Perinatal Psychology
by John M Rathbun, MD
Contents
A young woman and her fiancé came to see me because they wanted to
have a baby and they desired my opinion about when she should stop
taking her lithium. She was also on Wellbutrin and Cytomel. What
would you tell them?
A pregnant woman with a history of intractable depression came to
me because she knew from past experience that one electroconvulsive
therapy treatment would relieve her depression for up to a month,
but several health care professionals had told her that she
couldn't have ECT because it would hurt the baby. What would you
tell her?
Another patient of mine called because she was close to parturition
and wanted to know if she should stop her antidepressant before
delivery so she could breast feed. What would you tell her?
We used to think that pregnancy somehow protected women from severe
psychiatric illness, but new data indicate that women are at least
as likely to show psychiatric illness during pregnancy as at any
other time. A recent literature review showed rates of depression
in pregnancy anywhere from 5% to nearly 30%. When ten women with
previous history of panic disorder were studied during pregnancy,
seven continued symptomatic throughout the pregnancy.
A retrospective study of 29 women with OCD prior to pregnancy
showed that nearly 70% experienced no change in symptoms during
pregnancy; the other 30% were evenly divided between those who
experienced improvement during pregnancy and those whose OCD got
worse during pregnancy. Discontinuation of psychotropic medications
in pregnant women has been associated with high rates of relapse in
numerous reported cases of mood disorders, anxiety disorders, and
schizophrenia.
Psychiatric illness during pregnancy is not only common, but causes
considerable distress for the mother and risk for the fetus.
Compliance with recommended prenatal care is poor in proportion to
the severity of the illness. Common consequences of severe
psychiatric illness include malnutrition, dehydration, heavy
smoking, abuse of alcohol and other toxic substances, lack of rest,
lack of exercise, and chronic high levels of stress hormones such
as cortisol. These are all known risk factors for poor fetal
outcomes, including intellectual and behavioral problems which can
persist throughout life.
Diagnosis of psychiatric illness in pregnancy is complicated by the
frequency with which sleep and appetite disturbance are found in
uncomplicated pregnancies. Vivien Burt, who directs the Women's
Life Center at the University of California in Los Angeles, has
noted that during pregnancy, women with significant depression are
much more likely than healthy women to complain vociferously of
total insomnia.
Given the impersonal and hurried nature of so many clinical
encounters these days, I suggest routine screening of pregnant
women with a psychiatric symptom questionnaire, such as the Beck
Depression Inventory. The Beck is particularly useful in medical
settings because it ignores neurovegetative symptoms and
concentrates on depressive thinking patterns.
[see references]
It's important to distinguish illness which is dangerous from that
which is merely uncomfortable. Pregnancy is an inherently
uncomfortable condition. First pregnancies are among the most
profoundly disturbing events in most people's lives. One's anatomy
and physiology undergo cataclysmic changes, and one's personal
identity becomes absorbed in the universal human drama of bringing
a new life into the world.
Pregnancy can have many meanings, from the mysterious merger of two
lives into a common biological destiny, to an experience of
profound frustration, violation, and failure. The active, carefree
woman may become bedfast and subject to annoying regimens which she
doesn't dare resent because, of course, we all want to do what's
best for the baby. Morning sickness, uncharacteristic emotional
lability, and extreme dietary preferences are common stressors in
the first trimester. Nicotine craving and abstinence from the
solace of an occasional stiff drink may complicate the expectant
mother's adjustment. As delivery approaches, women often begin to
feel awkward and vulnerable, with additional discomfort from
backache and from compression of abdominal organs such as the
urinary bladder.
Given these stressors, it shouldn't be surprising that anxiety and
depressive reactions are the most common emotional disturbances in
pregnancy. They are usually manageable with counseling, support
groups, environmental manipulation, and nonspecific diversions such
as walking, massage, warm baths, and keeping up social contacts.
The provision of environmental support is particularly important in
all phases of reproduction. Our fragmented society is seriously
deficient in the supports offered to young families. Only in the
past few decades has it become common for young families to
relocate beyond easy reach of their families of origin. This
practice leaves the expectant mother with a dearth of competent
help when she most needs it.
Many young families need encouragement to ask for live-in
assistance from relatives in distant cities. Pregnant women and new
mothers need this kind of assistance. Provision of adequate
assistance is often the most important step to resolution of
emotional turmoil in a pregnant or lactating woman.
When depression and anxiety fail to respond to common-sense
approaches, professional psychotherapy is indicated. Brief hospital
stays and intensive outpatient programs will often be as effective
as medication in moderately severe cases.
Very severe cases of depression and anxiety often will not respond
to the low-risk management strategies previously discussed. Even
continuous hospitalization is not a sufficient treatment for the
most severely ill patients.
I hope you're now eager to hear which psychotropic medications have
been approved by the FDA for use in pregnant women. It's a very
short list. In fact, the list is still waiting for its first entry.
Nobody is eager to do research that involves giving psychotropic
medications to pregnant women. Furthermore, the species that have
been chosen for animal reproduction studies were selected because
they are cheap to keep, and because they breed rapidly, not because
their physiology is very similar to ours.
Cost considerations weigh against exposing a million rodents to
therapeutic blood levels of psychotropic medications; the
alternative is to expose a thousand rodents to very large doses.
Not surprisingly, bunnies fed lovely fresh salads during pregnancy
do better than those whose diet is largely pharmaceutical.
Given that corporate legal eagles have enormous influence on what
gets published in a drug's prescribing information, you won't find
much encouragement in the PDR for humane treatment of
psychiatrically ill pregnant women.
Even those of us who practice in Indiana, where the malpractice
situation is less obnoxious than elsewhere in the U.S., have reason
to hesitate before medicating pregnant women. After all, congenital
malformations are found at a base rate between two and seven per
one hundred live births. The use of unapproved medications during
a series of pregnancies seems likely to result in some cases of
birth defects which might be attributed to the medication by
parents whose guilt or anger can cause complications for themselves
and for their physicians.
OTOH, it is not true that doing nothing is always preferable to an
intervention that carries some risk. You can be sued as easily for
acts of omission as for acts of commission, and our profession
cannot pursue its stated goals without assuming some risk.
Keys to avoiding litigation are:
- be aware of reasonable standards of practice
- be familiar with research findings which may lead to changes
in the standards
- provide written justification of departures from
standard practices
- cultivate trust in your patients by taking time to show
your interest and concern for their welfare
- refer patients for consultation in cases where there is
above average potential for liability.
Malpractice litigation more commonly reflects a failure of empathy
on the doctor's part than a failure of technique. Doctors are
selected and schooled to be tough in the face of tough situations,
but this appearance of toughness is out of place in the presence of
a patient who's struggling to adjust to a bad outcome. Doctors who
are truly compassionate may be so affected by grief and anxiety
when things go out of control that they walk away when the patient
most needs their presence.
It's much better for all concerned if you can stay around and let
the patient see your sorrow over what's happened. You want to
emphasize whatever hope remains in a difficult case, but not to the
point of pretending that something's truly OK when it's obviously
not.
You can say, "I'm sorry about how this turned out!" without it
sounding like, "I'm sorry I botched your case!" Either statement
would be better than abrupt withdrawal or some other defensive
reaction.
Dr. Vivien Burt counsels her pregnant patients, in the presence of
a significant other, about the risks, benefits, and alternatives of
medical treatment. Then she asks the patient to write on one page
all the reasons for taking the treatment, and on a second page all
the reasons against taking the treatment. On the third page go
the woman's decision and her justification of the decision. A copy
is kept by the patient and another goes on the patient's chart.
Not only is this excellent documentation of informed consent, it's
a very useful tool in counseling women who are later overcome by
anxiety over having placed their baby at risk. The physiologic
stress of pregnancy and severe psychiatric illness can virtually
eliminate the patient's ability to recall, after the pregnancy, how
bad she felt and what she was told. Seeing the details in her own
handwriting is very helpful in such cases.
Concerns over gestational exposure to psychotropic medications have
focused on three areas: teratogenicity, neonatal toxicity, and
postnatal behavioral sequelae. Teratogenicity is of primary concern
when exposure occurs during the first trimester, although the fetal
brain develops throughout pregnancy and damage could occur after
the first trimester.
A relatively small number of cases of first trimester exposure to
antidepressants have been reported. These reports have suggested no
increased risk of birth defects. Given that major depression occurs
in nearly 10% of women, and that we've been freely treating these
women with tricyclic antidepressants for over 30 years, there are
probably millions of cases of accidental first trimester exposure.
In this context, the dearth of reports suggesting teratogenicity is
encouraging.
The newer antidepressants are generally less toxic for adults than
are the tricyclics. The serotonergic antidepressants are thought to
be relatively pure in their pharmacologic activity, and their main
effect is rather similar to that of amitriptyline, which is one of
the oldest antidepressants. Therefore, we would not expect the
newer antidepressants to be more fetotoxic than the tricyclics.
Observation, however, is better than theory.
Prozac was the first of the new breed of antidepressant, having
been introduced in this country by Eli Lilly ten years ago. It
immediately became the most prescribed antidepressant in the U.S.,
and has probably been used by twenty million people, of whom two-
thirds were likely to have been women. Lilly has maintained a
worldwide pregnancy registry which includes pregnancies occurring
during scientific studies as well as cases reported from
naturalistic clinical settings. As of 1996, they had over 1700
cases on file, which showed no increase in birth defects, no
suspicious clustering of abnormalities, and no increase in
spontaneous abortions. Data for other serotonergic antidepressants
are less voluminous, but no less reassuring.
With respect to perinatal complications, the picture is a bit less
clear. Tricyclic antidepressants are known to cause an
uncomfortable abstinence syndrome in some adults, lasting several
days. The same sort of thing has been seen in infants exposed to
these agents shortly before delivery. Interestingly, the long half-
life of Prozac's active metabolite norfluoxetine may be
advantageous when children are exposed to it immediately prior to
delivery: no abstinence syndrome has been identified with Prozac in
adults or in newborns.
The best long-term study of antidepressant-exposed fetuses followed
80 cases up to age seven. Compared to an unexposed control group,
the exposed children showed no adverse effect on IQ, no adverse
effect on language development, and no adverse effect on behavior.
Antidepressants such as Nardil and Parnate, which achieve their
effects through the inhibition of monoamine oxidase, are
contraindicated during pregnancy. They require dietary restriction
which can compromise the expectant mother's nutritional status,
they can raise or lower blood pressure, and there's a severe
adverse interaction with terbutaline, which is used to suppress
premature labor.
Given the known risks to mother and fetus from severe depression
during pregnancy, with the absence of any data suggestive of
increased risk to the fetus from exposure to antidepressants that
have been in widespread use for over 30 years, I would favor use of
antidepressants after appropriate counseling in selected cases. The
most evidence supports use of Prozac and the tricyclic
antidepressants, while MAOI antidepressants are contraindicated.
These data have application to the counseling of psychiatrically
ill women who wish to become pregnant. The preponderance of the
evidence is that depression is a progressive illness in many cases,
with a pronounced tendency to recur under stress. Although it has
long been felt appropriate to subject depressed persons to repeated
trials of medication reduction, that approach does more harm than
good. Reduction or discontinuation of antidepressant medication is
contraindicated when there's a strong family history of depression,
two or more distinct episodes of major depression, minimally-
provoked episodes of major depression, onset of major depression
before adulthood, or a stressful life situation in a person with a
history of major depression.
While there is around 15% risk of transmission of the illness to
each offspring, and the risk is doubled if both parents are
affected, the prognosis of major depression with appropriate
treatment is now so good that few physicians would discourage
conception because of this illness.
Given the high risk of relapse and low risk of fetal damage,
discontinuation of antidepressant medication in women who wish to
become pregnant cannot be recommended as a routine practice. Many
low-threat cases can reasonably be given a trial of dose reduction,
but exposing those with severe or chronic history to such risk is
inappropriate.
Electro-Convulsive Therapy (ECT) is the safest and most effective
treatment for severe mood disorders, and especially so in pregnant
women. The risk to the fetus is no more than the risk of brief
general anesthesia.
There are some drawbacks to the use of ECT. It costs nearly $500
per treatment, and usually requires six to twelve treatments in the
first few months, followed by at least one treatment monthly for
maintenance. It causes acute memory problems, which are almost
never persistent, but which require the patient who is getting
several treatments weekly to be supervised closely by friends and
relatives if the patient is not in the hospital.
The effects of ECT are rapid and dramatic: the response rate is as
high as 85%, even in refractory illness. Contrary to what you may
think, most people don't find ECT very unpleasant, and many prefer
it to medication because of its effectiveness and freedom from
daily side effects.
POSTNATAL ISSUES:
After delivery, things become a lot more difficult. Those of you
with children have probably already noticed this!
About 80% of women have mildly depressed mood during some portion
of the period between days three and twelve postpartum. This is not
surprising, given the stress of labor and delivery, the enormous
changes in hormone levels that occur at the end of pregnancy, and
the demand for the new mother to make an instant transition from
being taken care of by others to being the primary caretaker for an
infant that requires almost constant attention. Sleep deprivation
adds considerably to the stress of the first few months after
parturition.
Ordinary postpartum blues are easily managed if enough support and
assistance are available to the new mother, but the outcome is not
always benign. Severe postpartum psychiatric illness is the most
common complication of pregnancy, and can devastate both mother and
infant.
A woman is twenty times as likely to require psychiatric
hospitalization in the first month after pregnancy as in any other
month of her life. Between ten and fifteen per cent of women suffer
significant postpartum psychiatric illness, and the severity is
often extreme. Infanticide and suicide are very real risks in this
situation, and failure to thrive is the best that can be expected
in an infant whose mother is psychotic. A study of 700 cases
indicated that these infants do poorly for years afterward, with
intellectual, behavioral, and emotional problems.
The increased risk for postpartum psychiatric illness persists for
at least six months, and for as long as twenty-four months in some
studies. For persons with no prior psychiatric history, the risk of
severe postpartum psychiatric illness is 10%. If there's a history
of prior major depression, the risk rises to 25%. For women with a
history of postpartum psychiatric illness, the risk of postpartum
recurrence is 50%. If the prior postpartum illness was major
depression, the recurrence rate following a subsequent pregnancy is
62%. If she was psychotic during her prior postpartum illness, the
risk of postpartum recurrence is 75%. If a woman has postpartum
psychosis and becomes pregnant again within two years, the relapse
rate is nearly 100%.
Fortunately, severe postpartum psychiatric illness is largely
preventable. For example, if a woman with a prior history of
postpartum major depression is started on antidepressant medication
within 24 hours of delivery, the recurrence rate drops from sixty-
two percent to seven percent. Prompt and vigorous treatment with
medications or ECT likewise improves the outcome for other severe
postpartum psychiatric illness.
Some authorities have suggested that psychotropic medications be
reduced or discontinued for a week or two before the expected
delivery date. They base this recommendation on scattered case
reports of neonatal syndromes which have been attributed to
persistence of medication effects or to withdrawal effects. These
problems may occur, but they are infrequent and mild compared to
the high frequency and serious consequences of perinatal relapse in
the mother. I believe it's inappropriate to deprive a woman of
pharmacologic treatment for a severe, persistent psychiatric
illness at the very time when she's most likely to experience
recurrence.
LACTATION:
The issues surrounding treatment of psychiatric illness in women
following childbirth are considerably complicated by questions
related to breast feeding. This activity is highly valued by most
women and apparently quite beneficial to infants.
Breast feeding is less expensive than bottle feeding, and it
supplies the infant with nucleotides and enzymes which facilitate
digestion and absorption of nutrients. Breast-fed infants also
receive immune factors which prevent infections, with a measurable
improvement in survival. The longer-chain polyunsaturated fatty
acids found in human milk are thought to promote continued
development of the nervous system, which is relatively immature at
birth in a human infant compared to other animals. When evaluated
during the first year of school, both full-term and premature
infants show enhanced intellectual development if they were breast
fed. Mothers who breast feed benefit from hormonal factors which
shrink the uterus, suppress ovulation, and reduce risk of breast
cancer.
Of course there's no such thing as a free lunch. All psychotropic
medications appear in breast milk to some degree. Furthermore, the
infant's liver is relatively inadequate during the first two weeks
after full-term delivery. These facts cause much tension between
mothers and their doctors, and between one doctor and another.
Our increasingly fragmented and litigious system of health care
delivery often requires the collaboration of doctors specializing
in pediatrics, obstetrics, and psychiatry, each of whom may develop
a narrow focus on some issues without due consideration of
competing interests. Maximizing the welfare of both mother and
infant requires complex thinking.
Since major depression is the most common postpartum illness, there
are substantial data on babies exposed to antidepressants in breast
milk. It appears that normal newborns exposed to tricyclic
antidepressants through breast feeding rarely suffer ill effects,
and rarely have detectable blood levels of parent compounds or
active metabolites.
The main exception is doxepin. One eight-week-old infant became
sedated while being breast fed by a mother taking doxepin, and was
found to have accumulated an active metabolite of doxepin to a
concentration comparable to that found in his mother's blood. In
another report, a 10 week-old infant was found to have a
quantifiable level of desmethyldoxepin, but there was no ill
effect.
One case has been reported of an infant aged four weeks being
nursed by a woman taking nortriptyline, in which the infant had a
serum level about 10% of the mother's; there was no apparent effect
on the baby. There are numerous case reports of infants being
breast fed by women taking various tricyclic antidepressants other
than doxepin, of whom none had levels high enough to be quantified,
and none suffered an ill effect.
The serotonergic antidepressants have less data, and these data are
mixed. Fluoxetine and sertraline have the most data in this group;
both agents have active metabolites with long half lives, and both
have been found in the blood of infants being nursed by mothers
taking these medications.
In only one case was there a report of an adverse effect on the
infant: that child developed colic which got better within a few
days after breast feeding was discontinued. The problem returned
when the infant was given mother's milk in a bottle. This infant's
blood was found to contain levels of fluoxetine and norfluoxetine
comparable to those found in the mother. The accuracy of this
report has been questioned because the infant's blood was drawn
only two days after resumption of nursing following three weeks of
formula feeding, and the mother's milk contained an insufficient
amount of medication to give rise to such high serum levels in the
infant. Either there was laboratory error, or that infant
maintained a very high drug level for three weeks on formula, in
which case one wonders why the colic got better after only a few
days back on formula.
DEPRESSION SUMMARY:
To summarize, women with chronic or recurrent depression may
require antidepressant medication during pregnancy, which may be
continued up to initiation of labor and then restarted within 24
hours thereafter. There are no compelling data against breast
feeding on a tricyclic antidepressant other than doxepin.
Serotonergic antidepressants remain controversial because they more
commonly generate substantial serum levels, even though there's
only one report of a possible adverse effect.
It would be reasonable to consider reducing the doses of
serotonergic antidepressants in pregnant and lactating women with
augmentation by a tricyclic antidepressant other than doxepin,
thereby reducing fetal and infant exposure to the newer compound
while maintaining maternal health. This approach can be criticized
because it involves exposure to two agents, but lower doses of both
agents can be used, so the side effects may be less.
The situation I have just described calls for extensive discussion
of the risks, benefits, and alternatives. While we can't promise
safety, the risk of the mother going off medication so she can
breast feed is unacceptably high, and this should be clearly
communicated. Careful monitoring of the infant's development is
mandatory, and it's reasonable to obtain a serum level if the
baby's behavior changes substantially from baseline. Serum levels
may also be indicated to alleviate anxiety in parents and
physicians. After ten weeks of age, infants can metabolize drugs
more than twice as fast as adults, so the risk of accumulation of
toxic metabolites is very low.
BIPOLAR DISORDER:
When it comes to bipolar disorder, the situation becomes
considerably more troublesome. Bipolar disorder is a more dangerous
illness to the mother and fetus, with a very high rate of relapse
when medication is discontinued. Tricyclic antidepressants are
known to make bipolar disorder worse, sometimes very much worse.
Serotonergic antidepressants appear to be better tolerated, but
have some risk of precipitating mania. Almost all the treatment
options for mania are unattractive during pregnancy.
There are four anticonvulsants with antimanic properties. Of these,
carbamazepine and valproate are known teratogens. Gabapentin and
lamotrigine are too new to have much data.
Lithium is the oldest known mood stabilizer. It is also a known
teratogen, although the risks are manageable. Initial reports of
lithium's teratogenicity came from a registry that attracted mostly
problem reports and lead to substantial overestimation of the
risks.
First trimester exposure to lithium causes Ebstein's anomaly, which
is almost always lethal. The rate is now thought to be about one
case for every 1000 exposures. This low rate of a serious outcome
must be compared with the 50% relapse rate for bipolar disorder
after 20 weeks off lithium. A bipolar in full relapse presents
serious dangers to self and others, much more so during pregnancy.
Only in the mildest cases should lithium withdrawal be considered
in the first trimester.
When first-trimester exposure to lithium occurs, a level II
ultrasound should be performed between 16 and 18 weeks gestation to
rule out Ebstein's anomaly, which can be diagnosed reliably by this
method.
Lithium doses must often be higher during pregnancy due to
increased renal clearance. Maintenance of hydration during
pregnancy and delivery are particularly important for pregnant
women on lithium. Lithium-induced diabetes insipidus in the fetus
can occasionally cause maternal respiratory embarassment due to
expansion of amiotic fluid.
Bipolar disorder is the most strongly inherited illness in
psychiatry. With one affected parent, the morbid risk is 33%, and
with two affected parents, around 67% become ill. Any family
history of bipolar disorder confers significant increased risk.
Bipolar disorder is also a lot more difficult to control than
unipolar depression, and more hazardous to all concerned. These
facts must be made known to any woman of childbearing age who has
any family or personal history of bipolar disorder, either in
herself or in her partner.
Lithium is present in breast milk in rather high concentrations, so
breast feeding is not recommended for mothers who must take
lithium. Bipolar disorder has a high risk of catastrophic relapse,
making it inappropriate to suggest stopping the lithium as an
alternative to stopping the breast feeding.
PSYCHOSIS:
Psychosis during pregnancy is a dire situation for mother and
fetus. Psychotic persons will not follow any prescribed regimen,
and they are seriously deficient in basic self-care, self-
protection, and common-sense restraints on behavior. Such cases
often require involuntary hospitalization for diagnostic studies
and initiation of pharmacologic treatment.
In cases where a diagnosis of schizophrenia has been established,
there's usually no alternative to maintenance treatment with
antipsychotic medication. Intermittent medical treatment of
schizophrenia is unsafe because full or partial relapse is
inevitable when adequate levels of antipsychotic medication are not
maintained throughout the patient's life. Relapse commonly triggers
a major crisis which places the patient, the fetus, and other close
contacts at risk for serious injury or death.
The oldest antipsychotic medications are known as "low-potency"
neuroleptics because the effective dose is on the order of 1000 mg
daily. These agents have prominent anticholinergic and
antiadrenergic side effects. They used to be given to nonpsychotic
pregnant women in low doses to treat hyperemesis gravidarum. Data
from these cases suggest that such exposure in the first trimester
increases the rate of birth defects by about four cases per
thousand.
The second generation antipsychotic medications are known as "high-
potency" neuroleptics, because they are effective in daily doses
under 100 mg. These agents are much less likely to cause
anticholinergic and antiadrenergic side effects, but they can cause
imbalance in the extrapyramidal motor system leading to stiffness
and rigidity of voluntary muscles. There is no evidence linking
these agents with birth defects, and they've been around nearly
thirty years. Continuous administration throughout pregnancy is
preferred, because intermittent administration carries a high risk
of relapse and requires much larger doses, leading to increased
fetal exposure and uncomfortable muscular side effects.
Most of the medications we use to relieve muscular side effects in
persons taking neuroleptics are suspected teratogens; this includes
benztropine, trihexyphenidyl, and amantadine. The safest agent for
managing extrapyramidal syndromes in pregnant women appears to be
diphenhydramine.
The newest group of antipsychotic medications includes clozapine,
risperidone, and olanzapine. We don't yet have enough data on these
agents to be reassured about fetal risk.
Current data favor using the lowest effective dose of a high-
potency neuroleptic on a continuous basis throughout pregnancy for
schizophrenic women. The most data in this regard are for
haloperidol, which comes in a long-acting injectable form that has
a half life of nearly a month and keeps serum levels as low as
possible. Since medication noncompliance is a major problem in the
maintenance treatment of schizophrenia, the long-acting injectable
medications are strongly preferred.
Children of schizophrenic mothers are at high risk for poor
outcome. There's a high rate of perinatal death, fetal
malformations, and postnatal difficulties with intellectual and
social development. Schizophrenia is as strongly inherited as major
depression, and the consequences are so devastating as to make
genetic counseling obligatory.
Those offspring who don't turn out schizophrenic have a high rate
of other significant psychiatric illness. Few schizophrenic women
can meet a normal child's needs for affection, stability of
environment, and consistent discipline appropriate to the child's
developmental level. Compliance with most forms of birth control
has been poor among chronic schizophrenics; those forms of birth
control which don't require the mother's consistent compliance are
to be preferred despite their drawbacks.
There's little data on the safety of antipsychotic agents in breast
feeding. Prudence would suggest against the practice, given what we
know about the effects of antipsychotic agents on the adult brain.
Stopping treatment to allow breast feeding would not be advisable
in any chronic psychosis, because the risk of relapse is too high
and psychotic relapse can be an irremediable disaster.
TRANQUILIZERS:
The situation regarding use of benzodiazepine tranquilizers in
pregnancy and lactation is very unclear. The best review I was able
to find [McElhatten in references] indicates
that diazepam accumulates
in the fetus to double or triple the maternal level. Some studies
have shown increased risk for oral cleft anomalies when diazepam is
given in the first trimester, while others have not. Diazepam use
during labor has been associated with low APGAR scores, apnea,
hypotonia, poor feeding, and loss of thermoregulation. Diazepam and
desmethyldiazepam were found in neonatal serum up to a week after
maternal exposure. Exposure to diazepam in breast milk leads to
ingestion by the infant of a dose about 5% of mother's dose on a
weight adjusted basis; neonates can't clear diazepam very well in
their first week, so infants exposed to diazepam in mother's milk
should be observed for sedation.
Lorazepam crosses the placenta more slowly than diazepam and is
metabolized more rapidly. Several studies have indicated a lack of
accumulation in the fetus above maternal blood levels. There have
been no reports of increased malformations in babies exposed to
lorazepam. One study indicated rapid clearance of lorazepam by
neonates, essentially complete within 24 hours. Apgar scores in
this study were unimpaired, although another study found that when
lorazepam was used during labor, the babies were often impaired in
a manner similar to those whose mothers were exposed to diazepam
during labor. Babies whose mothers take lorazepam and breast feed
provide a clinically insignificant dose to the infant unless they
ingest unusually high doses.
The situation for other benzodiazepines is intermediate between the
diazepam case and the lorazepam case. In general, benzodiazepines
with shorter half-lives and fewer active metabolites seem to be
less toxic to the fetus and neonate. Fortunately, benzodiazepine
use is rarely essential during pregnancy. For women who may become
pregnant while taking a benzodiazepine, lorazepam would be
preferred.
SUMMARY AND CONCLUSIONS:
In summary, we know a great deal more now than we did a few years
ago regarding indications and contraindications for psychotropic
medications in pregnant and lactating women.
Cautious optimism and thoughtful therapeutic activism are
appropriate when severe mood disorders make their appearance
perinatally.
Postpartum psychiatric illness is particularly common, severe, and
recurrent, but can often be managed without undue disruption of
bonding.
Breast feeding while taking tricyclic antidepressants is not
contraindicated, and the limited data regarding the newer
antidepressants is not particularly adverse.
Bipolar disorder and schizophrenia continue to present dilemmas
which warrant specialty consultation in every case, the more so in
conjunction with pregnancy.
THIS IS NOT MEDICAL ADVICE!
THE INFORMATION IN THIS DOCUMENT MAY NOT BE ACCURATE AND MAY NOT APPLY TO YOU.
ONLY YOUR DOCTOR CAN HELP YOU DETERMINE THE RISKS AND PREFERRED COURSE OF ACTION
IN YOUR INDIVIDUAL SITUATION.
YOU USE THIS INFORMATION AT YOUR OWN RISK!
Copyright 1999 John M Rathbun MD
Page last modified or reviewed on September 14, 2007
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Additional
Information
Postpartum
Depression
Depression
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FPN_7_5
Child-rearing
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Women's
Health
FPN_9_6
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