Oh baby! My patient is pregnant - Saint Anselm College · pregnant and postpartum women (Abramowitz, 2006). The USPSTF recommends screening for depression in the general adult population,
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3/22/2018
1
OH BABY! MY PATIENT IS PREGNANT
REPRODUCTIVE SAFETY OF PSYCHOTROPIC
MEDICATIONS
Alison Palmer, MS, APRN, WHNP-BC, PMHNP-BC
Women’s Health OBGYN / Psychiatric-Mental Health Nurse Practitioner
Manchester OBGYN Associates - Manchester, NH
OBJECTIVES
• Identify risks of untreated maternal
depression on the fetal and/or infant,
child, family relationships.
• Describe treatment options for
perinatal depression and postpartum
psychosis.
• List three risks to consider when
treating pregnant and lactating women
with psychotropic medications.
50 % of pregnancies are
UNPLANNED
“Are you sexually active?”
“What are using for birth control?”
“Are you considering a pregnancy
in the upcoming year?”
EFFECTS OF UNTREATED MATERNAL DEPRESSION
RISKS TO
PREGNANCY AND FETUS
RISKS TO
MOM, INFANT, CHILD, FAMILY
• Increased irritability/inconsolability of newborn
• Disturbed maternal-infant attachment
• Damaged stress responses
• Failure to thrive
• Behavior issues/cognitive delays
• Stress on couples’ relationship –
• (PPD risks to partners, as well)
• Suicide/infanticide
• Poor adherence to routine prenatal care
• Poor nutrition/self care
• Substance use
• Increased fetal cortisol
• Preeclampsia
• Preterm labor
• Low birth weight
“________” COMES
NATURALLY .
Fill in with any of the following childbearing tasks…
o Conception
o Carrying a pregnancy to term
o Birthing
o Breastfeeding
o Parenting
Myth
# 1
THE STILL FACE
EXPERIMENT –
DR. EDWARD TRONICK
• A mother denies her baby attention for
a short period of time.
• Prolonged lack of attention can move an
infant from good socialization, to periods
of bad but repairable socialization.
• In “ugly” situations the child does not
receive any chance to return to the good,
and may become stuck
3/22/2018
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1 in 7 women suffers from PPD
Up to 50% of women with PPD are never
detected
Women who have one episode of PPD have a 50%
chance of recurrence in a subsequent pregnancy
Suicide
accounts for ~20% of postpartum deaths
2nd most common cause of mortality in PP
women
POSTPARTUM DEPRESSION IS THE MOST COMMON COMPLICATION OF CHILDBIRTH
“MOMMY BRAIN” aka----NEUROPLASTICITY
• Oxytocin --------- Fall in LOVE
• Brain derived neurotrophic factor (BDNF)
• Triggers massive neuronal reorganization
• Tons of brain cells need to be obliterated and replaced with new
ones
• Allows for erasing learned behavior and replacing it with new
patterns
• Learning to feed, protect, care for offspring
• Sharpen verbal and emotional memories to recall potentially
threatening behaviors
• Affects our spatial learning --- Important for our ancestors to recall
where food was located when foraging
Postpartum
Depression
Anxiety Disorder OCD
Panic Disorder PTSD
Perinatal Mood and Anxiety Disorders
Postpartum
“Baby Blues”
Postpartum
Psychosis
LOW HIGH
Appetite
changes
Trouble sleeping
Irritability
Frequent crying
Restlessness
Unexpected
weight gain
or loss
High Anxiety
Feelings of being a bad mother
Dramatic mood swings
No contact w/baby
Suicidal/homicidal
ideation
BIOPSYCHOSOCIAL MODEL OF ANXIETY – CHILDBEARING
Genetics
Hormones
Neuro-
transmitters
Thinking
Styles
LIFE STRESS Scary
Thoughts
Kleiman, K. 2011
PERINATAL DEPRESSION SCREENING
General adult
population,
including
pregnant and
postpartum
women
The USPSTF recommends screening for
depression in the general adult population,
including pregnant and postpartum
women.
Screening should be implemented with
adequate systems in place to ensure accurate
diagnosis, effective treatment, and appropriate
follow-up. Journal of the American Medical Association on January 26, 2016 (JAMA.
2016;315(4):380-7).
• The majority of both mothers (91%) and fathers
(88%) report intrusive thoughts about their baby at
some point following the baby’s birth (Abramowitz, 2006).
• Message …you are telling the mother that to
some extent you expect this level of distress and
understand the internal struggle.
Thought of harming the infant in some way
WITHOUT THE INTENT TO DO
SO
Are very common in postpartum anxiety
“SCARY THOUGHTS”
VS
“PSYCHOSIS”
3/22/2018
3
ASSESSING FOR POSTPARTUM PSYCHOSIS
• Personal or Family history of bipolar illness or psychosis?
• Talking or acting in a strange manner?
• Unusually quiet and withdrawn, or speaking rapidly w/ difficulty focusing or concentrating?
• Auditory or visual hallucinations – claiming to see or hear things that others do not?
• Suspicious or paranoid – others out to get her
• Decreased need for sleep or food
• High degree of confidence
• Exaggerated sense of capabilities or self‐worth?
• Feel/appear abnormally hyperactive with racing thoughts and/or behaviors?
ADDRESS AND RULE OUT OTHER
MEDICAL OR PSYCHOLOGICAL ETIOLOGY
o Bipolar disorder
o Psychotic
illness/schizoaffective disorder
o Thyroid disorder
o Diabetes
o Autoimmune disorders
o Vitamin deficiencies
(Vit D)
Side effects of:
◦ Anticonvulsant meds
◦ Reglan
◦ OCPs
Rule out medical conditions that
might precipitate psychosis: • Toxicology screen
• CMET
• TSH
• B12, Folate
Skin to Skin
Contact Help in the Home PPD Support Groups
Social Support
Cognitive Behavioral
Therapy Exercise, Yoga,
Mindfulness/Meditation
Omega 3 Fatty Acids
Acupuncture
Complementary Alternative
Medicine
TREATMENT STRATEGIES
Beck, et.al. 2006; Kleiman, 2009; Freeman, 2010, Pearson, 2010;
“BUT….
WILL IT HURT MY BABY?”
• No decision during pregnancy is risk free
• Consider both pharm and non-pharm tx options
• Psychotherapy in addition to pharmacotherapy
and/or as an alternative when clinically appropriate
Include discussion on the medication’s potential
effect on:
• OB outcomes
• Congenital malformations
• PPHN
• Poor neonatal adaptation
• Long term neurocognitive development
ACOG 2008; Koren, et.al., 2012
“The safest medication in pregnancy is
the one that allows for full remission of
symptoms of anxiety/depression.”
Postpartum depression
50-62% risk after birth
• Pre-eclampsia
• 50% increased risk of developmental
delay at 18 months
• Poor self care
• Impaired bonding with baby
Persistent Pulmonary Hypertension of the Newborn (PPHN) – low absolute risk
• Preterm labor
• Transient neonatal withdrawal
• Long term developmental delays –
data mostly reassuring
• Majority of evidence does not suggest
association of increased risk of birth defects
above the baseline
BALANCING THE RISKS
UNTREATED
DEPRESSION IN
PREGNANCY
ANTIDEPRESSANT
USE
IN PREGNANCY
METABOLISM OF PSYCHOTROPIC MEDS IN PREGNANCY AND LACTATION
LOWER PSYCHOTROPIC DRUG LEVELS
DECREASED CLINICAL EFFECTIVENESS
INCREASED DRUG ELIMINATION
Slower gastric emptying
Plasma volume
Changes in protein binding
Sex steroids increase
CYP450 activity
Renal blood flow
3/22/2018
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APA/ACOG JOINT RECOMMENDATIONS Yonkers, et al, APA/ACOG Guidelines, Obstetrics & Gynecology, 2009
Women trying to conceive - histories of MDD:
Encourage period of euthymia
Sustained remission - may consider tapering and discontinuing.
More recently depressed or with symptoms: consider remaining on medication, optimizing medication
Mild - moderate MDD: psychotherapy first line tx
• Lifestyle components - nutrition, weight management, prenatal care, childbirth education;
• Treatment for substance abuse
• Document all exposures dating back to conception
Pregnant women with severe MDD: medication first-line
Pregnant women on antidepressants during pregnancy:
• take into account patient preferences, previous course of illness
• Medication selection should be based on known safety information
PRESCRIBING PITFALLS ……DON’T FALL INTO THESE COMMON MISCONCEPTIONS
DOES THIS MAKE
THE PATIENT OR PRESCRIBER
FEEL BETTER???
• Discontinuation of antidepressants near conception
• Using a lower antidepressant dose in pregnancy
• Switching to sertraline in pregnancy/postpartum
• Try supplements or alternative therapies
ANTIDEPRESSANT RISKS MATERNAL/FETAL RISKS TO CONSIDER
• SSRIs as a group do not increase risk
of congenital malformations above
baseline risk of 2-4%
• Gestational age decreased by ~4-7
days, SGA, lower birth weight
• similar risks for exposure to untreated sx vs. meds
• Miscarriage • small studies
• did not control well for psychiatric illness state,
smoking, drug use, age
• SSRI related ventricular
outflow defects,
craniosynostosis, omphalocele • extremely small risk
• not replicated in other studies
• Stop breastfeeding or defer antidepressant treatment
• Counseling mothers to pump and dump
• Use of non-benzodiazepine sedative hypnotics
DOES THIS MAKE
THE PATIENT OR PRESCRIBER
FEEL BETTER???
PERINATAL SLEEP STRATEGIES
• Make sleep a priority
• Establish a sleep plan in pregnancy – Postpartum Planning (DONA)
• Enlist the entire family.
• Treat mood and anxiety disorders
• SSRIs – generally very safe overall as a class
• TCAs are safe, but have more unpleasant side effects.
• Mood Stabilizers: Stabilize mood by preventing the highs and lows of this disorder
• Depakote and Tegretol = safe for BF, but NOT during pregnancy
Antipsychotic meds: used to treat psychotic illness, bipolar disorder, and sometimes to tx severe depression or treatment-resistant OCD.
• Haldol can be used in BF mothers when necessary.
• Zyprexa, Seroquel, Abilify have been used in pregn and BF, but R/B need to be weighed carefully.
• Anti-anxiety: benzodiazepines quickly relieve symptoms.
Should be used temporarily and primarily when the antidepressant is taking effect
• Sleep Meds: Ambien, Trazodone, low dose clonazepam safe in BF and short term use.
• Benzodiazepines: use while SSRI is taking effect use shortly before delivery is associated with floppy infant syndrome.
• Prenatal benzodiazepine exposure increased the risk of oral cleft, although the absolute risk increased by 0.01%.
3/22/2018
5
PREGNANCY:
Dosing
Impact on fetus
Registry information
1
LACTATION:
Amount of drug in breast milk Potential effects, if any
2
FEMALES AND MALES OF REPRODUCTIVE POTENTIAL:
Pregnancy testing
Contraception
Fertility related to the drug
3
~change to a “category B label” drug
DOES THIS MAKE THE PATIENT OR PRESCRIBER FEEL BETTER???
LIMITATIONS OF RESEARCH
Ethics • Retrospective studies
Confounding biases
• Obesity
• Maternal age
• Type of delivery
• Substance abuse
• Effects of other meds
• Poor prenatal care
FDA Labeling of Drugs
• A,B,C, D, X Correlation does
not equal “causation”
MARIJUANA USE IN PREGNANCY
• Number of Americans age12 or older who regularly used marijuana:
• 5.8% in 2007
• 17.3% in 2012
• Younger/socioeconomically disadvantaged women: 15-28%
• Estimated that half of female marijuana users continue using during pregnancy
Increases risks of :
• Intrauterine growth restriction
• Low birth weight
• Stillbirth
• Cognitive delays and deficits,
• Poor executive functioning
• ACOG committee opinion urges pregnant women to discontinue marijuana use.
OPIATE USE DISORDER IN PREGNANCY
• Medication metabolism rate increases as pregnancy progresses
• Split methadone dosing from once to twice daily
• Metabolism is accelerated in pregnancy = Larger clearance of
medication
• Factors to consider in treatment plan if pregnant women returns to
substance use:
• Environmental /social support/basic needs/personal safety factors
• Stage of pregnancy – pharmacokinetics
• Potential interactions changing metabolism of the opioid
contributing to relapse
PREGNANCY AND
BIPOLAR DISORDER
MED
MANAGEMENT
GUIDELINES
• Folate supplementation is advised
Comprehensive prenatal counseling should begin at least 3 months before pregnancy.
• Avoid abrupt discontinuation
• Increase psychosocial and clinical supports
Medication should be avoided if clinically feasible
(particularly first trimester)
• Use minimum effective dose
• Monotherapy is preferable
• Avoid changing effective medications unless there is significant safety or clinical advantage
• Increase frequency of clinical monitoring as indicated
If medication is pursued:
• Importance of SLEEP
• Postpartum prophylaxis
• Risks/benefits of breast-feeding
• Importance of social support
• identify support people
• educate family/supports on signs and symptoms to look for
Comprehensive postpartum counseling should begin before and be reinforced throughout pregnancy, emphasizing:
DISCONTINUE MEDS OR MOOD RELAPSE ???
Risks of alternative treatment
Risks of continuing mood stabilizer
More severe mood relapse
Hospitalization Suicide/infanticide
Impulsive behavior
Substance use
Poor care (self/infant)
Difficulty bonding
3/22/2018
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DISCONTINUATION OF LITHIUM
DURING PREGNANCY?
• Lithium 0.05 – 0.1% Ebstein’s anomaly w/1st tri exposure
Mood stabilizer considerations
• Preconception: 3 months prior - folate supplementation
• Valproic acid – 1-6% rate of NTD, high rate of impaired neurocognitive
development
• Carbamazepine: 1% risk NTD
• Lamotrigine – no risk of congenital anomalies after antenatal exposure
• Conflicting reports on oral cleft defects
ANTIEPILEPTICS AND MOOD STABILIZERS
May be associated with a small increase in congenital cardiac malformations, LITHIUM
• Physiologic alterations of pregnancy may affect pharmacokinetics of lithium
risk of fetal anomalies, neural tube defects, fetal valproate syndrome, and long term adverse neurocognitive effects. DEPAKOTE
• Avoid in pregnancy, if possible, especially during the first trimester
LAMICTAL
• Overall risk for malformations w/lamotrigine = 2.7% across several studies
• Potential maintenance therapy option for pregnant women with bipolar disorder
• Pregnancy increases lamotrigine clearance by >50%
Associated with fetal carbamazepine syndrome. Risk of neural tube defect TEGRETOL
• Avoid in pregnancy, if possible, especially during the first trimester.
ACOG, 2008; Hale, 2012; Vemuri, et.al., 2011
BREASTFEEDING CONSIDERATIONS AND MEDS
• Most SSRIs and TCAs have not been
associated with health problems for
breastfeeding infants
• Fluoxetine has been reported to
accumulate in infants (longer half life)
• Consider alternatives as a 1st line
treatment unless the patient has a
history of good response to this
drug
Hale, 2014
• Prescribe the lowest therapeutically
effective dose
• Trace amounts of all antidepressants
are found in breast milk
• Measuring serum levels in the
neonate is not recommended.
• Pedi provider should follow and monitor
for side effects secondary to med
exposure
• Inform pedi if there is a med change
BREASTFEEDING CONSIDERATIONS AND MEDS
• Relative Infant Dose
• <10% considered safer
• Maternal side effects – predict infant safety concerns
• Lab monitoring – testing mom? Then, test baby
• Pregnancy exposure higher than breastfeeding
• Long-term effects not well studied
• Pump and Dump?
• maintain supply of pumped breast milk
• take the medication immediately after a feeding
• at baby’s next feeding, bottle feed expressed milk
• At this time, pump milk from both breasts and discard
• resume regular breastfeeding at the next feeding
REPRODUCTIVE SAFETY RESOURCE SITES
ADHD
PSYCHOSTIMULANT USE IN PREGNANCY AND LACTATION
• evaluate the severity of impact on executive functioning skills.
If discontinuing a psychostimulant
• discuss the possible risk of intrauterine growth restriction.
• Monitor growth by third trimester ultrasound.
If continuing a psychostimulant
• Re-evaluate
• Is it worth it to stay on that alternative med for the remainder of the pregnancy?
If one changes to a “safer” med (TCA, bupropion), and the medication is NOT therapeutically managing the mother’s symptoms:
3/22/2018
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SCHIZOPHRENIA
Nearly double the risk of perinatal complications to that of general population:
• higher rate of operative delivery, NICU admission, neonatal morbidity
High potency 1st generation antipsychotics preferred to low potency
2nd generation antipsychotics less studied
• Overall no increased risk of congenital anomalies
• Considerations: metabolic effects, blood dyscrasias, movement disorders
KEY POINTS:
PHARMACOLOGICAL TREATMENT OF PERINATAL WOMEN
Avoid discontinuing
meds that provide
psychiatric stability
1
Previously effective
meds
Minimal effective dose
Symptom remission as
the goal
2
Carefully substitute
less teratogenic agents
if necessary
3
Dose requirements
may be higher in the
second half of
pregnancy
Adjust accordingly
4
INTEGRATIVE CARE MODELS addresses barriers related to
Stigma
Fear of losing parental rights
Lack of obstetric provider training in clinical aspects of
depression care and communication skills
Lack of standardized processes for
depression care
Lack of specialized reproductive psych
providers
Lack of specialized referral networks
Inadequate capacity for follow-up and care
coordination
MOTHER-BABY MENTAL HEALTH INTENSIVE OUTPATIENT PROGRAMS
• Pregnant or Postpartum (up to 1-3 yrs)
• Serious/Disabling PMD symptoms
• Marked impairments in multiple areas
• Not imminently dangerous to self/others
• Can function outside of 24hr care
• Social Support system
• Readiness for change
(voluntarily participates in program)
Pine Rest Mother-Baby
Program – Grand Rapids, MI
QUESTIONS?
REFERENCES
American College of Obstetricians and Gynecologists Committee on Obstetric Practice. (2015). Committee opinion No. 631: Screening for perinatal depression. Obstetrics &
Gynecology, 125, 1272-5.
American College of Obstetricians and Gynecologists (ACOG). Use of psychiatric medications during pregnancy and lactation. Washington (DC): American College of
Obstetricians and Gynecologists (ACOG); 2008 Apr. 20 p.(ACOG practice bulletin; no. 92).
Cox, J.L., et al. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry. 1987; 150:782-786.
Freeman, M. (2010, September 21). Omega-3 Fatty Acids: the basics for clinicians and patients [Blog post]. Retrieved from www.womensmentalhealth.org
Hale, T. (2012). Medications and Mother’s Milk. In (15th ed.). Hale: Amarillo, TX .
Koren, G. and Nordeng, H. (2012). Antidepressant use during pregnancy: the benefit-risk ratio. American Journal of Obstetrics and Gynecology, 207, 3, 157-63.
Kleiman, K. and Wenzel, A. (2011). Droppin the Baby and Other Scary Thoughts: Breaking the Cycle of Unwanted Thoughts in Motherhood.
Routledge: New York, NY.
Hosseini SM, Biglan MW, Larkby C, Brooks MM, Gorin MB, Day NL. Trait anxiety in pregnant women predicts offspring birth outcomes. Paediatr Perinat Epidemiol. 2009
Nov;23(6):557-66.
Latendresse G, Wong B, Dyer J, Wilson B, Baksh L, Hogue C. Duration of Maternal Stress and Depression: Predictors of Newborn Admission to Neonatal Intensive Care Unit
and Postpartum Depression. Nurs Res. 2015 Sep-Oct;64(5):331-41
Nonacs, R. (2014). Medications and Pregnancy: A Focus on the Pharmacokinetics [Blog post]. Retrieved from www.womensmentalhealth.org November 19, 2014
Substance Abuse and Mental Health Services Administration. Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants. HHS
Publication No. (SMA) 18-5054. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018.
Tronick, E., Als, H., Adamson, L.,Wise, S., & Brazelton, T. B. (1978). The infants’ response to entrapment between contradictory messages in face-to-face interactions. Journal
of the American Academy of Child Psychiatry, 17, 1–13.
US Food and Drug Administration. Pregnancy and Lactation Labeling Final Rule.
http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/Labeling/ucm093307.htm. Accessed January 8, 2016.
Vemuri, M. and Williams, K. (2011). Treating bipolar disorder during pregnancy: optimal outcomes require careful preconception planning, medication risk/benefit analysis.
Current Psychiatry, 10, 9, 59-66.
Yonkers, K., Wisner, K., Stewart, D., Oberlander, T., Dell, D., Stotland, N., Ramin, S., Chaudron, L., and Lockwood. C. (2009). The management of depression during
pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstetrics and Gynecology, 114, 3, 703 – 13.
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