I have a patient with bipolar II disorder who is stable on Abilify and Lexapro.
She was on Seroquel during her first pregnancy, and had a healthy baby, but she does not want to go back on Seroquel as she tolerates Abilify much better.
Is there a greater risk to the fetus if she remains on Abilify and becomes pregnant than there would be if she switches to Seroquel and becomes pregnant?
Also, since she wishes to remain on current meds if possible, do I need to do a taper since her depression has been in remission about 16 months?
Answered by:
Kristen Leight
This case raises many important issues about the treatment of psychiatric illness, and bipolar disorder in particular, during pregnancy.
As a general principle, decisions about medication treatment during pregnancy must weigh the risks of illness exposure against the risks of fetal exposure to medication. Pregnancy does not protect women with bipolar disorder from mood episodes, and the postpartum period is one of extremely high risk for the development of mood episodes, as well as for postpartum psychosis. Studies suggest that women with bipolar disorder who discontinue their medications prior to pregnancy are at higher risk for recurrence of symptoms, particularly depression, during pregnancy.
Decisions regarding medication management of bipolar disorder during pregnancy must be made on an individual basis and take into account many factors, including, but not limited to, the woman's history of illness, severity of episodes, history of self-injury/suicidality/violence, prior response to medications, and treatment compliance, as well as her social supports and her level of functioning. The woman and her partner's preference about medication treatment should be strongly weighted in the decisions. Pre-conception planning, as in this case, is optimal.
In general, it is advisable for a woman to be on as few medications as possible during pregnancy, and at the lowest effective dose possible. If there is time during pre-conception planning, a woman might be tried on a medication that has more available reproductive safety information. All psychotropic medications diffuse across the placenta, and none has been approved by the FDA for use during pregnancy. Risks of prenatal exposure that must be considered include risk of teratogenesis, neonatal and obstetrical effects, neonatal toxicity, and long-term neurobehavioral sequelae.
There have been a fair number of studies evaluating the safety of the selective serotonin reuptake inhibitors (SSRIs), which includes escitalopram (Lexapro). With regard to congenital malformations, most data support their safety or suggest that there is a small increased risk for certain ones, with low absolute risks overall. Other risks to consider include persistent pulmonary hypertension of the newborn, a rare and serious condition which affects that infant's pulmonary circulation and thus oxygenation; limited data suggests as possible increased risk with ths SSRIs. Neonatal withdrawal symptoms (jitteriness, increased or decreased tone, feeding difficulties, respiratory difficulties) can occur in 25-30% infants exposed to SSRIs in utero. There is debate about the association of SSRIs with preterm birth and low birthweight. A woman should be informed about all of these possibilities, as well as counseled about the associated risks with untreated illness, when options are discussed.
There is comparatively little information on the reproductive safety of the class of atypical antipsychotic medication, which includes both quetiapine (Seroquel) and aripiprazole (Abilify). More information is available on quetiapine than aripiprazole, and the limited data regarding quetiapine does not suggest an increased risk of congenital malformation above the baseline 2-4% seen in the general population. For aripiprazole, there is no data on the first trimester use in humans, and animal studies suggest that it may interfere with embryo development (at doses of 10 mg/kg/day in rats). Atypical antipsychotics are associated with weight gain, insulin resistance, and hypertension, and these are safety issues to be considered when assessing whether to use them in pregnancy. Massachusetts General Hospital has organized a pregnancy registry for atypical antipsychotics (1-866-961-2388).
Non-pharmacologic interventions, such as psychotherapy, sleep scheduling, support groups, and nutrition counseling, can be useful in mood maintenance for women with bipolar disorder who become pregnant.
In general, consultation with a specialist in perinatal psychiatry can help a patient and her provider consider all available treatment options and develop a plan for management during pregnancy.
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Kristin Leight, M.D., M.A.
Instructor in Clinical Psychiatry
Dr. Leight is an Instructor in Clinical Psychiatry and a Fellow in Women's Mental Health at The Women's Program in Psychiatry at Columbia. As such, she provides expert consultation and treatment to women with psychiatric illness related to the reproductive life cycle. Last year, Dr. Leight also worked as an inpatient psychiatry attending at Columbia's Milstein 9 Garden North Unit. Dr. Leight supervises psychiatry residents and teaches both residents and medical students.
Dr. Leight is also a psychoanalytic candidate at the Columbia Psychoanalytic Center and has a private practice. >>> Read more info
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