Clinical Pearls in Prescribing Medications for Perinatal Patients

Sara Robinson, DNP, RN, PMHNP-BC, shares her insights on prescribing medications for perinatal patients. She acknowledges that prescribing psychiatric medication in the perinatal context may evoke hesitation for prescribers, but notes that a lot of information commonly found in the field might be out of date yet persists in clinical myth. For example, Robinson points out that US Food and Drug Administration (FDA) categories for pregnancy were phased out around 10 years ago, but are still referred to frequently in practice. The more contemporary shift is to the FDA’s Pregnancy and Lactation Labeling Rule instead—a rule for labeling content of medications which assists providers in determining benefit versus risk of a prescription and providing recommendations to pregnant women and nursing mothers.¹

When evaluating patients, Robinson outlines that “we need to evaluate not only the risk of the medication exposure to the mother and the infant, but the very serious consideration of the untreated mental illness and those effects, which can be quite severe.” Providers must weigh potential benefits from continuing treatment for the pregnant patient’s mental health with the potential risk for the infant, keeping in mind that leaving the patient’s illness untreated may also still increase risk for both the patient and the infant.

Robinson notes another myth that persists surrounding perinatal mental health is that there is no safest and best medication for use by pregnant patients. However, she adds, there are recent data which refute many assumptions made historically about being unable to use common medications during pregnancy. Robinson maintains that if a treatment works for the mother, it should be evaluated with consideration of continuing the medication with informed consent and appropriate shared decision making. Still, there is a wide acknowledgement that a particular medication, Depakote, has known teratogenicity and causes longer term negative neurodevelopmental outcomes. This medication should be avoided in all patients who may become pregnant. It is also important to note that guidelines for pregnancy vs lactation do differ in terms of evidence and recommendations.

During pregnancy, “there are pharmacokinetic changes…that can also impact medication responses and therefore [medication] levels,” Robinson says.² These chemical changes related to pregnancy can significantly alter how a patient responds to their medication after becoming pregnant. With more providers being aware of this interaction between psychiatric medication and pregnancy, pregnant patients can receive stronger perinatal mental health care.

Robinson encourages providers to engage in continued training on perinatal mental health, and to explore resources that will benefit providers and their patients directly. Useful resources to explore include the Massachusetts General Hospital Women’s Mental Health Center and Postpartum Support International (PSI). Notably, the MGH Women’s Mental Health Center manages a patient medication registry, where pregnant women taking psychiatric medication can opt in to have their data added to the registry. Robinson notes that with more data in this registry, providers will be able to better serve this specific patient population. With PSI, they provide a number of patient-facing resources, as well as a consultation line and a list of providers certified in perinatal mental health treatment. Robinson reminds that “the number one complication of pregnancy…is perinatal mental health conditions,” encouraging providers to stay educated on this important topic.

Dr Robinson is assistant professor and director of the Psychiatric-Mental Health Nurse Practitioner specialty at the University of Maryland School of Nursing.

References

1. Pregnancy and lactation labeling final rule. Accessed July 1, 2025. https://www.fda.gov/vaccines-blood-biologics/biologics-rules/pregnancy-and-lactation-labeling-final-rule.

2. Yue M, Kus L, Katta S, et al. Pharmacokinetics of antidepressants in pregnancy. J Clin Pharmacol. 2023;63 Suppl 1:S137-S158