This document provides information on FDA pregnancy drug labeling categories and discusses various antidepressant and other psychotropic medications. It describes the FDA categories A through X for evaluating risks of medications during pregnancy and lists common antidepressants along with their FDA categories. For each medication class, it summarizes potential risks to the fetus or newborn based on available studies. The document emphasizes making individualized treatment decisions and monitoring for potential neonatal side effects.
Psychotropics consultation in pregnant and lactating womenIbrahim Talha
my presentation about psychotropics in pregnant and lactating woman, my target is to help to know how mental illness affect mother and baby and how drugs affect mother and baby and when we start medications and how
Antipsychotics and mood stabilizers in pregnancyMohamed Sedky
Objectives:
Background risk of spontaneous congenital anomalies
The impact of mental illness on pregnancy
The impact of pregnancy on mental illness
The impact Antipsychotics and mood stabilizers on pregnancy outcome
Recommendations for prescribing during pregnancy
What to include in discussions with a pregnant women
Psychotropics consultation in pregnant and lactating womenIbrahim Talha
my presentation about psychotropics in pregnant and lactating woman, my target is to help to know how mental illness affect mother and baby and how drugs affect mother and baby and when we start medications and how
Antipsychotics and mood stabilizers in pregnancyMohamed Sedky
Objectives:
Background risk of spontaneous congenital anomalies
The impact of mental illness on pregnancy
The impact of pregnancy on mental illness
The impact Antipsychotics and mood stabilizers on pregnancy outcome
Recommendations for prescribing during pregnancy
What to include in discussions with a pregnant women
ADHD - Attention Deficit Hyperactivity Disorder
ADHD is the most common neurobehavioral
disorder of childhood. It is characterized by developmentally inappropriate and impairing levels of gross motor over activity, inattention and
impulsivity. It can continue through adolescence and
adulthood.
TREATMENT RESISTANT DEPRESSION IS A AREA THAT IS NOT EXPLORED MUCH, BUT IT REALLY NEEDS LOT OF ATTENTION AS IT IS ONE OF THE MOST COMMON OBSTACLE IN ACHIEVING COMPLETE REMISSION IN DEPRESSION
John Kane - Treatment-Resistant Schizophrenia: New Guidelines on Diagnosis an...wef
Presentation made at the live webinar hosted by the Schizophrenia Research Forum on the 21st of February, 2017 - http://www.schizophreniaforum.org/forums/treatment-resistant-schizophrenia-new-guidelines-diagnosis-and-terminology
Advanced nutrition for the brain series: stress, the HPA-axis and neuroinflammation. Targeted nutritional interventions for successful treatment of mental health conditions.
Inflammation is a major contributing factor to chronic modern illness and is driven, in part, by chronic stress and HPA-axis over stimulation. Mental health conditions, in particular clinical depression, are increasingly linked with neuroinflammation. As such, anti-inflammatory interventions are known to result in significant clinical benefits.
During this webinar Dr Bailey will discuss the biological mechanisms linking stress, chronic inflammation and mood disorders, together with a review of the current evidence for a targeted, anti-inflammatory nutrition approach to treatment. Nina will also clarify why some of the recent trials have failed to report benefits and how to optimise your anti-inflammatory interventions to treat clients with anxiety, depression, schizophrenia and PTSD.
Posttraumatic stress disorder (PTSD) is an anxiety disorder that a person may develop after experiencing or witnessing an extreme, overwhelming traumatic event during which they felt intense fear, helplessness, or horror.
Welcome to “Pregnancy, Drug Use, and the Law”, a one day public policy conference examining Tennessee law as it relates to pregnant women and new mothers, people who use and are sometimes dependent on drugs, and how we can create fair and effective policies that will support all Tennessee women and families.
ADHD - Attention Deficit Hyperactivity Disorder
ADHD is the most common neurobehavioral
disorder of childhood. It is characterized by developmentally inappropriate and impairing levels of gross motor over activity, inattention and
impulsivity. It can continue through adolescence and
adulthood.
TREATMENT RESISTANT DEPRESSION IS A AREA THAT IS NOT EXPLORED MUCH, BUT IT REALLY NEEDS LOT OF ATTENTION AS IT IS ONE OF THE MOST COMMON OBSTACLE IN ACHIEVING COMPLETE REMISSION IN DEPRESSION
John Kane - Treatment-Resistant Schizophrenia: New Guidelines on Diagnosis an...wef
Presentation made at the live webinar hosted by the Schizophrenia Research Forum on the 21st of February, 2017 - http://www.schizophreniaforum.org/forums/treatment-resistant-schizophrenia-new-guidelines-diagnosis-and-terminology
Advanced nutrition for the brain series: stress, the HPA-axis and neuroinflammation. Targeted nutritional interventions for successful treatment of mental health conditions.
Inflammation is a major contributing factor to chronic modern illness and is driven, in part, by chronic stress and HPA-axis over stimulation. Mental health conditions, in particular clinical depression, are increasingly linked with neuroinflammation. As such, anti-inflammatory interventions are known to result in significant clinical benefits.
During this webinar Dr Bailey will discuss the biological mechanisms linking stress, chronic inflammation and mood disorders, together with a review of the current evidence for a targeted, anti-inflammatory nutrition approach to treatment. Nina will also clarify why some of the recent trials have failed to report benefits and how to optimise your anti-inflammatory interventions to treat clients with anxiety, depression, schizophrenia and PTSD.
Posttraumatic stress disorder (PTSD) is an anxiety disorder that a person may develop after experiencing or witnessing an extreme, overwhelming traumatic event during which they felt intense fear, helplessness, or horror.
Welcome to “Pregnancy, Drug Use, and the Law”, a one day public policy conference examining Tennessee law as it relates to pregnant women and new mothers, people who use and are sometimes dependent on drugs, and how we can create fair and effective policies that will support all Tennessee women and families.
How can partners support one another to prevent perinatal depression and anxi...Pam Pilkington
Copyright Partners to Parents 2016.
Award winning speech presented at the Australasian Marce Society for Perinatal Mental Health 2015 Conference.
Findings used to create www.partnerstoparents.org
Medication in pregnancy by dr alka mukherjee nagpur m.s. indiaalka mukherjee
Pregnancy is a unique period in a woman’s life. Many changes are happening to her body that may affect the pharmacology of medications. During pregnancy, a woman’s gastric pH is increased and gastric motility is reduced which may interfere with the rate and extent of medication absorption. Maternal plasma volume is increased leading to changes in the volume of distribution. In addition, increases in progesterone and estradiol levels may affect the hepatic metabolism of some medications. Glomerular filtration rate is increased due to increase renal blood flow which may affect renally cleared medications. Despite the changes, the pharmacology of most medications is not altered enough to require dosing changes.1 The placenta is an organ of exchange allowing the mother to pass nutrients and medications to the fetus; therefore, medications administered to pregnant women have the potential to affect the growing fetus. The fetus is generally at the greatest risk of developing teratogenic effects from medications during the first trimester, but it is drug specific. The use of medications in pregnancy should be evaluated for the benefits and risks to both the mother and fetus. Upon evaluation, some medications may be used sparingly during some trimesters and contraindicated in others. 2 All efforts should be made to optimize the risk benefit ratio. Drugs with low molecular weight, low maternal protein binding, low ionization, and high lipophilicity are more likely to cross the placenta and cause pharmacologic affects.1 The developing fetus’s body systems are not mature; therefore, the fetus may lack the ability to metabolize medications causing teratogenic effects. 2 The FDA has categorized the potential teratogenic risk of medications by an A, B, C, D, X system.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
2. US FDA pregnancy drug
labeling categories
A -Adequate, well-controlled studies in pregnant
women have not shown an increased risk of fetal
abnormalities to the fetus in any trimester of
pregnancy.
.
3. B Animal studies have revealed no evidence of
harm to the fetus; however, there are no adequate
and well-controlled studies in pregnant women.
Or
Animal studies have shown an adverse effect, but
adequate and well-controlled studies in pregnant
women have failed to demonstrate a risk to the fetus
in any trimester
4. C Animal studies have shown an adverse
effect and
there are no adequate and well-controlled
studies in pregnant women.
Or
No animal studies have been conducted and
there are no adequate and well-controlled
studies in pregnant women.
5. D Adequate well-controlled or observational studies
in pregnant women have demonstrated a risk to the
fetus. However, the benefits of therapy may
outweigh the potential risk. For example, the drug
may be acceptable if needed in a life-threatening
situation or serious disease for which safer drugs
cannot be used or are ineffective.
6. X Adequate well-controlled or observational studies
in animals or pregnant women have demonstrated
positive evidence of fetal abnormalities or risks. The
use of the product is contraindicated in women who
are or may become pregnant.
10. Medication choices
Pre-conception taper
Stop medications entirely
Stop and restart if symptoms
Stop and restart after 1st trimester
Continue through pregnancy
Decrease dose
Reduce or discontinue in late
pregnancy
Transition to psychotherapy
11. General guidelines
Treat a woman as if she could become
pregnant at any time…
Up to 80% of pregnancies are unanticipated
Document use of birth control
Encourage use of folic acid and multivitamin
12. FDA labels
Patients read them
They will change
They will be changing
Standard information on background rates
Fetal risk data
Clinical considerations
Registry information
13. FDA Classifications
Most psychotropics are C
None are A
No antidepressants are FDA approved for
pregnancy
No drug is “safe”
No good randomized, placebo-
controlled studies
Most studies are retrospective, case
reports, and registry data
14. FDA categories of Antidepressants in Pregnancy as of
9/24/10
Medication Pregnancy Category Lactation Risk
Fluoxetine C Safety Unknown
Paroxetine D Safe
Sertraline C Safe
Citalopram C Safety Unknown
Escitalopram C Safety Unknown
Bupropion C Possibly Unsafe
Venlafaxine C Safety Unknown
Nortriptyline D Probably Safe
Amitriptyline C Probably Safe
Mirtazapine C Safety Unknown
Trazodone C Probably Safe
15. Pregnancy factors that may increase
medication concentrations
Reduced gastrointestinal motility
Absorption changes for some medications
Reduced fecal elimination
Serum proteins lower
May result in higher ‘free’ drug concentrations
16. Pregnancy factors that may decrease
medication concentration
Total blood volume increases 30 – 40%
2nd and 3rd trimesters extravascular volume
increases
○ Results in lower plasma levels of meds
Increased kidney plasma flow 30%
GFR increased by 50%
○ Renal excreted drugs have faster elimination
17. Pregnancy factors that may decrease
medication concentration
Nausea and vomiting
Reduced absorption
Increased liver metabolism
May result in increased elimination of certain
medications
18. Antidepressant Blood Levels and
Pregnancy
Prepregnancy Conception 20 weeks Delivery Postpartum
Adapted from Sit et al 2008
19. What should we be concerned about?
1. Organ malformation (teratogenicity)
○ Miscarriage is worst outcome of this
2. Neonatal Adaptation
○ Physical and behavioral symptoms noted
shortly after birth
Related to drug use near time of birth
Limited duration
A Long term behavioral abnormalities
20. Medication Background
Incidence of major birth defects in US is
2 to 4%
65 – 70% of unknown cause
2 – 4% medication related
Period of maximum vulnerability for birth
defects of the nervous system is 14 – 35
days post conception
21. Medication Background
Women usually find out when already
5-7 weeks gestation
Therefore, may want to keep same
medication if it’s working
22. Antidepressants During Pregnancy
SSRI complications
Congenital anomalies
Persistent Pulmonary Hypertension of
the Newborn
Neonatal adaptation syndrome
23. SSRIs DURING PREGNANCY AND RISK OF
PERSISTENT PULMONARY HYPERTENSION IN
THE NEWBORN: population based cohort study
from the five Norodic countries
The risk of persistent pulmonary
hypertension of the newborn is low, but
use of SSRIs in late pregnancy
increases that risk more than twofold .
The increase risk seems to be a class
effect
BMJ .2011JAN 12,:d8012.doi:10.1136/bmj
24. Paroxetine
Has FDA warning against using in first
trimester due to increased risk of cardiac
defects
25. Neonatal Adaptation
Syndrome
Cohort study (n = 120), included
venlafaxine
Neonatal abstinence syndrome
occurs in 30% of neonates exposed
to SRIs in utero
Monitor for 48 hours after birth
Levinson-Castiel R (2006) Arch Pediatr Adolesc Med 160:
173-176.
26. Neonatal Adaptation Syndrome
Tremors
Increased muscle tone
Feeding difficulties
Irritability
Respiratory problems
Increased reflexes
Increased crying
Sleep changes
Seizures
Moses-Kolko EL et al (2005) JAMA 293: 2372-2382
27. SSRIs and Persistent Pulmonary
Hypertension
N = 377 women with PPHN infants
N = 836 matched controls
Blinded nurses interviews
N = 14 PPHN infants exposed to SSRI
after 20 weeks gestation (n = 6 for controls)
OR = 6.1 (95% CI: 2.2-16.8)
Use of SSRI before 20 weeks or use of
non-SSRI at any time during pregnancy
not associated with PPHN
Risk increases from 2/1000 to 6/1000
Chambers CD et al (2006). NEJM 354;6: 579-587.
28. SSRI Long Term Effects
Prospective cohort study
TCA (n = 46), FLX (n = 40), No MDD (n =
36)
Children’s IQ, language, development,
temperament assessed and compared
○ Ages 15 -71 months
No differences between groups
IQ negatively associated with duration of
depression
Language negative associated with # MDD
episodes after delivery
Nulman et al (2002) AJP 159: 1889-1895.
29. Tricyclics in pregnancy
The studies are conflicting
Fetal tachycardia?
One case report
Neonatal symptoms
Tachypnea
Tachycardia
Cyanosis
Irritability
Hypertonia
Clonus
Spasm
ACOG 2007
30. Electroconvulsive Therapy
Safe and effective treatment
70% of patients who have not responded to
medications respond well to ECT
Effective for major depressive episode
○ Especially with psychosis or melancholic
features
Effective for manic episode
Effective for acute schizophrenia episode?
31. Non pharmacological
treatments
Decrease caffeine, nicotine, alcohol
Improve sleep
Increase relaxation
Psychotherapy
Interpersonal
Cognitive Behavioral
Support groups
Education
Marital counseling
Decrease psychosocial stressors
Communicate with obstetrical team
32. Breastfeeding
Most medications excreted into breast milk
Amount infant receives is based on mother
milk:plasma ratio and amount of breast milk received
Most important determinant of drug penetration
is mother’s plasma levels
Drug levels in breastmilk are less than what
crosses the placenta
33. Medications in
breastfeeding
Avoid long half life or sustained release
medications
Schedule medication dosing
immediately after feeding or right before
long rest period
Advise mother to monitor for
oversedation, especially with cosleeping
36. Anticonvulsants – Summary
Drug FDA Fetal Risk Summary
Lithium D Ebstein’s anomaly, “floppy baby” syndrome
reported
CBZ D FHS, NTD, neurodevelopment effects?
VPA D Major and minor congenital abnormalities,
intrauterine growth retardation, hyperbilirubinemia,
hepatotoxicity, transient hyperglycemia, neural tube
defects (day 17 – 30)
Topiramate C
Lamotrigine C Unsafe with breastfeeding
Gabapentin C 4 reports of normal pregnancy, 1 report of
respiratory distress
37. Lithium and
Breastfeeding
Breast Feeding
Breast milk [Li] = 30-100% mother serum [Li]
Cyanosis, ⇓ muscle tone, T-wave changes
Not a good idea
38. Anticonvulsants
All studies done in women receiving
anticonvulsants for epilepsy
None in women with primary psychiatric
disorder
Women with epilepsy bear more children
with malformations
○ 3.5 %
Morrow J et al (2006) J Neurol Neurosurg Psychiatry 77: 193-198.
42. Lamotrigine in
Pregnancy
N = 14 pregnant women
LTG monotherapy
LTG metabolism increases during
pregnancy
○ % in relative clearance (dose in mg/weight in
kg/serum conc in mg/L)
1st trimester = 118% higher
2nd trimester = 171% higher
3rd trimester = 208% higher
Postpartum = 4% higher
Pennell et al. Neurology; 62: 292-295, 2004
43. Antipsychotics in Pregnancy
Drug FDA Fetal risk summary
Haldol C
Chlorpromazine C
Aripiprazole C
Olanzapine C
Seroquel C
Risperidone C
Clozapine B
ZELDOX C
44. Benzodiazepines
Behavioral effects
Impaired learning and memory, absence of
startle reflexes, other sustained/subtle
behavior
Data is conflicting
45. BZD and Pregnancy
Drug FDA Fetal risk summary
Alprazolam D Reports are conflicting. Cleft plate risk increased to
7/1000. Withdrawal after in utero exposure reported
(crying/restlessness)
Clonazepam D Little data on teratogenicity. Newborn toxicity noted
(apnea, cyanosis, lethargy, and hypotonia).
Diazepam D Accumulates in fetus 1-3x mother. T1/2 prolonged.
Increased risk of cleft palate. Floppy infant
syndrome and withdrawal possibility.
Triazolam X Little data available, but similar to other BDZ.
47. NEROLEPTICS
Typical neuroleptics: Haldol ,clopixol
atypical neuroleptics: Risperidone,
Olanzapine ,Seroquel
Careful in choice in pregnancy and
lactation for the side effects.
Sedation with Seroquel.
Weight gain with olanzapine.
Risperidone could be a good choice in
pregnancy and lactation.
48. Take Home Points
Depression in pregnancy is common
Untreated depression in pregnancy carries
risks for both the mother and the child
No antidepressants are FDA approved in
pregnancy
But sertraline is generally agreed to be “safest”
Must weigh risks and benefits with the
mother (and partner) on an individual basis
49. Take Home Points
SSRIs may be associated with septal
defects, PPHN, and a neonatal
syndrome.
SSRIs are “safe” in breastfeeding
Sertraline and paroxetine probably safest
ECT is safe with pregnancy and
breastfeeding
50. Take Home Points
Lithium is moderately safe in pregnancy??
but not with breastfeeding
Carbamazapine and Valproic Acid are not
safe in pregnancy but moderately safe with
breastfeeding
Lamotrigine and the atypical antipsychotics
seem to be relatively safe in pregnancy but
need more data
Benzodiazepines are associated with
clefting
51. Resources
www. Motherisk.org
http://www.womensmentalhealth.org
http://www.emorywomensprogram.org
www.postpartumprogress.typepad.com
Yonkers et al, 2009 APA and ACOG
Consensus Statement, General Hospital
Psychiatry and Obstetrics and
Gynecology
(and eventually you may need to up the dose) Can alternative allow us to avoid med or use lower dose?
Why should you know this…your patients will read it..the good news? The FDA is going to change its labelling to include registry information, standard information on background rates
Paxil- OR 2.08 for congenital malformations – VSD – retrospective 3581 Swedish registry study – 4 % paxil major congenital anom vs 2 % with other AD 6.1 OR for PPH
Women get constipated, morning sickness
To appreciate some of the data that I’ll share on anti D in pg, some background info…
A couple of those helpful hints… It will be around for a while…though metabolism does change during pregnancy…