Pregnancy and breastfeeding
The spontaneous abortion rate in confirmed pregnancies is 10-20% and the risk of spontaneous major malformation is 2-3% (1 in 40). Drugs account for approximately 5% of all abnormalities.
Both valproate and carbamazepine are associated with an increased risk of spina bifida (1-2% and 0.5-1% respectively). Valproate is considered more dangerous than carbamazepine.
Lithium is associated with Ebstein's anomaly (relative risk 10-20 times that of control, absolute risk 1:1000)
Benzodiazepines appear to be associated with oral clefts in newborns and floppy baby syndrome.
Olanzapine is recommended by the Maudsley guidelines in the situation of a pregnant patient in need of an antipsychotic.
Paroxetine is more commonly associated with neonatal withdrawal than other SSRIs, it is also associated with an increased risk of congenital malformations (particulaly heart defects) compared with other antidepressants (Thormahelen 2006).
The following table shows the current Maudsley Guidelines on prescribing in pregnancy and breastfeeding.
Thormahelen G. Paroxetine Use During Pregnancy: Is it Safe? Ann Pharmacother October 2006 vol. 40 no. 10 1834-1837
Both valproate and carbamazepine are associated with an increased risk of spina bifida (1-2% and 0.5-1% respectively). Valproate is considered more dangerous than carbamazepine.
Lithium is associated with Ebstein's anomaly (relative risk 10-20 times that of control, absolute risk 1:1000)
Benzodiazepines appear to be associated with oral clefts in newborns and floppy baby syndrome.
Olanzapine is recommended by the Maudsley guidelines in the situation of a pregnant patient in need of an antipsychotic.
Paroxetine is more commonly associated with neonatal withdrawal than other SSRIs, it is also associated with an increased risk of congenital malformations (particulaly heart defects) compared with other antidepressants (Thormahelen 2006).
The following table shows the current Maudsley Guidelines on prescribing in pregnancy and breastfeeding.
| Drug class | Suggested in pregnancy | Suggested in breastfeeding |
|---|---|---|
| Antidepressants | Fluoxetine, sertraline, amitriptyline, imipramine, (avoid paroxetine, clomipramine, and all MAOI) | Sertraline |
| Antipsychotics | Olanzapine, quetiapine, haloperidol, clozapine, chlorpromazine | Olanzapine |
| Mood stabilisers | Avoid if at all possible, antipsychotic with mood stabilising properties is preferred | Avoid if possible and use antipsychotics instead. Valproate is recommended if essential |
| Sedatives | Promethazine (widely used but little data) Benzodiazepines (probably not teratogenic but avoid in late pregnancy due to floppy baby syndrome) | For anxiety - Lorazepam For insomnia - Zolpidem |
Thormahelen G. Paroxetine Use During Pregnancy: Is it Safe? Ann Pharmacother October 2006 vol. 40 no. 10 1834-1837
