Antipsychotic Medications in Pregnancy

“Through the TR_xeating For Two initiative, the Centers for Disease Control and Prevention has promoted a conceptual shift from the dogma that medications during pregnancy must be avoided to their use to “improve the health of women and babies by working to identify the safest treatment options for the management of common conditions before and during pregnancy” (http://www.cdc.gov/pregnancy/meds/treatingfortwo/facts.html).

Medication use by pregnant women is increasing across time and now is nearly universal. The average number of drugs (over the counter or prescribed, excluding vitamins and minerals) used any time in pregnancy increased from 2.5 in 1976 to 1978 to 4.2 in 2006 to 2008. In 2008, nearly 94% of women took at least 1 medication during pregnancy; in the first trimester, 82.3% used at least 1 and 27.6% reported taking 4 or more medications.² These staggering statistics highlight the public health importance of research to inform pharmacotherapy for pregnant women.”

The editorial summarizes the findings of the largest study to date to examine the risks of antipsychotic medications in pregnancy. The authors of this study used a very large database of information and a sophisticated methodology to address the primary problem with almost all retrospective studies on the subject: the fact that women who take psychiatric medications have higher rates of many other conditions that expose their infants to an increased risk of malformations (to cite just a few of those confounding variables – increased rates of depression itself, increased rates of substance and alcohol use, increased rates of smoking, and increased rates of other health conditions).

The authors of the study summarize the findings this way:

“Evidence from this large study suggests that use of APs early in pregnancy generally does not meaningfully increase the risk for congenital malformations overall or cardiac malformations in particular. The small increase in the risk for malformations observed with risperidone requires additional study.”

This is about as close to a clean bill of health as one can get for a class of medications.

When they adjusted for other conditions associated with psychiatric disorders in pregnant women they actually found that the risk of fetal malformation was lower in women who received antipsychotic medications then in women who did not (which is not to say that these medications are protective, but does perhaps point to the fact that treating psychiatric disorders is good for the fetus if the medications selected are relatively safe). The one exception was risperidone, but the authors point to a relatively small number of women studied and suggest that this finding needs to be replicated.