Congenital malformations, stillbirths, neonatal deaths.
Negative child outcomes persisting into adolescence.
Life-threatening obstetric complications for the mother (especially with SMI).
Lack of active treatment (especially psychotropics for SMI) is associated with perinatal suicides.

Withholding necessary medication solely due to pregnancy/lactation is generally discouraged.

Establishing clear safety profiles is difficult:

Ethical constraints prevent robust randomised controlled trials (RCTs).
Observational studies struggle to control for confounders (the illness itself, lifestyle factors, other meds).
Information evolves as more data becomes available. Interpret data cautiously.

The Balancing Act

Risks of Untreated Illness

(Mother & Fetus/Infant)

vs.

Risks of Medication

(Potential Fetal/Neonatal Effects)

Informed patient choice based on this balance is crucial.

Guiding Principles

For All Women of Child-Bearing Potential:

Always discuss possibility of pregnancy (half are unplanned).
Avoid known harmful drugs (Valproate, Topiramate, Carbamazepine) unless essential.
If essential, ensure full understanding of risks and reliable long-term contraception.

If Mental Illness is Newly Diagnosed During Pregnancy:

Prioritise non-pharmacological treatments first.
If medication needed: Try to avoid 1st trimester (organogenesis) unless benefits clearly outweigh risks.
Choose well-established drugs.
Use lowest effective dose.
Regularly review need, stop ineffective meds.

If a Woman on Psychotropics Plans Pregnancy:

Consider discontinuing treatment only if well, low relapse risk (thorough review needed).
For SMI/high relapse risk: Stopping generally not advisable. Consider switching cautiously to lower-risk drug (but switching itself carries relapse risk).
Address drug-induced hyperprolactinaemia (affects fertility).
Refer women with SMI for pre-conception counselling with perinatal specialist.

If a Woman on Psychotropics Discovers She is Pregnant:

Do not abruptly stop if SMI/high relapse risk (relapse often more harmful).
Often better to continue current effective medication than switch (minimises relapse risk, limits fetal exposure).
Valproate must be stopped immediately (discuss appropriate taper if applicable, though risk already incurred).
Review treatment plan early, as mood can fluctuate.

General Approach During Pregnancy:

Involve parents in decisions.
Use minimum number of drugs necessary (concurrently/sequentially).
Use lowest effective dose.
Be prepared to adjust doses (esp. upwards in 3rd trimester due to volume/enzyme changes). Plasma level monitoring can help (e.g., Lithium, Clozapine, Lamotrigine).
Refer women with SMI to specialist perinatal services.
Liaise with obstetric services (fetal screening).
Inform obstetric/neonatal teams about meds and potential complications.
Monitor newborn for withdrawal effects.
Document all decisions and plans clearly.
Consider fetal anomaly scans (e.g., 13 or 18-20 week ultrasound).

If the Patient Smokes:

Smoking significantly increases risks for poor pregnancy outcomes.
Strongly encourage switching to Nicotine Replacement Therapy (NRT) and refer to cessation services.
Vaping likely safer than smoking but carries risks; NRT generally preferred.
Be aware stopping smoking can increase plasma levels of certain drugs (e.g., Clozapine, Olanzapine).

Drug Navigator

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Breastfeeding Considerations

Offers significant long-term physical health and cognitive benefits for the child.
Generally encouraged for at least the first 6 months.
Concerns about medication safety can influence mother's decision.

RID is an estimate of the infant's dose relative to the mother's dose (adjusted for weight).

RID = (Infant Dose [mg/kg/day] / Maternal Dose [mg/kg/day]) * 100%

Calculated using assumed milk intake (150mL/kg/day) and milk drug concentration.
Infant plasma levels are a better measure but rarely available.
RID < 10% is generally considered compatible with breastfeeding.
Infant plasma levels < 10% of maternal levels also suggest safety threshold.
RID values are estimates and vary between studies. Use as a guide only.

Plan Ahead: Discuss breastfeeding safety when considering psychotropics pre-conception or early in pregnancy.
Avoid Switching: Don't switch meds late pregnancy/postpartum solely for breastfeeding (increases maternal relapse risk).
Continue When Possible: Usually continue the drug used during pregnancy (minimises infant withdrawal), unless known contraindication (Lithium, Clozapine).
Risk vs. Benefit: Weigh breastfeeding benefits against infant drug exposure risks. Consider infant health/gestational age (premature/unwell infants are more vulnerable).
Prioritize Maternal Treatment: Don't withhold necessary treatment. If best drug is contraindicated, advise bottle-feeding.
Starting Postpartum: Consider previous response; prefer drugs with low RID/plasma levels.
Half-Life: Be mindful of long half-life drugs accumulating in infant.
Monitoring: Watch infant for side effects (sedation, feeding issues, irritability, specific drug effects). Consider infant plasma levels if toxicity suspected.
Safe Sleep: Advise against bed-sharing if mother is on sedating medication.
Lowest Effective Dose / Minimize Polypharmacy.

(Remember: Continuing pregnancy drug is usually preferred, except for Clozapine/Lithium).

Antidepressants: Sertraline often considered first-line. Others available (see Navigator).
Antipsychotics: Olanzapine or Quetiapine may be considered. Avoid breastfeeding if taking Clozapine.
Mood Stabilisers: Mood-stabilising antipsychotics (Olanzapine/Quetiapine) may be considered. Avoid breastfeeding if taking Lithium.
Sedatives/Hypnotics: Best avoided. If necessary, choose short half-life.

Clinical Scenarios: Apply Your Knowledge

Scenario 1: Planning Pregnancy on Valproate

A 28-year-old woman with Bipolar I disorder, stable on sodium valproate (1000mg/day) for 3 years, expresses a desire to start trying for a baby within the next 6 months.

What is the MOST critical first step?

Scenario 2: Depression Discovered in Pregnancy

A 32-year-old woman, 14 weeks pregnant (planned), presents with her first episode of moderate-severe depression. Non-pharmacological measures (CBT referral initiated) haven't been sufficient. She has no prior psychiatric history.

Which antidepressant class is generally considered a reasonable first-line choice in pregnancy according to ACOG/COPE recommendations?

Scenario 3: Breastfeeding on Lithium

A 35-year-old woman managed effectively on Lithium for Bipolar I disorder during pregnancy (with close monitoring) has just delivered. She wants to breastfeed.

What is the standard recommendation regarding Lithium and breastfeeding?

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Foundations: Risks & Realities