Antipsychotics

From: Exposure to Psychotropic Medications and Other Substances during Pregnancy and Lactation: A Handbook for Health Care Providers

On this page:

Summary and recommendations
Fetal effects
Neonatal effects
Long-term effects on the child
Breastfeeding
Withdrawal effects on the mother
Effects of untreated illness

Examples

Typical antipsychotics: chlorpromazine (Largactil), haloperidol (Haldol), loxapine (Loxapac), perphenazine (Trilafon)

Atypical antipsychotics: clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal)

Approximately one to two per cent of the population, many of them women of childbearing age, live with schizophrenia,¹ for which the older typical and newer atypical antipsychotics are prescribed. Atypicals are also prescribed for other psychiatric conditions (e.g., bipolar disorder, postpartum psychotic depression).

Summary and Recommendations

A woman who requires antipsychotic medication during pregnancy and in the postpartum period should not change her treatment, if the medication is controlling her illness well. Treatment helps her to function well and be better equipped to adequately interact with and care for her baby.

Typical antipsychotics

Infants exposed to typical antipsychotics in the latter part of pregnancy should be watched carefully after birth for extrapyramidal symptoms such as severe rigidity and muscle spasms.
Infants whose mothers are taking typical antipsychotics while breastfeeding should be monitored carefully for signs of drowsiness or lethargy.

Atypical antipsychotics

Although there are no documented reports of adverse effects in neonates of mothers who took atypical antipsychotics during pregnancy, these babies should be monitored for several days following their birth for possible extrapyramidal symptoms.
Infants of mothers taking atypical antipsychotics while breastfeeding should be monitored carefully for signs of drowsiness or lethargy.
Due to the increased risk of diabetes associated with taking atypical antipsychotics, a woman’s blood sugar levels should also be monitored.

Fetal effects

Typical antipsychotics

The Collaborative Perinatal Project, conducted in Boston in the 1970s, monitored 142 mother-child pairs exposed to chlorpromazine during the first trimester. The project found that perinatal mortality rates and birth weights were similar to those for the general population.²

Atypical antipsychotics

Little information is available on the safety of atypical antipsychotics. A single study, documenting 151 pregnancy outcomes in exposed women, found a higher rate of low birth weight (i.e., 10 per cent in exposed babies versus two per cent in the comparison group).³

Major malformations

Typical antipsychotics

Chlorpromazine exposure has not been found to increase risk for major malformations.² In a study that assessed the safety of haloperidol and penfluridol in 215 pregnancies, rates of major malformations did not differ between the antipsychotic-exposed group and the control group.⁴

Atypical antipsychotics

In the single study available, no pregnancy outcomes showed any statistically significant differences of interest.³

Spontaneous abortion

Typical antipsychotics

Data on typical antipsychotic use and spontaneous abortion are not available.

Atypical antipsychotics

One study³ documents a higher spontaneous abortion rate in the group of women taking atypical antipsychotics (22 [or 14.5 per cent]) than in the group of women not taking atypical antipsychotics (13 [or 8.6 per cent]).

Neonatal effects

Typical antipsychotics

In a number of babies exposed in utero to typical antipsychotics, extrapyramidal symptoms (e.g., severe rigidity, muscle spasms, shaking or restlessness) caused by the mother’s use of antipsychotics while pregnant have been observed, which in some cases persisted for several months. A few cases of paralytic ileus have also been reported; however, most reports describing typical antipsychotic use in pregnancy conclude that there are no adverse effects on the neonate.⁵

Atypical antipsychotics

There are no reports of adverse neonatal effects in newborns exposed in utero to atypical antipsychotics.

Long-term effects on the child

Typical antipsychotics

Intelligence quotients of 1,309 four-year-olds born to women taking typical antipsychotic drugs during the first four lunar months of their pregnancy were similar to those of 48,973 four-year-old children of non-exposed women.²

Atypical antipsychotics

There are no studies on possible long-term effects of a mother’s atypical antipsychotic use.

Breastfeeding

Typical antipsychotics

Less than three per cent of the maternal dose of typical antipsychotics is excreted into the breast milk. Reports of drowsiness and lethargy in some infants have been documented, although many studies cite no adverse effects.⁶

Atypical antipsychotics

Less than five per cent of quetiapine is excreted into the breast milk;⁷ no reports of adverse effects of any other atypical antipsychotics on breastfeeding infants have been cited.

Withdrawal effects on the mother

Abrupt discontinuation of antipsychotic drugs, or a change from typical to atypical agents, can cause severe withdrawal and result in adverse physical symptoms, including exacerbation of the psychosis.⁸

Effects of untreated illness

Reports of adverse effects of untreated psychotic illness have been documented (e.g., polyserositis, rebound phenomenon, rapid relapse).⁹

In women who are pregnant or breastfeeding, untreated schizophrenia has been linked with higher rates of smoking, maternal malnutrition, low socioeconomic status, refusal or inability to take part in prenatal care, worsening of psychotic symptoms during pregnancy, poorer interaction between mother and baby, and increased suicide risk.¹⁰

Babies born to mothers with schizophrenia have a small but statistically significant increased risk of small size for gestational age, preterm delivery and low birth weight.¹¹ One study found that the risk of small size for gestational age, stillbirth, preterm delivery, low birth weight and infant death was doubled for mothers who had an acute episode during pregnancy, even controlling for higher rates of smoking in women with schizophrenia.¹² There is also an increased risk of placental abruption, infants in the lowest weight and growth decile, and congenital cardiovascular anomalies in infants born to mothers with schizophrenia.¹³

References

Morrato, E.H., Dodd, S., Oderda, G., Haxby, D.G., Allen, R. & Valuck, R.J. (2007). Prevalence, utilization patterns, and predictors of antipsychotic polypharmacy: Experience in a multistate Medicaid population, 1998–2003. Clinical Therapeutics, 29 (1), 183–195.
Slone, D., Siskind, V., Heinonen, O.P., Monson, R.R., Kaufman, D.W. & Shapiro, S. (1977). Antenatal exposure to the phenothiazines in relation to congenital malformations, perinatal mortality rate, birth weight and intelligence quotient score. American Journal of Obstetrics and Gynecology, 128 (5), 486–488.
McKenna, K., Koren, G., Tetelbaum, M., Wilton, L., Shakir, S., Diav-Citrin, O. et al. (2005). Pregnancy outcome of women using atypical antipsychotic drugs: A prospective comparative study. Journal of Clinical Psychiatry, 66 (4), 444–449; Quiz 546.
Diav-Citrin, O., Shechtman, S., Ornoy, S., Arnon, J., Schaefer, C., Garbis, H. et al. (2005). Safety of haloperidol and penfluridol in pregnancy: A multicenter, prospective, controlled study. Journal of Clinical Psychiatry, 66 (3), 317–322.
O’Connor, M., Johnson, G.H. & James, D.I. (1981). Intrauterine effects of phenothiazines. Medical Journal of Australia, 1 (8), 416–417.
Yoshida, K., Smith, B., Craggs, M. & Kumar, R. (1998). Neuroleptic drugs in breast-milk: A study of pharmacokinetics and of possible adverse effects in breast-fed infants. Psychological Medicine, 28 (1), 81–91.
Lee, A., Giesbrecht, E., Dunn, E. & Ito, S. (2004). Excretion of quetiapine in breast milk. American Journal of Psychiatry, 161 (9), 1715–1716.
Kinon, B.J., Basson, B.R., Gilmore, J.A., Malcolm, S. & Stauffer, V.L. (2000). Strategies for switching from conventional antipsychotic drugs or risperidone to olanzapine. Journal of Clinical Psychiatry, 61 (11), 833–840.
Viguera, A.C., Baldessarini, R.J., Hegarty, J.D., van Kammen, D.P. & Tohen, M. (1997). Clinical risk following abrupt and gradual withdrawal of maintenance neuroleptic treatment. Archives of General Psychiatry, 54 (1), 49–55.
Usher, K., Foster, K. & McNamara, P. (2005). Antipsychotic drugs and pregnant or breastfeeding women: The issues for mental health nurses. Journal of Psychiatric and Mental Health Nursing, 12 (6), 713–718.
Sacker, A., Done, D.J. & Crow, T.J. (1996). Obstetrics complications in children born of parents with schizophrenia: A meta-analysis of case-control studies. Psychological Medicine, 26 (2), 279–287.
Nilsson, E., Lichtenstein, P., Cnattingius, S., Murray, R.M. & Hultman, C.M. (2002). Women with schizophrenia: Pregnancy outcome and infant death among their offspring. Schizophrenia Research, 58 (2–3), 221–229.
Jablensky, A.V., Morgan, V., Zubrick, S.R., Bower, C., and Yellachich, L. (2005). Pregnancy, delivery, and neonatal complications in a population cohort of women with schizophrenia and major affective disorders. American Journal of Psychiatry 162 (1), 79–91.