Atypical Antipsychotics in the Treatment of Schizophrenia During Pregnancy and the Postpartum

Abstract

In this report, we discuss the case of a woman with paranoid schizophrenia who hoped to become pregnant. She was taking a stable daily dose of antipsychotic medication when she initially sought consultation about the safety of medication during pregnancy. This case examines 1) the challenges that arise when women with psychiatric disorders require treatment during pregnancy and lactation and 2) the balancing of competing needs that form the backbone of the risk-benefit analysis of medication use during pregnancy and the postpartum.Case Description "Ms. A" was a 38-year-old married woman with a history of psychosis who sought consultation about the safety of antipsychotic use during pregnancy and lactation. Ms. A had done well taking quetiapine for 5 years. A few years earlier, she had undergone an abortion after being told that her medication was not compatible with pregnancy. Subsequently, she and her husband sought consultation at a university hospital. HistoryMs. A had a history of psychiatric symptoms dating back to her teens. In high school, Ms. A remembered having depression, anorexia, and suicidal ideation. A music teacher at the time suggested to her parents that they seek psychiatric care. Her parents ignored the advice.In college, Ms. A became bulimic, and her depression worsened. She attempted suicide three times in her early 20s. At age 24, her weight fell to 90 lb, and she was severely depressed and developed delusions about communicating with God. She was initially diagnosed with bipolar disorder and treated with lithium and typical antipsychotics, including haloperidol and thiothixene. The addition of fluoxetine at one time caused such severe agitation that she again attempted suicide. She was diagnosed with schizophrenia after her final suicide attempt, which occurred when Ms. A thought she was the devil and that the world would be cured of evil if she died. Course of TreatmentThe initial psychiatric evaluation consisted of a detailed psychiatric and medical history followed by a discussion of the risks and benefits of medication use during pregnancy and the postpartum. The first consultant reviewed three possible courses of treatment: 1) discontinuation of medications before pregnancy, 2) use of medications until Ms. A had a positive pregnancy test and subsequent withdrawal of medication, and 3) use of antipsychotics throughout the pregnancy. Given Ms. A's severe history of psychosis and suicide attempts, she and her husband agreed with the consultant that medications should be continued throughout pregnancy and possibly during lactation. The consultant then reviewed the published literature on antipsychotics that existed at that time. Olanzapine had the most cases documented in the literature, and the consultant used this as a rationale for suggesting that Ms. A switch to olanzapine. Ms. A was titrated off of quetiapine and began taking olanzapine.Within 3 months, Ms. A had gained 20 lb. She was depressed, lethargic, anhedonic, and had severe memory and concentration difficulties. She slept at l...

The Pharmacotherapy of Perinatal Mood Disorders

“…34 Two neonates in the prospective cases had seizures, and one premature child had multiple anomalies and delayed development. There were five congenital malformations and five unspecified perinatal complications in the retrospective case reports.…”

“…Although there were three reports of limb malformations with the use of haloperidol and one with penfluridol in the first trimester, these effects were not replicated in other studies. 34 Another study found an increased risk of premature birth and lower birth weight in infants exposed to haloperidol and penfluridol. 35 Use of FGAs is limited by the risk of extrapyramidal symptoms (EPS) in the mother and possibly the neonate.…”

“…There have, however, been reports of a slightly higher incidence of congenital malformations with the use of low-potency FGAs in the first trimester, but no clear pattern of malformations is established. 34 Despite more-limited data on high-potency FGAs, they are generally preferred over low-potency agents. Although there were three reports of limb malformations with the use of haloperidol and one with penfluridol in the first trimester, these effects were not replicated in other studies.…”

“…There are also reports of children who were followed to age 5 with normal development whose mothers took clozapine during pregnancy. 34 Other concerns with clozapine use in pregnancy include orthostatic hypotension in the mother, which can reduce blood flow to the fetus, and agranulocytosis in the neonate. 34 Breastfeeding with clozapine has been reported in five cases, with three infants experiencing unwanted effects.…”

“…34 Other concerns with clozapine use in pregnancy include orthostatic hypotension in the mother, which can reduce blood flow to the fetus, and agranulocytosis in the neonate. 34 Breastfeeding with clozapine has been reported in five cases, with three infants experiencing unwanted effects. 37 Two demonstrated neurodevelopmental delays, one infant lethargy, and one infant agranulocytosis.…”