Psychotropic drugs in pregnancy and lactation

Women's Psychiatry

Brain disorders and mental diseases, in particular, are common and considered as a top global health challenge for the twenty-first century. Interestingly, women suffer more frequently from mental disorders than men. Moreover, women may respond to psychotropic drugs differently than men, and, through their lifespan, they endure sex-orientated social stressors. In this chapter, we present how women may differ in the development and manifestation of mental health issues and how they differ from men in pharmacokinetics and pharmacodynamics. We discuss issues in clinical trials regarding women participation, issues in the use of psychotropic medications in pregnancy, and challenges that psychiatry faces as a result of the wider use of contraceptives, of childbearing at older age, and of menopause. Such issues, among others, demand further women-oriented psychiatric research that can improve the care for women during the course of their lives. Indeed, despite all these known sex differences, psychiatry for both men and women patients uses the same approach. Thereby, a modified paradigm for women's psychiatry, which takes into account all these differences, emerges as a necessity, and psychiatric research should take more vigorously into account sex differences.

Lithium and pregnancy

The lifetime prevalence of bipolar affective disorder is approximately 1% in both men and women (Reiger et al, 1998). In women the illness is most prevalent in the child-bearing years (Robins et al, 1984). While lithium for the treatment of bipolar disorder is a cornerstone of modern psychopharmacology (Llewellyn et al, 1998), there are inherent problems in treating this sizeable subgroup of patients, as lithium presents small, but significant, risks to a potential foetus. It is also becoming increasingly obvious that serious mental illness poses a risk to the unborn child. This paper reviews those risks, presents a protocol in algorithmic form for dealing with the prescription of lithium in pregnancy and discusses practical issues pertaining to dosage and lithium monitoring.

The rights and wrongs of blood-brain barrier permeability studies: a walk through 100 years of history

Careful examination of relevant literature shows that many of the most cherished concepts of the blood-brain barrier are incorrect. These include an almost mythological belief in its immaturity that is unfortunately often equated with absence or at least leakiness in the embryo and fetus. The original concept of a blood-brain barrier is often attributed to Ehrlich; however, he did not accept that permeability of cerebral vessels was different from other organs. Goldmann is often credited with the first experiments showing dye (trypan blue) exclusion from the brain when injected systemically, but not when injected directly into it. Rarely cited are earlier experiments of Bouffard and of Franke who showed methylene blue and trypan red stained all tissues except the brain. The term “blood-brain barrier” “Blut-Hirnschranke” is often attributed to Lewandowsky, but it does not appear in his papers. The first person to use this term seems to be Stern in the early 1920s. Studies in embryos by Stern and colleagues, Weed and Wislocki showed results similar to those in adult animals. These were well-conducted experiments made a century ago, thus the persistence of a belief in barrier immaturity is puzzling. As discussed in this review, evidence for this belief, is of poor experimental quality, often misinterpreted and often not properly cited. The functional state of blood-brain barrier mechanisms in the fetus is an important biological phenomenon with implications for normal brain development. It is also important for clinicians to have proper evidence on which to advise pregnant women who may need to take medications for serious medical conditions. Beliefs in immaturity of the blood-brain barrier have held the field back for decades. Their history illustrates the importance of taking account of all the evidence and assessing its quality, rather than selecting papers that supports a preconceived notion or intuitive belief. This review attempts to right the wrongs. Based on careful translation of original papers, some published a century ago, as well as providing discussion of studies claiming to show barrier immaturity, we hope that readers will have evidence on which to base their own conclusions.

Barriers in the developing brain and Neurotoxicology

The brain develops and grows within a well-controlled internal environment that is provided by cellular exchange mechanisms in the interfaces between blood, cerebrospinal fluid and brain. These are generally referred to by the term "brain barriers": blood-brain barrier across the cerebral endothelial cells and blood-CSF barrier across the choroid plexus epithelial cells. An essential component of barrier mechanisms is the presence of tight junctions between the endothelial and epithelial cells of these interfaces. This review outlines historical evidence for the presence of effective barrier mechanisms in the embryo and newborn and provides an up to date description of recent morphological, biochemical and molecular data for the functional effectiveness of these barriers. Intercellular tight junctions between cerebral endothelial cells and between choroid plexus epithelial cells are functionally effective as soon as they differentiate. Many of the influx and efflux mechanisms are not only present from early in development, but the genes for some are expressed at much higher levels in the embryo than in the adult and there is physiological evidence that these transport systems are functionally more active in the developing brain. This substantial body of evidence supporting the concept of well developed barrier mechanisms in the developing brain is contrasted with the widespread belief amongst neurotoxicologists that "the" blood-brain barrier is immature or even absent in the embryo and newborn. A proper understanding of the functional capacity of the barrier mechanisms to restrict the entry of harmful substances or administered therapeutics into the developing brain is critical. This knowledge would assist the clinical management of pregnant mothers and newborn infants and development of protocols for evaluation of risks of drugs used in pregnancy and the neonatal period prior to their introduction into clinical practice.

Clozapine use in two women with schizophrenia during pregnancy

Stabilized patients who receive clozapine may wish to have children; but studies on pregnant women receiving clozapine treatment are limited. In this study, we report on clozapine use during pregnancy in two women. The first woman (Case 1) had two deliveries while she was receiving clozapine treatment for schizophrenia. Both her deliveries were term, uncomplicated vaginal deliveries, and the clozapine dose was reduced throughout pregnancy. The second woman (Case 2) developed schizophrenia after her first child was born. She became pregnant after clozapine initiation. She delivered twins by term, uncomplicated vaginal delivery. In our cases, no specific risks for the mothers and their children can be attributed to the use of clozapine. Physicians must be aware of the changes in fertility induced by prolactin-sparing drugs. Mothers who receive clozapine treatment should not be advised to breastfeed their children.

Evaluating the Postmarketing Experience of Risperidone Use During Pregnancy

BACKGROUND

A significant number of women of childbearing age have schizophrenia or other psychoses. This means that there is a considerable risk of in utero exposure to risperidone due to maternal use.

OBJECTIVE

To determine whether in utero exposure to the atypical antipsychotic risperidone is associated with poor pregnancy and fetal/neonatal outcomes.

METHODS

A search of the Benefit Risk Management Worldwide Safety database, using a selection of preferred terms from the Medical Dictionary of Regulatory Activities, was performed to identify all cases of pregnancy or fetal/neonatal outcomes reported in association with risperidone treatment from its first market launch (international birth date, 1 June 1993) to 31 December 2004. The main measures were the patterns and reporting rates of pregnancy (stillbirth and spontaneous and induced abortion) and fetal/neonatal outcomes (congenital abnormalities, perinatal syndromes and withdrawal symptoms) for women administered risperidone during pregnancy.

RESULTS

Overall, 713 pregnancies were identified in women who were receiving risperidone. Data were considered prospective in 516 of these, and retrospective in the remaining 197 cases. The majority of the known adverse pregnancy and fetal/neonatal outcomes were retrospectively reported. Of the 68 prospectively reported pregnancies with a known outcome, organ malformations and spontaneous abortions occurred 3.8% and 16.9% (when the 15 induced abortions were excluded from the denominator, as they were predominantly undertaken for nonmedical reasons), respectively, a finding consistent with background rates of the general population. There were 12 retrospectively reported pregnancies involving major organ malformations, the most frequently reported of which affected the heart, brain, lip and/or palate. There were 37 retrospectively reported pregnancies involving perinatal syndromes, of which 21 cases involved behavioural or motor disorders. In particular, there was a cluster of cases reporting tremor, jitteriness, irritability, feeding problems and somnolence, which may represent a withdrawal-emergent syndrome.

CONCLUSION

This comprehensive review of the Benefit Risk Management Worldwide Safety database for case reports of risperidone exposure during pregnancy represents the largest ever published dataset documenting pregnancy outcomes for women taking the atypical antipsychotic risperidone. It indicates that in utero exposure to risperidone does not appear to increase the risk of spontaneous abortions, structural malformations and fetal teratogenic risk above that of the general population. Self-limited extrapyramidal effects in neonates were observed after maternal exposure to risperidone during the third trimester of pregnancy. Risperidone should only be used during pregnancy if the benefits outweigh the potential risks.

A comparative study of pregnant women attending a tertiary obstetric unit and a district general hospital with a previous history of postnatal depression

The aim of this study was to compare pregnant women with a previous history of postnatal depression, attending a Tertiary Obstetric Unit in Belfast and a District General Hospital in Newry. Women with a previous history of postnatal depression recorded at booking for their most current pregnancy were studied between January 2001 and May 2002. A total of 443 women (6.6%) in Belfast had a history of postnatal depression, compared with 113 women (6%) in Newry. The most common age range was 31 - 35 years in both centres. Some 69% of women in Belfast compared with 81% of women in Newry were given treatment. Fluoxetine was the commonly prescribed drug for each centre. During this subsequent pregnancy, 19 women (4.3%) in Belfast and five women (4.4%) in Newry remained on antidepressants. There was one woman in each centre who took an overdose during this pregnancy. More women in Newry were given treatment. During the subsequent pregnancy, the percentages of women from each unit requiring antidepressant therapy were similar.

Implications for anaesthesia in a patient established on clozapine treatment

Clozapine is an atypical antipsychotic agent with a novel pharmacological profile and multiple clinical properties. Because of its side effects, it is recommended in treatment of severe resistant schizophrenia for which purpose it is remarkably effective. Little is known about the safety profile of clozapine during pregnancy and labour and because it is now used more commonly to manage schizophrenia, it is important that we as anaesthetists are aware of its many interactions and potential side effects. We present a case of a successful emergency caesarean section in a schizophrenic patient on clozapine treatment.

Retentissement néonatal de l'exposition aux benzodiazépines en fin de grossesse

INTRODUCTION

Since benzodiazepines (BZD) are largely prescribed during pregnancy, the Regional Pharmacovigilance Center (RPVC) of Tours regularly deals with questions about the risk of their administration to pregnant women and the monitoring of the newborns exposed in utero to these drugs. During the third trimester, we recommend a switch in the BZD maternal treatment to oxazepam, which has an intermediary half-life and no active metabolite, and a hospitalisation of the newborn in order to monitor his respiratory rate. The purpose of our study was to evaluate the neonatal consequences of BZD used at the end of pregnancy and to analysed if our recommendations were taken into account and if they were appropriate.

METHODS

From 1989 to the end of 2002, we studied the files in which women had received a BZD during the 30 days prior to delivery. We analysed maternal treatments, the outcome of pregnancy and the development of the newborn, the therapeutically attitude recommended and whether or not it was respected.

RESULTS

A total of 73 files were selected. Seventy neonates were born to 73 women. The newborns were hospitalised (73%) and they developed adverse reactions possibly related to the use of BZD (51,5%) : an impregnation syndrome (42%) characterized by hypotonia and hypoventilation, and a withdrawal syndrome (20%) with tremulations as the main symptom.

CONCLUSION

Considering the most frequent neonatal manifestations, hospitalization and the respiratory monitoring recommended by the RPVC seemed adequate. However, the switch to oxazepam was seldom done and its advantages should be pointed out.

The effects of dopaminergic/serotonergic reuptake inhibition on maternal behavior, maternal aggression, and oxytocin in the rat

Studies using dopaminergic and serotonergic agonists or antagonists implicate involvement of these systems in various aspects of early maternal behavior and postpartum aggression towards an intruder in rats, both of which are associated with the presence of oxytocin in specific brain regions. It is unclear however, if or how long-term uptake inhibition of either neurotransmitter system alone or in combination, affects oxytocin system dynamics or maternal behavior/aggression. Pregnant women frequently take drugs (antidepressants, cocaine) that induce long-term reuptake inhibition of dopamine and/or serotonin, thus it is important to understand these effects on behavior and biochemistry. Rat dams were treated throughout gestation with amfonelic acid, fluoxetine, or a combination of both, to investigate effects of reuptake inhibition of dopamine and serotonin systems respectively, on maternal behavior, aggression and oxytocin. The more appetitive aspects of maternal behavior (nesting, licking, touching) and activity were increased by the low dose of amfonelic acid, high dose of fluoxetine, or the high dose combination more than other treatments. Aggression was decreased by amfonelic acid and somewhat increased by fluoxetine. Dopamine uptake inhibition appears to have a strong effect on hippocampal oxytocin levels, while receptor dynamics may be more strongly affected by serotonin uptake inhibition.

Movement disorders in pregnancy

Movement disorders are not particularly common during pregnancy, with a few exceptions. RLS occurs most commonly followed by CG. Currently, with the incidence of rheumatic fever lower than previously, any woman who develops CG should be checked for illness other than rheumatic heart disease. The differential includes systemic lupus erythromatosis and antiphospholipid antibody syndrome. Regarding the use of dopaminergic agents, the dopamine agonist, pergolide, can be maintained during pregnancy for the treatment of PD, Segawa disease, and RLS. The use of levodopa and ropinirole should be limited during pregnancy because of the possible teratogenic effects. Amantadine is contraindicated during pregnancy. The data on selegiline are controversial; animal studies show possible serotonergic effects and teratogenic effects. If treatment is indicated in patients who have Tourette syndrome, the high potency neuroleptics drugs (haloperidol) are preferred to treat associated symptoms. Depression is a common comorbidity in patients who have PD, HD,Tourette syndrome, or other chronic neurologic diseases. Depression treatment during pregnancy is covered by Levy et al elsewhere in this issue. As discussed previously, most of the data on the use of drugs during pregnancy, especially the dopaminergic agents, are limited to animal studies and case reports. Therefore, it is in part left to the neurologist to decide on treatment based on the individual patient, clinical judgment, and inferences from animal studies and limited case reports.

Use of Antipsychotics in the Management of Schizophrenia during Pregnancy

The rapid development of pharmacotherapy has resulted in a growing clinical importance for the treatment of the increasing number of women with schizophrenia during pregnancy. An evolving database on reproductive health safety factors for women with schizophrenia has begun to be of assistance in optimising clinical benefits for women with childbearing potential. Given the prevalence of antipsychotic use during pregnancy in women with schizophrenia, it is important for the clinician to have a prepared approach to the administration of these agents. In general, the use of psychotropic medication during pregnancy is indicated when risk to the fetus from exposure to this medication is outweighed by the risks of untreated psychiatric illness in the mother. The preponderance of evidence from registries to large health surveys indicate that treatment with antipsychotic medication confers either no or a small nonspecific risk for organ malformations. According to the relevant literature published on the safety of antipsychotic medication during pregnancy, the findings are encouraging; however, the currently available data are very limited. Until there are more controlled prospective data on the impact of drugs on fetal and later development, the clinician will continue to work in a state of potential uncertainty, weighing partially estimated risks against managing individual clinical problems. The aim for the clinician should be to provide the best information available regarding the scope of possible risks associated with the treatment of schizophrenia during pregnancy. On the basis of the available data, generalisation is impossible and recommendations should be made on a drug-by-drug basis. The risks and benefits must always be carefully weighed for each patient on an individual basis. Only a woman who is well enough to acknowledge her pregnancy and her mental illness can effectively weigh the relative and partially unknown risks of treatment with antipsychotic medication against the highly probable risks of illness exacerbation if untreated.

Maternal selective serotonin reuptake inhibitor use during pregnancy and newborn neurobehavior

OBJECTIVE

This is a prospective study of the effects of maternal use of selective serotonin reuptake inhibitors (SSRIs) during pregnancy on newborn neurobehavioral integrity, including systematic measures of behavioral state, sleep organization, motor activity, heart rate variability (HRV), tremulousness, and startles.

METHODS

The sample included 17 SSRI-exposed and 17 nonexposed, full-birth-weight newborn infants who had no obvious medical problems and were matched on maternal cigarette use, social class, and maternal age. SSRI exposure was determined by medical records and maternal self-report during a standard interview. Behavioral state, startles, and tremulousness were evaluated for 1 hour between feedings. Automated recordings of motor activity and HRV were also assessed during a 15-minute subset sleep period. HRV was subjected to spectral analysis to detect rhythms in autonomic regulation. Exposed and nonexposed infant groups were compared on measures of neurobehavioral development both before and after adjustment for gestational age as a covariate.

RESULTS

SSRI-exposed infants had a shorter mean gestational age; were more motorically active and tremulous; and showed fewer rhythms in HRV, fewer changes in behavioral state, fewer different behavioral states, and a lower peak behavioral state. SSRI-exposed infants also had significantly more rapid eye movement sleep, which was characterized by longer continuous bouts in that state and higher numbers of spontaneous startles or sudden arousals. After effects of gestational age were covaried, significant differences continued to be found in tremulousness and all measures of state and sleep organization, but effects on startles, motor activity, and rhythms in HRV were no longer significant.

CONCLUSIONS

Results provide the first systematic evidence that women who use SSRIs during pregnancy have healthy, full-birth-weight newborn infants who show disruptions in a wide range of neurobehavioral outcomes. Effects on motor activity, startles, and HRV may be mediated through the effects of SSRI exposure on gestational age. Future research can lead to a better understanding of the effects of SSRI use during pregnancy and an improved public health outcome.

The effects of maternal depression on fetal heart rate response to vibroacoustic stimulation

To better understand the effects of untreated maternal depression on the fetus, this study examined fetal heart rate (FHR) and FHR reactivity to vibroacoustic stimulation in pregnant women with untreated depression. The 20 participants were 32- to 36-week pregnant women divided into groups with depression (N = 10) and without depression (N = 10) based on the Beck Depression Inventory (BDI; Beck, 1977; Beck & Steer, 1987). Participants were attached to a fetal heart monitor, and 10 min of baseline FHR were recorded. A vibroacoustic stimulus (VAS) was presented, and an additional 10 min of FHR were recorded. Fetuses of mothers with depression had an elevated baseline FHR and a 3.5-fold delay in return to baseline FHR after VAS presentation. Additionally, mothers with depression had significantly higher anxiety levels and took fewer prenatal vitamins during pregnancy. Delayed habituation of FHR in the fetuses of mothers with depression may be due to alterations in the internal hormonal environment and could have implications for postnatal information processing.

The role of sex hormones in psychopathology: focus on schizophrenia

The example of schizophrenia is used to illustrate how sex hormones affect the presentation of illness and its treatment. Organization and activation effects of hormones are explained, and behavior is shown to result from a complex interplay of hormones, brain mechanisms, and social pressures. Sex differences in schizophrenia (in onset age, symptoms, antipsychotic, and other treatment) are consequences of this interplay and impact on the clinician's ability to diagnose, treat, prognosticate, and prevent the disability and distress of schizophrenia.

Psychopharmacology in pregnancy

Clinicians are confronted with challenging situations when working with women who are pregnant and have a co-existing mental illness. A risk benefit assessment is helpful when identifying possible care interventions. Psychopharmaceutical intervention is a consideration when nonpharmacological interventions are ineffective or inappropriate. Informed consent based on known and unknown risks to the mother and fetus should be obtained. Literature and case reports are contradictory and not conclusive about the risks of medications used for psychiatric illnesses. This article reviews the literature and provides clinical guidelines for antipsychotic medications, antidepressant medications, mood stabilizing medications, and antianxiety medications.

Olanzapine-exposed pregnancies and lactation: early experience

Psychosis frequently occurs in women of childbearing potential who may have unplanned pregnancies. Understanding the risk of prenatal antipsychotic exposure can be of benefit in selecting therapies. The authors evaluated the in utero and lactation exposure effects of olanzapine, a novel antipsychotic that is used in treating schizophrenia, bipolar disorder, and other conditions and that may have expanded use in the childbearing population. All prospectively and retrospectively ascertained pregnancy reports were collected as a registry in the Lilly Worldwide Pharmacovigilance Safety Database. Outcomes were available from 23 prospectively ascertained olanzapine-exposed pregnancies. Spontaneous abortion occurred in 13%, stillbirth in 5%, major malformation in 0%, and prematurity in 5%, all within the range of normal historic control rates. There were 11 retrospectively ascertained cases of pregnancy. Two retrospectively ascertained cases of lactation exposure did not suggest infant risk. The early experience with olanzapine use in pregnancy and lactation is encouraging in that no obvious added risk to the fetus or infant was observed. Additional cases of pregnancy and lactation exposure need to be evaluated to determine whether these early findings are representative of the risks of olanzapine exposure to the fetus and infant. At this time, olanzapine should only be used during pregnancy and lactation when the potential benefit justifies the potential risk to the fetus or infant.

Anticonvulsant use during lactation

The issue of prescribing anticonvulsant drugs during lactation is clinically important, but also complex. Data for some drugs are completely lacking and for other drugs information is only available from single dose or short term studies or case reports. Moreover, limited knowledge exists about the practical impact of the drug concentrations found in breast milk and there are great methodological problems in the assessment of possible adverse drug reactions in infants. Nevertheless, based on current knowledge, some recommendations can be suggested. Treatment with carbamazepine, valproic acid (sodium valproate) and phenytoin is considered compatible with breastfeeding. Treatment with ethosuximide or phenobarbital (phenobarbitone)/primidone should most probably be regarded as potentially unsafe and close clinical monitoring of the infant is recommended if it is decided to continue breastfeeding. Occasional or short term treatment with benzodiazepines could be considered as compatible with breastfeeding, although maternal diazepam treatment has caused sedation in suckling infants after short term use. During long term use of benzodiazepines, infants should be observed for signs of sedation and poor suckling. Only very limited clinical data are available for the new generation anticonvulsant drugs and no clearcut recommendations can be made until further data are present. If it is decided to continue breast feeding during treatment with these drugs, the infant should be monitored for possible adverse effects. In general, the drug should be given in the lowest effective dose, guided by maternal serum or plasma drug concentration monitoring. If breast feeding is avoided at times of peak drug levels in milk, the exposure of the infant can be reduced to some extent. As breast milk has considerable advantages over formula milk, the benefits of continuing breast feeding should always be taken into consideration in the risk-benefit analysis.

Use of psychoactive medication during pregnancy and possible effects on the fetus and newborn. Committee on Drugs. American Academy of Pediatrics

Psychoactive drugs are those psychotherapeutic drugs used to modify emotions and behavior in the treatment of psychiatric illnesses. This statement will limit its scope to drug selection guidelines for those psychoactive agents used during pregnancy for prevention or treatment of the following common psychiatric disorders: schizophrenia, major depression, bipolar disorder, panic disorder, and obsessive-compulsive disorder. The statement assumes that pharmacologic therapy is needed to manage the psychiatric disorder. This decision requires thoughtful psychiatric and obstetric advice.

Effect of antenatal exposure to paroxetine (paxil) on growth and physical maturation of mice offspring

OBJECTIVE

Our purpose was to determine, in a placebo-controlled manner, whether antenatal exposure to paroxetine affected long-term growth and physical maturation of mice offspring.

METHODS

Forty-one CD-1 mice consumed paroxetine (n = 21) or a placebo (n = 20) for 2 weeks before conception and throughout gestation. The daily dose of paroxetine (Paxil; 30 mg/kg/d) was known to achieve concentrations in the serum equivalent to the upper therapeutic level in humans and in the fetal brain equivalent to that of the adult mouse. Growth and physical maturation of the offspring were compared by paired t-test, Welch's corrected test, and Fisher's exact test.

RESULTS

The maternal weight gain, litter sizes, number of fetal resorptions, and gestational age at delivery were not different between the paroxetine and the placebo-exposed offspring. Newborn pups exposed to paroxetine were more likely to have low birthweights (1.65 gm vs. 1.70 gm; P < 0.05) and narrower heads (7.7 mm vs. 8.1 mm; P < 0.05). Body weight, body length, and head circumference measurements increased in a manner that was indistinguishable between the two groups of offspring, regardless of gender. No differences in achievement of physical milestones (lower incisor eruption, eye opening, and development of external genitalia) were noted between the two groups. The reproductive capability and the perinatal outcomes of the second-generation offspring were unaffected by paroxetine exposure.

CONCLUSION

A clinically relevant dose of paroxetine, when given throughout gestation, did not affect long-term growth and physical maturation of mice offspring.

Effects of antipsychotics on the unborn child: what is known and how should this influence prescribing?

The onset of psychosis during pregnancy presents difficult management decisions. A complete and thorough physical and obstetric examination is always warranted to look for possible physiological precipitants. The treatment of pregnant patients with psychotic symptomatology requires close contacts between family members, non-physician professionals involved in the patient's care (e.g. social workers, case managers and home healthcare nurses), and the physicians overseeing the patient's management (e.g. internists, obstetricians and psychiatrists). In mild and less disabling cases it may be possible to avoid medication intervention but this approach risks adverse behaviour consequences resulting from a possible worsening of the patient's symptomatology. Avoiding medication requires an environment in which the patient has strong social supports. Risks are present whether medication is initiated or not, and treatment decisions require a careful assessment of the risks and benefits involved. Initiating medication raises the possibility of obstetric, teratogenic, neurobehavioural and neonatal toxic effects. Research on the risks imposed by antipsychotic drug use during pregnancy is incomplete and raises questions regarding appropriate management. The first trimester represents a period of increased susceptibility to medication-induced teratogenesis. The use of low potency phenothiazines during the first trimester may increase the risk of congenital abnormalities by an additional 4 cases per 1000 (odds ratio = 1.21, p = 0.04) The pharmacological profiles of antipsychotic medications also present adverse effects which need to be considered during pregnancy (hypotension, sedation, etc.). Less is known about the risk of adverse consequences resulting from the use of newer atypical antipsychotic medications. Electroconvulsive therapy is another treatment modality and its use may circumvent the need to introduce antipsychotic medication during pregnancy. It must be stressed that. given current knowledge, no treatment regimen can be considered completely safe. Ultimately many factors must be evaluated when treating psychosis during pregnancy, however, no decision is risk-free.

Anticonvulsants and breast feeding: a critical review

Progress in the diagnosis and management of seizure disorders and the availability of effective anticonvulsive medications has enabled increasing numbers of epileptic women of child-bearing age to raise families. Breast feeding, which these women may wish to choose, provides health, nutritional, immunological, developmental, social, economic and environmental benefits. The traditional anticonvulsants, such as phenytoin, carbamazepine and valproic acid (valproate sodium), are generally considered safe for use during breast feeding; however, observation for adverse effects is recommended. The use of phenobarbital while breast feeding is controversial because of its slow elimination by the nursing infant. The newer anticonvulsants, such as clobazam, felbamate, gabapentin, lamotrigine, oxcarbazepine, tiagabine, topiramate, and vigabatrin, are used mainly as adjunctive therapy. Data on the use of these drugs in pregnancy and lactation, and regarding long term effects on cognition and behaviour, are sparse. Weighing the benefits of breast feeding against the potential risk to the nursing infant, breast feeding is considered to be safe when the mother is taking carbamazepine, valproic acid or phenytoin. Infant monitoring for potential adverse effects is advisable when the mother is taking phenobarbital, clobazam, gabapentin, lamotrigine, oxcarbazepine or vigabatrin. Monitoring of infant serum drug concentrations is advisable but not compulsory. The use of felbamate, tiagabine and topiramate during breast feeding should await further study.

Antipsychotics and breast-feeding: a review of the literature

Many women with mental illnesses would like to breast feed their infants. In light of the limited but rapidly growing data, it seems that in some cases the possible physiological and psychological benefits may outweigh putative risks. All antipsychotics are secreted into breast milk but the concentrations and effects vary. There is a subgroup of mothers with mental illnesses who want to breast feed their infants and who are receiving a single established antipsychotic drug (principally, haloperidol or chlorpromazine) at the lowest possible clinically effective dose. As a tentative conclusion, this group could experience benefits from being able to nurse which would outweigh the risk of exposing their babies to very small amounts of antipsychotic drugs. However, larger study groups with longer follow-up periods would be required to confirm this tentative conclusion. Those mothers who require 2 or more antipsychotic drugs simultaneously and those taking one drug, but at the upper end of the recommended dose range, should not be advised to breast feed. Safety considerations suggest that women taking atypical antipsychotics would be advised not to breast feed because of the limited experience with these agents. When mothers taking antipsychotic drugs do nurse, it is desirable to monitor drug concentrations in breast milk and in the infants themselves. Close monitoring of the infant is essential.

Adverse pregnancy outcome in schizophrenic women: occurrence and risk factors

Low birth weight and preterm birth are important predictors of infant mortality and morbidity, and may increase the risk of schizophrenia. These adverse outcomes of pregnancy could be associated, therefore, with increased risk in children genetically predisposed to schizophrenia. The aim of this review was to describe the occurrence of risk factors for low birth weight, preterm birth, and perinatal death among schizophrenic women, and to describe the incidence of those adverse pregnancy outcomes among schizophrenic women. Smoking, substance abuse, and low socioeconomic status are associated with fetal growth retardation, preterm birth, and perinatal death, and also with schizophrenia. Therefore, increased incidence of adverse pregnancy outcome should be expected in schizophrenic women. The available evidence suggests that schizophrenic women are at increased risk of delivering infants with low birth weight, but the existing studies are of small statistical power. Preterm birth and perinatal death have only been investigated little among schizophrenic women. An important focus of future research should be to establish the risk of adverse pregnancy outcome, and to study the association between the suspected risk factors and pregnancy outcome in schizophrenic women. In clinical work with pregnant schizophrenic women, efforts should be made to prevent exposure to suspected risk factors like smoking, substance use, and socioeconomic problems. This could possibly decrease the mortality and morbidity, including the risk of schizophrenia in the offspring, and clarify the importance of environmental and genetic factors in the etiology of schizophrenia.

A guide to the safety of CNS-active agents during breastfeeding

For most agents with CNS activity, there are limited data regarding their safety in breastfeeding. Any decision to institute treatment for a neurological or psychiatric disorder must weigh the benefits of maternal treatment against the potential harm to the breastfeeding mother of withholding medication which may improve her illness. For the neonate, one must balance the risk of medication exposure against the benefit of receiving breast milk. Most tricyclic antidepressants can be used in lactating women. Because of the limited data, selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors should only be used with due consideration of the potential adverse effects. Breastfeeding is best avoided by women who require lithium therapy, because of both the immature excretory systems in the infant and relatively high doses received by the infant. There is little information about the safety of antipsychotic medications in breastfeeding. Concerns include toxicity and abnormal neurological development in the infant. These agents may be used with caution. Most agents which cause depression of the CNS, including opiates and sedatives, can be used in small doses and for short courses in breastfeeding mothers. Most anticonvulsants can be used in lactating women. Reference texts and consultation with experts are useful adjuncts to discussion of the risks and benefits of therapy with the patient. The scope of this review is limited to drugs with therapeutic uses, thus drugs of abuse are not discussed, nor are caffeine and alcohol (ethanol).