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Safety of psychotropic drugs for pregnant and breastfeeding women
- AK Al-Sheikhli (28 October 2004)
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A Question
- Larry Culliford (29 October 2004)
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Dangers of psychotropic drugs for pregnant and breastfeeding women
- Ellen C G Grant (29 October 2004)
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We ought never to forget Thalidomide?
- AK Al-Sheikhli (29 October 2004)
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A Correction
- Louise Howard, Roger Webb, University of Manchester (3 November 2004)
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Judious treatment of psychosis should not be withheld during pregnancy
- Jai B Sharma, Prof Suneeta Mittal, Prof DN Mendhekar (3 November 2004)
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Periconceptional care is important in psychosis
- Monika Malhotra (4 November 2004)
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Prescribing for breastfeeding mothers
- Carol MA Campbell (23 November 2004)
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Research on psychotropic drugs in pregnant and breastfeeding women
- Eileen McGinn (8 January 2005)
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AK Al-Sheikhli, Psychiatrist Medical Centre,Nuneaton,CV11 5HX,UK
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EDITOR--It was interesting to read the editorial of Howard et al(1). My comment: 1.During pregnancy, we ought to avoid the use of certain drugs for e.g mood stabilisers, such as lithium, valporates, cabamazepine, also benzodiazipines, atypical antipsychotics. We ought to avoid the use of polypharmacy drugs. Check whether the drug crosses the placenta, e.g, from general medicine, unfractioned heparin and low molecular weight heparins do not cross the placenta and are probably safe for the fetus; in contrast to heparin, coumarin cross the placenta and can cause bleeding in the fetus and teratogenicity(2). Avoid drugs with long half-life. 2.Regarding breastfeeding women, although it is well known that all tricycic antidepressants, SSRIs, other new antidepressants, mood stabilisers, benzodiazepines, atypical and conventional antipsychotics, are all excreted in the milk, the amount varies according to the drug, dose, patient, frequency of taking the drug, its metabolites whether active or not?, half-life of the drug..etc. So I think certain group of drugs ought not to be used, like mood stabilisers, benzodiazepines, and atypical antipsychotics. Also we ought to avoid polypharmacy. 3.Whether to use the drug in breastfeeding or pregnant women, we ought not to use certain drugs like mood stabilisers..etc. Avoid polypharmacy, avoid drugs which are known to cross the placenta, or are excreted in good amounts in the milk of breastfeeding women, and after all to be familiar with few drugs which they have been in use for long time, so the bad we know is better than the good we don't know? Thanking you,
References, 1.Howard L,Webb R,and Abel K,Safety of antipsychotic drugs for pregnant and breastfeeding women with non-affective psychosis,BMJ 2004;329:933-934. 2.Jilma E,Sridhar K,and LipG,ABC of antithrombotic therapy:Antithrombotic therapy in special circumstances,1-pregnancy and cancer,BMJ 2003;326:37- 40. Competing interests: None declared |
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Larry Culliford, Consultant Psychiatrist Brighton CMHC, 79 Buckingham Road, Brighton, BN1 3RJ
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Do 2% of women really develop a non-affective psychosis? This seems like a very high figure. Competing interests: None declared |
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Ellen C G Grant, physican and medical gynaecologist KT2 7JU, UK
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What causes postpartum depression? The sudden falls in high levels of oestrogen and progesterone can cause depressive mood changes after childbirth. Falls in hormone levels premenstrually and postmenopausally can have a similar effects but why do some women have problems coping with these physiological changes? The obvious answer is that lack of enzyme co-factors such as zinc, copper and magnesium or deficiencies in B vitamins and essential fatty acids, impair normal mechanisms which should be able to respond flexibly, even in many of those with genetic predispositions to psychotic mental illnesses. This approach is advocate by The Schizophrenia Society of Great Britain and is widely appreciated by many patients. Until nutritional analyses becomes generally used, many women, and indirectly their infants, will be given potentially dangerous drugs instead of the essential nutrients they both usually need. Competing interests: None declared |
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AK Al-Sheikhli, Psychiatrist Medical Centre,Nuneaton,CV11 5HX,UK
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EDITOR--In response to the editorial of Howard et al(Journal 2004;329:933- 934), we ought not to forget thalidomide. It was a sedative which was synthesised in 1954 in Grunenthal, Germany, licensed 4 years later as a sedative, to be discontinued in 1961 for its teratogenic effect. So before prescribing any drug to a pregnant women, among which are psychotropic drugs, we ought to remember thalidomide. Thanking you,
Competing interests: None declared |
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Louise Howard, Senior Lecturer in Women's Mental Health Health Services Research Department, Institute of Psychiatry, King's College London, Roger Webb, University of Manchester
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Thank you for giving us the opportunity to correct this. The correct statistic should be "approximately 0.2-0.3% of women of childbearing age develop a nonaffective psychotic disorder" rather than "2% of women develop a non-affective psychotic disorder". Competing interests: None declared |
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Jai B Sharma, Assistant Professor of Obstetrics and Gynaecology All India Institute of Medical Sciences, New Delhi 110016, Prof Suneeta Mittal, Prof DN Mendhekar
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The article on antipsychiatric medication during pregnancy and lactation by Howard et al is a very timely article as this area of obstetric care is becoming more and more common and important more so due to more and more cases of psychiatric disorders being diagnosed and treated by medication during pregnancy and lactation.There is little consensus as to which,if any, medicines are absolutely safe for mother and fetus during pregnancy for anti-psychiatric treatment. The psychiatric conditions can not be left untreated in pregnancy as significant associations have been observed between schizophrenia and premature rupture of membranes, low birth weight, prematurity, forceps delivery and onset of scizophrenia in the children later (1).Pregnancy can potentiate underlying affective symptomatology psychosis.There are ethical and legal dilemmas in the management of schizophrenic patients during pregnancy particularly ethical and legal considerations that center on the right of the mother as well as continually evolving definition of fetal rights (2). Although we argue whether the antipsychiatric medications are safe for the mother and baby or not, not treating the patients is often associated with poor maternal and perinatal outcome.We have reported a case of an illegitimate pregnancy in an untreated scizophrenic patient who was brought to the doctors for the first time at 34 weeks and had developed preeclampsia and delivered a male baby weighing 2350 g with Apgar score of 4 at 1 minute. Baby had seizures on third day and was found to have bilateral inguinal hernias and pneunonia of lower lung zone and was found to have atrial septal defect with valvular pulmonary stenosis on echocardiography (3).While appropriate and timely treatment of psychosis with olanzapine or clozapine during pregnancy was associated with successful pregnancy outcome for both mother and baby in our experience(3,4). We feel a pregnancy in a psychiatric patient is a high risk pregnancy needing continuous treatment by a dedicated team of a psychiatrist, an obstetrician and a neonatologist and appropriate antipsychiatric medication should be given to them even in first trimester. They should be regularly seen in antenatal clinic with serial ultrasonic monitoring for fetal growth and wellbeing for satisfactory outcome. An effective contraception should be used by them to avoid unwanted pregnancies. References: 1.Jones JB, Rantakallio P, Hartikainen et al. Schizophrenia as a long term outcome of pregnancy,delivery and perinatal complications:a 28 years followup of the 1966 North Finland General Population Birth Cohort. Am J Psychiatry 1998;155:355-364. 2.Pozzo EE, Marsh FH. Psychosis and pregnancy: some new ethical and legal dilemmas for the physician. Am J Obstet Gynecol 1987;156:426-7. 3.Sharma JB, Mendhekar DN, Jiloha RC, Malhotra M, Wadhwa L. Pregnancy outcome in an illegitimate pregnancy in an untreated schizophrenic patient. Int J Gynecol Obstet Ind 2004;7:49-50. 4. Mendhekar DN, War L, Sharma JB, Jiloha RC. Olanzapine and pregnancy. Pharmacopsychiatry 2002;35:122-3. 5. Mendhekar DN, Sharma JB, Srivastava PK,War L. Clozapine and pregnancy. J Clin Psychiatry 2003;64:850. Competing interests: None declared |
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Monika Malhotra, Specialist Registrar in Obstetrics and Gynaecology Guy's and St Thomas Hospital, London
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The article by Howard et al on antipsychiatric medication during pregnancy and breast feeding raises certain questions. The psychiatric conditions during pregnancy will be more often seen in future due to more stressful conditions, better and early diagnosis and availability of better antipsychiatric drugs. The psychiatric conditions and the antipsychiatric medication often cause hyperplolactinemia and amenorrhoea making diagnosis of pregnancy more difficult. With the result the patients are not adequately treated during the most crucial phase of embryogenesis putting the patient and her fetus at jeopardy as they may get drugs which may not be safe in pregnancy. Ideally all women in reproductive age group with psychosis should be considered potentially at risk of pregnancy and should be adequately treated with safer medicines to avoid any adverse effect of the disease or medication on the mother and fetus. They should use an effective contraception if they are not planning pregnancy. In case of pregnancy they should be regularly monitored from early pregnancy by obstetrician, psychiatrist, social worker and paediatrician. They should be given folate supplementation and should have serial fetal monitoring with ultrasound including an anomaly scan in second trimester to rule out any fetal anomaly and for fetal well beiong and growth later for better pregnancy outcome. Competing interests: None declared |
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Carol MA Campbell, community paediatrician (staff grade) Community Paediatric Department, Bridgeview House, Gransha Park, Londonderry BT47 1TN
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Howard et al (1) stress the desirability of breastfeeding exclusively for six months, and also the importance of knowing the safety of medication taken during lactation. Most drugs taken by a breastfeeding mother appear in her milk in only miniscule quantities (there are some important exceptions). It is therefore almost always possible to select appropriate medication, and rarely necessary to withhold treatment or to recommend that breastfeeding should be abandoned because of treatment. Unfortunately, a number of commonly used sources, including the British National Formulary, give very limited information on the use of drugs in lactation. Hale (2) provides an excellent review, updated two- yearly, of hundreds of drugs with respect to their pharmacology and safety or otherwise during lactation. His book would be a valuable asset in all hospital and primary care settings used by breastfeeding mothers. It may be ordered from www.iBreastfeeding.com and www.babyfriendly.org.uk. References 1. Howard L, Webb R, Abel K. Safety of anti-psychotic drugs for pregnant and breastfeeding women with non-affective psychosis. BMJ 2004;329:933-4 2. Hale TW. Medications and mother's milk (11th ed.). Pharmasoft Publishing: Amarillo, 2004. Competing interests: None declared |
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Eileen McGinn, MPH NY NY 10003
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The fact that so little is known about psychotropic drugs and pregnancy/lacation, either about risk factors or protective factors for mother and infant, despite the widespread use of these drugs in the general population, is a public health nightmare. Several types of research other than clinical trials are available to inform us about benefits and harms associated with psychotropic drugs used during preganancy and lactation. Molecular, cellular, animal and epidemiologial research is available to offer insights about outcomes of pregnancies with neonates exposed to various drugs. We have long known about higher rates of teratogenicity with lithium and antiepileptic drugs. In 2003, we learned about the withdrawal syndromes of neonates exposed to SSRIs in utero. At the end of 2004, we learned that rodents exposed in utero to SSRIs had "significant detrimental effects on bone mineral accrual" with "reduced mass". 1 We also learned that treatment of developing mice with fluoxetine "produced abnormal emotional behaviors in adult mice", which developed anxious,helpless behavior as adults 2. At the Society for Neuroscience annual meeting in October 2004, researchers discussed their "concerns about the safety of the most widely prescribed antidepresants in preganant women and young children". 3 We know that all atypical antipsychotic drugs, especially olanzapine and clozapine are associated with metabolic syndrome. After three years, 35% of people chronically treated with olanzapine have developed diabetes. We need much more knowledge about nutrients, supplements, support systems, and ways to reduce stressors and personal triggers for episodes of psychosis during pregnancy and beyond. Incidence of post-partum psychosis should be studied for clues as to how to reduce this problem. Databases should be mined now to give us more information about pregancy outcomes, and ways to improve them. 1 Endocrinology 2004 November 11 2 Science 2004 October 29;306(5697):879-81 3 WebMD October 26, 2004 Early Exposure to Prozac May Up Anxiety Risk Competing interests: None declared |
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