New York City, New York. Maternal-Fetal Medicine. New York. Family Medicine. Louis Area. Primary Care. Primary Care Physician. Norwich, Connecticut. Internal Medicine. Internal Medicine Physician. Fluoxetine Prozac. Paroxetine Paxil. Sertraline Zoloft. Bupropion Wellbutrin. Duloxetine Cymbalta.
Mirtazapine Remeron. Venlafaxine Effexor. Adapted with permission from the American College of Obstetricians and Gynecologists. ACOG practice bulletin no. Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol. Ten to 16 percent of pregnant women meet diagnostic criteria for depression, and up to 70 percent of pregnant women have symptoms of depression. Studies have shown a relapse rate of 68 percent in women who discontinue antidepressant therapy during pregnancy.
Untreated maternal depression is associated with increased rates of adverse outcomes e. There is limited evidence of teratogenic effects from the use of antidepressants in pregnancy and adverse effects from exposure during breastfeeding.
Exposure to selective serotonin reuptake inhibitors SSRIs late in pregnancy has been associated with transient neonatal complications; however, the potential risks associated with SSRI use must be weighed against the risk of relapse if treatment is discontinued. Treatment with SSRIs or selective norepinephrine reuptake inhibitors during pregnancy should be individualized. Paroxetine Paxil should be avoided by pregnant women and women who plan to become pregnant, and fetal echocardiography should be considered for women exposed to paroxetine during early pregnancy.
Because abrupt discontinuation of this drug is associated with withdrawal symptoms and a high rate of relapse, prescribing information about discontinuation of therapy should be followed carefully. The combination of breastfeeding and SSRI use has not been studied extensively; however, medication exposure from breastfeeding is less than the exposure that occurs transplacentally.
Isolated adverse effects have been reported, the most notable of which was an infant who had transient apnea after being exposed to citalopram Celexa. Generally, no long-term neurobehavioral studies have been done in infants exposed to SSRIs through breast milk. Most tricyclic antidepressants seem to be safe during lactation except for doxepin Sinequan , which reportedly led to an incident of infant respiratory depression.
Rates of postpartum relapse in women with bipolar disorder range from 32 to 67 percent. Perinatal episodes of the disorder tend to be depressive and are more likely to recur in subsequent pregnancies. The risk of postpartum psychosis is increased by as much as 46 percent in women with this disorder.
The use of lithium during pregnancy has been associated with congenital cardiac malformations, fetal and neonatal cardiac arrhythmias, hypoglycemia, premature delivery, and other adverse outcomes. However, neurobehavioral sequelae were not found in a five-year follow-up of 60 school-age children exposed to lithium during gestation.
The decision to discontinue lithium therapy during pregnancy because of fetal risks should be weighed against the maternal risks of illness exacerbation. The physiologic changes of pregnancy may affect the absorption, distribution, metabolism, and elimination of lithium, and close monitoring of lithium levels during pregnancy and the postpartum period is recommended. The following guidelines have been suggested for women with bipolar disorder who are taking lithium and plan to conceive: Lithium therapy should be gradually tapered before conception in women who have mild, infrequent episodes.
Lithium therapy should be tapered before conception, but gradually restarted after organogenesis in women who have more severe episodes and are at moderate risk of short-term relapse. Lithium therapy should be continued throughout the pregnancy in women who have severe, frequent episodes, and these patients should be counseled about the reproductive risks associated with therapy.
The use of lithium during breastfeeding has been associated with a number of adverse effects; however, only 10 maternal-infant dyads have been studied. Effects included lethargy, hypotonia, hypothermia, cyanosis, and electrocardiography changes. No long-term studies have examined the neurobehavioral consequences of lithium therapy during breastfeeding.
Several antiepileptic drugs are used in the treatment of bipolar disorder, including valproic acid Depakene , carbamazepine Tegretol , and lamotrigine Lamictal. However, data on the fetal effects of these drugs come primarily from studies of women with seizures. It is not clear whether the underlying pathology of epilepsy contributes to the teratogenic effect of these drugs on the fetus.
Exposure to valproic acid during pregnancy is associated with an increased risk of neural tube defects, craniofacial and cardiovascular anomalies, fetal growth restriction, and cognitive impairment.
Carbamazepine exposure during pregnancy is associated with facial dysmorphism and fingernail hypoplasia. It is unclear whether carbamazepine use increases the risk of neural tube defects or developmental delay. Although these drugs are superior to lithium in the treatment of patients with mixed episodes or rapid cycling, they should be avoided during pregnancy.
The use of lamotrigine during pregnancy has not been associated with any major fetal anomalies and is an option for maintenance therapy in women with bipolar disorder.
Valproic acid use during lactation has been studied in 41 maternal-infant dyads; only one infant was adversely affected with thrombocytopenia and anemia. E-mail: ni. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. Abstract Research on psychotropic medications during pregnancy and lactation is limited as often involves complex ethical issues.
Keywords: Antipsychotic, atypical antipsychotic, lactation, neonatal toxicity, neurotoxicity, pregnancy, teratogen.
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