Psychotropic medications in pregnant women: treatment dilemmas

Objectives: To review the evidence from all studies of adverse effects on infant outcome of psychotropic medications taken during pregnancy. Data sources: MEDLINE January 1976 - February 1998, EMBASE 1976 - February 1998, and bibliographies of retrieved articles. Study selection and data extraction: All studies focusing on adverse effects associated with psychotropic drug use during pregnancy, with a particular focus on prospective controlled studies. Outcome criteria: Congenital anomalies, perinatal complications and neurobehavioural sequelae. Data synthesis: 23 studies were identified, nine of which were prospective controlled studies: five involving antidepressants (tricyclic antidepressants [TCAs] and selective serotonin reuptake inhibitors [SSRIs]), one each involving lithium and carbamazepine, and two involving benzodiazepines. As statistical synthesis was not possible given the heterogeneity of outcome criteria, a qualitative review is provided. Neither the SSRIs nor the TCAs appear to cause major congenital anomalies, but both may be associated with a small increased risk of minor anomalies, prematurity and neonatal complications. Benzodiazepines, lithium, anticonvulsants and chlorpromazine do lead to an increased rate of congenital anomalies as well as neonatal problems. Studies of longer-term neurobehavioural sequelae of psychotropic medications are very limited, but at present do not indicate any adverse effects. Conclusions: While some psychotropes are associated with congenital anomalies and perinatal complications, mental illness per se may also be associated with an adverse outcome in the infant. Clearly, the risks to both mother and infant need to be carefully weighed and discussed with the parents.