Antipsychotic medications in pregnancy: Balancing the needs of mother and child
Consider Jenny, first diagnosed with schizophrenia in her 20’s. After years of suffering the severe symptoms of her illness along with medication side-effects, she was commenced on a new class of medications, “atypical antipsychotics”. She was finally able to live a normal life, employed and in love. She fell pregnant. Not knowing the safety of antipsychotics in pregnancy, Jenny’s doctor stopped her medication. This lead to a devastating cascade of events: Jenny’s relapse in mental illness, the ending of her relationship, an early caesarian section and her child being taken from her. Even after the recommencement of medication, Jenny was unable to see her daughter. In desperation, she ended her life.
Unfortunately, such tragedies have occurred due to a lack of knowledge surrounding antipsychotic medications in pregnancy. Today, greater efficacy in treating psychotic illness means that women living with these conditions can expect to live normal, productive lives and for more and more women, this includes the chance to become a mother.
Evidence shows there is a significantly increased risk of severe mental disorders during the perinatal period, including schizophrenia and bipolar disorder. The reasons for this remain unclear, however include major shifts in hormones, the immune system, sleep disturbance and psychosocial stressors.
During pregnancy, medications are also impacted by dilution, hormonal, liver and kidney factors. An increased dose of antipsychotic medication is subsequently required to achieve the same concentration of the drug in the body. Therefore alterations in medication doses during this time may have more significant effects than anticipated. All psychotropic medications readily diffuse across the placenta to the fetus due to small molecular size and ability to dissolve in lipids.
As described, the effects of stopping antipsychotic medications in pregnancy can be devastating to women with severe mental illnesses. But what of the potential health effects of continuing treatment, to both the mother and child?
The Australian National Register of Antipsychotic Medications in Pregnancy (NRAMP)
NRAMP is an observational nationwide study. The first of it’s kind, it was established in 2005 to address this lack of information.
In terms of maternal health, weight gain (>15kg) and gestational diabetes occurred at a significantly higher rate than the general Australian population.
Babies in the NRAMP study had around three times the risk of respiratory distress than the general population. There were also higher rates of preterm babies and those born with withdrawal symptoms.
Although an increased rate of congenital malformations was found in the study, the malformations found do not support any specific patterns that can be attributed to particular drugs. The increased overall rate was impacted by factors such as other medications, lesser contact with antenatal care services and unhealthy behaviors.
Importantly, the findings for infant development have been reassuring. Infants observed up to 1 year postpartum have met major milestones including walking, talking and basic socialization.
Therefore, it needs to be recognized that this is a vulnerable population and where possible, access to specialist perinatal care and tertiary hospitals is recommended. For those using antipsychotic medications for off-label reasons or less severe mental illness, other options of treatment during pregnancy should be explored.
However, it is clear that there are devastating outcomes associated with discontinuing antipsychotic medications in women with severe psychiatric illness. For these women this research provides reassurance that there are no definitive fetal malformations associated with antipsychotics during pregnancy and the majority of mothers and children do well.
The most important message is that all women with mental illness of reproductive age need to have a considered discussion with their doctors to discuss the best management plan for them when choosing to have a baby.
Antipsychotic use in pregnancy.
Kulkarni J, Storch A, Baraniuk A, Gilbert H, Gavrilidis E, Worsley R
Expert Opin Pharmacother. 2015 Jun