Psychiatric Disorders during Pregnancy: How to Tackle the Problem
Pregnancy and Psychiatric Disorders:
Management of psychiatric disorders during pregnancy is a subject that is gaining significance with every passing day. As more and more cases of different types of psychiatric disorders during pregnancy are reported health care providers are becoming too confused about how to tackle this kind of a situation! The main problem that leads to confusion is if drugs should be continued or not. There are a large number of studies demonstrating high rates of relapses when medications are stopped in patients suffering from mood disorders, anxiety disorders and schizophrenia. The decision to discontinue drugs when women with these disorders become pregnant or plan to conceive becomes more difficult. Health care providers face the challenge of minimizing the risk to the fetus, at the same time limiting the impact of maternal morbidity on the mother. Deciding what constitutes reasonable risk during pregnancy requires shared responsibility but the ultimate decision rests with the informed patients and their relatives.
Psychotropic Medications during Pregnancy:
All psychotropic medications diffuse across the placenta, which exposes the fetus to some degree of risk. The adverse effects of psychotropic drugs are maximum in the first trimester when organ formation occurs. However it has been noted that psychotropic drugs are also harmful even after organogenesis or the organ formation stage as intra-uterine exposure during second and third trimester can lead to postnatal complications. No psychotropic drugs have been approved by the US Food and Drug Administration (FDA) for use during pregnancy. To guide physicians about the reproductive safety of various drugs FDA has come up with a classification of drugs into five risk categories (A, B, C, D and X). While category A drugs are the safest during pregnancy, category X drugs are contraindicated by having fetal risks that far outweigh the benefit to the patient. Drugs in the categories B to D are considered to have intermediate risks, which are greatest in category D. Most psychotropic drugs fall in category C and thus fetal risk can’t be ruled out. The classification system being ambiguous and misleading quite often psychiatrists rely on other sources of information while recommending psychotropic medicines during pregnancy (Table 1).
Risks associated with Psychiatric Disorders during Pregnancy:
Schizophrenia: There is a significant risk of stillbirth, infant death, preterm delivery and low birth weight with highest risk for those women who are in an episode of schizophrenia.
For more information on schizophrenia and other psychotic disorders you can read: The Psychosis of Schizophrenia and Other Psychotic Disorders
Bipolar Disorder: Women with bipolar disorder are at a high risk for symptom exacerbation during the immediate postpartum period and recurrence rates within first three to six postpartum months are above 60 per cent.
Depression: It is associated with preterm labor and low birth weight. Women with history of major depression are at approximately 25 per cent risk of relapse of depression after childbirth (postpartum depression).
Treatment options for various Psychiatric Disorders:
Schizophrenia: Patients who have prior history of psychosis and develop mild psychotic symptoms during pregnancy should use anti-psychotics. Women with history of schizophrenic episodes should be maintained with anti-psychotics before and during pregnancy.
Bipolar Disorder: In case of mild to moderate bipolar disorder mood stabilizing drugs can be discontinued before or at any positive documentation of pregnancy. In the first trimester patient could be maintained without drugs. In case of severe bipolar disorder mood stabilizers should be continued throughout pregnancy.
Depression: In case of mild depression non pharmacological strategies like psychotherapy and counseling should be used. In case of severe depression including diminished oral intake, suicidal attempt and presence of psychotic symptoms pharmacological intervention is warranted.
Some general rules that should be followed before and during pregnancy by the relatives of the patient and health care providers are:
- Insisting for planned pregnancy
- Considering pregnancy as “high risk pregnancy”
- Use of lowest possible dose of drugs for the shortest period of time
- While using psychotropic medications risk factors for poor prenatal outcome like obesity, smoking and consumption of alcohol should be considered
- Compassionate behavior of close relatives and most importantly of husband
- Adherence to prenatal vitamins with a healthy diet
- Visiting health care providers regularly
The decision to introduce psychotropic medications in pregnancy should be taken in the light of severity of the mental disease and drugs should be used only when the potential risk to the fetus from the exposure to drugs is outweighed by the risk of untreated psychiatric disorder. The choice of drugs should depend on the balance between safety and efficacy profile.