Psychotropic medication during pregnancy and lactation

Despite the traditional notion that pregnancy is a time of joy and emotional well being, evidence suggests that it does not protect women against mental illness. Untreated mental illness carries wide-ranging repercussions for mother, child and family that often outweigh those associated with treatment. Clinical management is complex, involving competing risks to mother and offspring; the challenge lies in effectively treating mental illness, whilst minimising exposure of the child to harmful medication. The paucity of robust published evidence on which to base the principles of psychiatric care further compounds the issue. Pregnancy significantly affects plasma drug levels and immature foetal/neonatal physiology renders the child prone to damage from pharmacological agents, all of which cross the placenta/enter breast-milk to varying degrees. Risks include teratogenicity, obstetrical complications, perinatal syndromes, and long-term behavioural problems. Despite evidence that some psychotropic drugs may be safe during pregnancy, knowledge regarding the risks of antenatal exposure to medications remains far from complete. The pregnant or breastfeeding woman requires an individualised risk-benefit analysis with regard to the commencement or continuance of psychotropic medication. If treatment is deemed necessary, monotherapy at the lowest possible dose should be prescribed. More robust safety data is available for older psychotropic drugs, which should be employed in preference to newer agents with unestablished safety profiles. Pregnant/breastfeeding women should also be educated with regard to early detection of signs of drug toxicity in both themselves and their babies. Despite shared responsibility, the ultimate decision with regard to reasonable risk, and what constitutes it, rests with the informed patient. Close psychiatric monitoring and coordinated multidisciplinary care with the obstetrician and paediatrician combine with such informed patient choices to comprise the components of a holistic model of care, targeted at optimizing the complex management of women with psychiatric illness during pregnancy.