What is known about prescription and use of antipsychotic and other medications during pregnancy, in pregnant women with schizophrenia?

There is extensive information in the American Psychiatric Association Practice Guideline for The Treatment of Patients with Schizophrenia, Third Edition (APA, 2020) regarding prescription of medications during pregnancy in patients with schizophrenia, as well as risks and benefits of treatments during pregnancy.

The following highlights are summarized from the APA Practice Guideline for Schizophrenia: General pregnancy and post-partum considerations:

• “It is essential to consider the potential benefits of treatment as well as the potential harms of untreated illness and the potential for negative fetal or neonatal effects when making decisions related to the use of psychiatric medications in women of child-bearing potential.”
• “Untreated or inadequately treated maternal psychiatric illness can result in poor adherence to prenatal care, inadequate nutrition, increased alcohol or tobacco use, and disruptions to the family environment and mother–infant bonding.”

Considerations for women with childbearing potential and at risk for pregnancy:

• If pregnancy is not desired: Effective contraception should be obtained (or assistance provided).
• For women planning to become pregnant, who are pregnant, or in the post-partum period: Collaboration is essential (e.g., patient, obstetric practitioner, persons of support).
• For women who are breastfeeding: Collaboration is essential (e.g., infant’s pediatrician).

Considerations for treatment during pregnancy, risks/benefits:

• All psychotropic medications cross the placenta, are present in amniotic fluid and enter human breast milk. The greatest risk for teratogenesis occurs between gestational weeks three and eight. Thus, the benefits of continued treatment (e.g., minimizing relapse) will generally outweigh the potential for fetal risk if pregnancy is identified after the eighth week.
• The available data, limited to observational and registry-based studies, suggest SGAs and FGAs have minimal effect in terms of teratogenic or toxic effects on the fetus.
• There does appear to be a risk of withdrawal symptoms or neurological effects with use of antipsychotic medications in the third trimester. Symptoms may include agitation, abnormally increased or decreased muscle tone, tremor, sleepiness, severe difficulty breathing, and difficulty in feeding.
• However, the benefits of treatment for the mother and the longer-term benefits of treatment for the infant (e.g., enhanced mother–infant bonding, better adherence to prenatal care and nutrition, lesser rates of prenatal alcohol or tobacco use) will generally favor continuing and not tapering antipsychotic treatment.

General considerations:

• Lowest effective dose using a single medication. It is also preferable to maintain efficacy with one agent at a higher dose than using multiple agents.
• It is usually not advisable to switch to a different antipsychotic medication if symptoms are well-controlled. Changing medications exposes the fetus to two different medications and also increases the possibilities for symptom relapse in the patient.
• Physiologic alterations of pregnancy may affect the absorption, distribution, metabolism, and elimination of medications and may necessitate adjustments in medication doses. Monitoring for symptom recurrence and side effects throughout the pregnancy and post-partum period is needed.
• Regular prenatal care is essential to assuring optimal maternal-fetal outcomes. Important elements include monitoring for diabetes (e.g., increased risks of obesity and hyperglycemia) and folate supplementation (e.g., reduce risks of neural tube defects).
• Infants may be exposed to clinically significant levels of medication and the long-term effects are not known. Using a shared decision-making model, a review of potential benefits and potential risks should be discussed with mothers who wish to breastfeed.

Information related to the use of antipsychotic medications during pregnancy and while breastfeeding can be found on the following websites:

• U.S. Food and Drug Administration (FDA)
• RePROTOX
• TERIS
• U.S. National Library of Medicine’s LactMed
• For women who have been treated with an SGA during pregnancy, enrolling in the National Pregnancy Registry for Atypical Antipsychotics is suggested (MGH Center for Women’s Mental Health, 2019).

REFERENCE

• The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Schizophrenia, Third Edition. American Psychiatric Association (2020).