Psych meds in pregnancy Flashcards
The components of an ideal pregnancy?
- planned
- prenatal vitamins started 6 wks prior to conception
- 15% of ideal body wt at time of conception
- routine prenatal care
- no meds
- no obstretical complications
- breastfeed w/o difficulty
- euthymia (positive attitude) throughout pregnancy and postpartum
Reality of pregnancy?
- around 50% unplanned
- usually don’t realize pregnant until 4th-7th week
- 84.5% result in viable infant, 2-4% reqr surgical intervention
- 80% prescribed meds (includes prenatal vitamins)
- of these 33% are psychotropic meds
Risk for psych disorders in women?
- mood disorders: risk of depression and dysthymia 2x that of men during childbearing years
- Anxiety: risk of anxiety and panic disorder higher as well
- bipolar and psychotic disorders seem to be about sam ein both sexes except during pregnancy and postpartum when risk increases
Is pregnancy mood protective?
- no, 70% report depressive sxs and 10-15% meet criteria
- panic disorder may actually get better during pregnancy
- OCD is exacerbated, 25% have first onset during pregnancy
- postpartum blues: mood lability, depression, resolves in 2 weeks, mother still happy she has had her child
- postpartum depression: more prevalent in adolescent mothers, men also get postpartum depression
- postpartum psychosis: 1-2/1000 live births with onset within first 6 weeks postpartum - overt psychotic sxs - believe their child is possessed
Untreated illnesses that aren’t benign can lead to?
- preterm delivery
- lower birth wt
- spontaneous abortion
- pre-eclampsia
- instrumental deliveries: c-sections
- operative deliveries
Poor neonatal outcomes from disorders being left untx?
- poor neonatal adaptation: excessive crying, irritability, erratic sleep
- increased risk of admission to NICU
- growth retardation
- lower APGAR scores
- decreased head circumference
Untx disorders affect on child development?
- negative effect on fetal-maternal bonding
- difficulty with affect regulation
- cognitive delays
- maladaptive social interactions
- increased levels of anxiety and fear
- increased levels of ADHD
- high levels of cortisol from mom - leads to disturbance in hypothalamic pituitary adrenal axis fxn - long term effects in child
Risk to mother if disorders are left untx?
- poor nutrition, impaired self care
- failure to follow medical/prenatal guidelines
- worsening of co-morbid medical illness
- increased exposure to ETOH, tobacco and drugs
- impact on family
- postpartum psych complications
Tx options in pregnancy?
- non-pharm: psychosocial options psychotherapy massage light therapy (like in SAD) exercise - electroconvulsive therapy: anesthetic agent only risk to mother, very effective - given muscle relaxant - induce a seizure
Key pharmcotherapy concepts in pregnancy - placental barrier?
placental barrier:
- lipid solubility: more lipophilic drugs tend to cross barrier more efficiently than nonlipophilic
- MW: wts of 500 D or less facilitate crossing the barrier (insulin and heparin can’t cross)
- ionization: drugs taht are nonionized at physiologic pH cross placenta more efficiently
key pharm concepts in pregnancy - safe period?
- first trimester: highest risks of birth defect
- first 14 days - all or none - no effect or miscarriage
- 14-60: cell diff, organogenesis
- up to 32 days - neural tube defect
- 21-56 days: heart forms
- 42-63: cleft palate occurs
- try to keep off meds during first trimeseter - keep on antidepressants if already on
key pharm concepts in preg- pharmacokinetics?
physiologic changes:
increased plasma volume = dilutional effect
increased glomerular filt= excretion increased
slowing of gastric motility
increased action of liver: drugs breakdown faster
increased protein binding - less med available for use
US FDA pregnancy categories?
- A: generally considered safe
- B: caution advised
- C: weigh risks/benefits
- D: weigh risks/benefits
- X: risks outweigh benefits
New FDA drug labeling?
3 sections:
- pregnancy: list out risks, labor and delivery
- lacation
- females and males of reproductive potential
First line tx of depression in pregnancy?
- zoloft
Antidepressants and assoc birth defects?
- paxil - RV outflow tract defects - failure of normal circulatory transition - R to left
- prozac - VSDs (not first line in lactation - accum in neonate)
- celexa - neural tube defects
- failure of normal circulatory transition - R to L extrapulm shunting of blood, hypoxemia
- study shown that theses defects are same in these drugs as background (Not being on drugs) - same risk as not being on paxil
TCAs used in preg?
- amitriptyline, nortriptyline, desipramine
SNRIs used in preg?
- venlafaxine (effexor)
- duloxetine (cymbalta)
others:
bupropion
trazodone
mirtazipine
Depression and correlation with birth defects?
- overall women with depression tx or not will have higher risks of birth defects
What is neonatal withdrawal syndrome?
- exposure to/withdrawal from SSRI or SNRI
- sxs:
tremor, restlessness, increased muscle tone, increased crying - resolves 1-4 days after birth - transient, no risk
Main mood stabilizer used in pregnancy? Assoc defects?
- lithium: mainstay for acute and maintenance therapy
- 2.8% rate of congenital anomalies
- epstein’s anomaly (downward displacement of tricuspid valve into R ventricle and RV hypoplasia): not stat. sig.
fetal high resolution US
fetal echo at 18-20 weeks - floppy baby syndrome
- neonatal hypothyroidism
- nephrogenic diabetes insipidus
Congenital anomalies and effects of mood stabilizer: lamotrigene (lamictal)?
- 1.4-4.6% of congenital anomalies
- try to keep under 200 mg esp during 1st and 3rd trimester
- cardiac, GI, GU, neural tube defects dose dependent with 1st trimester exposure
- SJS - most serious risk
Use of valproate (depakote) during pregnancy? What other supplement should you be on?
- mood stabilizer - don’t use!!!
- human teratogen - category D
- neural tube defect at 5-9%: risk at 17-30 days postconception
- irritability, jitteriness and feeding problems
- growth retardation
- lower IQ scores
- 3-4 folic acid through first trimester if on depakote
- safe in breast feeding
Carbamazepine safety?
- human teratogen
- craniofacial defects, developmental delays, fingernail hypoplasia, neural tube defects
- decrease birth wt. decreased head circumference
- safe in breast feeding
- other mood stabilizers:
oxcarbazepine, gabapentin - no increased risk of defects
topiramate - risk of defects?
- alone = no increased risk
- polypharm - increased risk
- topiramate used to help with wt gain or assist with wt loss brought on by psychotropic meds = leads to increased risk for congenital malformations
First gen/typical antipsychotics used? Indications? Safety?
- phenothiazines and butyrophenones
- for hyperemesis
- psychotic disorders
- Category C
- transient neonatal sxs secondary to extrapyramidal side effects
Atypical and second gen antipsychotics used in pregnancy? Risk for what?
- olanzapine (zyprexa), quetiapine (seroquel), risperidone (risperdal): up to 4.1% of congenital abnorm, slight increased risk for low birth wt, possible risk for gestational diabetes
- ziprasidone, aripiprazole (abilify)
- clozapine (clozaril)
Benzos used in pregnancy? Thought to be assoc with what?
- clonzepam, lorazepam (ativan), alprazolam (xanax), diazepam (valium) - thought to be assoc with cleft palate, recent studies have shown that there isn’t that strong of an assoc
- neonatal withdrawal syndrome:
tremor
irritability
diarrhea
vomiting
hypertonicity - just tx this sx
- try to stay away from this during first trimester
sedatives/hypnotics used in pregnancy?
- zolpidem (ambien), zaleplon (sonata), escopiclone (lunesta)
- marketed for insomnia
- preg C
- no sig pregnancy outcomes
- most commonly used is ambien
Breast feeding benefits?
- decreased rates of: SIDS GI probs anemia respiratory ailments otitis media obesity
Key principles of lactation pharm?
- drugs with low oral bioavailability are unlikely to cause systemic effects
- drugs enter milk mainly by diffusion - maternal drug levels proportional to breast milk leve, breastfeeding just b/f next dose will result in lower levels in milk, shorter half life drugs are preferred over once daily dosed drugs
- lipid solubility - higher lipid solubility more in milk
- protein binding: more protein bound, less in milk
- MW: higher, less in milk
- pH: higher pH easier to pass in milk
- est of milk prod: long term, and daily
- neonatal physiology: hepatic enzyme acitivity, glomerular filtration
- safety in pregnancy doesn’t equate to safety in lactation
Risk categories in lactation?
- L1 = safest
- L2 = safer, remote risk
- L3 = moderately safe, risk possible
- L4 = possibly hazardous, postive evidence of risk
- L5 = CI
L2 antidepressants?
- zoloft, prozac, elavil, tofranil, pamelor
L3 antidepressants?
effexor, cymbalta, remeron, wellbutrin (can dry up milk, lower seizure threshold), trazodone
Mood stabilizers L2?
- tegretol, depakote**, neurontin
Mood stabilizers L3?
- lithium - use only with close observation, baby has to have blood levels drawn
- lamictal
- topamax: just dont give
- trileptal
Typical antipsychotic - lactation safety?
L2: haldol - baby sedated while feeding
L3: chlorpromazine, perphenazine
Atypical antipsychotics - lactation safety?
- L2: seroquel, zyprexa, geodon
- L3: risperdal, abilify, clozaril
Benzos lactation safety?
- L3: xanax, klonopin, valium, ativan
- worried about sedation in the infant
Hypnotics lactation safety?
- L2: lunesta, sonata, ambien
- want to use sonata, shorter half life
- give at qhs, wake up feed baby, should be low enough amt in system to safely feed baby
Barriers to tx during pregnancy?
- stigma
- unacceptability of tx
- guilt
- anxiety
- financial
Risk vs Benefit in tx?
- analysis:
maternal psychiatric hx
potential deleterious effects of untx illness
info about med: somatic, perinatal, neurobehavioral - Goal is to minimize exposure
- there is no such thing as non-exposure - either exposed to medicine or illness (adverse effects in both)
