Dr Bavi Vythilingum

Rondebosch Medical Centre

In SA 30 -40% of women have antenatal

depression

Decision to treat – benefit to mother vs risk to child

More accurate – look at benefit to mother and

child vs risk to mother and child

First line

Alone – effective in mild to moderate depression

Generally SSRI’s and TCA’s safe in pregnancy

and breastfeeding

Antipsychotics – reasonably safe

Mood stabilisers – teratogenic risk

ECT – option

Monotherapy

Lowest effective dose

First line pharmacotherapy

Citalopram, sertraline appear best tolerated

No long term behavioural effects

Several studies linking SSRI use to ◦ Cardiac defects

Large database studies

No face to face interview

Multiple confounders – adequate power?

Qualitatively different cases vs control ◦ Other drug use, higher rates FAS, older

No control for effect parenting

“(There is a) distinct lack of research analysis available with reference to the potential impact of non-iatrogenic confounders on pregnancy”

“Further, well-designed research is needed to differentiate definitively the detrimental impact of depression on pregnancy outcomes from potential iatrogenic events.”

Gentile S. Acta Psychiatr Scand. 2011 Apr;123(4):266-75.

63,395 women, 699 (1.1%) used antidepressants

Not suggest a strongly increased risk of

malformations, preterm birth, or low birth weight

following prenatal exposure to antidepressants.

Adjustments for level of maternal depression and

various sociodemographic and lifestyle factors

Six published studies ◦ only three studies adequately powered.

3 studies – increased risk

Absolute risk cannot be determined,

BUT probably less than 1%.

Information does not support discontinuation or

lowering the dose of the antidepressant.

14 studies

majority of studies - no difference between those

exposed and controls

only two studies identified statistically significant

differences in motor function.

Figueroa 2010

No link SSRI use and ADHD

Maternal mental illness

Croen et al 2011

20 cases rates 6.7%

50 controls rates 3.3%

Cases older mothers, more likely to be LBW,

preterm – adjust for this

Effects mental illness

Parenting

No increased teratogenic risk

More adverse side effect profile ◦ particularly postural hypotension

◦ constipation

◦ lethality in overdose

Generally used as second line agents.

Venlafaxine, duloxetine, bupropion ◦ Less data

◦ Probably safe

◦ Figueroa study – link bupropion and ADHD

MAOI’s – no data, avoid due to dietary restrictions,

risk hypertension

Petersen et al 2011

Pregnancy was a major determinant of cessation

of antidepressant medication, and most women

did not receive further antidepressant

prescriptions beyond 6 weeks of gestation.

“Often the risk of the untreated disorder is left out

of the risk/benefit equation of the evaluation of a

medication (or underappreciated)”

The overall benefit of treatment seems to

outweigh the potential risks.

Risk of teratogenecity

Absolute risk is not clear but appears to be small

Psychotherapy treatment of choice for perinatal

depression

Weigh risk benefit ratio

Teratogenic risk ◦ Lithium Ebstein’s anomaly 1-5% (vs 0.5 – 1% risk)

◦ Na Valproate NTD, other anomalies, 3x vs other

antiepileptics, 4x general population

◦ Carbamazepine 1% risk neural tube defects (vs 0.1%

risk)

◦ Lamotrigine limited evidence, cleft palate

◦ Atypicals – olanzapine, quetiapine evidence limited,

neonatal effects

Lithium – safest

Lamotrigine, atypicals – appears safe

Individualise for patient

Adequate risk counselling

DO NOT STOP MEDICATION

Minimal decrease in risk of defects vs high risk

relapse

Continue meds at lowest effective dose

Early US and anomaly scan

FOLATE

Changing maternal blood volumes

Increase doses during pregnancy ◦ Lithium – levels monthly first 2 trimesters, every fortnight

thereafter

◦ Valproate, CBZ – guided clinically, checking levels every

2 -3 months useful

Liaise closely with obstetrician

Hospital

Adequate pain control

IV line up

Stop lithium, benzo’s at onset labour, recommence

post delivery after checking level

High risk for post natal depression/psychosis

Small increased risk for cardiac/oral cleft malformations with first-trimester exposure.

Neonatal toxicity (“floppy infant syndrome”) /withdrawal

Avoid in the first trimester,late in the third trimester

To minimize neonatal withdrawal, gradually taper the mother’s benzodiazepine before delivery ◦ Taper 3 to 4 weeks before the due date and discontinue at least 1

week before delivery.

◦ If benzodiazepines cannot be tapered

use a short acting agent

advise the mother to discontinue benzodiazepine use as soon as she thinks she is going into labour.

MOST WOMEN ON MEDS CAN

BREASTFEED!!!!!

Risk of child dying from diarrhoea, respiratory

disease, malnutrition higher than medication side

effects

Breastfeeding, bedsharing mothers get more

sleep

Case by case basis

Lowest effective maternal dose

All meds excreted into breastmilk

Watch baby ◦ Jaundice

◦ Excessive sleepiness

Pre term – probably best not to breastfeed

Antidepressants – generally safe

Antipsychotics ◦ Infant sedation

◦ Neonatal EPSE

Mood stabilisers ◦ All present problems

◦ Consider risk benefit carefully

Lithium ◦ Maternal hydration important

Anticonvulsant class ◦ Rashes

Sulpiride

Antipsychotic with theoretical mood elevation

properties at low doses

Side effect of increasing milk supply

Sedating

NOT an effective antidepressant

All medications present risk – some higher than

others

Weigh risk benefit ratio

PNDSA www.pndsa.org ◦ 0828820072

◦ info@pndsa.org.za

Otispregnancy.org

www.infantrisk.com