Psych Congress
Psych Congress
Source:

Freeman MP. Treatment of psychiatric disorders during pregnancy. Presented at: Psych Congress 2020 Virtual Experience; Sept. 10-13, 2020 (virtual meeting).

Disclosures: Freeman reports serving on the advisory boards of Alkermes, Otsuka and Sunovion; as a research investigator for JayMac and Sage; on the Independent Data Safety and Monitoring Committee for Janssen (Johsnon & Johnson); and on the Steering Committee for Educational Activities at Medscape. She also reports being employed by Massachusetts General Hospital, a role for which she works with the MGH Clinical Trials Network and Institute and for which she has received research funding from multiple pharmaceutical companies and NIMH, as well as working with the MGH National Pregnancy Registry, which is currently sponsored by Alkermes Inc., Forest/Actavis, Otsuka America Pharmaceutical Inc., Sunovion Pharmaceuticals Inc. and Teva.
September 12, 2020
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Expert outlines clinical considerations for psychotropic medications during pregnancy

Source:

Freeman MP. Treatment of psychiatric disorders during pregnancy. Presented at: Psych Congress 2020 Virtual Experience; Sept. 10-13, 2020 (virtual meeting).

Disclosures: Freeman reports serving on the advisory boards of Alkermes, Otsuka and Sunovion; as a research investigator for JayMac and Sage; on the Independent Data Safety and Monitoring Committee for Janssen (Johsnon & Johnson); and on the Steering Committee for Educational Activities at Medscape. She also reports being employed by Massachusetts General Hospital, a role for which she works with the MGH Clinical Trials Network and Institute and for which she has received research funding from multiple pharmaceutical companies and NIMH, as well as working with the MGH National Pregnancy Registry, which is currently sponsored by Alkermes Inc., Forest/Actavis, Otsuka America Pharmaceutical Inc., Sunovion Pharmaceuticals Inc. and Teva.
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Clinicians must make important considerations regarding the use of psychotropic medications and substances among pregnant women, according to a presenter at the Psych Congress 2020 Virtual Experience conference.

Marlene Freeman, MD
Marlene P. Freeman

“Any woman of reproductive potential who we are treating, we should consider the fact that she is very likely to become pregnant during her treatment,” Marlene P. Freeman, MD, associate director of the Center for Women’s Mental Health at Massachusetts General Hospital, said during the presentation. “From the very initial selection of medication, we want to be thinking about reproductive safety profiles for female patients.”

pregnant woman holding pills
Source: Adobe Stock

According to Freeman, both untreated psychiatric disorders and potential treatments can pose risks for women, but patients often focus more on the risks associated with the treatments vs. the untreated disorder.

With the increasing medical and recreational availability of marijuana, Freeman said patients may assume it is a safer alternative to psychotropic medication, but it’s important to think of the substance as more akin to alcohol and as risky to consume during pregnancy. Specifically, studies have shown an association between its use and poor obstetrical outcomes, such as prematurity, fetal growth restriction and lower birth weight.

“We hear from a lot of patients that they’re using marijuana for morning sickness, so it is important that we talk to patients about risks of marijuana and that we also document its use,” Freeman said.

Study results have suggested that untreated psychiatric disorders are linked to poor obstetrical outcomes. For example, Freeman said untreated antenatal depression may negatively affect maternal weight gain, and untreated anxiety during pregnancy may increase fetal exposure to cortisol.

According to Freeman, selective serotonin reuptake inhibitor antidepressant use is common during pregnancy and does not appear associated with increased risk for major malformations, which is a major concern during first trimester exposures. However, results of recent case-control studies suggested inconsistent data regarding teratogenic risk of individual SSRIs. Results of 19 studies showed that certain SSRIS, such as paroxetine, may increase risk for cardiovascular malformations. Moreover, although early studies suggested an association between SSRI use during pregnancy and increased risk for autism among offspring, recent meta-analyses did not support this association.

Freeman emphasized that studies do not support the discontinuation of antidepressants in the third trimester, despite medication package inserts suggesting women should seriously consider doing so.

“The last thing we want to do is to set up a woman around the time that she's taking a newborn baby home from the hospital to experience a relapse to a serious mood or anxiety disorder, so we've never done that in our program,” Freeman said.

Regarding treatments for bipolar disorder in pregnancy, lithium appears to have a risk ratio for cardiac malformations of 1.2 to 1.7. Further, Freeman noted that valproic acid is considered the worst teratogen known among psychotropics, with a rate of major malformations of 10% or higher.

According to an analysis of a large administrative Medicaid database, risperidone was associated with a small increased risk for overall and cardiac malformations. Results of prospective studies showed no significant difference in risk for major malformations between typical and atypical antipsychotic medications.

Additional considerations for psychotropic use during pregnancy include the following:

  • Recent studies of first trimester benzodiazepine use did not suggest teratogenicity, but late pregnancy exposure appeared linked to possible withdrawal, neonatal sedation, hypotonia and cyanosis.
  • Although studies are few, non-benzodiazepine hypnotics overall appeared not to increase risk for teratogenicity.
  • Study findings suggested a small increased risk for preeclampsia and preterm birth among women taking prescription stimulant medications.

“Pregnancy itself is inherently risky, and there are so many variables that go into pregnancy outcomes,” Freeman said. “We want to make sure that we're looking at the whole picture and that we're looking at it holistically. It's an area where we want collaborative decision making so we can provide the data for women, but we want to be teammates in terms of making the right decision for each individual patient.”