Principles of psychotropic use during pregnancy

All psychotropics cross the placenta (albeit to varying degrees)–if a psychotropic is taken during pregnancy, the fetus will be exposed to it. Consequently, treatment choice must optimise the health and safety of the patient and fetus—consider:

  • the severity of the psychiatric disorder and potential benefits if a psychotropic is used; see Potential benefits and harms to the patient and fetus associated with psychotropic use during pregnancy
  • drug safety profile during pregnancy, see What is covered in this topic?
  • whether the patient plans to breastfeed and the safety profile of the drug in breastfeeding
  • the current gestational stage because the risk of harm caused by the drug to the fetus may be limited to a particular gestational period
  • switching to a drug with a superior safety profile in pregnancy and breastfeeding; also consider the drug’s efficacy for the disorder and the patient’s previous response to treatment
  • the effect of pregnancy on the drug’s pharmacokinetics and pharmacodynamics
  • nonpharmacological treatments.
Table 1. Potential benefits and harms to the patient and fetus associated with psychotropic use during pregnancy

[NB1] [NB2]

Fetus

Patient

Potential harms of psychotropic use

  • miscarriage
  • fetal death in utero
  • stillbirth
  • preterm birth
  • congenital abnormality [NB3]
  • growth restriction
  • poor neonatal adaptation
  • long-term neurodevelopmental effects [NB4]
  • stress and worry about potential for harms from drug exposure

Potential benefits of psychotropic use

  • reduced:
    • abuse and neglect
    • adverse outcomes from an active psychiatric disorder during pregnancy [NB5]
  • reduced:
    • relapse of psychiatric disorder
    • suicide
    • self-harm
    • relationship deterioration
    • use of harmful substitutes (eg alcohol)
Note:

NB1: See the relevant drug monograph for additional information on potential harms.

NB2: Data on potential fetal harms caused by psychotropics are often confounded by the underlying disorder—see Overview of psychotropic pregnancy data.

NB3: The background rate of congenital malformations in the general population is approximately 3%.

NB4: Long-term neurodevelopmental effects of psychotropic exposure during pregnancy remain largely unexplored.

NB5: Adverse outcomes from an active psychiatric disorder during pregnancy include preterm labour, low birth weight and poor neonatal vital signs.

There is no risk-neutral or universally applicable treatment for a pregnant patient with a psychiatric disorder; individualise treatment, based on the considerations listed above. Do not avoid using a psychotropic if it is indicated; an active psychiatric disorder during pregnancy can have a significant impact on both patient and fetus.

Avoid abruptly stopping a psychotropic upon discovering pregnancy. Ongoing treatment may be required and, even if treatment will be stopped, gradual withdrawal reduces the risk of relapse. Furthermore, stopping or switching the drug may not remove the risk of fetal harm (depending on gestational stage). If the patient is taking sodium valproate, carbamazepine or lithium, urgently decide on a treatment approach; see Sodium valproate or carbamazepine during pregnancy or Lithium use during pregnancy.

Involve the patient and, if the patient consents, their significant other(s) in treatment decisions (see also Shared decision making). Educate them about the harm–benefit profile of the relevant treatments during pregnancy and breastfeeding and provide information in consumer-friendly formats, which are available from:

The above websites also provide updated information on the use of drugs in pregnancy for clinicians.

Avoid polypharmacy and use the lowest possible dose in patients who are pregnant to reduce the risk of adverse fetal outcomes. Physiological changes during pregnancy may alter pharmacokinetics in unpredictable ways. The magnitude of these changes is usually greatest in the third trimester. Total volume of distribution and kidney clearance increases, drug protein binding reduces and cytochrome P450 enzyme activity changes; these factors may necessitate a dose alteration, depending on the patient’s presentation. If available, use therapeutic drug monitoring to guide the lowest effective dose12.

A fetal anatomy scan is offered to pregnant Australians at 18 to 20 weeks gestation. Encourage a patient who has taken a psychotropic during the first trimester to have this scan to check for congenital malformations.

If an infant was exposed to a psychotropic antenatally, consider the need for observation in the initial postpartum period.

For more information about drug use in pregnancy, see here.

1 A list of Australian laboratory test databases is available at the Australasian Association for Clinical Biochemistry and Laboratory Medicine (AACB) ‘Testing for health’ website.Return
2 For information on therapeutic reference ranges of psychotropics, see Hiemke C, Bergemann N, Clement HW, Conca A, Deckert J, Domschke K, et al. Consensus guidelines for therapeutic drug monitoring in neuropsychopharmacology: update 2017. Pharmacopsychiatry 2018;51(1-02):9-62. [URL]Return