Antipsychotic Use in Pregnancy: how to weigh the risks

DISCLAIMER

The content provided in this Substack post is for entertainment and informational purposes only and is not intended to serve as medical advice. The views and opinions expressed herein are those of the writer and should not be taken as definitive or authoritative. Readers should not rely solely on the information provided in this post to make decisions about patient care. Instead, use this content as a starting point for further research and consult a qualified healthcare professional before making any changes to treatment or medication regimens.

---

Introduction:

Pregnancy is a time of heightened concern for the wellbeing of both mother and developing baby. For women with psychiatric conditions such as schizophrenia, bipolar disorder, or severe depression, it also poses complex therapeutic challenges. Antipsychotics, a mainstay of treatment for these conditions, have important implications when used during pregnancy. Understanding the pros and cons of their use is crucial in making informed decisions that balance maternal mental health against potential risks to the fetus.

In this post, we will begin with two case studies & then review pros & cons of utilizing antipsychotics in pregnancy as well as a risk:benefit analysis.

Case Study #1:

Jane is a 32-year-old woman with a history of Bipolar I Disorder spanning over a decade. Her illness course has been marked by several severe manic episodes, with one episode necessitating hospitalization. Jane has been stable on her current regimen of quetiapine (Seroquel) for the past two years.

Recently, Jane discovered that she's pregnant. At her 8-week prenatal visit, she voiced concerns about the ongoing use of her antipsychotic medication due to potential risks to her unborn child. It's been two years since Jane's last manic episode, and she is worried about the dual challenge of managing a potential relapse during her pregnancy and the implications of her medication on her baby's development.

Considerations and Decision-Making Process:

1. Severity of Jane's illness: Given Jane's history of severe manic episodes, there's a significant risk of relapse if her medication is discontinued. Studies show that untreated bipolar disorder during pregnancy can lead to various adverse outcomes (Bodén et al., 2012).

2. Current Stability: Jane's two-year symptom-free period indicates that her current quetiapine regimen effectively manages her bipolar disorder.

3. Risk to Fetus: While data is limited, available research suggests that the use of atypical antipsychotics, including quetiapine, does not significantly increase the risk of major congenital malformations (Huybrechts et al., 2016).

4. Impact on Pregnancy: Quetiapine can be associated with gestational diabetes and weight gain, so these factors need to be closely monitored during pregnancy (McKenna et al., 2005).

In consultation with Jane, considering the severity of her illness, her current stability, the available safety data on quetiapine use in pregnancy, and the potential risks of medication discontinuation, it was decided that Jane would continue her treatment with quetiapine.

Conclusion:

This case highlights the complexity of decision-making when managing psychiatric conditions in pregnant patients. Each case demands an individualized approach, considering the nuances of the woman's psychiatric condition, her current state of stability, the risk to the fetus, and the relative safety of the medication in use.

The decision-making process should be a collective effort, involving the patient, her family, and her healthcare team. Regular monitoring during the pregnancy is essential, and strategies to manage the postpartum period should be planned early to ensure the best possible outcomes for both mother and child. Maintaining open lines of communication, offering reassurance, and providing comprehensive care are integral to navigating these challenging scenarios successfully.

---

Case Study #2:

Mary is a 29-year-old woman with a seven-year history of Bipolar I Disorder. Her psychiatric history includes periods of stability punctuated by occasional depressive episodes, but no significant manic episodes for the past five years. Mary has been stable on her current regimen of olanzapine for three years.

Upon discovering that she's pregnant, Mary expresses concern about the continued use of her antipsychotic medication. The primary reason for her apprehension is the potential risk her medication might pose to her unborn child.

Considerations and Decision-Making Process:

1. Severity of Mary's illness: Mary's bipolar disorder, characterized primarily by depressive episodes and a significant period without manic episodes, suggests a potentially lower risk of relapse if her medication is discontinued, as compared to a patient with a history of frequent and severe manic episodes.

2. Current Stability: Mary's three-year symptom-free period, despite having occasional depressive episodes, indicates that she is currently in a stable phase of her illness.

3. Risk to Fetus: Olanzapine use in pregnancy has been associated with increased risks of gestational diabetes and excessive maternal weight gain, which can lead to adverse obstetric outcomes (Newham et al., 2008). Furthermore, some studies suggest a potential increased risk for congenital malformations, although this remains controversial (Epstein et al., 2013).

4. Patient Preference: Mary's own concerns and preferences are critical. She has strong reservations about the continued use of her antipsychotic medication, which are taken seriously.

After detailed discussions about the potential risks and benefits, Mary and her care team decide to cautiously discontinue olanzapine. The team puts together a robust monitoring plan to detect early signs of relapse and includes a contingency for rapid reintroduction of medication if required.

Conclusion:

This case illustrates the critical and complex decision-making process required when considering the discontinuation of antipsychotic medications during pregnancy. The safety of the mother and fetus, the severity and course of the mother's illness, and the patient's personal preferences and concerns must all be carefully weighed.

The decision should be a collaborative one, with ongoing communication among the woman, her family, and her healthcare providers. It's important to have a close monitoring plan in place and to prepare for all potential outcomes, including the need for emergent medication management. With careful planning and thoughtful management, we can navigate these challenging clinical situations and strive for the best possible outcomes for both mother and baby.

---

Pros of Antipsychotic Use in Pregnancy:

1. Maternal Stability: For many women with serious psychiatric conditions, antipsychotics are essential for maintaining mental stability. Abrupt discontinuation can lead to symptom recurrence or exacerbation, which can carry serious risks for both the mother and the baby, including poor prenatal care, self-harm, and risk of postpartum psychosis.

2. Evidence of Relative Safety: Many typical (first-generation) and atypical (second-generation) antipsychotics have been used in pregnancy without clear evidence of major congenital malformations or direct neurodevelopmental harm. However, research is ongoing, and data for newer medications may be limited.