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Flashcards in Psych meds in pregnancy Deck (42):
1

The components of an ideal pregnancy?

- planned
- prenatal vitamins started 6 wks prior to conception
- 15% of ideal body wt at time of conception
- routine prenatal care
- no meds
- no obstretical complications
- breastfeed w/o difficulty
- euthymia (positive attitude) throughout pregnancy and postpartum

2

Reality of pregnancy?

- around 50% unplanned
- usually don't realize pregnant until 4th-7th week
- 84.5% result in viable infant, 2-4% reqr surgical intervention
- 80% prescribed meds (includes prenatal vitamins)
- of these 33% are psychotropic meds

3

Risk for psych disorders in women?

- mood disorders: risk of depression and dysthymia 2x that of men during childbearing years
- Anxiety: risk of anxiety and panic disorder higher as well
- bipolar and psychotic disorders seem to be about sam ein both sexes except during pregnancy and postpartum when risk increases

4

Is pregnancy mood protective?

- no, 70% report depressive sxs and 10-15% meet criteria
- panic disorder may actually get better during pregnancy
- OCD is exacerbated, 25% have first onset during pregnancy
- postpartum blues: mood lability, depression, resolves in 2 weeks, mother still happy she has had her child
- postpartum depression: more prevalent in adolescent mothers, men also get postpartum depression
- postpartum psychosis: 1-2/1000 live births with onset within first 6 weeks postpartum - overt psychotic sxs - believe their child is possessed

5

Untreated illnesses that aren't benign can lead to?

- preterm delivery
- lower birth wt
- spontaneous abortion
- pre-eclampsia
- instrumental deliveries: c-sections
- operative deliveries

6

Poor neonatal outcomes from disorders being left untx?

- poor neonatal adaptation: excessive crying, irritability, erratic sleep
- increased risk of admission to NICU
- growth retardation
- lower APGAR scores
- decreased head circumference

7

Untx disorders affect on child development?

- negative effect on fetal-maternal bonding
- difficulty with affect regulation
- cognitive delays
- maladaptive social interactions
- increased levels of anxiety and fear
- increased levels of ADHD
- high levels of cortisol from mom - leads to disturbance in hypothalamic pituitary adrenal axis fxn - long term effects in child

8

Risk to mother if disorders are left untx?

- poor nutrition, impaired self care
- failure to follow medical/prenatal guidelines
- worsening of co-morbid medical illness
- increased exposure to ETOH, tobacco and drugs
- impact on family
- postpartum psych complications

9

Tx options in pregnancy?

- non-pharm:
psychosocial options
psychotherapy
massage
light therapy (like in SAD)
exercise
- electroconvulsive therapy: anesthetic agent only risk to mother, very effective - given muscle relaxant - induce a seizure

10

Key pharmcotherapy concepts in pregnancy - placental barrier?

placental barrier:
- lipid solubility: more lipophilic drugs tend to cross barrier more efficiently than nonlipophilic
- MW: wts of 500 D or less facilitate crossing the barrier (insulin and heparin can't cross)
- ionization: drugs taht are nonionized at physiologic pH cross placenta more efficiently

11

key pharm concepts in pregnancy - safe period?

- first trimester: highest risks of birth defect
- first 14 days - all or none - no effect or miscarriage
- 14-60: cell diff, organogenesis
- up to 32 days - neural tube defect
- 21-56 days: heart forms
- 42-63: cleft palate occurs
- try to keep off meds during first trimeseter - keep on antidepressants if already on

12

key pharm concepts in preg- pharmacokinetics?

physiologic changes:
increased plasma volume = dilutional effect
increased glomerular filt= excretion increased
slowing of gastric motility
increased action of liver: drugs breakdown faster
increased protein binding - less med available for use

13

US FDA pregnancy categories?

- A: generally considered safe
- B: caution advised
- C: weigh risks/benefits
- D: weigh risks/benefits
- X: risks outweigh benefits

14

New FDA drug labeling?

3 sections:
- pregnancy: list out risks, labor and delivery
- lacation
- females and males of reproductive potential

15

First line tx of depression in pregnancy?

- zoloft

16

Antidepressants and assoc birth defects?

- paxil - RV outflow tract defects - failure of normal circulatory transition - R to left
- prozac - VSDs (not first line in lactation - accum in neonate)
- celexa - neural tube defects
- - failure of normal circulatory transition - R to L extrapulm shunting of blood, hypoxemia

- study shown that theses defects are same in these drugs as background (Not being on drugs) - same risk as not being on paxil

17

TCAs used in preg?

- amitriptyline, nortriptyline, desipramine

18

SNRIs used in preg?

- venlafaxine (effexor)
- duloxetine (cymbalta)

others:
bupropion
trazodone
mirtazipine

19

Depression and correlation with birth defects?

- overall women with depression tx or not will have higher risks of birth defects

20

What is neonatal withdrawal syndrome?

- exposure to/withdrawal from SSRI or SNRI
- sxs:
tremor, restlessness, increased muscle tone, increased crying
- resolves 1-4 days after birth - transient, no risk

21

Main mood stabilizer used in pregnancy? Assoc defects?

- lithium: mainstay for acute and maintenance therapy
- 2.8% rate of congenital anomalies
- epstein's anomaly (downward displacement of tricuspid valve into R ventricle and RV hypoplasia): not stat. sig.
fetal high resolution US
fetal echo at 18-20 weeks
- floppy baby syndrome
- neonatal hypothyroidism
- nephrogenic diabetes insipidus

22

Congenital anomalies and effects of mood stabilizer: lamotrigene (lamictal)?

- 1.4-4.6% of congenital anomalies
- try to keep under 200 mg esp during 1st and 3rd trimester
- cardiac, GI, GU, neural tube defects dose dependent with 1st trimester exposure
- SJS - most serious risk

23

Use of valproate (depakote) during pregnancy? What other supplement should you be on?

- mood stabilizer - don't use!!!
- human teratogen - category D
- neural tube defect at 5-9%: risk at 17-30 days postconception
- irritability, jitteriness and feeding problems
- growth retardation
- lower IQ scores
- 3-4 folic acid through first trimester if on depakote
- safe in breast feeding

24

Carbamazepine safety?

- human teratogen
- craniofacial defects, developmental delays, fingernail hypoplasia, neural tube defects
- decrease birth wt. decreased head circumference
- safe in breast feeding


- other mood stabilizers:
oxcarbazepine, gabapentin - no increased risk of defects

25

topiramate - risk of defects?

- alone = no increased risk
- polypharm - increased risk
- topiramate used to help with wt gain or assist with wt loss brought on by psychotropic meds = leads to increased risk for congenital malformations

26

First gen/typical antipsychotics used? Indications? Safety?

- phenothiazines and butyrophenones
- for hyperemesis
- psychotic disorders
- Category C
- transient neonatal sxs secondary to extrapyramidal side effects

27

Atypical and second gen antipsychotics used in pregnancy? Risk for what?

- olanzapine (zyprexa), quetiapine (seroquel), risperidone (risperdal): up to 4.1% of congenital abnorm, slight increased risk for low birth wt, possible risk for gestational diabetes
- ziprasidone, aripiprazole (abilify)
- clozapine (clozaril)

28

Benzos used in pregnancy? Thought to be assoc with what?

- clonzepam, lorazepam (ativan), alprazolam (xanax), diazepam (valium) - thought to be assoc with cleft palate, recent studies have shown that there isn't that strong of an assoc
- neonatal withdrawal syndrome:
tremor
irritability
diarrhea
vomiting
hypertonicity
- just tx this sx
- try to stay away from this during first trimester

29

sedatives/hypnotics used in pregnancy?

- zolpidem (ambien), zaleplon (sonata), escopiclone (lunesta)
- marketed for insomnia
- preg C
- no sig pregnancy outcomes
- most commonly used is ambien

30

Breast feeding benefits?

- decreased rates of:
SIDS
GI probs
anemia
respiratory ailments
otitis media
obesity

31

Key principles of lactation pharm?

1. drugs with low oral bioavailability are unlikely to cause systemic effects
2. drugs enter milk mainly by diffusion - maternal drug levels proportional to breast milk leve, breastfeeding just b/f next dose will result in lower levels in milk, shorter half life drugs are preferred over once daily dosed drugs
3. lipid solubility - higher lipid solubility more in milk
4. protein binding: more protein bound, less in milk
5. MW: higher, less in milk
6. pH: higher pH easier to pass in milk
7. est of milk prod: long term, and daily
8. neonatal physiology: hepatic enzyme acitivity, glomerular filtration
9. safety in pregnancy doesn't equate to safety in lactation

32

Risk categories in lactation?

- L1 = safest
- L2 = safer, remote risk
- L3 = moderately safe, risk possible
- L4 = possibly hazardous, postive evidence of risk
- L5 = CI

33

L2 antidepressants?

- zoloft, prozac, elavil, tofranil, pamelor

34

L3 antidepressants?

effexor, cymbalta, remeron, wellbutrin (can dry up milk, lower seizure threshold), trazodone

35

Mood stabilizers L2?

- tegretol, depakote**, neurontin

36

Mood stabilizers L3?

- lithium - use only with close observation, baby has to have blood levels drawn
- lamictal
- topamax: just dont give
- trileptal

37

Typical antipsychotic - lactation safety?

L2: haldol - baby sedated while feeding
L3: chlorpromazine, perphenazine

38

Atypical antipsychotics - lactation safety?

- L2: seroquel, zyprexa, geodon
- L3: risperdal, abilify, clozaril

39

Benzos lactation safety?


- L3: xanax, klonopin, valium, ativan
- worried about sedation in the infant

40

Hypnotics lactation safety?

- - L2: lunesta, sonata, ambien
- want to use sonata, shorter half life
- give at qhs, wake up feed baby, should be low enough amt in system to safely feed baby

41

Barriers to tx during pregnancy?

- stigma
- unacceptability of tx
- guilt
- anxiety
- financial

42

Risk vs Benefit in tx?

- analysis:
maternal psychiatric hx
potential deleterious effects of untx illness
info about med: somatic, perinatal, neurobehavioral
- Goal is to minimize exposure
- there is no such thing as non-exposure - either exposed to medicine or illness (adverse effects in both)