treatment principles used for schizophrenia in pregnancy
Antipsychotic treatment used throughout pregnancy
If patients already maintained on antipsychotic this is often not changed
Olanzapine often used
General treatment principles used for depression in pregnancy
Starting antidepressants is postponed to the 2nd trimester where possible
If a patient is on an antidepressant already with a high risk of relapse they are maintained on that antidepressant
CBT often tried first
General treatment principles used for bipolar affective disorder in pregnancy
Most patients who become pregnant on medication are maintained on their medication
Consider stopping mood stabilisers pre pregnancy for women who have been stable for a long time
Avoid valproate
Medications given if valproate or carbamazepine are given during pregnancy
5mg OD folic acid and prophylactic vitamin K
TCAs which should be given preferentially during pregnancy
Nortriptyline
Desipramine
SSRI which should not be used in pregnancy
Paroxetine
Increase in spontaneous abortion with maternal use of SSRIs
13.3%
Cardiac malformations linked to maternal use of paroxetine during pregnancy
VSD
ASD
SSRIs/SNRIs with the highest risk of neonatal withdrawal syndrome
Paroxetine
Venlafaxine
SSRI with the most evidence to suggest its safety in pregnancy
Fluoxetine
SSRI with the least placental exposure
Sertraline
Risk of infant malformation if lithium is used in the first trimester
10%
Increased risk of Ebstein’s anomaly with maternal use of lithium during pregnancy
10-20x increased
Absolute risk of Ebstein’s anomoly with maternal use of lithium during pregnancy
1 in 1000
Percentage risk of spina bifida in an infant with maternal use of carbamazepine during pregnancy
0.5-1%
Most common abnormalities caused by maternal use of carbamazepine during pregnancy
Fingernail hypoplasia
Developmental delay
Craniofacial defects
Most teratogenic mood stabiliser
Valproate
Risk of birth defects with maternal use of valproate during pregnancy
7.2%
Congenital anomalies caused by maternal use of valproate during pregnancy
Neural tube defects
Digit and limb defects
Congenital cardiac disease - VSD, pulmonary stenosis
Urogenital malformations including hypospadias
Low birth weight
Most common adverse effect of maternal use of valproate in pregnancy
Low IQ in the child
Congenital defect seen with maternal use of lamotrigine during pregnancy
Cleft palate
Congenital abnormalities seen with maternal use of benzodiazepines during pregnancy
Oral cleft malformation
Urinary tract malformation
Monitoring requirements for pregnant women remaining on lithium
Level taken every 4 weeks
Dose requirements for pregnant women remaining on lithium
Increased dose required in third trimester
Dose requirement rapidly goes back to usual after delivery
Antipsychotic most often used to treat schizophrenia during pregnancy
Olanzapine
Ultrasound and ECHO monitoring required when lithium is used in pregnancy, to screen for Ebstein’s anomaly
6 weeks gestation
18 weeks gestation
Risks to infant of SSRI use during pregnancy
Neonatal irritability
Spontaneous abortion
Premature birth
Reduced birth weight
Risk of neural tube defect when valproate is used during pregnancy
1%
Physiological change during pregnancy which leads to the most risk during ECT
Delayed gastric emptying
Risk relating to delayed gastric emptying when giving ECT while pregnant
Aspiration
Neurocognitive function most affected in children exposed to valproate during pregnancy
Verbal IQ
Prevalence of Ebstein’s anomoly in the general population
1 in 20000
Where valproate treatment is deemed necessary in pregnancy, maximum dose limit
1000mg/day
Drug class which can cause persistent pulmonary hypertension in the infant when taken in late pregnancy
SSRIs
Antidepressant recommended first line for a pregnant woman
Sertraline
Infant effects of benzodiazepine use during pregnancy
Urinary tract malformations
Oral cleft/malformations
Floppy baby syndrome
First line medication for insomnia during pregnancy
Promethazine
Drugs associated with Ebstein’s anomoly
Lithium
Benzodiazepines
Monitoring of lithium levels required if continued through pregnancy
Monthly until 36 weeks
Weekly after 36 weeks
