Reproductive psychiatry

What medication is the Spina Bidifa birth defect most common with ?

VPA

Is epilepsy a contraindication to pregnancy?

No

What 2 drugs pose the highest risk for pregnancy in epilepsy

VPA

Topirimate

______ AED doses tend to increase risk of brith defects in Pregnancy

Higher

AEDs taken during the _______ trimester increase the risk of defects in the offspring of WWE

First

_______ probably does not substantially increase the risk of defects in the pddpring of WWE

Crabamazepine

What AEDs post the highest risk of poor neurodevelopmental outcomes in baby

VPA

Phenobarbital

What 2 drugs increase in clearance during pregnancy and how do we adjust dose?

Lamotrigine & Lithium

may need to increase dose, decrease right when baby comes

Is breasfeeding while on AEDs OK?

•Breastfeeding is good and OK except sedating drugs

Highly protein bound drugs are _______ likely to go into breast milk

Less

Are antipsychotics associated with increased risk for malformationsi n pregnancy

No

Second gen antipsychotics are associated with what risks in pregnancy

weight gain and gestational diabetes in pregnant individual, increased infant size, poor neonatal adaptation syndrome, neurodevelopment delays that resolve by 12 month

First gen antipsychotics are associated with what risks in pregnancy

low birth weight, preterm delivery, transient EPS and withdrawal with 3rd trimester use

Recommendations for antipsychotic use in pregnancy

generally antipsychotic patient has been taking will be continued if efficacious

Close metabolic monitoring during pregnancy

Lithium poses a risk of _______ in the 1st trimester in pregnancy

Cardiac malformations in baby

Reccommendations for Lithium in Pregnancy

• Provide education on teratogenic risks of lithium and discuss birth control options with individuals who could become pregnant

• Avoid use in individuals considering pregnancy

• If used during pregnancy, avoid use during first trimester if possible

• Increase frequency of lithium monitoring and dose adjust as needed (usually require higher doses during pregnancy)

• reduce dose to pre-pregnancy levels postpartum

What bipolar meds pose the higest risk of teratogenicity

VPA

Lithium

What bipolar meds pose the lower risk of teratogenicity

Lamotrigine

Second gen antipsychotics

Antidepressants (adjunct)

Benzo use in pregnancy

Not reccommended- if neccessary, at least taper before delviery

Postpartum depression

Postpartum depression generally refers to depression during the 12 months following birth

Onset of depression symptoms can occur prior to, during or after pregnancy:

Treatmeant of mild to moderate postpartum depression

Start with psychotherapy

Antidepressants if psychotherapy not effective or available)

Which antidepressants for postpartum

SSRI

SNRI

Bupropion

Mirtazepine

Treatmeant of severe postpartum depression

1) Start with antidepressant

2) Consider Zuranolone or Brexanolone if not antidepressant not effective

Risks of SSRIs/SNRIS in pregnanacy

Newborns who have been exposed to SSRIs/SNRIs in utero occasionally experience neonatal adaptation syndrome (NAS), which generally exhibits as some combination of respiratory distress 7, 23-26, feeding difficulty 23, 27, jitteriness 23, irritability, temperature instability 23, 24, sleep problems 28, tremors 29, ...

General Reccs of antidepressant use in pregnancy

• joint decision between individual and their provider

• present with risks of both antidepressant use during pregnancy and untreated depression for informed decision

• If antidepressant is to be continued, recommend agent individual is currently taking (if effective and well tolerated)

• If newly starting antidepressant during or after pregnancy, usually select SSRI based on previously discussed factors, also considering compatibility with breast feeding

• Utilize lowest effective dose, increase frequency of monitoring, adjust doses as necessary

FDA approved meds for Post partum depression

Zuranolone

Brexanolone

Zuranolone dosing

50mg/day PO in the evening with fatty meal (absorption) for 14 days

Zuranolone time to benefit

3 days

Zuranolone ADEs & warnings

ADEs: somnolence, headaches

Warnings: driving impairment due to CNS depressant effects, advised not to drive for at least 12 hours after taking the pill

T/F Brexanolone Requires onsite clinician monitoring for excessive sedation or loss of consciousness

True

Brexanolone Dosing

Administered continuously over 60 hours as single IV infusion (inpatient setting)

Brexanolone time to benefit

(24 – 60 hours)

Brexanolone ADEs

dry mouth, flushing/hot flashes, loss of consciousness, sedation/somnolence