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Summary postpartum disorder- psychiatry
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Chapter 28Postpartum Disorders
246
, Chapter 28: Postpartum Disorders
General principles of prescribing during pregnancy - Reference: Maudsley Prescribing Guidelines in Psychiatry,
13th edition, 2018.
In all women of child bearing potential
o Always discuss the possibility of pregnancy – half of all pregnancies are unplanned.
o Avoid using medications that are contraindicated during pregnancy in women of reproductive age
(especially valproate and carbamazepine). If these medications are prescribed, women should be made
fully aware of their teratogenic properties even if not planning pregnancy. Consider prescribing folate.
Valproate should be reserved for post-menopausal women only. Its use in younger women should be treatment
of last resort.
If mental illness is newly diagnosed in a pregnant woman
o Try to avoid all medications during the first trimester (when major organs are being formed) unless benefits
outweigh risks.
o If non-drug treatments are not effective/appropriate, use an established drug at the lowest effective dose.
If a woman taking psychotropic medications is planning a pregnancy
o Consideration should be given to discontinuing treatment if the woman is well and at low risk of relapse.
o Discontinuation of treatment for women with serious mental illness and at high risk of relapse is unwise but
consideration should be given to switching to a low-risk medication. Be aware that switching medications
may increase the risk of relapse.
If a woman taking psychotropic medication discovers that she is pregnant
o Abrupt discontinuation of treatment post-conception for women with serious mental illness and at a high
risk of relapse is unwise. Relapse may ultimately be more harmful to the mother and child than continued,
effective drug therapy.
o Consider remaining with current (effective) medication rather than switching, to minimise the risk of relapse
and hence the number of medications to which the foetus is exposed.
If the patient smokes (smoking is more common in pregnant women with psychiatric illness)
o Always encourage switching to nicotine replacement therapy – smoking has numerous adverse outcomes,
nicotine replacement therapy does not.
In all pregnant women
o Ensure that the parents are as involved as possible in all decisions.
o Use the lowest effective dose.
o Use the medication with the lowest known risk to mother and foetus.
o Prescribe as few medications as possible, but simultaneously and in sequence.
o Be prepared to adjust doses as pregnancy progresses and medication handling is altered. Dose increases are
frequently required in the third trimester when blood volume expands by around 30%. Plasma monitoring
may be helpful, where available. Note that hepatic enzyme activity changes markedly during pregnancy;
CYP2D6 activity is increased by almost 50% by the end of pregnancy while the activity of CYP1A2 is
reduced by up to 70%.
o Consider referral to specialist perinatal services.
o Ensure adequate foetal screening.
o Be aware of potential problems with individual medications around the time of delivery.
o Inform the obstetric team of psychotropic use and possible complications.
o Monitor the neonate for withdrawal effects after birth.
o Document all decisions.
Psychotropics recommendations during pregnancy
o Antidepressants
Women who are a high risk of relapse are best maintained on the same antidepressant during and after
pregnancy.
When initiating an antidepressant in a woman planning a pregnancy, previous response must be taken
into account. Sertraline is an option.
o Antipsychotics
There is no clear evidence that any antipsychotic is a major teratogen. Consider using/continuing the
medication the mother has previously responded to rather than switching prior to/during pregnancy.
Screen for adverse metabolic effects. Offer the woman an oral glucose tolerance test. Arrange for the
woman to give birth in a unit with access to neonatal intensive care facilities.
When initiating an antipsychotic in a woman planning pregnancy, previous response must be taken into
account. Quetiapine has a relatively low rate of placental passage.
o Mood stabilisers
Valproate must be stopped if a woman becomes pregnant.
Avoid other anticonvulsants unless risks and consequences of relapse outweigh the known risk of
teratogenesis.
247
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