dr bavi vythilingum rondebosch medical centre
TRANSCRIPT
Dr Bavi Vythilingum
Rondebosch Medical Centre
In SA 30 -40% of women have antenatal
depression
Decision to treat – benefit to mother vs risk to child
More accurate – look at benefit to mother and
child vs risk to mother and child
First line
Alone – effective in mild to moderate depression
Generally SSRI’s and TCA’s safe in pregnancy
and breastfeeding
Antipsychotics – reasonably safe
Mood stabilisers – teratogenic risk
ECT – option
Monotherapy
Lowest effective dose
First line pharmacotherapy
Citalopram, sertraline appear best tolerated
No long term behavioural effects
Several studies linking SSRI use to ◦ Cardiac defects
Large database studies
No face to face interview
Multiple confounders – adequate power?
Qualitatively different cases vs control ◦ Other drug use, higher rates FAS, older
No control for effect parenting
“(There is a) distinct lack of research analysis available with reference to the potential impact of non-iatrogenic confounders on pregnancy”
“Further, well-designed research is needed to differentiate definitively the detrimental impact of depression on pregnancy outcomes from potential iatrogenic events.”
Gentile S. Acta Psychiatr Scand. 2011 Apr;123(4):266-75.
63,395 women, 699 (1.1%) used antidepressants
Not suggest a strongly increased risk of
malformations, preterm birth, or low birth weight
following prenatal exposure to antidepressants.
Adjustments for level of maternal depression and
various sociodemographic and lifestyle factors
Six published studies ◦ only three studies adequately powered.
3 studies – increased risk
Absolute risk cannot be determined,
BUT probably less than 1%.
Information does not support discontinuation or
lowering the dose of the antidepressant.
14 studies
majority of studies - no difference between those
exposed and controls
only two studies identified statistically significant
differences in motor function.
Figueroa 2010
No link SSRI use and ADHD
Maternal mental illness
Croen et al 2011
20 cases rates 6.7%
50 controls rates 3.3%
Cases older mothers, more likely to be LBW,
preterm – adjust for this
Effects mental illness
Parenting
No increased teratogenic risk
More adverse side effect profile ◦ particularly postural hypotension
◦ constipation
◦ lethality in overdose
Generally used as second line agents.
Venlafaxine, duloxetine, bupropion ◦ Less data
◦ Probably safe
◦ Figueroa study – link bupropion and ADHD
MAOI’s – no data, avoid due to dietary restrictions,
risk hypertension
Petersen et al 2011
Pregnancy was a major determinant of cessation
of antidepressant medication, and most women
did not receive further antidepressant
prescriptions beyond 6 weeks of gestation.
“Often the risk of the untreated disorder is left out
of the risk/benefit equation of the evaluation of a
medication (or underappreciated)”
The overall benefit of treatment seems to
outweigh the potential risks.
Risk of teratogenecity
Absolute risk is not clear but appears to be small
Psychotherapy treatment of choice for perinatal
depression
Weigh risk benefit ratio
Teratogenic risk ◦ Lithium Ebstein’s anomaly 1-5% (vs 0.5 – 1% risk)
◦ Na Valproate NTD, other anomalies, 3x vs other
antiepileptics, 4x general population
◦ Carbamazepine 1% risk neural tube defects (vs 0.1%
risk)
◦ Lamotrigine limited evidence, cleft palate
◦ Atypicals – olanzapine, quetiapine evidence limited,
neonatal effects
Lithium – safest
Lamotrigine, atypicals – appears safe
Individualise for patient
Adequate risk counselling
DO NOT STOP MEDICATION
Minimal decrease in risk of defects vs high risk
relapse
Continue meds at lowest effective dose
Early US and anomaly scan
FOLATE
Changing maternal blood volumes
Increase doses during pregnancy ◦ Lithium – levels monthly first 2 trimesters, every fortnight
thereafter
◦ Valproate, CBZ – guided clinically, checking levels every
2 -3 months useful
Liaise closely with obstetrician
Hospital
Adequate pain control
IV line up
Stop lithium, benzo’s at onset labour, recommence
post delivery after checking level
High risk for post natal depression/psychosis
Small increased risk for cardiac/oral cleft malformations with first-trimester exposure.
Neonatal toxicity (“floppy infant syndrome”) /withdrawal
Avoid in the first trimester,late in the third trimester
To minimize neonatal withdrawal, gradually taper the mother’s benzodiazepine before delivery ◦ Taper 3 to 4 weeks before the due date and discontinue at least 1
week before delivery.
◦ If benzodiazepines cannot be tapered
use a short acting agent
advise the mother to discontinue benzodiazepine use as soon as she thinks she is going into labour.
MOST WOMEN ON MEDS CAN
BREASTFEED!!!!!
Risk of child dying from diarrhoea, respiratory
disease, malnutrition higher than medication side
effects
Breastfeeding, bedsharing mothers get more
sleep
Case by case basis
Lowest effective maternal dose
All meds excreted into breastmilk
Watch baby ◦ Jaundice
◦ Excessive sleepiness
Pre term – probably best not to breastfeed
Antidepressants – generally safe
Antipsychotics ◦ Infant sedation
◦ Neonatal EPSE
Mood stabilisers ◦ All present problems
◦ Consider risk benefit carefully
Lithium ◦ Maternal hydration important
Anticonvulsant class ◦ Rashes
Sulpiride
Antipsychotic with theoretical mood elevation
properties at low doses
Side effect of increasing milk supply
Sedating
NOT an effective antidepressant
All medications present risk – some higher than
others
Weigh risk benefit ratio
PNDSA www.pndsa.org ◦ 0828820072
Otispregnancy.org
www.infantrisk.com
