Obstetric and Fetal Pharmacology is an important clinical issue for physicians and patients because of the potential for teratogenic risk, perinatal syndromes, and effect on neonatal development. This page focuses specifically on (Obstetric and Fetal Psychopharmacology). Decisions regarding treatment should be a shared decision between obstetric and mental health clinicians, and the patient before the pregnancy occurs whenever possible. Untreated psychiatric illness comes with its own risks, including significant impacts on maternal and neonatal health, including suicide and infanticide.
Medications[1] | |
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No Effect (Safe to use) | • Benzodiazepines: diazepam, clonazepam, lorazepam • Divalproex, valproic acid • Gabapentin • Pregabalin • Lacosamide • Levetiracetam |
Decreased Effectiveness | • Carbamazepine • Clobazam • Lamotrigine (>300 mg/day may reduce contraceptive efficacy; <150 mg/day does not appear to affect efficacy) • Oxcarbazepine • Phenobarbital • Phenytoin • Topiramate (>200 mg/day) |
Medication | Recommendations |
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Paroxetine | Use in pregnant women and women planning pregnancy should be avoided, if possible. Fetal echocardiography should be considered for women who are exposed to paroxetine in early pregnancy. |
Effects | |
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Lithium | Exposure in pregnancy is associated with a small increase in congenital cardiac malformations (including Ebstein's anomaly) with a risk ratio of 1.2–7.7. |
Valproic acid | Exposure in pregnancy is associated with an increased risk neural tube defects, fetal valproate syndrome, and long-term adverse neurocognitive effects. It should be avoided in pregnancy, if possible, especially during the first trimester. |
Carbamazepine | Exposure in pregnancy is associated with fetal carbamazepine syndrome. It should be avoided in pregnancy, if possible, especially during the first trimester. |
Medication Class | Birth Defects | Pregnancy | Delivery | Neonatal | Lactation | Treatment Options |
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Benzodiazepines | Possible increased incidence of cleft lip or palate | Ultrasonography for facial morphology | Floppy infant syndrome | Neonatal withdrawal syndrome | Infant sedation reported | Clonazepam, lorazepam, alprazolam |
SSRIs, SNRIs, TCAs | None confirmed | Decreased serum concentrations across pregnancy | None | Neonatal withdrawal syndrome | None | Fluoxetine, sertraline, paroxetine, citalopram, nortriptyline |
Lithium | Increased incidence of heart defects (Ebstein's anomaly) | Ultrasonography or fetal echocardiography for heart development or both. Decreased serum concentrations across pregnancy | Intravenous fluids. Increased risk for lithium toxicity in mother | Increased risk for lithium toxicity in infant. Risk of birth increased weight. | Monitor infant CBC, TSH, and lithium levels | Sustained release lithium |
Antiepileptics | Increased incidence of birth defects | Decreased serum concentrations across pregnancy. Need folate supplementation, Vitamin K for some antiepileptic drugs | None | Neonatal symptoms, need to give Vitamin K for some anti-epileptic drugs | Monitor infant CBC, liver enzymes, and antiepileptic drug levels | Lamotrigine, carbemazepine |
Antipsychotics | None Confirmed | Avoid anticholinergic medications for side effects. | None | Possible risk for neuroleptic malignant syndrome and intestinal obstruction | None | Haloperidol |
Guideline | Location | Year | Website | |
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BC Best Practice Guidelines for Mental Health in the Perinatal Period | Canada | 2014 | Link | |
American College of Obstetricians and Gynecologists (ACOG) Psychotropic Medication Guidelines | USA | 2008 | • Link (AAFP) • Link (ACOG) |
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American Psychiatric Association (APA) and ACOG Depression Guidelines | USA | 2009 | - | Link |
National Institute for Health and Care Excellence (NICE) | UK | 2014, 2020 | - | Link |
British Association for Psychopharmacology (BAP) | UK | 2017 | Link | |
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) | Australia, New Zealand | 2018 | Link |