Considerations in treating psychoses including schizophrenia in the perinatal period

Although most of the outcome data mentioned in this section come from studies conducted in patients with schizophrenia. this section is intended to apply to all psychotic disorders. It is reasonable to extrapolate the data from schizophrenia because psychosis spectrum disorders respond to similar treatments and there is a lack of evidence for targeted treatment.

Patients with psychotic disorders are at increased risk of adverse obstetric outcomes such as low birth weight infants, small-for-gestational age infants, preterm labour and placental abruption. Some of these outcomes are partially attributable to increased rates of smoking, problem drug use, poor nutrition and lower socioeconomic status among this population. The psychotic disorder may in itself be a risk factor for minor congenital abnormalities in offspring.

Patients with psychotic disorders have higher rates of custody loss compared with patients with other psychiatric disorders. Maternal psychotic disorders have also been associated with increased risk of neonatal mortality.

These adverse outcomes must be considered and weighed against the potential harms of antipsychotic use during pregnancy and while breastfeeding. Patients with a psychotic disorder have the best chance of parenting their infant in the long term if their disorder is well controlled with low residual symptoms, and if they have a partner or another highly supportive person to assist in parenting.

Managing a patient with a psychotic disorder during the perinatal period is complex and requires a multidisciplinary approach including the patient’s general practitioner, psychiatrist (preferably with perinatal expertise), and obstetric team, and a paediatrician. If possible, refer the patient to a specialist perinatal mental health service. The approach to treating psychoses including schizophrenia is not different in the perinatal period. In fact, robust rather than undertreatment is in the best interest of the patient and their child because of the increased risk of poor psychiatric, obstetric and parenting outcomes.

Patients with psychotic disorders should ideally give birth in a tertiary referral hospital with a specialist neonatal care unit and psychiatric team. If this is not possible, seek advice from the patient’s psychiatrist and a paediatrician.

Do not stop an antipsychotic abruptly because of the increased risk of relapse. The decision to continue antipsychotics should be made after weighing up the relatively uncertain harms associated with antipsychotic exposure in the perinatal period (see Antipsychotic use in pregnancy and Antipsychotic use while breastfeeding) and the harms associated with relapse, including psychiatric admission and exposure to polypharmacy during acute treatment.