Seventeen recommendations for antipsychotic use during pregnancy
The risks of taking antipsychotics during pregnancy have become important clinical topics. Evidence suggests that antipsychotics can elevate risks associated with pregnancy and neonatal prognosis, including preterm delivery, low or high neonatal weight, gestational diabetes, neonatal withdrawal reactions, and abnormal muscle movements. The long-term neurodevelopmental prognosis of neonates exposed to antipsychotics is unknown and has been examined in only four studies, two of which were on first-generation antipsychotics and two on second-generation drugs. The impact of maternal psychiatric disorders (especially schizophrenia and bipolar disorder) on mother and child/mother and daughter cannot be ignored when considering drug-related risks.
The following are 17 recommendations made by the investigators for the use of antipsychotics during pregnancy.
1. Consider the most appropriate form of antipsychotic medication possible before pregnancy, given that the patient may be unknowingly pregnant.
2. Use the lowest effective dose possible. However, the focus should be on “efficacy” rather than “dose. Incomplete treatment can expose the fetus to both treated and untreated risks and should be avoided.
The effects of therapeutic alliances and non-pharmacological treatments should be maximized.
4. Close liaison should be established between functions related to perinatal care, including psychiatry, psychology, obstetrics, pediatrics, midwifery, social work, and maternal and child care.
5. Obtain at baseline those biological indicators that may be affected by the condition and medications.
6. Ensure that the information in the informed consent form regarding the pros and cons of treatment is sufficiently detailed.
Take folic acid 5mg/d in the first trimester and during pregnancy; there is evidence that this may have a neuroprotective effect, as does the multivitamin.
8. Monotherapy whenever possible.
9. Ideally, obstetric care should be done by a medical team specializing in the management of high-risk situations.
10. Fetal development, obstetric physiology and the mother’s mental status should be adequately monitored during the course of pregnancy.
Ultrasound evaluation of the nuchal translucency should be performed at 12 weeks of gestation and a high-resolution fetal morphology scan at 20 weeks.
In view of the possible increased risk of metabolic syndrome and gestational diabetes, a glucose tolerance test should be performed early in midterm pregnancy (14-16 weeks) instead of a glucose screening test; these tests should be repeated at 28 weeks of gestation.
Given the increased risk of impaired fetal growth (low or high weight), scans should be performed at 28 and 34 weeks of gestation for fetal growth; repeat after 34 weeks of gestation as indicated by the physician.
14. At delivery, observe the neonate for withdrawal symptoms, toxic reactions, extrapyramidal reactions, sedation and other adverse effects; ensure thorough morphological examination is performed.
15. After delivery, establish and apply a mental health care plan (Mental Health Care Plan): low-stimulation environment; ensure sleep; close liaison between departments; and extend the mother’s stay, if necessary, to observe any neonatal abnormalities secondary to antipsychotic exposure.
16. Identify early warning signs of psychiatric relapse and the medical pathway after relapse.
17. Give clear recommendations and preferences for breastfeeding, whether breastfeeding or not; ideally, discuss the pros and cons of specific medications prior to delivery; circumvent the inhibitory effects of medications on breastfeeding.