Mood disorders frequently have a chronic or recurrent course, and women with mood disorders typically experience the onset of these disorders before or during their reproductive years.1 Therefore, women commonly experience mood episodes during the perinatal period (during pregnancy and postpartum). Many women plan for a pregnancy with a preexisting mood disorder and while receiving maintenance treatment with psychotropic medication. Ideally, women plan ahead to conceive and make any necessary treatment changes to maximize wellness and minimize fetal medication exposure—especially to medications that are known teratogens or have unknown reproductive safety profiles.
However, about 50% of pregnancies in the US are unplanned. This fact underscores the need to routinely counsel women of reproductive potential about their medications, regardless of their plans to conceive.2 It is also of major importance to select medications for women of reproductive potential that would be of least risk should they experience an unplanned pregnancy.
Plan for the unplanned
The psychopharmacologist should actively inquire about a woman’s plans for conceiving. If a woman is not planning to become pregnant, contraception should be discussed routinely. If a woman is using hormonal contraception, such as an oral contraceptive, there are important potential drug actions to factor into medication dosing.3
Many women who report that they are not trying to conceive are not using an effective contraceptive. One recent national study demonstrated that among young women, one-third were using the “withdrawal method” as their primary form of birth control. Among them, 21.4% experienced an unintended pregnancy.4
Our role is 2-fold: we need to actively integrate patients’ desires for pregnancy into our treatment plans, but also extend the use of selective prescribing for women of reproductive potential regardless of stated plans.
Pregnancy has inherent risks
The rate of congenital malformations in the general population of the US is approximately 3% of all pregnancies.5 Maternal age is a known risk factor for pregnancy complications and birth defects, as are smoking, alcohol use, uncontrolled diabetes, and obesity.5 In most cases, causes of birth defects are unknown. Decision making around treatments for psychiatric disorders in pregnancy requires consideration of what is known about the medications in pregnancy, the disorder being treated, and exposures to the baby of both untreated maternal illness and medication. For women of reproductive age planning pregnancy, the CDC recommends the following5:
• Take folic acid (higher doses are recommended when a woman is taking an anticonvulsant before trying to conceive6)
• Maintain healthy diet and weight
• Continue regular physical activity
• Quit/abstain from tobacco use, alcohol, and drugs
• Communicate with health care professionals about screening for and management of chronic diseases
The CDC also recommends that sexually active women who wish to delay or avoid pregnancy should use effective contraception correctly.
Dr Freeman is Associate Professor of Psychiatry at the Harvard Medical School; Medical Director, Clinical Trials Network and Institute; and Director of Clinical Services, Perinatal and Reproductive Psychiatry Program at the Massachusetts General Hospital in Boston. She has received research support from GSK and Lilly; is on the advisory boards of Lundbeck, Taleeda, Otsuka, and Genentech; and does medical editing for DSM Nutritional Products.
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5. Centers for Disease Control and Prevention. National Center on Birth Defects and Developmental Disabilities. http://www.cdc.gov/ncbddd/aboutus/birthdefects-bd-maternal.html. Accessed November 27, 2013.
6. Wilson RD, Johnson JA, Wyatt P, et al; Genetics Committee of the Society of Obstetricians and Gynaecologists of Canada; The Motherrisk Program. Pre-conceptional vitamin/folic acid supplementation 2007: the use of folic acid in combination with a multivitamin supplement for the prevention of neural tube defects and other congenital anomalies. J Obstet Gynaecol Can. 2007;29:1003-1026.
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9. Center for Drug Evaluation and Research, US Department of Health, Education, and Welfare. Guidance for Industry: General Considerations for the Clinical Evaluation for Drugs. http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatory Information/Guidances/ucm071682.pdf. Accessed November 28, 2013.
10. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry. 2009;31:403-413.
11. Nguyen HT, Sharma V, McIntyre RS. Teratogenesis associated with antibipolar agents. Adv Ther. 2009;26:281-294.