ACOG bulletin offers safety tips on how to treat depressed moms-to-be

June 2, 2008

An updated bulletin from ACOG offers advice on how to treat pregnant patients with mental disorders.

Points to remember

Pharmacists are often asked about the safety of medication use during pregnancy. Psychiatric medications pose an even greater worry to patients due to their clinical and adverse effects. Add to this the vague nature of pregnancy ratings, and the situation can be very stressful for pharmacists. The fear of hurting an unborn child and the potential liability therein are among the biggest concerns of pharmacists.

Simply avoiding psychiatric drugs during pregnancy is not a solution. Discontinuation of therapy or sub-optimal therapy in a pregnant or nursing patient is exchanging the fetal or neonatal risk with the risk of untreated mental illness. All this makes the guidelines published by the American College of Obstetricians and Gynecologists (ACOG) in its April bulletin especially useful to pharmacists.

ACOG issued its recommendations based on multiple factors. Included were the clinical consequences of exposure to the child, the potential effect of untreated psychiatric illness, and various therapeutic options. The ACOG bulletin provides evidence of which medications have a better or worse safety profile.

About 10%-20% of women will struggle with some symptoms of depression during pregnancy. Among the selective serotonin reuptake inhibitors (SSRIs), the panel concluded that paroxetine should be avoided in pregnancy especially in the first trimester. However, it should not be stopped abruptly but tapered appropriately. Cognitive behavior therapies are effective treatments for mild to moderate depression and should be considered in pregnancy.

Lithium use may be associated with a small increase in congenital cardiac malformations, according to the bulletin. Neonatal lithium toxicity is also a risk, symptoms of which include flaccidity, lethargy, and poor suck reflexes. ACOG therefore established the following guidelines for women with bipolar disorder who plan to conceive and are presently prescribed lithium.

First, patients with mild and infrequent episodes should discontinue lithium gradually before conception. In patients with severe episodes but who only have a moderate risk of relapse, lithium should be tapered prior to conception and restarted after organogenesis, after the eighth week. In patients who have frequent and severe episodes, treatment of lithium should be continued and counseling on reproductive risk should be provided.

Both of the antiepileptics valproate and carbamazepine are associated with congenital malformations. Valproate is connected to neural tube defects and other birth abnormalities. Carbamazepine exposure in pregnancy is associated with fetal carbamazepine syndrome, which manifests as facial dysmorphism and fingernail hypoplasia. Lamotrigine's safety profile seems favorable compared with other treatment options.

At one time studies showed benzodiazepines caused an increased risk of oral cleft. However, ACOG pointed out, recent studies show there is no link between benzodiazepines and congenital anomalies. Should benzodiazepine therapy be discontinued, it should not be done so abruptly.

Finally, ACOG stated that there are limited data concerning the use of atypical antipsychotics in pregnancy. A prospective comparative study showed a higher incidence of low birth rate when patients were exposed to atypical antipsychotics. Typical antipsychotics have a better documented safety profile, ACOG found.

THE AUTHOR is a pharmacist at Dear Drugs in Brooklyn, N.Y.