Treatment
Meds and Pregnancy
If you are a female or know someone who is, you need to be reading this.
At a symposium at the American Psychiatric Association’s annual meeting in May 2003, Zachary Stowe MD of Emory University asked the psychiatrists in the audience how many treat women of reproductive age. Just about everyone raised their hands. How many treat these patients with folate? he asked. A minority raised their hands. How many give these patients a pregnancy test? he asked. No one raised their hands.
"You must treat all women patients of reproductive age as if they were pregnant on the first day," Dr Stowe advised. The rate of birth defects for women on psychiatric meds is one in 11, he said, with the danger period in the first trimester, especially for lithium and the anticonvulsant mood stabilizers.
Bipolar Meds
In another symposium, Lee Cohen MD of Harvard outlined some of those risks:
For lithium, the risk of fetal heart defects, especially Ebstein’s anomaly, is .05 percent in the first trimester, 10 to 20 times that of the general population. For Depakote, there is a thee to eight percent risk of fetal spina bifida in the first trimester, and an unspecified risk of heart defects and behavioral abnormalities. For Tegretol, there is an 0.5 to one percent risk of spina bifida in the first trimester and an unspecified risk of craniofacial anomalies and microcephaly. Lamictal is probably the safest of the anticonvulsants, with manufacturer GlaxoSmithKline’s registry of 293 pregnancies through Sept 2002 showing no major birth defects (keeping in mind this symposium was sponsored by GSK).
Dr Stowe advised that "new and improved" meds means there is no data. Older generation antipsychotics such as Haldol are considered safe during all phases of pregnancy, while there is little data for the newer atypicals such as Zyprexa. Factors that need to be considered are obesity and hyperglycemia side effects, which are risk factors for congenital malformations. Risperdal, which can cause hyperprolactinemia (affecting menstrual and sexual function), could be problematic during pregnancy.
No decision is risk-free, both speakers observed. Those thinking of going off their meds need to consider that maternal depression can result in higher rates of drug, alcohol, and substance use, poor self-care, nutrition, and sleep, plus pre-term labor and babies with lower birth weights and developmental deficits..
Planned pregnancy is the safest way to go in terms of fetal risk. For women with bipolar disorder, tapering and discontinuing mood stabilizers is advised prior to conceiving. Stopping mood stabilizers on discovering one is pregnant (say after five weeks) may be too late, as one is well into the teratogenic (birth defects) phase by this time. For severe bipolar disorder, staying on a mood stabilizer throughout all phases of pregnancy may be considered. Going back on a mood stabilizer is recommended for the second and third trimesters, with this very important proviso, that more than one med increases the chance of birth defects. Dr Stowe advised you do not expose a woman to a second medication as there is no data. Monotherapy, he said, at any dose is preferable to two meds, and switching meds at delivery is dumb. One gram of folate is recommended for all women, up to four grams if a woman is on Depakote.
Other options for pregnant women include psychotherapy, ECT, light therapy, calcium channel blockers, and omega 3.
For those wishing to avoid pregnancy: Tegretol, Trileptal, and Topamax accelerate the metabolism of estrogen and progesterone, which can result in birth control failure.
The American Psychiatric Association in its 2002 Bipolar Treatment Guideline advises that women who choose to remain on their mood stabilizers should be screened for fetal neural tube defects before the twentieth week of gestation and go for ultrasound at 16 to 18 weeks to detect any cardiac abnormalities in the fetus. Since pregnancy can affect medication levels, periodic monitoring is necessary. At delivery, lithium levels rise dramatically unless care is taken to ensure hydration or lowering the dose or both.
Being stabilized prior to giving birth is critical, as the risk for postpartum relapse for bipolar patients who are ill during pregnancy is nearly 70 percent, according to a 1998 Harvard study, as opposed to 27.8 percent for those who stay well during pregnancy.
Antidepressants
Regarding antidepressants, the American Psychiatric Association in its 2000 Treatment Recommendations for Patients with Major Depressive Disorder advises:
"There is no evidence that tricyclic antidepressants, [Prozac}, or newer SSRIs cause either intrauterine death or major birth defects. However, in one large study, three or more minor physical anomalies occurred more commonly in infants exposed to [Prozac] than in a comparison group. This study also demonstrated that fetuses exposed to [Prozac] after 25 weeks' gestation had lower birth weights, which were associated with lower maternal weight gain."
In June 2004, the FDA instructed manufacturers to add the following to their product labeling:
"Neonates exposed to Effexor, other SNRIs (Serotonin and Norepinephrine Reuptake Inhibitors), or SSRIs (Selective Serotonin Reuptake Inhibitors), late in the third trimester of pregnancy have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. Such complications can arise immediately upon delivery."
The APA advises that going off an antidepressant carries its own risks, including: low birth weight (associated with the mother not looking after herself), suicidality, marital discord, the inability to engage in appropriate obstetrical care, and difficulty caring for other children.
Conclusion
Once again, it is emphasized that no decision is risk-free. Couples wanting to have kids are advised to consider the relative risks in consultation with their physicians, ideally prior to conception.
Updated July 13, 2004, reviewed Feb 10 2008
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