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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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

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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”

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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

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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%.

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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

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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:

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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.