Safe Prescribing in Pregnancy: Key Takeaways from Dr. Ashleigh Macaulay's MMHS Conference

1. Prescribing in Pregnancy Dr Ashleigh Macaulay MMHS Conference 13th May 2019

2. Take Home Messages

3. Take Home Messages

4. Baseline rates

5. Prescribing Principles • How do we balance the risk? • Things to consider in pregnancy...... • Past Hx • Severity of illness, previous response and patient choice • Mums ability to cope with illness Sx • Impact of untreated mental illness • Risk of stopping medications suddenly • Consider non-pharmacological interventions if appropriate

6. Prescribing Principles

7. Antipsychotics in pregnancy

8. Antipsychotics in pregnancy • Clozapine • High risk patients by default • Treatment resistant = ? What is the benefit of changing • No risk of malformations. • Neonatal seizures. • No benefit to switching due to relapse risk • Normal blood monitoring applies

9. Summary; Antipsychotics

10. Summary; Antipsychotics

11. Antidepressants in pregnancy • Sertraline has least placental exposure • Fluoxetine is thought to be the safest • Risks • Persistent hypertension of the newborn • Lower birth weight • Increased early birth (days) • Post partum haemorrhage • Paroxetine – increased congenital cardiac malformations. Less safe than other SSRI’s • No evidence of any short or long-term effects on intelligence and language development,

12. SSRI Counselling • First line medication –during and out with pregnancy • Frequently used • Common side effects • GI disturbance = nausea (different or additional to pregnancy sx) • Headache • Initial irritability/Worsening anxiety • Self limiting for 7-10 days • Not addictive • May have discontinuation Sx – don’t suddenly stop

13. Antidepressants in pregnancy • Most experience with amitriptyline and imipramine • Foetal exposure is high but widely used with no apparent detriment to the foetus • No effects on later child development • Risk of pre-term delivery • Third trimester use can cause neonatal withdrawal (mild and self limiting)

14. Antidepressants in pregnancy • Venlafaxine – may increase cardiac defects, withdrawal and cleft palate • Trazodone, bupropion and mirtazapine – not recommended • MOAI’s are not recommended – high risk of congenital malformations • ECT – anaesthetic risk

15. Mood Stabilisers in pregnancy • Conversations pre-conception! • No mood stabiliser is completely safe • Carbamazepine and Valproate (most teratogenic) increase neural tube defects and should be avoided/discontinued ASAP • Switch to antipsychotics • Acute mania – commence antipsychotics

16. Mood Stabilisers in pregnancy • Lithium • Previous risks are overestimated • Known association to Ebsteins anomaly (absolute risk is 1;1000. Li increases 10-20x). Remains very small risk overall • Relapse rates are up to 70% after discontinuation so may have to be restarted • Regular ECHO and enhanced US • Alterations to dose in 3rd trimester • Not safe in breastfeeding

17. Mood Stabilisers in pregnancy Lamotrigine • Good evidence that lamotrigine is not a risk in pregnancy or afterwards • No increase in malformation rate • No evidence of developmental problems for the children • Considerations • Levels of sedation • Development of a rash • Slow titration of medication

18. Benzodiazepines • Not linked to any teratogenic effects • No increase in spontaneous abortions • Risk of oral clefts is reported to be about 7 in 1000 births with diazepam. • Trimesters 2 and 3: No associated damage. • Birth: “floppy baby syndrome”. Mild withdrawal which is short-lived. Can reduce dose before delivery.. • Milestones: There may be a slight slowing of the child’s development and weight gain over the first year or so but this seems to only last a couple of years. Then it goes back to normal.

19. Breastfeeding

20. Breastfeeding

21. Perinatal Considerations

22. Any questions? • ashleighmacaulay@nhs.net