Mental health, psychiatric medications, and pregnancy
According to ACOG, it is estimated that more than 500,000 pregnancies in the U.S. each year involve individuals who have psychiatric conditions that were present before the pregnancy or emerge during pregnancy, and an estimated one third of all pregnant individuals are exposed to a psychiatric medication at some point during pregnancy. It is difficult to find evidence-based information on the management of mental health conditions in pregnancy, especially when the pregnant individual needs medications. Having an obstetrical care provider who is knowledgeable about management of mental health conditions in pregnancy, as well as the medications needed to treat the individual, is crucial.
Impact of maternal psychiatric conditions on a pregnancy
Consequences of lack of treatment or under-treatment on pregnancy outcomes
General treatment concepts
Specific meds for treatment of depression, bipolar disorder, anxiety, schizophrenia, and ADHD
Recommendations from MFM and psychiatry
Psychiatric medications in pregnancy
Jump to these topics within the conversation:
8:13 When to have the conversation with a healthcare provider about pregnancy and psychiatric medications
12:22 The consequences of untreated mental health conditions, including depression, bipolar disorder, and schizophrenia
17:17 Depression medications and pregnancy
22:20 Postpartum depression risk
25:00 Tricyclic antidepressants and pregnancy
31:45 Lithium and pregnancy
41:45 Anxiety disorders and medications
46:00 PTSD and treating underlying disorders that lead up to anxiety
53:00 Treating ADHD in pregnancy
Stopping psychiatric meds out of "concern for the fetus" is not the answer
As a maternal-fetal medicine specialist, I have heard of other providers telling patients to stop taking their psychiatric medications as soon as they find out they are pregnant. They say this because they are concerned about the effects of medications on the fetus. However, telling a pregnant individual to discontinue their medication(s) likely replaces any fetal or neonatal risks of medication exposure for the risks of an untreated mental health disorder to the pregnant individual. With a pregnancy, there are two people to think of—the pregnant person and the fetus.
exposure to additional medication or herbal remedies
increased alcohol and tobacco use
deficits in mother–infant bonding
disruptions within the family environment
As Dr. Kristin Lasseter says in our conversation, “Even if you’re thinking about the fetus, it’s important to remember that the illness itself is actually more risky for the fetus than the medication.”
General treatment concepts
Ideally, multidisciplinary approach to managing the care of a pregnant individual with a mental health condition should involve the obstetrical care provider and mental health clinician.
Some basic rules of prescribing psychiatric meds in pregnancy include:
A single medication at a higher dose is favored over multiple medications.
Avoid changing medications if possible.
The selection of medication should be based on whether or not the patient has responded favorably in the past to that medication, prior exposure during pregnancy, and available reproductive safety information.
Medications with fewer metabolites, higher protein binding (decreases placental passage), and fewer interactions with other medications are preferred
Table from ACOG PB 92
Resources
Dr. Lasseter recommends using these specific websites to find evidence-based info:
Mother to Baby: Telephone: 866-626-6847. Mother To Baby, a service of the non-profit Organization of Teratology Information Specialists, is dedicated to providing evidence-based information to mothers, health care professionals, and the general public about medications and other exposures during pregnancy and while breastfeeding. MotherToBaby affiliates support and contribute to worldwide initiatives for teratology education and research.
PostPartum Support International: 1-800-944-4773. They offer online support groups, loss and grief resources, and multiple other tools.
Infant Risk Center: Telephone: 806-352-2519. Consumers can call the call center directly to receive information about medications during pregnancy or while breastfeeding. The InfantRisk Center at Texas Tech University Health Sciences Center is a call center based solely on evidence-based medicine and research. They are dedicated to providing current and accurate information to pregnant and breastfeeding mothers and healthcare professionals. They are a training center for medical and pharmacy students and medical residents in the use of drugs in pregnant and breastfeeding mothers.
Massachusetts General Hospital (MGH) Women ‘s Mental Health: The MGH Library on Women ‘s Mental Health is a repository of useful information and frequently referenced articles compiled into different specialty areas, including psychiatric disorders during pregnancy and postpartum.
Your OBGYN or psychiatrist can call the postpartum support international (PSI) line and get a second opinion about staying on or starting medications during pregnancy. This line offers specific information from those who are specialized in this subject.
Summary of Recommendations and Conclusions from ACOG PB 92: "Use of Psychiatric Medications During Pregnancy and Lactation"
The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):
Lithium exposure in pregnancy may be associated with a small increase in congenital cardiac malformations, with a risk ratio of 1.2–7.7.
Valproate exposure in pregnancy is associated with an increased risk of fetal anomalies, including neural tube defects, fetal valproate syndrome, and long-term adverse neurocognitive effects. It should be avoided in pregnancy, if possible, especially during the first trimester.
Carbamazepine exposure in pregnancy is associated with fetal carbamazepine syndrome. It should be avoided in pregnancy, if possible, especially during the first trimester.
Maternal benzodiazepine use shortly before delivery is associated with floppy infant syndrome.
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
Paroxetine use in pregnant women and women planning pregnancy should be avoided, if possible. Fetal echocardiography should be considered for women who are exposed to paroxetine in early pregnancy.
Prenatal benzodiazepine exposure increased the risk of oral cleft, although the absolute risk increased by 0.01%.
Lamotrigine is a potential maintenance therapy option for pregnant women with bipolar disorder because of its protective effects against bipolar depression, general tolerability, and a growing reproductive safety profile relative to alternative mood stabilizers.
Maternal psychiatric illness, if inadequately treated or untreated, may result in poor compliance with prenatal care, inadequate nutrition, exposure to additional medication or herbal remedies, increased alcohol and tobacco use, deficits in mother–infant bonding, and disruptions within the family environment.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
Whenever possible, multidisciplinary management involving the patient’s obstetrician, mental health clinician, primary health care provider, and pediatrician is recommended to facilitate care.
Use of a single medication at a higher dose is favored over the use of multiple medications for the treatment of psychiatric illness during pregnancy.
The physiologic alterations of pregnancy may affect the absorption, distribution, metabolism, and elimination of lithium, and close monitoring of lithium levels during pregnancy and postpartum is recommended.
For women who breastfeed, measuring serum levels in the neonate is not recommended.
Treatment with all SSRIs or selective norepinephrine reuptake inhibitors or both during pregnancy should be individualized.
Fetal assessment with fetal echocardiogram should be considered in pregnant women exposed to lithium in the first trimester.
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Electronic resources for information related to the fetal and neonatal effects of psychiatric drug therapy in pregnancy and with breastfeeding include Reprotox and TERIS.
Shannon M. Clark, MD, MMS is a double board certified ObGyn and Maternal-Fetal Medicine Specialist, and founder of Babies After 35. In her roles as a clinician, educator and researcher at UTMB-Galveston, she focuses on the care of people with maternal and/or fetal complications of pregnancy. Dr. Clark has taken a special interest in pregnancy after the age of 35, which according to age alone, is considered a high-risk pregnancy.
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