Explanation:

Nicotine replacement therapy (NRT) is considered the safest option, followed by vaping. Traditional tobacco smoking carries the greatest risk to the fetus and should be avoided wherever possible.

Explanation:

• Late Pregnancy Pharmacokinetics: Renal clearance of lithium changes significantly during pregnancy, increasing mid-pregnancy but often decreasing rapidly around the time of delivery. Fluid balance also shifts dramatically during labor and delivery.
• NICE Guidance: To avoid toxicity (due to decreased clearance) or subtherapeutic levels (due to earlier increased clearance), guidelines like NICE recommend more frequent monitoring of lithium levels (e.g., weekly) from 36 weeks gestation onwards and close attention to the mother's fluid status, especially leading up to and during labor.

Explanation:

• Key Concerns: Z-drugs (like zolpidem, zopiclone) are generally not associated with an increased risk of major structural malformations (teratogenicity). However, some studies suggest potential associations with adverse perinatal outcomes like lower birth weight, preterm delivery, or small for gestational age (SGA) infants.
• Clinical Practice: Non-pharmacological approaches remain first-line for insomnia. Z-drugs are used cautiously, for short durations, if benefits outweigh potential risks.

Explanation:

• Guideline Position (e.g., NICE): Benzodiazepines are generally avoided during pregnancy due to potential risks. These include dependence (maternal and neonatal), sedation, and neonatal withdrawal symptoms or "floppy baby syndrome" (hypotonia, respiratory depression) if used near term.
• Appropriate Use: Their use should be restricted to short durations for managing severe, acute anxiety or agitation where benefits clearly outweigh risks. Abrupt discontinuation is also risky due to maternal withdrawal.

Explanation:

• Safety Data: Current evidence suggests lamotrigine does not have a significant association with adverse neurodevelopmental outcomes (like lowered IQ or increased autism risk). This contrasts sharply with valproate, which has a well-established, significant risk.
• Other Agents: Data on methylphenidate are more mixed, with some studies suggesting potential small risks but not as definitive or severe as valproate. Carbamazepine also carries some neurodevelopmental risks, though generally considered less severe than valproate.

Explanation:

• Rapid Response: Electroconvulsive therapy (ECT) is a highly effective treatment for severe, life-threatening, or treatment-resistant psychiatric conditions, including severe depression (with psychosis or suicidality), mania, or catatonia.
• Use in Pregnancy: It is considered relatively safe during pregnancy when administered by experienced teams with appropriate anaesthetic and obstetric monitoring to minimize risks to both mother and fetus. It often works more rapidly than medications, which is crucial in urgent situations.

Explanation:

Due to the risk of neonatal adaptation or discontinuation symptoms, delivery should occur in a facility equipped for neonatal resuscitation and intensive care if needed.

Explanation:

• Mechanism: Serotonin plays a role in platelet function. SSRIs and SNRIs inhibit serotonin reuptake in platelets, potentially impairing aggregation and slightly increasing the risk of bleeding.
• Clinical Relevance: This mechanism is thought to contribute to a modestly increased risk of postpartum haemorrhage (PPH) when these medications are used near the time of delivery. While the absolute risk increase is small, it's a recognized potential complication.

Explanation:

Despite earlier concerns, recent meta-analyses have not confirmed significant teratogenic risk with SNRIs, including venlafaxine.

Explanation:

• Classic Presentation: The rapid onset (typically within days to 2-4 weeks postpartum) of severe symptoms including hallucinations, delusions, agitation, confusion, disorganized behaviour, and dramatic mood shifts (often between mania and depression) is characteristic of postpartum psychosis.
• Risk Factor: A personal history of bipolar disorder is the single strongest risk factor for developing postpartum psychosis. This condition is considered a psychiatric emergency requiring immediate assessment and treatment, often including hospitalization.

Explanation:

Although the evidence is weak, clomipramine has been associated with a potential increased risk of cardiovascular defects, warranting caution during pregnancy.

Explanation:

Given the potential for severe relapse in patients stabilized on clozapine, it is generally advised to continue treatment during pregnancy. Plasma level monitoring is recommended, particularly if smoking status changes, due to its effect on metabolism.

Explanation:

• Presentation: Exposure to SSRIs (and SNRIs) in the late third trimester can lead to a transient syndrome in the newborn known as poor neonatal adaptation syndrome (PNAS) or neonatal withdrawal/toxicity. Symptoms can include jitteriness, irritability, increased muscle tone, feeding difficulties, respiratory distress, and temperature instability.
• Management: These symptoms are usually mild and self-limiting, resolving within days to weeks, but may require supportive care and monitoring in a nursery setting.

Explanation:

Brain structural changes were observed in adolescents exposed to SSRIs in utero, but the clinical relevance of these findings remains unclear due to lack of outcome data.

Explanation:

Emerging data indicate a small increased risk of major congenital malformations with pregabalin. Women of reproductive age should be informed and advised to use reliable contraception.

Explanation:

• Usage History: Promethazine, an antihistamine with sedative properties, has a relatively long history of use in pregnancy, primarily for nausea and vomiting (hyperemesis gravidarum). While not risk-free, it's often considered a potential short-term option for insomnia if non-pharmacological methods (like sleep hygiene, CBT-I) fail.
• Alternatives: Benzodiazepines (diazepam, clonazepam, lorazepam) and Z-drugs (zolpidem) are generally avoided for sleep during pregnancy due to risks of dependence, withdrawal, and potential neonatal effects. They are reserved for more severe, acute situations.

Explanation:

• PPHN Risk: Some studies have suggested a possible association between exposure to SSRIs (and possibly SNRIs) in the third trimester and a small increased risk of Persistent Pulmonary Hypertension of the Newborn (PPHN). PPHN is a serious condition where the infant's circulatory system fails to adapt properly after birth, leading to breathing difficulties.
• Risk Context: While the association has been reported, the absolute risk remains low, and the findings across studies have not been entirely consistent. It represents one potential risk to discuss when weighing the benefits and risks of continuing antidepressants late in pregnancy.

Explanation:

FGAs have been linked to increased rates of postpartum hemorrhage during vaginal birth and changes in placental parameters, suggesting the need for obstetric vigilance during delivery.

Explanation:

• Cardiac Risk: Exposure to lithium, particularly during the first trimester (the period of organogenesis), has been associated with an increased risk of Ebstein's anomaly. This is a congenital heart defect affecting the tricuspid valve.
• Risk Context: While the relative risk is elevated compared to the general population, the absolute risk remains low (estimated around 1 in 1000).
• Monitoring: If lithium is continued during pregnancy, fetal echocardiography is recommended to screen for this and other potential cardiac abnormalities.

Explanation:

Women with SMI should be offered specialist input before pregnancy to discuss relapse risk, medication planning, and coordinated perinatal care. This helps in minimizing risks to both the mother and fetus.

Explanation:

• High Vulnerability: The postpartum period is a time of extremely high risk for mood episodes in women with bipolar disorder. Specifically, women with a history of bipolar I disorder or a previous episode of postpartum psychosis face a very high recurrence risk, estimated to be as high as 25-50%, for postpartum psychosis following subsequent deliveries.
• Clinical Importance: This underscores the critical need for careful pre-conception planning, close perinatal monitoring, and often prophylactic medication strategies for these women.

Explanation:

Antipsychotics are the first-line pharmacological option for acute mania during pregnancy. If ineffective, electroconvulsive therapy (ECT) may be considered, especially in severe or refractory cases.

Explanation:

The observed association between SSRI use and heart defects may be confounded by the underlying psychiatric condition, rather than the medication itself.

Explanation:

• Alternative Strategy: In situations where traditional mood stabilisers (especially valproate, but sometimes also lithium or carbamazepine) are deemed too high-risk or are contraindicated, using a second-generation antipsychotic (SGA) as monotherapy is often a recommended strategy for managing bipolar disorder during pregnancy.
• Rationale: Certain SGAs (e.g., olanzapine, quetiapine, risperidone, lurasidone) have demonstrated efficacy in managing both mania and depression in bipolar disorder and may have a more favourable teratogenic profile than valproate. However, they carry their own risks (e.g., metabolic effects, neonatal adaptation) that need careful consideration and monitoring.

Explanation:

• Rationale: Due to the very high risks of major congenital malformations and adverse neurodevelopmental outcomes associated with valproate, guidelines strongly advise stopping the medication as soon as pregnancy is confirmed. The potential harm from continued exposure outweighs the risks of abrupt cessation in this context.
• Follow-Up: Immediate cessation should be followed by an urgent psychiatric or neurological review to assess the need for alternative treatment and manage the underlying condition.

Explanation:

Carbamazepine can interfere with vitamin K metabolism, increasing the risk of neonatal bleeding. Prophylactic administration of vitamin K to both mother and baby is advised in the third trimester and at birth.

Explanation:

• Pharmacokinetic Changes: Pregnancy significantly increases the metabolic clearance of lamotrigine, primarily through enhanced glucuronidation (UGT enzyme activity).
• Clinical Consequence: This leads to a substantial drop in serum lamotrigine concentrations (often by 50% or more), particularly in the second and third trimesters. This reduction can result in loss of efficacy (breakthrough seizures or mood episodes) if the dose is not adjusted upwards based on clinical response and potentially therapeutic drug monitoring. Postpartum, clearance rapidly returns to baseline, necessitating dose reduction to avoid toxicity.

Explanation:

• Relative Safety: Compared to other commonly used mood stabilisers like valproate, carbamazepine, lithium, and topiramate, lamotrigine (when used as monotherapy) consistently shows the lowest risk of inducing major congenital malformations. Its risk profile is often considered close to that of the general population.

Explanation:

While no causal link was established between antipsychotic exposure and neurodevelopmental disorders, aripiprazole was flagged for further study due to a potential safety signal.

Explanation:

Targeted fetal screening at 13 or 18–20 weeks is advised for early detection of structural abnormalities in women exposed to antipsychotics during the first trimester.

Explanation:

• Relapse Rate: Landmark research (e.g., Cohen et al., 2006, JAMA) demonstrated a high risk of depressive relapse during pregnancy among women who discontinued their maintenance antidepressant medication. In that study, 68% of women who stopped their medication relapsed, compared to only 26% of women who continued their medication.
• Clinical Implication: This highlights that pregnancy itself is not protective against depression recurrence and that stopping effective treatment carries a substantial risk of relapse, emphasizing the importance of careful risk-benefit assessment and shared decision-making.

Explanation:

Studies indicate that the observed increased risk of neurodevelopmental disorders is likely attributed to maternal mental illness itself, rather than antipsychotic exposure, emphasizing the role of confounding factors.

Explanation:

• Metabolic Effects: Among the second-generation antipsychotics (SGAs), olanzapine (along with clozapine) carries the highest risk for causing significant metabolic side effects, including substantial weight gain, insulin resistance, hyperglycemia, and dyslipidemia.
• Gestational Diabetes Risk: This propensity translates into a significantly increased risk of developing gestational diabetes mellitus (GDM) when used during pregnancy. Close monitoring of weight and glucose levels is essential for women taking olanzapine during pregnancy. Aripiprazole, lurasidone, and ziprasidone generally have lower metabolic risks.

Explanation:

• Pharmacokinetic Advantage: Research indicates that sertraline typically has lower concentrations in fetal plasma relative to maternal plasma compared to many other SSRIs. This suggests lower placental transfer.
• Clinical Impact: This pharmacokinetic property contributes to its frequent recommendation as a first-line choice when initiating antidepressant treatment during pregnancy, as it may minimize fetal exposure to the medication.

Explanation:

Non-drug approaches such as psychological therapies should be considered first-line when mental illness is newly diagnosed in pregnancy, particularly for mild to moderate cases, to avoid unnecessary fetal exposure to psychotropic medications.

Explanation:

• Pre-conception Planning: Valproate should ideally be discontinued before conception due to its high teratogenic and neurodevelopmental risks.
• Tapering: A gradual taper (e.g., over 2-4 weeks, or longer depending on clinical stability and dose) is generally recommended to minimize the risk of relapse associated with abrupt withdrawal. Abrupt cessation might be needed if pregnancy is already confirmed, but planned discontinuation allows for a safer transition.
• Folic Acid: High-dose folic acid (typically 5 mg/day) should be started before conception and continued through the first trimester, especially when discontinuing or potentially being exposed to any antiepileptic drug, to reduce the risk of neural tube defects (though it doesn't eliminate valproate's other risks).

Explanation:

• Breast Milk Transfer: Sertraline is known to have low transfer into breast milk, resulting in very low or undetectable serum levels in most breastfed infants.
• Safety Profile: It has been extensively studied in breastfeeding mothers and is generally considered one of the safest antidepressant choices during lactation, with minimal reports of adverse effects in infants.
• Contraindicated/Cautioned Drugs: Clozapine and lithium are generally contraindicated due to significant infant exposure and potential for serious toxicity. Fluoxetine has higher transfer and a long half-life, increasing accumulation risk. Valproate transfer is low but its overall risk profile warrants caution.

Explanation:

A database study reported a tenfold increase in fetal alcohol disorders among SSRI-exposed infants, possibly reflecting confounding from maternal alcohol use in depression.

Explanation:

For bipolar depression in pregnancy, cognitive behavioral therapy (CBT) is preferred for moderate symptoms. For more severe cases, SSRIs may be considered, and lamotrigine is also an option due to its relative safety profile.

Explanation:

• Safety Profile: Sertraline (and often escitalopram) is generally recommended as the first-line SSRI during pregnancy. This preference is based on accumulated data suggesting a relatively favorable safety profile compared to some alternatives.
• Paroxetine: Specifically avoided as a first choice due to early study concerns linking it to a potential increased risk of fetal cardiac defects.
• TCAs, SNRIs: Tricyclic antidepressants (TCAs) like amitriptyline and SNRIs like venlafaxine are typically considered second-line options. They might be used if the patient has a history of successfully responding to them or if SSRIs are ineffective or not tolerated, but they are not the usual starting point for a treatment-naive pregnant patient.

Explanation:

• Regulatory Warning (MHRA): The Medicines and Healthcare products Regulatory Agency (MHRA) in the UK advises against the use of modafinil during pregnancy. This is based on data suggesting an increased risk of congenital malformations, including cardiac defects, orofacial clefts, and hypospadias.
• Contraception Advice: Consequently, women of childbearing potential using modafinil must be advised to use effective contraception.

Explanation:

• Pharmacokinetic Changes: Pregnancy induces (increases the activity of) several key hepatic cytochrome P450 (CYP) enzymes (e.g., CYP3A4, CYP2D6, CYP2C9) and UDP-glucuronosyltransferase (UGT) enzymes.
• Clinical Impact: This increased enzyme activity leads to faster metabolism and lower plasma concentrations of many psychotropic drugs that are substrates for these enzymes (e.g., lamotrigine, some antidepressants, some antipsychotics). This may necessitate dose increases during pregnancy to maintain efficacy. Conversely, enzyme activity returns to baseline relatively quickly postpartum, requiring dose reductions to avoid toxicity.

Explanation:

A large 2023 study observed a potential association between chlorprothixene and increased risk of cardiac malformations in pregnancy, prompting the need for further investigation.

Explanation:

Mirtazapine was not associated with increased risks of malformations, miscarriage, stillbirth, or neonatal death in this large population-based study.

Explanation:

• Current Evidence: While benzodiazepines and Z-drugs can cause short-term neonatal issues like sedation or withdrawal ("poor neonatal adaptation"), large-scale epidemiological studies have not found a consistent or robust causal link between prenatal exposure and long-term neurodevelopmental disorders such as Autism Spectrum Disorder (ASD) or significantly impaired cognitive function, once confounding factors are considered.
• Primary Concerns Remain: The main concerns continue to be dependence, withdrawal, and perinatal sedation/hypotonia.

Explanation:

Severe mental illness in pregnancy significantly increases the risk of obstetric near misses—defined as life-threatening complications requiring urgent intervention. These events highlight the importance of close monitoring and multidisciplinary care in this population.

Explanation:

• High Teratogenicity: Valproate carries a substantial risk of major congenital malformations, particularly neural tube defects (like spina bifida) and craniofacial anomalies.
• Neurodevelopmental Risks: Furthermore, exposure is strongly associated with significant risks of adverse neurodevelopmental outcomes, including lower IQ scores and an increased likelihood of autism spectrum disorder in the child. For these reasons, its use is strongly discouraged and often contraindicated in pregnancy.
• Safer Options: If a mood stabiliser is essential, lamotrigine is generally preferred due to a lower risk profile. Lithium remains a viable option, especially for bipolar I disorder, but requires careful monitoring and discussion of its own risks (e.g., Ebstein's anomaly).

Explanation:

• Known Teratogenicity: Topiramate exposure during pregnancy, particularly in the first trimester, is associated with an increased risk of orofacial clefts (cleft lip and/or cleft palate).
• Neurodevelopmental Concerns: Additionally, there are emerging concerns about potential adverse effects on fetal growth and neurodevelopment. Effective contraception is strongly recommended for women of childbearing potential taking topiramate.

Explanation:

Lithium should be discontinued during labour, and plasma levels should be checked 12 hours after the last dose to guide postpartum re-initiation and prevent toxicity.

Explanation:

In utero exposure to valproate is linked to broad cognitive deficits beyond IQ reduction, including poorer performance in language skills, attention, memory, executive functioning, and adaptive behaviour. These deficits are more pronounced than those associated with other mood stabilisers like carbamazepine or lamotrigine.

Explanation:

• Lithium in Breast Milk: Lithium is readily excreted into breast milk, often reaching concentrations that are 30-100% of maternal serum levels.
• Infant Risk: Neonates and infants have immature renal function, making them less efficient at clearing lithium. This can lead to accumulation and potential toxicity, manifesting as lethargy, hypotonia, poor feeding, dehydration, temperature instability, cyanosis, and potentially thyroid or kidney problems. Because of this significant risk, breastfeeding is generally discouraged or contraindicated for mothers taking lithium.

Explanation:

• Preventing Relapse: Given the very high risk of relapse (mania, depression, or psychosis) in the postpartum period for women with bipolar disorder, major guidelines (like those from the American College of Obstetricians and Gynecologists - ACOG, and collaborative perinatal mental health groups) strongly recommend continuing effective maintenance medication throughout pregnancy (if risks are acceptable) and crucially, into the postpartum period.
• Rationale: Discontinuing effective treatment at delivery significantly increases the likelihood of a severe postpartum episode, which can have devastating consequences for the mother, infant, and family. The risks of relapse often outweigh the risks of continuing medication (unless the specific drug is contraindicated, e.g., valproate for breastfeeding).

Explanation:

• High Relapse Risk: The immediate postpartum period poses an extremely high risk of relapse, particularly mania or psychosis, for women with bipolar disorder. Prophylactic treatment is often essential.
• Lithium Efficacy: For women who responded well to lithium previously, restarting it soon after delivery is a highly effective strategy for preventing postpartum episodes. Lithium is considered the gold standard for relapse prevention in bipolar disorder.
• Monitoring: Close monitoring of maternal lithium levels is crucial postpartum due to rapid shifts in fluid balance and renal clearance. If breastfeeding is considered (which is generally discouraged with lithium), meticulous infant monitoring would be required, but avoiding breastfeeding is usually recommended. Fluoxetine alone is inadequate for bipolar maintenance. Valproate is generally avoided postpartum if breastfeeding due to limited safety data and potential risks (though transfer is low). Waiting for symptoms allows potentially severe relapse.

Explanation:

• Reasoning: Studies suggest that quetiapine tends to cross the placenta to a lesser extent compared to some other second-generation antipsychotics like olanzapine. This characteristic makes it a frequently considered option when antipsychotic treatment is deemed necessary during pregnancy.
• Clozapine Avoidance: Clozapine is generally avoided unless absolutely essential due to its significant risks, including maternal agranulocytosis (requiring blood monitoring) and potential for neonatal complications like seizures and sedation.

Explanation:

• Key Preventive Step: Certain anticonvulsant medications (particularly valproate and carbamazepine) interfere with folate metabolism and increase the risk of the fetus developing neural tube defects (NTDs), such as spina bifida.
• Recommendation: Supplementation with high-dose folic acid (typically 5 mg per day, significantly higher than the standard prenatal dose) is recommended for all women taking these medications who are planning pregnancy or potentially could become pregnant. It should be started ideally before conception and continued through at least the first trimester to help mitigate this specific risk, although it doesn't eliminate all potential teratogenic effects of the drugs.

Explanation:

• Potential Neonatal Effects: If maternal lithium levels are therapeutic or high around the time of delivery, the neonate can experience effects due to lithium exposure crossing the placenta. This can manifest as hypotonia ('floppy baby syndrome'), lethargy, poor feeding, cyanosis, respiratory difficulties, thyroid dysfunction, and potentially lower Apgar scores. Cardiac rhythm disturbances (like T-wave changes) are also possible.
• Monitoring: These effects necessitate careful neonatal monitoring, often in a special care setting, if significant lithium exposure occurs near term.

Explanation:

Women with SMI require referral to specialist perinatal mental health services for tailored, multidisciplinary care throughout pregnancy, birth, and the postpartum period.

Explanation:

• Confounding Factors: While some initial studies suggested possible links between prenatal antidepressant exposure and neurodevelopmental disorders like Autism Spectrum Disorder (ASD) or ADHD, larger and more methodologically rigorous studies have often found that these associations diminish or disappear after adequately controlling for confounding factors, particularly the severity of the underlying maternal mental illness itself.
• Current Understanding: At present, there is no definitive evidence proving a causal link between antidepressant use during pregnancy and these specific long-term neurodevelopmental outcomes. The risk associated with untreated maternal depression is also a critical consideration.

Explanation:

While the overall risk is low, bupropion has been associated with a small increase in the rate of ventricular septal defects in some studies.

Explanation:

TCAs cross the placenta significantly, with measurable levels in both the umbilical circulation and amniotic fluid, indicating considerable fetal exposure.

Explanation:

Cariprazine is associated with developmental risks based on animal data. Although human data are limited, current guidance recommends avoiding its use in pregnancy unless no alternatives exist.

Explanation:

Lithium has been linked with higher rates of spontaneous preterm birth and LGA babies, although some studies have not consistently replicated these findings.

Explanation:

MAOIs carry both fetal teratogenic risks and the maternal danger of hypertensive crisis, especially when combined with certain foods or medications, making them unsuitable for use in pregnancy.

Explanation:

• Evidence Summary: Some large observational studies have suggested a potential small increase in the risk of certain congenital cardiac malformations with first-trimester exposure to methylphenidate.
• Risk Context: The absolute risk increase appears modest, and the data are not as strong or consistent as the risks associated with known teratogens like valproate. It is not considered strongly contraindicated, but requires careful risk-benefit discussion.

Explanation:

Up to 40% of preschool-aged children exposed to valproate in utero may experience developmental delay, making it one of the highest-risk medications in pregnancy.

Explanation:

• Cardiac Concerns: Early observational studies raised concerns about a possible association between first-trimester exposure to paroxetine and an increased risk of congenital cardiac malformations, particularly ventricular and atrial septal defects.
• Clinical Guidance: Although the absolute risk increase is considered small and some later studies have yielded conflicting results, this initial signal has led many guidelines to recommend avoiding paroxetine as a first-line agent in pregnancy or in women planning pregnancy, if other effective options are available.

Explanation:

While lithium levels may need dose adjustment during pregnancy, an arbitrary 50% increase is not recommended. NICE supports careful dose titration and consideration of continuation or switching based on clinical risk.

Explanation:

Despite reassuring neurodevelopmental data overall, some parents have reported behavioural concerns in children exposed to lamotrigine during pregnancy. These reports warrant monitoring, even though broader developmental outcomes appear unaffected.

Explanation:

• Mechanism: Certain psychotropic medications, particularly first-generation antipsychotics and some second-generation agents like risperidone and paliperidone, can significantly increase prolactin levels (hyperprolactinaemia) by blocking dopamine D2 receptors in the pituitary gland.
• Impact on Fertility: Elevated prolactin levels can suppress the hypothalamic-pituitary-gonadal axis, leading to menstrual irregularities (oligomenorrhea or amenorrhea), anovulation, and galactorrhea, thereby impairing fertility and making conception difficult. Switching to a prolactin-sparing antipsychotic (e.g., aripiprazole, quetiapine) may be necessary if fertility is desired.

Explanation:

Valproate should not be initiated or continued in women of childbearing potential unless two specialists have reviewed the case and agreed that no suitable alternative exists. This reflects the strict regulatory control due to valproate’s teratogenicity.

Explanation:

Sertraline may carry a relatively lower risk of neonatal adaptation issues compared to other SSRIs, making it a preferred option when indicated during pregnancy.

Explanation:

• Reasoning: Significant fluid shifts occur during labor and delivery, which can rapidly alter maternal lithium concentrations and increase the risk of toxicity in both the mother and the neonate (who receives lithium via the placenta).
• Guidance: Therefore, guidelines like NICE typically recommend temporarily withholding lithium doses once established labor begins. It can usually be restarted postpartum once the mother's fluid balance and renal function have stabilized, with close monitoring of lithium levels.

Explanation:

While oxcarbazepine may carry a lower risk than valproate, evidence is limited. A 2022 meta-analysis suggested a small, non-significant increase in congenital malformations and an association with fetal/perinatal death in a few studies.

Explanation:

• Risks with Clozapine: Clozapine is known to lower the seizure threshold in adults. This property, combined with placental transfer, raises concerns about a potential increased risk of seizures in neonates exposed in utero, particularly near delivery.
• Other Concerns: This adds to other significant risks associated with clozapine (maternal agranulocytosis, sedation, metabolic effects), making it a medication reserved for treatment-refractory cases, especially during pregnancy.

Explanation:

Schizoaffective disorder is associated with a substantially increased risk of postpartum psychosis, particularly when combined with a personal or family history of bipolar illness or previous postpartum episodes.

Explanation:

The study identified oral clefts as a potential risk specifically associated with olanzapine, while gastroschisis and brain anomalies were flagged as possible risks across all SGAs. These are considered safety signals, warranting further research.

Explanation:

• Key Principle: The risk of untreated or undertreated severe maternal depression during pregnancy can be significant for both the mother and the fetus. If a woman is stable and responding well to a specific antidepressant like venlafaxine, the benefits of maintaining her mental health often outweigh the potential risks of continuing the medication.
• Relapse Risk: Discontinuing an effective medication carries a high risk of relapse, which could be more detrimental than potential medication effects. Switching medications also carries risks of non-response or new side effects. Continuing requires ongoing monitoring and discussion of potential neonatal adaptation issues.

Explanation:

• Floppy Baby Syndrome: This term describes a constellation of symptoms in newborns exposed to benzodiazepines (like diazepam) near delivery. It includes hypotonia (poor muscle tone), lethargy, feeding difficulties, and respiratory depression.
• Benzodiazepine Risk: While other sedatives might cause neonatal sedation, benzodiazepines are classically associated with this syndrome due to their mechanism of action and ability to cross the placenta. Close neonatal monitoring is essential if exposure occurs late in pregnancy.

Explanation:

• Guideline Recommendations: For mild to moderate anxiety or depression during pregnancy, evidence-based psychological therapies, such as Cognitive Behavioural Therapy (CBT), are recommended as the first-line approach.
• Stepped Care: Medications like SSRIs (e.g., sertraline) are typically considered if psychological interventions are ineffective, symptoms are severe, or the patient prefers medication after discussing risks and benefits. Promethazine and diazepam are generally reserved for short-term management of severe symptoms or specific situations.

Explanation:

• Risk of Bleeding: SSRIs and SNRIs can potentially increase the risk of bleeding, including postpartum haemorrhage (PPH), by interfering with platelet serotonin uptake, which is necessary for aggregation.
• Relative Risk: While the risk applies to the class, some evidence suggests that sertraline may have one of the lower relative risks for PPH compared to other SSRIs and SNRIs. However, caution regarding bleeding risk is warranted with all these agents late in pregnancy.

Explanation:

• Guideline Considerations (e.g., NICE): For women who are psychiatrically stable on lithium and discover they are pregnant, guidelines often recommend considering a gradual taper (e.g., over 4 weeks) during the first trimester. This aims to minimize the risk of teratogenicity, particularly Ebstein's anomaly (a cardiac defect), associated with early lithium exposure.
• Balancing Risks: However, this must be balanced against the very high risk of relapse (especially postpartum) if lithium is stopped. If the relapse risk is deemed extremely high, continuing lithium with close monitoring, including fetal echocardiography, may be the safer overall option. This requires careful shared decision-making between the patient and clinical team.

Explanation:

Studies have shown a statistically significant association between TCA exposure during pregnancy and an increased risk of preterm birth.

Explanation:

These medications are associated with significant teratogenic risks. If their use is unavoidable, the prescriber must ensure that the patient has a reliable and ongoing contraception plan to prevent pregnancy while on treatment.

Explanation:

Initial concerns regarding a link between haloperidol and limb defects have not been supported by larger, more recent studies, indicating the initial association was likely not robust.

Explanation:

• Pharmacokinetics: Fluoxetine has a very long half-life, and its active metabolite, norfluoxetine, has an even longer half-life. Both compounds transfer into breast milk.
• Accumulation Risk: This long duration of action increases the potential for the drug and its metabolite to accumulate in the nursing infant's system, particularly in younger or premature infants. While often well-tolerated, there are more reports of potential adverse effects (e.g., irritability, colic, poor feeding, poor weight gain) with fluoxetine compared to shorter-acting SSRIs like sertraline or paroxetine, making it generally less preferred if initiating treatment during lactation.

Explanation:

• Preferred Option: Among the commonly used mood stabilisers, lamotrigine generally has the lowest reported rate of major congenital malformations when used as monotherapy, with rates often close to the baseline risk in the general population (~2-3%).
• Comparisons: Valproate carries the highest risk. Carbamazepine and topiramate have known risks (e.g., neural tube defects for carbamazepine, clefts for topiramate). Lithium carries a risk of Ebstein's anomaly. This makes lamotrigine a frequent first choice when a mood stabiliser is needed for women of childbearing potential or during pregnancy.