Taking Drugs While Pregnant

Cecilie M Lander, Associate Professor of Neurology, University of Queensland, and Senior Visiting Neurologist, Royal Brisbane and Women’s Hospital, Brisbane

No antiepileptic drug is completely safe to use in pregnancy as the risk of fetal abnormality is increased. Valproate should be avoided if possible because of the risk of major malformations. Ideally a plan for managing the woman’s epilepsy during pregnancy should be prepared before conception. The occurrence of an unexpected pregnancy should not trigger sudden cessation or alteration of antiepileptic drug treatment without medical advice. The smallest effective dose of a drug with a low risk of teratogenicity should be used. Doses may need adjustment as the pharmacokinetics of some drugs change during pregnancy. Data are limited, but most antiepileptic drugs seem to have little effect on full-term breastfed babies.

Uncontrolled epilepsy in a pregnant woman is a serious and potentially life-threatening condition for both mother and child. Most pregnant women with epilepsy will need to take at least one antiepileptic drug. The goal for all concerned is a healthy, seizure-free mother and an undamaged child. The following somewhat contradictory issues need to be considered concurrently.

• The optimum treatment of the mother’s epilepsy requires that the most appropriate antiepileptic drug be used in effective doses throughout pregnancy. This requires  knowledge of specific epileptic syndromes and also antiepileptic drug pharmacokinetics before, during and after pregnancy.
• Any adverse effect that the antiepileptic drug could have on the developing child needs to be avoided or minimised during pregnancy and lactation.

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Debra Kennedy, Director, MotherSafe, Royal Hospital for Women, and Conjoint Lecturer,School of Women’s and Children’s Health, University of New South Wales, Sydney

There are limited data on the safety of antipsychotic drugs in pregnancy and breastfeeding. Reports of congenital abnormalities in the babies of women taking typical antipsychotics are uncommon, although chlorpromazine may cause symptoms in the neonate. No increased risk with atypical antipsychotics has yet emerged. If women can be managed with a low dose of a single antipsychotic drug the benefits of breastfeeding are likely to outweigh the risk of harmful effects.

The lifetime prevalence of schizophrenia is 0.5–1%. The peak incidence in women is during their childbearing years, but treatment can reduce fertility. The older antipsychotic drugs increase prolactin, resulting in significantly lower fertility rates than with the atypical antipsychotic drugs. The newer antipsychotics are also being used increasingly to treat other psychiatric disorders such as major depression and bipolar disorder. Many women with well-controlled psychiatric disease are therefore now able to contemplate pregnancy, but they have concerns about the effect of treatment on their offspring. Addressing these concerns is difficult because of a lack of data.

Typical antipsychotic drugs

Studies examining the use of the older antipsychotic drugs in pregnancy have not shown a significantly increased risk of birth defects above the baseline rate of 3% in the general population. There have been reports of two infants exposed to haloperidol with isolated limb defects, but they were also exposed to other drugs and thus there is no clear causal relationship with haloperidol. In contrast, there have been several larger studies which have not shown an increased risk of birth defects. Babies exposed to haloperidol and chlorpromazine in utero may show extrapyramidal abnormalities, similar to those seen in adults, for weeks after birth. Other suspected withdrawal symptoms following intrauterine exposure to chlorpromazine have included paralytic ileus, necrotising enterocolitis, fever, cyanotic spells and transient heart block.
Long-term follow-up studies of children have been reassuring. While these drugs probably still have their place in the treatment of acutely psychotic patients, they have largely been superseded by the atypical antipsychotics for long-term therapy.

Flupenthixol and the depot preparation zuclopenthixol are thioxanthene major tranquillisers. There are minimal human data apart from some case reports of normal outcomes following use in pregnancy. Like the older antipsychotic drugs they have been shown to affect fertility via dopamine and prolactin pathways.

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GIDEON KOREN, M.D., ANNE PASTUSZAK, M.SC., AND SHINYA ITO ,M.D.

Before marketing a new drug, the manufacturer almost never tests the product in pregnant women to determine its effects on the fetus. Consequently, most drugs are not labeled for use during pregnancy. Typically, descriptions of drugs that appear in the Physicians’ Desk Reference and similar sources contain statements such as, “Use in pregnancy is not recommended unless the potential benefits justify the potential risks to the fetus.” Since the risk has been adequately established for only a few drugs, physicians caring for pregnant women have very little information to help them decide whether the potential benefits to the mother outweigh the risks to the fetus. These typical disclaimers,although understandable from the medicolegal standpoint, put large numbers of women and their physicians in difficult situations for several reasons. One is that at least half the pregnancies in North America are unplanned,and every year, hundreds of thousands of women therefore expose their fetuses to drugs before they know they are pregnant. Such women often interpret the statement that use during pregnancy is not recommended as meaning that the drug is not safe during pregnancy. There is evidence that this perception of fetal risk causes many women to consider or even seek termination of otherwise wanted pregnancies. Another reason is that with  the recent increase in the age at which women have children, conditions that necessitate long-term drug therapy are diagnosed in larger numbers of women Bbefore pregnancy.  Furthermore, for pregnant women with certain conditions once believed to be incompatible with pregnancy, such as systemic lupus erythematosus and heart diseases, the outcome of pregnancy has improved dramatically in the past few decades.

In this article, we review current knowledge of the fetal and neonatal effects of prescription and over-the-counter drugs given to pregnant women, with an emphasis on the approaches used to determine safety and risk. In addition, we review approaches to communicating such information to pregnant women and their families.

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By Densie Schlingman DVM

Let’s start this article with three facts that need to be understood from the beginning.

1. There are no drugs approved for use in alpacas in Canada at this time.
2. Drugs that are used in alpacas have their dosages, frequency and safety extrapolated from other species.
3. All drugs, dosages, safety and use discussed in this article have come from my past experiences or from other veterinarians. This does not guarantee that there will be no adverse affects from them when used by the reader.

Last but not least, there will probably never be drugs approved for alpacas in the near or distant future due to the extreme costs required to have an animal included on a label. This problem also applies to sheep and goat drug usages. The following are drugs I have used and feel confident in recommending. Remember, if given a choice, it is best not to use drugs during pregnancy, especially during the first 60 days when the embryo is developing. This is the time when the fetus is forming and implanting into the uterus. It is common for there to be a high incidence of early embryonic loss or reabsorbtion of the fetus, and I do not want drugs to increase this risk. However, if the situation indicates a drug is needed, then it should be given to save the mother. You can always re-breed at a later date.

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