Transcript Psychiatric Disorders and Medications During Pregnancy and the

Hala Salah
Lecturer of psychiatry
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Prenatal Classes
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Newspaper articles
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Community lectures
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Family involvement in the educational process
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Routine prenatal screening
-Exercise
-Diet:
Omega 3
Protein
Hydration
Vit. (B)
-Plan
-For women with histories of postpartum depression
consider prophylactic antidepressants
- For those who were treated during pregnancy
◦ Rest
◦ Proper nutrition
◦ Help with infant and household responsibilities
◦ Family and friends support systems
◦ Avoidance of isolation
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Type of illness (bipolar)
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Severity
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Medications needed
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Infant issues
Individual patient approach is needed
Quality of
mother’s life
Benefits of breast
feeding
Precious baby
Risks of drug-induced
toxicity in breast-fed
infant
Psychotropics
Social Support
Psychotherapy
ECT
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Psychosocial therapies
◦ First choice for those with mild to moderate symptoms of PPD
◦ Cognitive-behavioral therapy
◦ Interpersonal psychotherapy- focuses on patient’s interpersonal
relationship and changing roles
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Group therapy
◦ Helps to increase support network
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Family and marital therapy
◦ More rapid recovery
◦ More appreciative of partner’s contribution
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Peer-support groups
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Four factors are needed in order to understand
problems related to breast-feeding by mothers taking
psychotropic medication:
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the prescribed dose;
the level of the drug in the mother’s blood plasma;
the level in the breast milk;
and the levels in the infant’s serum.
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Medication’s diffusion across membranes,
Molecular weight and its lipophilicity.
The timing of the dose in relation to the
infant’s feeding patterns.
Drug’s dosage and frequency, its
pharmacodynamics and pharmacokinetics.
Maternal / Infant / Drug
Maternal:
• Drug dosage and duration of therapy
• Route and frequency of administration
• Metabolism
• Renal clearance
• Blood flow to the breasts
• Milk pH and composition
Maternal / Infant / Drug
Infant:
• Age of the infant
-preterm
- full term 3w
8-12w
• Feeding pattern
• Amount of breast milk consumed
• Drug absorption, distribution, metabolism and elimination
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Most drugs are transferred into milk by the passive
diffusion processes and hence maternal drug .
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Active or carrier-mediated transport occurs for some.
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Drugs must pass from the maternal plasma, through the
capillary walls, into the alveolar cells lining milk duct.
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During the first few days of life there are large gaps
between these alveolar cells, which allow most
molecules to cross through easily.
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For psychotropics the arbitrary concentration in the
infant’s plasma of 10% of the established therapeutic
maternal dose is used as the upper threshold where the
risks of a particular drug’s side-effects are low and
treatment is accepted as safe
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The newborn’s health should be taken
consideration when planning breast-feeding
into
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Preterm immature infants should not be exposed to
psychotropics
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Infants’ hepatic, renal and cardiac functions should be
checked before they are breast-fed by mothers on
psychotropic medication
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Infants older than 10 weeks are at a lower risk for
adverse effects of tricyclics and there is no evidence of
accumulation in the infant
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The newborn should be examined regularly for any
possible adverse events of medication
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All professionals involved in the care of the infant
should be informed of psychotropic medication usage
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Increase risk of suicide after initiation of medication
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If significant anxiety or insomnia present, consider
adding benzodiazepine
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Close follow-up
SSRI
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SSRI preferred initially.
Drug levels are low to undetectable.
All effective in open trials (Moretti, 2009).
SSRIs such as fluoxetine, sertraline, paroxetine and
citalopram are safe during breast-feeding (Berle, 2004).
Sertraline is considered as first line in USA (Altshuler
et al. (2001).
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Tricyclics have a less favorable side effect profile and a
much higher risk of morbidity and mortality from
overdose.
However, it is relatively safer and low levels of drugs
are secreted for most tricyclics.
Tricyclics such as amitryptyline, imipramine,
nortriptyline and clomipramine are safe during breastfeeding (Becker, 2009).
Doxepin is contraindicated (respiratory depression).
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Trazodone appears to be of lower risk because only 1%
passes into the milk, although drowsiness and poor
feeding have been reported. Data are limited to a few
cases and caution is advised in use of the drug.
- It has been mentioned in certain studies that
Mirtazapine can be used as first-line treatment and,
because of its action on histamine H1 receptors, may be
preferred in some patients with postnatal depression,
when night-time sedation is required (Snellen, 2007)
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Venlafaxine is considered safe (Snellen, 2007).
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Bupropion: Few studies found no adverse effects (in
one case, it lead to occurance of seizure in the new
born) (Becker, 2009).
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Conventional antipsychotics have been used for
decades and the accumulated data show that they are
safe during breast-feeding (Phenothiazines may
increase risk of SIDS).
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New information is starting to emerge about some
atypical antipsychotics such as olanzapine and
risperidone but their safety has yet to be established
(Moreeti,2009)
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There is currently no information on quetiapine and
amisulpride and therefore it is not safe to expose
newborns to these medications
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Clozapine accumulates in breast
contraindicated during breast-feeding
milk
and
is
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Lithium is contraindicated during breast-feeding (high
serum level, but 3 studies recommended its use with
caution if no other options available. (Hale , 2004)
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There is little evidence of adverse events in infants
breast-fed by mothers taking carbamazepine or sodium
valproate, although transient hepatic toxicity is possible
with the former (Moretti, 2009)
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Lamotrigine is considered moderately safe in practice
(But with high serum level in infant-be careful of risk
of Steven Johnson syndrome) (Becker, 2009).
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It is unsafe to expose infants to repeated doses of longacting benzodiazepines
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Shorter acting agents such as oxazepam, alprazolam
and lorazepam are preferred by most authors (Becker,
2009). It must be used for short term.
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Buspirone, zaleplon and zopiclone are better avoided
because of limited safety data on their use.
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Psychiatric emergency! Inpatient treatment
Mood stabilizers
Antipsychotics
Benzodiazepines
Lithium prophylaxis
Electroconvulsive therapy
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The decision to prescribe antipsychotics to breast-feeding
women should depend on individual risk/benefit analysis
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The current available research does not allow any absolute
and clear recommendation because much of the work on
psychotropic medication in breast-feeding is limited to
single case reports, small series and naturalistic data
collection
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Causes and consequences of different adverse events are not
yet widely studied

Berle J.O. The challenges of motherhood and mental
health. World Psychiatry. 2004;3(2):p101–102.
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Becker M.A, Mayor G.F, Elisabeth J.S. Psychotropic
Medications and Breastfeeding. Primary Psychiatry.
2009;16(3):p42–51
-Hale T.W. Drug Therapy and Breastfeeding:
Antidepressants, Antipsychotics, Antimanics, and
Sedatives. Neo Reviews. 2004;5(10):e451.
-Moretti M.E. Psychotropic Drugs in Lactation. Can J
Clin Pharmacol. 2009;16(1):p e49–e57.
-Snellen M, Galbally M, Udechuku A, Spalding G,
Munro C, Drinkwater P. Psychotropic Medication in
Pregnancy/Lactation. Revised 2nd Edition. Mercy
Health & Aged Care: Melbourne; 2007. Pharmacy
Department Mercy Hospital for Women. October 2007
Thank you