Medication During Pregnancy

To consider:

  • Effect on developing child (aka neurodevelopmental concerns, meaning what are the effects on the long-term development of psychology)
  • Effect on delivery
  • Effect on child after birth (eg risk of withdrawal)
  • Is everyone who should ideally be looped-in looped in? Other parents, doctors.
  • Make sure patients are fully consented to risks and benefits.
  • Typical consent language is “I offered to patient to have all parties present and other doctors informed for risks and benefits of all medications, but patient declined due to X reasons”
  • Simplify simplify simplify: be on as few meds as possible. Let patient choose “which of these meds most keeps you stable?” choose a sleep med, not three, minimize benzos.
  • No need to switch to TMS or anything like that.
  • If on a cocktail multiple classes of meds see an high risk Ob-Gyn, the cocktail is an index of biological severity.
  • Level of functioning (chronically mentally ill v. high fx)
  1. Harvard’s Women’s mental health: Enter your medications in the search center
  2. mcpapformoms.org/obstetics: lots of data
  3. mothertobaby.org: excellent for patients
    1. Enter depression or anxiety see the risks of depression in pregnancy
    2. Click on fact sheets for your particular medication
    3. 3-5% baseline risk is meant to realize that any problem you get is from your psych medication
  4. ADs stay on what works at the dose that works. SNRI, SSRI, NDRIs dont increase birth defects, but can be jittery and fussy for first three days poor neonatal adaptation syndrome. Withdrawal from serotoning. It isn’t really true that zoloft is safest in pregnancy. But less in breast milk which is why it is pushed. Trintellix and vybiid there is very little data.
  5. Antipsychotics: The only one you really want to watch out for is risperdal. Increased risks of birth defects. All other studied atypicals don’t increase risk above baseline (not latuda). Zyprexa can cause weight gain and increase risk of gestational diabetes.
  6. Bipolar Meds generally speaking you want to go off Depakote. Li is ok to stay on if you are stable, but slight increased risk of Epstein’s anomaly if on in first trimester. Lamictal or atypical is preferred. No tegretol or depakote.
  7. Benzos: Ideally low dose, ideally short half life (eg ativan better than klonopin or xanax). Infrequent, eg. 0.5mg po qd for anxiety. Ativan or klonopin 1mg po qd is occassional. OB’s tend to dislike benzos in pregnancy. Risk of withdrawal in newborn.
  8. Stimulants: IR is generally ok. Tend to taper ADHD unless funcitoning is really endangered, switch to IR from XR. There is no increased birth defects, but neurodevelopmental issues are unknown. Many people stay on their meds. Increased risk of pre-eclampsia, so ideally providers know.
  9. Marijuana: No clear safe amount, not recommended.
  10. Go to a high-risk Ob-Gyn

Cases: