EDITORIAL

PSYCHOTROPIC DRUG USE IN PREGNANCY

E. MOHANDAS

Chief Consultant in psychological

Medicine

Elite Mission Hospital, Trichur.
      The exists so much confusion about the use of psychotropic drugs in pregnancy as both the psychiatrists and obstetricians are very little informed of the teratogenic potential of these drugs. Whether pregnancy places a woman at higher risk for developing psychotic illness is quite controversial an issue (Sitland - Marken et al , 1989). On the other hand there are reports suggesting a protective role of pregnancy against psychiatric illness (Rosenberg & Silver, 1965; Sim,1963). It has been estimated  that 10%(Boethius, 1978) to 36% (Heinonen et al, 1977) of pregnant women report the use of atleast one psychotropic drug during pregnancy. At estimated 3% of all new borns have congenital malformation and around 3% of these are reported to be the result of drugs or environmental chemicals (Globus, 1980; Kalter & Warkany, 1983). The contribution of psychotropic medication to teratogenesis is still unclear (Calabrese & Gulledge, 1985). Excellent reviews on this topic  can be seen elsewhere (Elia et al ,1987;Cohen et al,1989; Andrade, 1991). Literature abounds with anecdotal teratogenic effects of psychotropic drugs, but definite conclusions cannot be drawn because of the many limitation of the reports. These limitation include:
a) No definite conclusion can be drawn from case reports
b) Double-blind studies cnnot be done due to ethical reasons
c) Various confounding factors have to be considered. These factors include meternal age, previous obstetric complications (miscarriage, still birth) other drug use (licit and illicit), physical illness, gravidity, parity, ethnicity, socio-economic group, nutritional status and history of psychiatric disorder.
       An outline on the reported teratogenic effects of psychotropic drugs and the current opinion on their use in pregnancy is outlined below.
NEUROLEPTICS
a) Weak teratogenic potential only; safe in humans during pregnancy.
b) Chronic maternal use may produce some reversible effects in the neonatesedation, agitation, depression of reflexes, respiratory depression and cyanosis. Extrapyramidal signs manifesting in hypertonicity, tremor,poor sucking and swallowing may accur. Neonatal jaundice has been described in some cases.
c) Dose reaching the infant through breast milk is very minimal.
d) Although not contraindicated for use in any trimester of pregnancy, if possible antipsychotics should be avoided between weeks 4 and 10, especially weeks 6 and 10. Phynothiazines with a three-carbon aliphatic side chain may be associated with a greater risk of malformation compared with other phenothiazines.
e) Low potency phenothiazines are more pron to produce maternal orthostatic hypotension, which may contribute to uteroplacental insufficiency.
ANTIDEPRESSANTS
a) Sporadic case reports of congenital malformations, especially skeletal. No confirmation in subsequent studies.
b) Chronic use during third trimester may produce urinary retention and tachyarrhythmias in this neonate.
c) Relatively safe during pregnancy and lactation.
BENZODIAZEPINES
a) No fetal teratogenicity in humans if less than 30 mg of diazepam equivalent is used.
b) Third trimester use may produce floppy infant syndrome and neonatal withdrawal syndrom.
c) Mild sedation may occur in breast-fed infents.
d) Anecdotal case reports of mental deficiency, spastic diplegia, deafness, microcephaly, duodenal atresia, Meckels diverticulum, oral clefts, etc.
LITHIUM
a) The physiological changes of pregnancy such as increased plasma volume, increased glomerular filtration rate and sodium retention lead to greater distribution and elimination of lithium necessitating increased dosage of lithium to maintain therapeutic levels, Lithium does has to be decreased during the last month of pregnancy and discontinued 2 to 3 days before delivery.
b) Cardioteratogenicity potential is very weak (Mogens Shoe, Oct. 1990) although Ebstein anomaly (Risk 5-10%) has been reported in previous studies.
c) Nonteratogenic effects of lithium reported in the literature are: Prematurity, macrosomia, perinatal morality, floppy infant syndrome, congenital euthyroid goitre.
d) Lithium appears in the breast milk at approximately half the maternal serum concentration. The serum lithium level in the breast fed infants is about half of that in the mother in the first week, and one- Third thereafter (Linden and Rich, 1983).
e) If possible avoid lithium carbonate in the first trimester. If exposed to lithium before weeks 12, consider fetal cardiac ultrasound at week 20. After week 12 lithium may be reintroduced. Discontinue or decrease doze by 50% prior to delivery.
REFERENCES:-
    Andrade C (1991) Somatic therapies in pregnancy and lactation: Theoretical issues and clinical guidelines for psychiatric practice. In Current Trends in Neurology and Psychiatry, Edited by E, Mohandas et al, Trichur Psychiatrists Guild, 1-23
    Boethius G(1978) quoted by Christopher L.J., Devel. Med. Child Neurol, 20:380
    Calabrese JR, Gulledge AD (1985) Psychotropics during pregnancy and lactation: a review. Psychosomatics 26:413-426
    Cohen Ls, Heller VL, Resebaum JF (1989) Treatment Guidelines for psychotropic drug use in pregnancy. Psychosomatics 30:25-33
    Elia J, Katz IR, simpson GM (1987) Teratogenicity of Psychotherapeutic medication. Psychopharmacology Bulletin 23:531-586
    Globus N (1980) Teratology for the obstetricians-Current status. Gynaecology55: 269-277
    Kalter J, Warkany J (1983) Congenital malformations Part 1: etiologic factors and their role in prevention Mew England Journal of Medicine 308:424-431
    Linden S, Rich CL (1983) The use of lithium during pregnancy and lactation. Journal of Clinical psychiatry 44:358-361
    Rosenberg AJ, Sikver E (1965) Suicide, Psychiatrists and Therapeutic abortion. California Medicine 102: 407407-411
    Sim M  (1963) Abortion and the psychiatrist. British Medical journal 5350:145-148
    Sitland- Marken PA, Rickman LA, Wells BG, et sl (1989) pharmacologic Management of Acute Mania in pregnancy. Journal of Clinical Psychopharmacology 9: 78-87