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Psychiatric disorders in pregnancy, is there a cure for tinnitus 2011 - Test Out

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Mental health disorders in pregnancy. Mental health issues in antenatal and postnatal period.
Although pregnancy has typically been considered a time of emotional well-being, recent studies suggest that up to 20% of women suffer from mood or anxiety disorders during pregnancy. Although data accumulated over the last 30 years suggest that some medications may be used safely during pregnancy, knowledge regarding the risks of prenatal exposure to psychotropic medications is incomplete. While these categories are often used to make decisions regarding medication use during pregnancy, this category system has important limitations: Often there is a paucity of human data used to designate category assignment, and new data are infrequently used to update category assignment. Most psychiatric medications are labeled as “C” or “D,” without a clear demarcation in safety between the these categories.
Women with histories of psychiatric illness frequently come in for consultations regarding the use of psychotropic medications during pregnancy. Decisions regarding the initiation or maintenance of treatment during pregnancy must reflect an understanding of the risks associated with fetal exposure to a particular medication but must also take into consideration the risks associated with untreated psychiatric illness in the mother. Depression and anxiety during pregnancy have been associated with a variety of adverse pregnancy outcomes.
All medications diffuse readily across the placenta, and no psychotropic drug has yet been approved by the Food and Drug Administration (FDA) for use during pregnancy.
Although the data suggest that some medications may be used safely during pregnancy if clinically warranted, our knowledge regarding the long-term effects of prenatal exposure to psychotropic medications is incomplete. Behavioral teratogenesis refers to the potential of a psychotropic drug administered during pregnancy to have long-term neurobehavioral effects. Bupropion may be an option for women who have not responded to fluoxetine or a tricyclic antidepressant, as data thus far have not indicated an increased risk of malformations associated with bupropion use during pregnancy. Scant information is available regarding the reproductive safety of monoamine oxidase inhibitors (MAOIs), and these agents are generally not used in pregnancy as they may produce a hypertensive crisis when combined with tocolytic medications, such as terbutaline. With regard to the newer antidepressants, prospective data on 150 women exposed to venlafaxine (Effexor) during the first trimester of pregnancy suggest no increase in risk of major malformation as compared to non-exposed controls. Another prospective study assessed outcomes in 147 women taking either nefazodone (n=89) or trazodone (n=58) during their first trimester of pregnancy and compared them to two control groups of women exposed to either non-teratogenic drugs (n = 147) or to other antidepressants (n=147). For women with bipolar disorder, maintenance treatment with a mood stabilizer during pregnancy can significantly reduce the risk of relapse. While other anticonvulsants are being used more frequently in the treatment of bipolar disorder, there is limited information on the reproductive safety of these newer anticonvulsants, specifically gabapentin (Neurontin), oxcarbazepine (Trileptal), tigabine (Gabitril), levetiracetam (Keppra), zonisamide (Zonegran). Atypical antipsychotic medications are increasingly being used to treat a spectrum of psychiatric disorders, including psychotic disorders and bipolar disorder, as well as treatment refractory depression and anxiety disorders.
For the latest information on psychiatric disorders during pregnancy, please visit our blog. Welcome to the Massachusetts General Hospital Center for Women’s Mental Health, a perinatal and reproductive psychiatry information center.
Influenza during pregnancy is not only miserable for Mom, but new research has shown that it may be linked to developing bipolar disorders later in life. Researchers combed over medical records from 1959 to 1966 of pregnant women who received obstetric care from Kaiser Permanente Health Plan’s Northern California region as well as records from a county behavioral facility. They found 72 cases of bipolar disorder through interviews of 214 individuals, and another 23 from a previous study called Prenatal Determinants of Schizophrenia Study, which also asked about bipolar disorder. When compared to individuals who had no psychiatric disorders, and comparing influenza rates in their mothers, it was found that bipolar disorder was nearly 4 times more likely to occur if Mom had influenza during her pregnancy.

The study was weakened by the very small sample size they had to work with, but it is still something that pregnant women should consider during flu season. The study didn’t find an increased incidence of bipolar disorder with other respiratory or viral illnesses, but it’s still a good idea to try to keep those germs at bay -- nothing is more miserable while pregnant than being sick. Particularly vulnerable are those women with histories of psychiatric illness who discontinue psychotropic medications during pregnancy. One study indicated that during the course of pregnancy, 70.8% of the women experienced at least one mood episode.
Thus, it is relatively common for patients to discontinue or to avoid pharmacologic treatment during pregnancy. Food and Drug Administration (FDA) provided guidelines to drug companies for labeling medications with regard to their safety during pregnancy.
The FDA is currently working on improving the current labeling system, and they are considering the provision of more information about the risks and benefits in a descriptive format and information about the risks of the untreated disorder for which the medication is used. Not infrequently, women present with the first onset of psychiatric illness while pregnant. Psychiatric illness in the mother is not a benign event and may cause significant morbidity for both the mother and her child; thus, discontinuing or withholding medication during pregnancy is not always the safest option.
Women who suffer from psychiatric illness during pregnancy are less likely to receive adequate prenatal care and are more likely to use alcohol, tobacco, and other substances known to adversely affect pregnancy outcomes. When prescribing medications during pregnancy, one must consider the following risks associated with prenatal exposure: risk of teratogenesis, risk of neonatal toxicity, and risk of long-term neurobehavioral sequelae. During the earliest stages of pregnancy, formation of major organ systems takes place and is complete within the first 12 weeks after conception.
Because neuronal migration and differentiation occur throughout pregnancy and into the early years of life, the central nervous system (CNS) remains particularly vulnerable to toxic agents throughout pregnancy.
There has been particular controversy around paroxetine use in pregnancy, as past reports have suggested that first trimester exposure to paroxetine was associated with an increased risk of cardiac defects including atrial and ventricular septal defects. The most recent information from the Bupropion Pregnancy Registry maintained by the manufacturer GlaxoSmithKline includes data from 517 pregnancies involving first trimester exposure to bupropion. Importantly, neonatal effects have been reported with both untreated mood and anxiety disorders, as well as with medication, and limited studies have adequately teased out these variables.
The first of these studies followed a cohort of 135 children who had been exposed to either tricyclic antidepressants or fluoxetine (Prozac) during pregnancy (most commonly during the first trimester) and compared these subjects to a cohort of non-exposed controls. However, many of the medications commonly used to treat bipolar disorder carry some teratogenic risk when used during pregnancy. Also, valproate exposure during pregnancy has been associated with poorer neurocognitive development in children followed to three years of age. The International Lamotrigine Pregnancy Registry was created by GlaxoSmithKline (GSK) in 1992 to monitor pregnancies exposed to lamotrigine for the occurrence of major birth defects.
In clinical practice, higher potency neuroleptic agents such as haloperidol (Haldol), perphenazine (Trilafon), and trifluoperazine (Stelazine) are recommended over the lower potency agents in managing pregnant women with psychiatric illness. To this end, the National Pregnancy Registry has been created to prospectively gather information regarding outcomes in infants exposed in utero to these newer atypical antipsychotic medications. Food and Drug Administration (FDA) recently updated labels for the entire class of antipsychotic drugs to include warnings regarding the use of antipsychotic drugs (both the typical and atypical agents) during pregnancy. Exposure during pregnancy at any time was correlated with an increased risk, although third-trimester influenza infections seemed to be associated with a higher risk.

We are thankfully mostly out of influenza season this year, but pregnant women are usually encouraged by their doctors to get a flu vaccine. In a recent study which prospectively followed a group of women with histories of major depression across pregnancy, of the 82 women who maintained antidepressant treatment throughout pregnancy, 21 (26%) relapsed compared with 44 (68%) of the 65 women who discontinued medication. Many pregnancies are unplanned and may occur unexpectedly while women are receiving treatment with medications for psychiatric disorders.
Therefore, discussion around risks of exposures during pregnancy may be broken down by the timing of exposure or trimester, with particular vigilance around first trimester exposures.
While exposures to teratogens early in pregnancy may result in clear abnormalities, exposures that occur after neural tube closure (at 32 days of gestation) may produce more subtle changes in behavior and functioning. Among the TCAs, desipramine and nortriptyline are often preferred since they are less anti-cholinergic and the least likely to exacerbate orthostatic hypotension that occurs during pregnancy.
In another report, there were no differences in malformation rates among women who took mirtazapine (Remeron) (n=104) during pregnancy as compared to women who took other antidepressants or controls exposed to known nonteratogens. In general, the SSRIs, specifically fluoxetine, citalopram, and sertraline, are the antidepressants most commonly used during pregnancy.
These syndromes appear to affect about 25% of babies exposed to antidepressants late in pregnancy. Another limitation is that few studies have attempted to assess maternal mood during pregnancy or at the time of delivery.
One important consideration is that discontinuation of or reductions in the dosage of mediation in the latter part of pregnancy may increase the risk of postpartum depression, as the postpartum period is a time of increased vulnerability to psychiatric illness and depression or anxiety during pregnancy has been associated with postpartum depression. For this reason, some women may choose to use an atypical antipsychotic agent during pregnancy (especially during the first trimester) in order to avoid using a known teratogen, such as lithium or valproic acid.
The new drug labels now contain more details on the potential risk for abnormal muscle movements (extrapyramidal signs or EPS) and withdrawal symptoms in newborns exposed to these drugs during the third trimester of pregnancy. In addition to avoiding the virus for your own health and safety, new research has linked maternal influenza infection with an increased risk of their child developing bipolar disorder later in life. For newer drugs, this designation usually occurs in the absence of systematic human pregnancy data.
Many women may consider stopping medication abruptly after learning they are pregnant, but for many women this may carry substantial risks.
Preterm delivery is another potential pregnancy complication among women experiencing distress during pregnancy. Since the initial report on this topic, three studies have found no association between antidepressant use during pregnancy and PPHN, and one study showed a much lower risk than the 1% originally reported.
A more recent report from the same group that followed a cohort of children exposed to fluoxetine or tricyclic antidepressants for the entire duration of the pregnancy yielded similar results. Pregnancy complications related to maternal depression and anxiety in late pregnancy have also been described, including an increased risk for having pre-eclapsia, operative delivery, and infant admission to a special care nursery for a variety of conditions including respiratory distress, hypoglycemia, and prematurity. Of all of the medications used for psychiatric disorders, the one with the greatest potential of serious birth defects is valproate (valproic acid, Depakote). With a risk of neural tube defect ranging from 1 to 6%, this drug is often considered one of last resort in reproductive aged women, since the risk for teratogenicity is high in very early pregnancy, before many women realize they are pregnant.

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