Psych meds in pregnancy Flashcards Preview

Psych > Psych meds in pregnancy > Flashcards

Flashcards in Psych meds in pregnancy Deck (42)
Loading flashcards...
1
Q

The components of an ideal pregnancy?

A
  • 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
Q

Reality of pregnancy?

A
  • 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
Q

Risk for psych disorders in women?

A
  • 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
Q

Is pregnancy mood protective?

A
  • 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
Q

Untreated illnesses that aren’t benign can lead to?

A
  • preterm delivery
  • lower birth wt
  • spontaneous abortion
  • pre-eclampsia
  • instrumental deliveries: c-sections
  • operative deliveries
6
Q

Poor neonatal outcomes from disorders being left untx?

A
  • poor neonatal adaptation: excessive crying, irritability, erratic sleep
  • increased risk of admission to NICU
  • growth retardation
  • lower APGAR scores
  • decreased head circumference
7
Q

Untx disorders affect on child development?

A
  • 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
Q

Risk to mother if disorders are left untx?

A
  • 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
Q

Tx options in pregnancy?

A
- 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
Q

Key pharmcotherapy concepts in pregnancy - placental barrier?

A

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
Q

key pharm concepts in pregnancy - safe period?

A
  • 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
Q

key pharm concepts in preg- pharmacokinetics?

A

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
Q

US FDA pregnancy categories?

A
  • A: generally considered safe
  • B: caution advised
  • C: weigh risks/benefits
  • D: weigh risks/benefits
  • X: risks outweigh benefits
14
Q

New FDA drug labeling?

A

3 sections:

  • pregnancy: list out risks, labor and delivery
  • lacation
  • females and males of reproductive potential
15
Q

First line tx of depression in pregnancy?

A
  • zoloft
16
Q

Antidepressants and assoc birth defects?

A
  • 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
Q

TCAs used in preg?

A
  • amitriptyline, nortriptyline, desipramine
18
Q

SNRIs used in preg?

A
  • venlafaxine (effexor)
  • duloxetine (cymbalta)

others:
bupropion
trazodone
mirtazipine

19
Q

Depression and correlation with birth defects?

A
  • overall women with depression tx or not will have higher risks of birth defects
20
Q

What is neonatal withdrawal syndrome?

A
  • 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
Q

Main mood stabilizer used in pregnancy? Assoc defects?

A
  • 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
Q

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

A
  • 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
Q

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

A
  • 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
Q

Carbamazepine safety?

A
  • 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
Q

topiramate - risk of defects?

A
  • 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
Q

First gen/typical antipsychotics used? Indications? Safety?

A
  • phenothiazines and butyrophenones
  • for hyperemesis
  • psychotic disorders
  • Category C
  • transient neonatal sxs secondary to extrapyramidal side effects
27
Q

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

A
  • 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
Q

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

A
  • 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
Q

sedatives/hypnotics used in pregnancy?

A
  • zolpidem (ambien), zaleplon (sonata), escopiclone (lunesta)
  • marketed for insomnia
  • preg C
  • no sig pregnancy outcomes
  • most commonly used is ambien
30
Q

Breast feeding benefits?

A
- decreased rates of:
SIDS
GI probs
anemia
respiratory ailments
otitis media
obesity
31
Q

Key principles of lactation pharm?

A
  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
Q

Risk categories in lactation?

A
  • L1 = safest
  • L2 = safer, remote risk
  • L3 = moderately safe, risk possible
  • L4 = possibly hazardous, postive evidence of risk
  • L5 = CI
33
Q

L2 antidepressants?

A
  • zoloft, prozac, elavil, tofranil, pamelor
34
Q

L3 antidepressants?

A

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

35
Q

Mood stabilizers L2?

A
  • tegretol, depakote**, neurontin
36
Q

Mood stabilizers L3?

A
  • lithium - use only with close observation, baby has to have blood levels drawn
  • lamictal
  • topamax: just dont give
  • trileptal
37
Q

Typical antipsychotic - lactation safety?

A

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

38
Q

Atypical antipsychotics - lactation safety?

A
  • L2: seroquel, zyprexa, geodon

- L3: risperdal, abilify, clozaril

39
Q

Benzos lactation safety?

A
  • L3: xanax, klonopin, valium, ativan

- worried about sedation in the infant

40
Q

Hypnotics lactation safety?

A
    • 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
Q

Barriers to tx during pregnancy?

A
  • stigma
  • unacceptability of tx
  • guilt
  • anxiety
  • financial
42
Q

Risk vs Benefit in tx?

A
  • 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)