Week 13: Pregnancy and Lactation Research

Post#1 Pregnancy and Lactation Research by Barbra Scheirer

Depression

Treating a pregnant patient with antidepressants during the pregnancy is not without risks. Risks of treating the patient include premature, low birth weight, long-term neurodevelopmental abnormalities, neonatal withdrawal syndrome, congenital cardiac complications, especially with paroxetine, and newborn persistent hypertension syndrome (Stahl, 2013). Risks of not treating depression in the pregnant patient include relapse of major depression, increased suicidality, poor self-care, poor motivation for pre-natal care, disruption of mother-infant bonding, self-harm, harm to infant, low birth weight and developmental delays (Stahl, 2013). The patient and practitioner need to discuss and weigh the risks and benefits of treatment versus not treating on a case-by-case basis (Stahl, 2013). Many times, the benefits of continuing treatment outweigh the risks (Stahl, 2013).

For the pregnant and breastfeeding patient with depression, the Va/DoD clinical guidelines on treatment recommend the application of psychotherapeutic approaches such as cognitive behavioral therapy, interpersonal therapy, mindfulness-based cognitive therapy, behavioral therapy, or ACT as first-line treatment (2016). ECT is another recommended option for treatment of depression in pregnant mothers. For medication, antidepressants are recommended. However, it is necessary to ensure that the prescribed medication does not adversely affect the mother and child’s health outcomes. According to Anderson et al. (2020), the best antidepressant to consider for the mother during this period would be sertraline. I would prescribe Sertraline 50 mg po daily and increase up to 200 mg daily. It is considered safe for the mother and the baby, and for the lactating mother as well. Sertraline passes into breast milk in very small amounts and do not have harmful effects on the baby. Mother should monitor baby for adverse effects such as sedation and irritability, which in this case, the drug should be discontinued (Stahl, 2017).

Bipolar Disorder

To treat bipolar disorder in the pregnant or lactating mother, the first-line psychotherapeutic treatment recommended is family-focused therapy, psychoeducation, and bipolar-specific CBT. The first-line pharmacotherapeutic treatment for bipolar disorder in pregnant or lactating women is lithium, which is safe during pregnancy (Stahl, 2017). Lithium should not be administered to patient with Brugada syndrome, kidney disease, cardiovascular disease, or sodium depletion.

During lactation, the drug should be changed to valproic acid. While valproic acid passes into breastmilk, the levels are low or undetectable, and does not affect infants (Tomson et al., 2015). However, infants should be monitored for liver toxicity during this period as valproic acid has such potential effects. Lithium is only considered safe for use in non-pregnant women and women who are not lactating, as it passes into breastmilk and leaves the baby with high lithium levels in the blood. High blood lithium levels may cause the infant to have seizures or go into a coma.

Patient Teaching

Mothers on sertraline must take the medication at the same time each day. If the medication is an oral concentrate, the patient must dilute it with a liquid before taking it. Patient should avoid cola drinks and caffeine because they cause serotonin syndrome leading to sweating, agitation, nausea, and tachycardia, among other symptoms. Patient should monitor unusual changes in their behavior anxiety, and when they develop suicidal ideations.

Mothers with bipolar disorder on medication should notify the clinician if they are taking any anticonvulsant medication before embarking on treatment using valproic acid. When administered to pregnant mothers, valproates increase MCM risk in infants when taken with anticonvulsant medication (Tomson et al., 2015). Lactating patient should monitor the infant for sedation, petechiae, hematuria, and thrombocytopenia and consult their clinician if these symptoms manifest.

References

Anderson, K., Lind, J., Simeone, R., Bobo, W., Mitchell, A., & Riehle-Colarusso, T. et al. (2020). Maternal Use of Specific Antidepressant Medications During Early Pregnancy and the Risk of Selected Birth Defects. JAMA Psychiatry, 77(12), 1246. https://doi.org/10.1001/jamapsychiatry.2020.2453

Department of Veterans Affairs. (2016). VA/DOd Clinical Practice Guideline For The Management Of Major Depressive Disorder. Washington.

Stahl, S. (2013). Stahl's essential psychopharmacology (4th ed.). Cambridge University Press

Stahl, S. (2017). Prescriber's Guide: Antidepressants: Stahl's Essential Psychopharmacology. Cambridge University Press

Tomson, T., Xue, H., & Battino, D. (2015). Major Congenital Malformations in Children of Women with Epilepsy. Seizure, 28, 46-50. https://doi.org/10.1016/j.seizure.2015.02.019