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Semelhante a Psychotropics consultation in pregnant and lactating women
Semelhante a Psychotropics consultation in pregnant and lactating women (20)
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Psychotropics consultation in pregnant and lactating women
- 1. Psychotropics consultation in pregnant and lactating women Dr Ibrahim Talha Specialist ofpsychiatry Nizwa polyclinic..
- 2. My goals Bythe end of mypresentation I want •Know the importance of managing mental illness during pregnancy and lactation •Know all data related to psychotropic drugs regarding safetyand hazards on the baby during pregnancy and lactations
- 3. Introduction •Pregnancy and lactationconsidered stressingperiods in lifeofany woman,so pregnant and lactatingwomenareat higher risk for developing mentalillness. •According to WHO, prevalenceof mentalillnesses amongpregnant women about 10%and about 13% amongwomen inpostpartum period •Indeveloping countriesthis iseven higher, i.e. 15.6%during pregnancy and 19.8%after child birth •Depression, anxiety, psychosis, andothers mentalillnessescanaffect pregnant and lactatingmothers
- 4. Estimated Prevalence of Selected Psychiatric Illnesses During Pregnancy Disorder Illness Estimated prevalence (%) Depressive disorders Major depression 13-20 Bipolar disorder Unknown Anxiety disorders General anxiety disorder 8.5 Panicdisorder 1-2 Post-traumatic stress disorder 3.5 Obsessive-compulsive disorder 0.2-1.2 Eating disorders Anorexia only 1.4 Bulimia only 1.6 Both anorexia and bulimia 0.7 Psychoticdisorders Post partumpsychosis Other psychosis 0.1-0.2% Unknown
- 5. Who is at risk ? • Under certain circumstances ,any woman can develop mental disordersduring pregnancy and after delivery , especially in the firstyear after delivery, but riskis higher in patients with • Previous mental illness, 70% of women with a history of recurrent major depressionwill relapse during pregnancy 50% of women with untreated BipolarDisorderwill develop an episode in Pregnancy • Poverty • Extremestress • Exposureto violence (domestic, sexual) • Low social support
- 6. Mental illness and drugs which is more serious? Once the patient diagnosed to have mental illness, we have to choose betweenone oftwo decisions 1-continue without medications and this may expose the patient and the baby to ?certainrisk 2-start medications and this may exposethe baby to ?some risk So what is the decision that should be taken?
- 7. Effects of untreated mental disorders during pregnancy and lactation on mother and baby Both mother and baby will be affected. • The mother may became unable to live normally ,loss of interest, self neglect, poorappetite and sleep, in psychosis, she losses her touch with reality and become unable to care herself and her baby. • The risk of suicide is also a consideration, and in psychotic illnesses, the risk of infanticide, though rare,must be taken into consideration. • Babies during pregnancy are at high risk for under development and low birth weight, stillbirth and pretermlabour. • Motherwholosses her interest and unable to care her self , will be unable to satisfy herbaby emotional and physical needs, and this may results in depression in babies too ( failure to thrive) • Babies bornfor mentally ill mothers ,have high possibility to developsameillness in the future
- 8. Effects of psychotropics on pregnant woman and her baby during pregnancy and lactation •What do you think about effect on the mother? •What do you think abouteffect on the baby ?
- 9. Answers •Positive effect on the mother. •Positive effecton the baby but drugs may have side effects on the baby as follow
- 10. Effects of psychotropic during pregnancy and after birth on the mother and the infant. Continued • Someof the psychotropic drugs may have side effectson baby, (congenital, neurological ,,respiratory,and cognitive effect) Congenital effects Neurological side effects Respiratory side effects Cognitive side effects First trimester:heartdefects, (mainly valve, septum),ex.. Ebstein's anomaly,(tricuspid valve defect,) anencephaly, and abdominal wall defects spinal defects suchas spina bifida((folic acid intake prior to conception and during first trimester reducethe risk(SSRI’s and Lithium) cleft lip(benzodiazepines) Extrapyramidal(antipsychotics) Withdrawal symptoms after delivery;(varyin severity, with some being self-limitedand others requiringICU support and prolonged hospitalization) Floppy infant syndrome (benzodiazepines) SSRI’s in 3rd trimestermay cause persistent pulmonary hypertensionof the newborn (not sure) lower cognitive test scores(sodium valproate) Effect of untreated mental illness may be greater than effect of drugs on the baby
- 11. Effects of psychotropic during pregnancy and after birth on the mother and the infant. Continued •All the results from case reports and short term studiesbut no long term studies, so it is difficultto formulate any generalizations regardingthe safety of these medications. •Generally for the current time, noabsolute contraindications for any of the psychotropic drugs but some drugsare known to have higher risk on the fetus thanother •So we should consider the risk and benefits of medications on both the mother andbaby
- 12. What to do? •Would a physician tell a pregnant woman with epilepsy, ‘Stop your meds and ride out the seizures until you deliver’? •Are the medications of pregnant women with mental illness somehow more “optional? •Theanswer……
- 13. What to do?. Continued •So pregnant and lactating womenwith mental illness should be treated appropriately •Treatmenthas good impact on both the mother and the baby •Non treated women areat risk for serious complications and also the baby
- 14. Management and consultation To achieve the best management and get the best results • We should diagnosis the problem as earlyas possible • We should use non biological ways if wecan and so long as effective • if obliged to use medications we have to use the safest drug • We have to use singlemedicationas possible • We have to start lowand increase slow • We have to observe the outcome of medications anddecide accordingly • We have to consult the patient about the drugs and clarifyingevery thing about the drug andsharing the patient in taking the decision. • Take care of drug interactions • Folate must be prescribed
- 15. Consultation about medications N/A No availabledata PregnancyRisk Categories A Controlled studies showno risk B No evidence ofrisk inhumans C Risk cannot be ruled out D Positive evidence ofrisk X Contraindicated in pregnancy Lactation Risk Categories L1 Safest L2 Safer L3 Moderatelysafe L4 Possibly hazardous
- 16. Antidepressants Medications Effect in pregnancy Lactation Medications Effect in pregnancy Lactation Amitriptyline D L2 Mirtazapine C L3 Clomipramine C L2 Maprotiline B L3 Imipramine D L2 Bupropion B L3 Nortriptyline D L2 Venlafaxine C L3 Fluoxetine C L2 in older infants; L3 in neonatalperiod Nefazodone C L4 Paroxetine D L2 Duloxetine C L3 Sertraline C L2 Safest (maprotiline and bupropion) then (SSRI’’s), during pregnancy, nearly all safe during lactation,MAOI should be avoided because of congenital abnormalities and drug interaction Escitalopram C L3 in older infants Fluvoxamine C L2 Citalopram C L3
- 17. Typical antipsychotics Medications Effect in pregnancy Lactation Haloperidol C L2 Trifluoperazine C N/A Chlorpromazine C L3 Perphenazine C N/A Pemozide C L4 Fluphenazine C L3 Thioridazine C L4 Haloperidol safest during pregnancy andlactation
- 18. Atypical antipsychotics Medications Effect in pregnancy Lactation Olanzapine C L2 Risperidone C L3 Aripiprazole C L3 Clozapine B L3 Quetiapine C L4 Ziprasidone C L4 Olanzapine and clozapine safest during pregnancy and lactation
- 19. Mood stabilizers Medications Effectin pregnancy Lactation Carbamazepine D L2 Divalproex acid D L2 Gabapentin C L2 Lamotrigine C L3 Lithium carbonate D L3 Oxcarbazepine C L3 Topiramate C L3 Carbamazepine, depakine and lithium are unsafe in pregnancy, others safe, and all are safe during lactation but better to avoid lithium during lactation as kidney still immature, Gabapentin has been reportedto cross into breast milk at almost 100% of the maternal levels so better to be avoided
- 20. Benzodiazepines Benzodiazepines Name Effectinpregnancy Lactation Diazepam D L3 Clonazepam D L3 Alprazolam D L3 Lorazepam D L3 Bromazepam D L3 Not safein the first and third trimester, can beused during lactation Benzodiazepines for insomnia Flurazepam X L3 Triazolam X L3 Quazepam X L2 Not safeduring pregnancy,can beused during lactation
- 21. Sedative/Hypnotic/Antianxiety Medications Effectin pregnancy Lactation Clonidine C L3 Buspirone B L3 Hydroxyzine X-Growthrestriction, structural anomalies and death at any time in pregnancy L1 Propranolol C L2 Zaleplon C L2 Zolpidem B L3 Some aresafe during pregnancy, all can be used during lactation
- 22. Medications for Side Effects Medications Effect in pregnancy Lactation Procyclidine (kemadrine) C L3 Benztropine (Cogentin) C L3 Biperiden (Akineton) C N/A Bromocriptine C L5
- 23. Pregnancy and lactation summary •Being pregnant and giving birth to achild is anexhaustingphysical andemotionalexperience. •A woman whohasor develops mentalillnessdeserves support, not shaming. •Assess thesituationand takedecision regarding starting biological treatment or not as untreated mentalillnessmay affect motherand baby badlyand effect maybe greaterthanpossibleside effect of drugs •Sharing themotherisimportant
- 24. Pregnancy and lactation summary. Continued • Avoid medications during pregnancy without good reason • If decision to start medications, weighrisk benefit ratio • Try to chose single drug, the most effective drug withlowest possible side effects and we may start with one drug during pregnancy andreplace by another one during lactation. • Patient falls pregnant on medication 1. Do not stop medications so long as controlled andthere is risk for relapse if stopped 2. Continuemeds at lowesteffective dose 3. EarlyUS and anomaly scan 4. Folate supplement
- 25. Pregnancy and lactation summary. Continued •Some medications need to be stoppedshortly before delivery for safety of the baby but medications should be resumedagain after delivery for avoiding relapse of mental illnessin the mother •Delivery should be at hospital to manage any possible side effects to the foetus and mother. •For better practice in the future we need ,case reporting, more researchesand long term studiesfor betterunderstanding of the safety of psychotropic medications exposure in fetus and neonates.
- 26. Thanks for listening Any questions
Notas do Editor
- The tricyclic antidepressants are most commonly used for comorbid conditions and when other treatments have failed. TCAs, which were once the treatment of choice for depression and panic, remain effective and are not associated with teratogenesis. Doses may need to be adjusted as the pregnancy proceeds. While data analysis has shown that exposure in pregnancy does not increase the incidence of teratogenesis, neonatal withdrawal symptoms have been associated with these medications, so careful monitoring of the newborn is essential. Monoamine oxidase inhibitors (MAOIs) The MAOIs are contraindicated in pregnancy, based on animal studies that have reported increased rates of congenital abnormalities. 2 Other non-SSRI antidepressants • buproprion • mirtazapine • trazodone Limited data are available on the use of these medications
- Low-potency typical antipsychotics (e.g., thioridazine) have been associated with increased risk of mild malformations. High-potency typical antipsychotics (e.g., haloperidol) have not been associated with increased risk. Low-potency typical antipsychotics (e.g., thioridazine) have been associated with increased risk of mild malformations. High-potency typical antipsychotics (e.g., haloperidol) have not been associated with increased risk.
- Low-potency dopamine blockade neuroleptics have been associated with an increased rate of congenital abnormalities. High-potency dopamine blockade antipsychotic medications have not been associated with congenital abnormalities. However, data are limited, and little or no information is available on clozapine, ziprasidone, and quetiapine. Ziprasidone is not yet available in Canada, but to date there are no reports of increased risk with exposure The long-term developmental effects of neuroleptic exposure on the infant dopamine system and receptors are still unclear. Recent data on haloperidol, olanzapine, and quetiapine are encouraging, with no adverse effects reported. Clozapine has been associated with sedation, irritability, and seizures in infants. There are limited data available on the other atypical neuroleptics, thus caution is recommended.
- Limited information is available regarding lamotrigine, topiramate, and gabapentin use in pregnancy. Carbamazepine and valproic acid use during the first trimester has been associated with an increased risk of neural tube defects, as well as minor and major fetal malformations, low birth weight, and thrombocytopenia. Lithium use in pregnancy has been associated with a pronounced increase in the rate of Ebstein anomaly; however, recent literature suggests that this rate is much lower than previously reported (1 in 4000 vs 1 in 400). If lithium is continued in pregnancy, because of the risk of decompensation, drug levels should be monitored carefully. The dose may need to be increased by as much as 100% in pregnancy to maintain symptom control, but should be decreased by at least 50% at the time of delivery to avoid toxicity in both mother and newborn. Lithium has been reported to cross into breast milk at approximately 40% to 50% of the maternal levels. The use of lithium during lactation is contraindicated because the neonatal kidney is still immature and the risk for lithium accumulation is high. Low serum levels have been detected in infants exposed to carbamazepine and valproate through breast milk, suggesting that these drugs are compatible with breastfeeding. However, the possible association between these drugs and thrombocytopenia and hepatotoxicity indicates that close monitoring of the infant is necessary. Gabapentin has been reported to cross into breast milk at almost 100% of the maternal levels and is, therefore, not recommended for use in breastfeeding women. Little information exists on the use of lamotrigine and topiramate, so caution is advised.
- Benzodiazepines • lorazepam (short) • clonazepam (med) • alprazolam (short) • diazepam (long) Exposure to high-dose benzodiazepines in utero has been associated with newborn withdrawal symptoms, including irritability and restlessness, apnea, cyanosis, lethargy, and hypotonia. No longterm effects have been reported, although data are limited. Drugs with a short or medium half-life (lorazepam, clonazepam) at the lowest effective doses should be used. Case reports indicate that milk plasma concentrations vary from 0.1% to 0.5% of the maternal dose for different benzodiazepines. Sedation, lethargy, impaired respiration, and withdrawal have been reported in exposed infants after prolonged use. Therefore, if these medications are indicated, the minimum dose required for symptom relief should be used, and the infant should be monitored regularly.