Pregnancy can be a challenging time for women with long-term mental disorders. While mental illness is common among women of childbearing age, it can bring increased difficulties and risks during and after pregnancy, such as birth complications and a worsening of symptoms.
Dr. Jacqueline Frayne from the King Edward Memorial Hospital for Women in Perth, Western Australia, says, “Although pregnancy and childbirth can be a time of great joy, for some women and their families it may also be a time of turmoil.” She explains that the rate of serious mental illness, such as schizophrenia, is fairly low but up to one in five women will experience “clinically diagnosable depression or anxiety” during pregnancy and the postpartum period.
Taking medication for these conditions can be a cause of anxiety for both the patient and her physician. The pros and cons of medication to mother and baby need to be considered, alongside many other factors that impact on maternal and fetal wellbeing.
Dr. Frayne recommends that “specialist opinion is sought early and a multidisciplinary approach with access to specialist care offered if possible. Continuity of care, especially in the context of a trusting therapeutic relationship, is optimal,” she adds.
She says the treatment plan during pregnancy should be based on the woman’s current mental state and medication, as well as her history of past mental illness and previous treatment, and family history of mental illness during pregnancy. Her support network, pregnancy-related fears, drug and alcohol use should also be considered.
A recent study found that “medications with potential for fetal harm” were being taken by 16 percent of women treated for depression. There is a lack of pregnancy safety data for many medications. However, stopping treatment suddenly is not recommended as this can cause side effects and possible relapse.
For example, in the case of bipolar disorder, relapse is often due to the discontinuation of preventive drugs. Although mild manic episodes can often be managed without drugs, severe manic episodes need to be treated because the possible consequences of injury, stress, malnutrition, profound sleep deprivation and suicide could pose more risk to the fetus than the side effects of the drug.
Lithium should be avoided in the first trimester of pregnancy, whenever possible, as it has been linked to a small but significantly increased risk of birth defects, particularly of the heart. The normal maintenance dose should be re-established as soon as possible following delivery, or if lithium is the only medication that controls symptoms, it can be re-introduced in the second trimester.
Other bipolar medications such as carbamazepine (Tegretol) and sodium valproate (Depakote) also carry some risks of fetal malformation, but physicians may still consider using these medications on the minimum effective dose, alongside regular monitoring.
For generalized anxiety disorder and panic disorder, low-risk medications are available. As an alternative to drugs, patients should be offered cognitive behavioral therapy or psychotherapy, as should those with obsessive-compulsive disorder or post-traumatic stressdisorder.
The selective serotonin reuptake inhibitor (SSRI) antidepressant paroxetine (sold as Seroxat, Paxil) is not considered safe during pregnancy. The prescribing information says, “Epidemiological studies have shown that infants born to women who had first trimester paroxetine exposure had an increased risk of cardiovascular malformations.
“If a patient becomes pregnant while taking paroxetine, she should be advised of the potential harm to the fetus. Unless the benefits of paroxetine to the mother justify continuing treatment, consideration should be given to either discontinuing paroxetine therapy or switching to another antidepressant.”
Antidepressant medications cross the placental barrier and may reach the fetus, but research has shown that most other SSRIs are safe during pregnancy. Birth defects or other problems are possible, but they are very rare.
Tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors (SNRIs) have not been found to have any serious effects on the fetus, and have been safely used thoughout pregnancy for many years. On the other hand, monoamine oxidase inhibitors (MAOIs) have been associated with increased risk of malformations and may interect with drugs used in labour (e.g., meperidine).
Nevertheless, there have been reports of neonatal withdrawal symptoms after the use of SSRIs, SNRIs, and tricyclics during late pregnancy. These include agitation, irritability, a low Apgar score (physical health at birth) and seizures.
Benzodiazepines should not be used during pregnancy, particularly in the first trimester, as they may cause birth defects or other infant problems. The U.S. Food and Drug Administration has categorized benzodiazepines into either category D or X meaning potential for harm in the unborn has been demonstrated.
If used in pregnancy, benzodiazepines with a better and longer safety record, such as diazepam (Valium) or chlordiazepoxide (Librium), are recommended over potentially more harmful benzodiazepines, such as alprazolam (Xanax) or triazolam (Halcion).
Pregnancy outcomes for antipsychotic medications vary widely depending on the type of drug. Exposure to low-strength antipsychotics during the first trimester is associated with a small additional risk of congenital anomalies overall. Haloperidol (Haldol) has been found not to cause birth defects.
The National Institute of Mental Health states, “Decisions on medication should be based on each woman’s needs and circumstances. Medications should be selected based on available scientific research, and they should be taken at the lowest possible dose. Pregnant women should be watched closely throughout their pregnancy and after delivery.”
Women taking these medications and who intend to breastfeed should discuss the potential risks and benefits with their physicians.
References
Frayne, J. et al. Motherhood and mental illness: Part 1 – toward a general understanding. Australian Family Physician, Vol. 38, August 2009, pp. 594-600.
Cleary, B. J. et al. Medication use in early pregnancy-prevalence and determinants of use in a prospective cohort of women.Pharmacoepidemiology and Drug Safety, Vol. 19, April 2010, pp. 408-17.
