Week 13: Pregnancy and Lactation Research

Post#2 Pregnancy and Lactation Research by Kathryn Sutherland

The purpose of this discussion board post is to review my case studies for modules 5 and 7 and to apply them to a patient who is pregnant. My thoughts on changing the treatment plan will be shared based on scholarly sources. Additionally, I will be discussing the pharmacological agents chosen in regard to lactation. Furthermore, patient education that is necessary to include will be provided.

Based on the client’s presentation in the module 5 case study and the DSM-5, the patient met the criteria for major depressive disorder and therefore would best be treated with an antidepressant (APA, 2013). The medication I initially chose to prescribe to this patient was Escitalopram 10mg once daily (Stahl, 2017). In terms of the use of Escitalopram during pregnancy, there have not been any randomized control trials investigating this medication. According to Stahl, (2017) during the first trimester and throughout pregnancy, this medication is not generally recommended. When choosing to continue this medication during pregnancy, the risks need to be calculated. The risks of taking this medication include potential alterations of fetal development during the first trimester and a risk of bleeding during delivery in the third trimester. Additionally, neonates that have been exposed to SSRIs during the third semester have developed additional complications (Stahl, 2017). Other findings show that gestation is shorter with antidepressant use as well as lower birth weight (Burt, 2016).

If this medication were to be stopped, there are also additional risks that need to be calculated. The risks of not taking this medication include effects on maternal mental health and the potential for limited mother and child bonding. One study found that there was a 68% relapse rate in women who stopped their antidepressants around the time of conception (Burt, 2016). In terms of lactation, a portion of this medication is found in breast milk and trace amounts have been found in children. Again, the risks of treatment vs nontreatment need to be weighed and considered for both the infant and mother who wish to lactate when taking this medication. The child may become irritable or sedated with the use of escitalopram during lactation. Formula feeding may become necessary if this is the case (Stahl, 2017).

Patient education should be provided to the patient to allow for an informed decision for both use during pregnancy and lactation. Patient education should include the risk of continuing treatment, the risk of stopping treatment, and potential additional options that could be changed in the treatment plan such as increasing therapy and other non-pharmacological interventions during pregnancy. Additional nonpharmacological interventions include getting an adequate amount of exercise, getting adequate sleep, and receiving adequate nutrition and prenatal care. The acuity and the severity of the patient’s condition also need to be considered when adjusting the treatment plan. Prior to making any specific changes, all of these risks and benefits need to be calculated for each specific case.

In the module 7 case study, the patient is presenting in a manic state including, inflated including self-esteem and grandiosity, decreased need for sleep, pressure, and rapid speech, flight of ideas, distractibility, increase in goal-directive behavior. These are all presenting symptoms of a manic episode (APA, 2013). Based on this information, I chose to start the patient on lithium with a starting dose of 300mg QHS and increase until a target lithium level is reached which is considered to be 0.8mEq/L. I also chose to add Risperdal starting dose of 1mg twice per day (Puzantian & Carlat, 2016).

Some experts believe that lithium is still the gold standard treatment for those suffering from bipolar disorder, even in pregnancy (Burt, 2016). This is due to the fact there is a major risk if the patient decompensates. Lithium use during pregnancy has been shown to pose an increase risk of birth defects. However, other mood stabilizers such as valproate have higher rates. There is a higher risk of cardiac anomalies in babies whose mother was taking lithium during pregnancy. Serum lithium levels should be taken every 4 weeks if treatment is continued. Fluid balance should be monitored closely if the patient is continued on therapy as lithium levels can become toxic more quickly. For the patient who does continue on lithium during pregnancy, close monitoring is necessary (Burt, 2016). Full, therapeutic lithium levels are found in breast milk. Bottle feeding is recommended for lithium. Risperdal is also not recommended during breastfeeding as it is found in breast milk (Stahl, 2017).

For the treatment of bipolar disorder, atypical antipsychotics may be preferable over lithium or anticonvulsants for pregnancy. For example, haloperidol has been shown to be useful in the stabilization of manic symptoms and does not carry a risk of birth defects (Hendrick, 2017). The risk/reward benefit and the acuity of the patient’s symptoms need to be taken into consideration when choosing a pharmacological agent for bipolar disorder in pregnancy. Nonpharmacological interventions include encouraging patients to get adequate hydration, sleep, nutrition, and prenatal care. The patient should also be encouraged to attend psychotherapy. Patient education should include the risks, benefits, signs, and symptoms of lithium toxicity and the nonpharmacological interventions.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Burt, V. (2016, July). How to Evaluate and Treat Mood Disorders in Pregnancy. https://www-thecarlatreport-com.regiscollege.idm.oclc.org/the-carlat-psychiatry-report/how-evaluate-and-treat-mood-disorders-pregnancy/.

Hendrick, V. (2021). Bipolar disorder in pregnant women: Screening, diagnosis, and choosing treatment for mania and hypomania. UpToDate. https://www.uptodate.com/contents/bipolar-disorder-in-pregnant-women-screening-diagnosis-and-choosing-treatment-for-mania-and-hypomania?

Puzantian, T. & Carlat, D. (2016). Medication Fact Book for Psychiatric Practice (3rd ed.). Newburyport, MA: Carlat Publishing, LLC.

Stahl, S. (2017). Essential psychopharmacology: The prescriber's guide (6th ed.). Cambridge, England: Cambridge University Press