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Safety of Psychotropic Drugs in Pregnancy and Breastfeeding

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Pharmacovigilance in Psychiatry

Abstract

Pharmacovigilance studies are vital to our understanding of the safety of medications in pregnancy, but great care must be taken in the analysis and interpretation of observational data to avoid problems with confounding and bias. Data on drug excretion in breast milk and possible effects of the breastfed infant often stem from case reports or small case series, making the generalization of the results a challenge. This chapter reviews the safety of psychotropic drugs in pregnant and breastfeeding women and discusses methodological issues that have to be dealt with in the interpretation of published data.

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References

  • Anderson PO, Pochop SL, Manoguerra AS (2003) Adverse drug reactions in breastfed infants: less than imagined. Clin Pediatr (Phila) 42(4):325–340

    Article  Google Scholar 

  • American Academy of Pediatrics (2012) Policy statement: breastfeeding and the use of human milk. Pediatrics 129(3):e827–e841

    Google Scholar 

  • Bellantuono C, Tofani S, Di Sciascio G, Santone G (2013) Benzodiazepine exposure in pregnancy and risk of major malformations: a critical overview. Gen Hosp Psychiatry 35(1):3–8

    Article  PubMed  Google Scholar 

  • Berle JO, Spigset O (2011) Antidepressant use during breastfeeding. Curr Womens Health Rev 7(1):28–34

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Berle JO, Steen VM, Aamo TO, Breilid H, Zahlsen K, Spigset O (2004) Breastfeeding during maternal antidepressant treatment with serotonin reuptake inhibitors: infant exposure, clinical symptoms, and cytochrome p450 genotypes. J Clin Psychiatry 65(9):1228–1234

    Google Scholar 

  • Brandlistuen RE, Yström E, Nulman I, Koren G, Nordeng H (2013) Prenatal paracetamol exposure and child neurodevelopment: a sibling-controlled cohort study. Int J Epidemiol 42(6):1702–1713

    Google Scholar 

  • Bromley R, Weston J, Adab N, Greenhalgh J, Sanniti A, McKay AJ et al (2014) Treatment for epilepsy in pregnancy: neurodevelopmental outcomes in the child. Cochrane Database Syst Rev 10:CD010236

    Google Scholar 

  • Cohen LS, Altshuler LL, Harlow BL, Nonacs R, Newport DJ, Viguera AC et al (2006) Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 295(5):499–507

    Article  CAS  PubMed  Google Scholar 

  • Cornisha AM, McMahona CA, Ungerera JA, Barnettb B, Kowalenkoc N, Tennant C (2005) Postnatal depression and infant cognitive and motor development in the second postnatal year: the impact of depression chronicity and infant gender. Infant Behav Dev 28:407–417

    Article  Google Scholar 

  • Dev VJ, Krupp P (1995) Adverse event profile and safety of clozapine. Rev Contemp Pharmacother 6:197–208

    CAS  Google Scholar 

  • Dolovich LR, Addis A, Vaillancourt JM, Power JD, Koren G, Einarson TR (1998) Benzodiazepine use in pregnancy and major malformations or oral cleft: meta-analysis of cohort and case-control studies. BMJ 317(7162):839–843

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • EMA (2014) CMDh agrees to strengthen warnings on the use of valproate medicines in women and girls. Available from http://www.ema.europa.eu/docs/en_GB/document_library/Press_release/2014/11/WC500177638.pdf Cited 20.05.2015

  • Fortinguerra F, Clavenna A, Bonati M (2009) Psychotropic drug use during breastfeeding: a review of the evidence. Pediatrics 124(4):e547–e556

    Article  PubMed  Google Scholar 

  • Galbally M, Snellen M, Power J (2014) Antipsychotic drugs in pregnancy: a review of their maternal and fetal effects. Ther Adv Drug Saf 5(2):100–109

    Article  PubMed  PubMed Central  Google Scholar 

  • Gardiner SJ, Kristensen JH, Begg EJ, Hackett LP, Wilson DA, Ilett KF et al (2003) Transfer of olanzapine into breast milk, calculation of infant drug dose, and effect on breast-fed infants. Am J Psychiatry 160(8):1428–1431

    Article  PubMed  Google Scholar 

  • Gentile S (2007) Use of contemporary antidepressants during breastfeeding: a proposal for a specific safety index. Drug Saf 30(2):107–121

    Article  CAS  PubMed  Google Scholar 

  • Gentile S, Galbally M (2011) Prenatal exposure to antidepressant medications and neurodevelopmental outcomes: a systematic review. J Affect Disord 128(1-2):1–9

    Article  CAS  PubMed  Google Scholar 

  • Grigoriadis S, VonderPorten EH, Mamisashvili L, Eady A, Tomlinson G, Dennis CL et al (2013) The effect of prenatal antidepressant exposure on neonatal adaptation: a systematic review and meta-analysis. J Clin Psychiatry 74(4):e309–e320

    Article  PubMed  Google Scholar 

  • Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ (2010) A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry 67(10):1012–1024

    Article  PubMed  PubMed Central  Google Scholar 

  • Hägg S, Spigset O (2000) Anticonvulsant use during lactation. Drug Saf 22(6):425–440

    Article  PubMed  Google Scholar 

  • Hale TW (2014) Medications and mothers’ milk, 16th edn. Hale Publishing, Plano

    Google Scholar 

  • Hermansen TK, Melinder A (2015) Prenatal SSRI exposure: effects on later child development. Child Neuropsychol 21(5):543–569

    Google Scholar 

  • Hunt N, Silverstone T (1995) Does puerperal illness distinguish a subgroup of bipolar patients? J Affect Disord 34(2):101–107

    Article  CAS  PubMed  Google Scholar 

  • Ito S (2000) Drug therapy for breast-feeding women. N Engl J Med 343(2):118–126

    Article  CAS  PubMed  Google Scholar 

  • Kelly LE, Poon S, Madadi P, Koren G (2012) Neonatal benzodiazepines exposure during breastfeeding. J Pediatr 161(3):448–451

    Article  CAS  PubMed  Google Scholar 

  • Klinger G, Stahl B, Fusar-Poli P, Merlob P (2013) Antipsychotic drugs and breastfeeding. Pediatr Endocrinol Rev 10(3):308–317

    PubMed  Google Scholar 

  • Koren G, Nordeng H (2012) Antidepressant use during pregnancy: the benefit-risk ratio. Am J Obstet Gynecol 207(3):157–163

    Article  PubMed  Google Scholar 

  • Kozma C (2001) Valproic acid embryopathy: report of two siblings with further expansion of the phenotypic abnormalities and a review of the literature. Am J Med Genet 98(2):168–175

    Article  CAS  PubMed  Google Scholar 

  • Lanza di Scalea T, Wisner KL (2009) Antidepressant medication use during breastfeeding. Clin Obstet Gynecol 52(3):483–497

    Article  PubMed  Google Scholar 

  • Lupattelli A, Spigset O, Koren G, Nordeng H (2014) Risk of vaginal bleeding and postpartum hemorrhage after use of antidepressants in pregnancy: a study from the Norwegian Mother and Child Cohort Study. J Clin Psychopharmacol 34(1):143–148

    Article  CAS  PubMed  Google Scholar 

  • Lupattelli A, Spigset O, BjörnsdĂłttir I, Hameen-Anttila K, MĂĄrdby AC, Panchaud A et al (2015) Patterns and determinants of low adherence to psychotropic medications during pregnancy – a multinational study. Depress Anxiety 32(6):426–436

    Google Scholar 

  • McElhatton PR (1994) The effects of benzodiazepine use during pregnancy and lactation. Reprod Toxicol 8(6):461–475

    Article  CAS  PubMed  Google Scholar 

  • Meador K, Reynolds MW, Crean S, Fahrbach K, Probst C (2008) Pregnancy outcomes in women with epilepsy: a systematic review and meta-analysis of published pregnancy registries and cohorts. Epilepsy Res 81(1):1–13

    Article  PubMed  PubMed Central  Google Scholar 

  • Misri S, Corral M, Wardrop AA, Kendrick K (2006) Quetiapine augmentation in lactation: a series of case reports. J Clin Psychopharmacol 26(5):508–511

    Article  PubMed  Google Scholar 

  • Moses-Kolko EL, Bogen D, Perel J, Bregar A, Uhl K, Levin B et al (2005) Neonatal signs after late in utero exposure to serotonin reuptake inhibitors: literature review and implications for clinical applications. JAMA 293(19):2372–2383

    Article  CAS  PubMed  Google Scholar 

  • Nager A, Sundquist K, Ramirez-Leon V, Johansson LM (2008) Obstetric complications and postpartum psychosis: a follow-up study of 1.1 million first-time mothers between 1975 and 2003 in Sweden. Acta Psychiatr Scand 117(1):12–19

    CAS  PubMed  Google Scholar 

  • Newport DJ, Pennell PB, Calamaras MR, Ritchie JC, Newman M, Knight B et al (2008) Lamotrigine in breast milk and nursing infants: determination of exposure. Pediatrics 122(1):e223–e231

    Article  PubMed  PubMed Central  Google Scholar 

  • Newton ER (2004) Breastmilk: the gold standard. Clin Obstet Gynecol 47(3):632–642

    Article  PubMed  Google Scholar 

  • Non AL, Binder AM, Kubzansky LD, Michels KB (2014) Genome-wide DNA methylation in neonates exposed to maternal depression, anxiety, or SSRI medication during pregnancy. Epigenetics 9(7):964–972

    Article  PubMed  PubMed Central  Google Scholar 

  • Nordeng H (2016) Drug utilisation studies in pregnancy. In: Elseviers M, Andersen M, Benko R (eds.). Drug utilization research: methods and application. Wiley-Blackwell, Hoboken, NJ, USA

    Google Scholar 

  • Nordeng H, Spigset O (2005) Treatment with selective serotonin reuptake inhibitors in the third trimester of pregnancy: effects on the infant. Drug Saf 28(7):565–581

    Google Scholar 

  • Nordeng H, Ystrom E, Einarson A (2010) Perception of risk regarding the use of medications and other exposures during pregnancy. Eur J Clin Pharmacol 66(2):207–214

    Article  PubMed  Google Scholar 

  • Nordeng H, van Gelder MM, Spigset O, Koren G, Einarson A, Eberhard-Gran M (2012) Pregnancy outcome after exposure to antidepressants and the role of maternal depression: results from the Norwegian Mother and Child Cohort Study. J Clin Psychopharmacol 32(2):186–194

    Article  CAS  PubMed  Google Scholar 

  • Nordeng H, Gjerdalen G, Brede WR, Michelsen LS, Spigset O (2014a) Transfer of aripiprazole to breast milk: a case report. J Clin Psychopharmacol 34(2):272–275

    Google Scholar 

  • Nordeng H, Ystrøm E, Eberhard-Gran M (2014b) Medication safety in pregnancy – results from the MoBa-study. Nor J Epidemiol 24(1-2):161–168

    Google Scholar 

  • Nordmo E, Aronsen L, Wasland K, Smabrekke L, Vorren S (2009) Severe apnea in an infant exposed to lamotrigine in breast milk. Ann Pharmacother 43(11):1893–1897

    Article  PubMed  Google Scholar 

  • O’Hara MW, Schwain AM (1996) Rates and risk of postpartum depression – a meta-analysis. Rev Psychiatry 8:37–54

    Article  Google Scholar 

  • Ă–hman R, Hagg S, Carleborg L, Spigset O (1999) Excretion of paroxetine into breast milk. J Clin Psychiatry 60(8):519–523

    Google Scholar 

  • Pennell PB, Peng L, Newport DJ, Ritchie JC, Koganti A, Holley DK et al (2008) Lamotrigine in pregnancy: clearance, therapeutic drug monitoring, and seizure frequency. Neurology 70(22 Pt 2):2130–2136

    Article  CAS  PubMed  Google Scholar 

  • Petersen I, McCrea RL, Osborn DJ, Evans S, Pinfold V, Cowen PJ et al (2014) Discontinuation of antipsychotic medication in pregnancy: a cohort study. Schizophr Res 159(1):218–225

    Article  PubMed  Google Scholar 

  • Petersen I, McCrea R, Lupattelli A, Nordeng H (2015) Women’s perception of risks in pregnancy: multinational population based internet survey. BMJ Open 5(6):e007390

    Google Scholar 

  • Poobalan AS, Aucott LS, Ross L, Smith WC, Helms PJ, Williams JH (2007) Effects of treating postnatal depression on mother-infant interaction and child development: systematic review. Br J Psychiatry 191:378–386

    Article  CAS  PubMed  Google Scholar 

  • Rubin ET, Lee A, Ito S (2004) When breastfeeding mothers need CNS-acting drugs. Can J Clin Pharmacol 11:e257–e266

    PubMed  Google Scholar 

  • Schaefer C, Peters PWJ, Miller RK (2015) Drugs during pregnancy and lactation: treatment options and risk assessment, 3rd edn. Elsevier, Amsterdam

    Google Scholar 

  • Soubry A, Murphy S, Huang Z, Murtha A, Schildkraut J, Jirtle R et al (2011) The effects of depression and use of antidepressive medicines during pregnancy on the methylation status of the IGF2 imprinted control regions in the offspring. Clin Epigenetics 3:2

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Spigset O, Hägg S (1998) Excretion of psychotropic drugs into breast milk. CNS Drugs 9:111–134

    Article  CAS  Google Scholar 

  • Stephansson O, Kieler H, Haglund B, Artama M, Engeland A, Furu K et al (2013) Selective serotonin reuptake inhibitors during pregnancy and risk of stillbirth and infant mortality. JAMA 309(1):48–54

    Article  CAS  PubMed  Google Scholar 

  • Strom BL, Kimmel SE, Hennessy S (eds.) (2012) Pharmacoepidemiology, 5th edn. Wiley-Blackwell, Hoboken, NJ, USA

    Google Scholar 

  • Susser E, Eide MG, Begg M (2010) Invited commentary: the use of sibship studies to detect familial confounding. Am J Epidemiol 172(5):537–539

    Article  PubMed  Google Scholar 

  • Tomson T, Battino D, Bonizzoni E, Craig J, Lindhout D, Sabers A et al (2011) Dose-dependent risk of malformations with antiepileptic drugs: an analysis of data from the EURAP epilepsy and pregnancy registry. Lancet Neurol 10(7):609–617

    Article  CAS  PubMed  Google Scholar 

  • Vajda FJ, Eadie MJ (2005) Maternal valproate dosage and foetal malformations. Acta Neurol Scand 112(3):137–143

    Article  CAS  PubMed  Google Scholar 

  • van Mil NH, Steegers-Theunissen RP, Bouwland-Both MI, Verbiest MM, Rijlaarsdam J, Hofman A et al (2014) DNA methylation profiles at birth and child ADHD symptoms. J Psychiatr Res 49:51–59

    Article  PubMed  Google Scholar 

  • Viguera AC, Nonacs R, Cohen LS, Tondo L, Murray A, Baldessarini RJ (2000) Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance. Am J Psychiatry 157(2):179–184

    Article  CAS  PubMed  Google Scholar 

  • Viguera AC, Newport DJ, Ritchie J, Stowe Z, Whitfield T, Mogielnicki J et al (2007) Lithium in breast milk and nursing infants: clinical implications. Am J Psychiatry 164(2):342–345

    Article  PubMed  Google Scholar 

  • Weissman AM, Levy BT, Hartz AJ, Bentler S, Donohue M, Ellingrod VL et al (2004) Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants. Am J Psychiatry 161(6):1066–1078

    Article  PubMed  Google Scholar 

  • Wikner BN, Källen B (2011) Are hypnotic benzodiazepine receptor agonists teratogenic in humans? J Clin Psychopharmacol 31(3):356–359

    Google Scholar 

  • World Health Organization (WHO) (2003) Infant and young child feeding. World Health Organization, Geneva

    Google Scholar 

  • Wurst KE, Poole C, Ephross SA, Olshan AF (2010) First trimester paroxetine use and the prevalence of congenital, specifically cardiac, defects: a meta-analysis of epidemiological studies. Birth Defects Res A Clin Mol Teratol 88(3):159–170

    Article  CAS  PubMed  Google Scholar 

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Spigset, O., Nordeng, H. (2016). Safety of Psychotropic Drugs in Pregnancy and Breastfeeding. In: Spina, E., Trifirò, G. (eds) Pharmacovigilance in Psychiatry. Adis, Cham. https://doi.org/10.1007/978-3-319-24741-0_15

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  • DOI: https://doi.org/10.1007/978-3-319-24741-0_15

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