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Flashcards in Psych meds in pregnancy Deck (42)
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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