Management of Psychotic Disorders during Pregnancy and the Postpartum Period

Pregnant patients diagnosed with psychotic disorders are classified as a high-risk pregnancy group, as they are at higher risk for stillbirth and infant mortality and have an insufficient capability to maintain and manage pregnancy [1]. The recent increase in use of atypical anti-psychotic medications has reduced the possibility of infertility caused by hyperprolactinemia; as a result, patients with psychotic disorders are increasingly getting pregnant and giving birth [2]. It is important to clearly understand their clinical course and treatment methods during pregnancy and the postpartum period.

Patients with psychotic disorders experience more complications during pregnancy compared to generally healthy mothers. In particular, schizophrenic patients are known to exhibit a significantly high frequency of impaired glucose tolerance and gestational diabetes during pregnancy [3]. Treatment of schizophrenia using atypical anti-psychotic medications has increased recently, though susceptibility to diabetes has not significantly decreased [4]. Such patients experience many more obstetric complications compared to generally healthy mothers due to heavy substance abuse, such as smoking and alcohol intake [5]. Moreover, the typically low socioeconomic statuses and poor familial support systems of these patients adversely affect their antenatal care [6]. Psychotropic medications that are used continuously during pregnancy can also increase the frequency of complications [7].

When patients with psychotic disorders become pregnant, clinicians must clearly inform them of the advantages and disadvantages of continuing pregnancy with and without continuing treatment [8]. As mentioned above, the very high risk of issues due to cessation of treatment for psychotic disorders during pregnancy leads to typical advice to continue treatment during pregnancy. Various treatment options and possible side effects or complications must be disclosed. Explanations of the effects of treatment on patients and their fetuses must be provided to them, as well as to their spouses and family members. The absolute baseline risks of side effects and complications should be described rather than the relative risks, because patients and their family members can more easily understand when the natural frequencies of risks are discussed. Given that risks vary according to psychiatric history and social support, clinicians must discuss risk factors comprehensively.

The use of anti-psychotic medications is widely recognized as advantageous for patients with psychotic disorders who want to become pregnant or breastfeed after birth despite the toxicity of such medications to their fetuses, neonates, and children [6]. Physiological changes associated with psychotic disorders are also known to adversely affect feto-placental integrity and fetal central nervous system development. Moreover, behavioral disturbance associated with psychotic disorder can cause fatal distress to mothers and adversely affect mother-infant interactions after birth [6].

Although the continuous administration of anti-psychotics to patients with psychotic disorders during pregnancy is widely recommended, the mechanisms by which anti-psychotics impact fetuses are poorly understood because randomized controlled trials cannot be conducted for ethical reasons [7]. There has been only one large controlled study on the use of anti-psychotics during pregnancy [9], and it targeted hyperemesis gravidarum patients, limiting broad generalization of the results. In addition, the doses of the anti-psychotics used were too small, and only conventional anti-psychotics were used. In a meta-analysis, the use of low potency anti-psychotics during the first trimester resulted in a small additional risk of congenital anomalies [10]. However, in a recent prospective matched case-control study, there was no evidence of increased fetal malformation risk in mothers exposed to anti-psychotics (151 cases) [11].

Infants who are exposed to anti-psychotics during the fetal period may experience side effects, including respiratory depression, neonatal behavioral abnormalities, difficulty with oral feeding, and extrapyramidal symptoms [10]. These side effects, however, are known to disappear within several days. School children exposed to anti-psychotics during the fetal period display no evidence of increased behavioral problems or intellectual abnormalities [11].

The effects of atypical anti-psychotics on pregnancy are also not clearly understood. In a previous study, olanzapine was associated with an increased the risk of gestational diabetes but not with teratogenicity [12]. Risperidone and quetiapine are also not significantly associated with teratogenicity [11]. Clozapine can theoretically cause fetal agranulocytosis, so mothers are advised to replace it with other medications [8]. Considering the limited data on the effects of atypical anti-psychotics during pregnancy, clinicians must continuously update their information and strictly follow general guidelines on the use of drugs during pregnancy. The known effects of psychotropic agents on the fetus are summarized in Table 1.

The general guidelines for use of psychotropic medications in patients with psychotic disorders during pregnancy include the following. 1) Avoid contraindicated drugs during pregnancy, particularly sodium valproate and carbamazepine. 2) Avoid drug use as much as possible during the first trimester. If not possible, use the lowest effective dose. 3) Avoid polypharmacy as much as possible. 4) Upon recognition of pregnancy, do not abruptly discontinue psychotropic drug intake. Consider discontinuation only when the symptoms are mild and the recurrence risk is negligible. 5) Not only patients, but also their family members must be informed of the advantages and disadvantages of the selected psychotropic drugs. 6) Monitoring drug plasma level is important as blood volume changes with pregnancy. 7) Screening and evaluation of the fetus must be conducted on a regular basis. 8) All clinicians involved in patient care (including obstetric staff) must be informed of psychotropic drug intake.

Psychotic disorder patients are less capable of managing infants after birth compared to healthy mothers, particularly in cases of schizophrenia rather than affective psychoses [13]. Nevertheless, schizophrenic patients can nurture their infants with spousal or psychosocial support. If post-natal child protection is a problem, it must be discussed and reviewed before delivery. Various methods of assessing psychotic disorder patients for their capability to appropriately nurture older children have been reported [14,15], but few methods or frameworks have been established for assessing the capability of psychotic disorder patients to care for infants. Accordingly, clinicians must conduct multilateral and comprehensive assessments of a patient’s ability to appropriately respond to the developmental needs of children, as well as environmental factors and the availability of supportive family members.

Just as maternal mental illness affects children, the characteristics of the children also affect the psychiatric condition of the mother. Patients who suffer from irritability or behavior disturbance toward their children are known to have a high risk of postnatal depression [14]. The psychiatric conditions of newborns must be monitored, but the bond between mother and child must be maintained as much as possible.

The most critical psychiatric emergency symptom in psychotic disorder patients after birth is delusion associated with children [13]. Patient-child separation must be considered in this case. Negative maternal symptoms, such as social withdrawal, apathy, and lethargy, eventually deteriorate the communication and socialization capabilities of children [13]. Considering the more negative effects of poor maternal insight into the impact of their psychiatric disorder on their children, education regarding their disease is very important [14]. Since anti-psychotics can further deteriorate negative symptoms, clinicians must pay attention to them. All patient symptoms can affect the psychological development of the children, so close psychiatric monitoring of patients and their children is required.

In summary, patients with psychotic disorders belong to a high-risk pregnancy group. Their symptoms can deteriorate or recur due to pregnancy, and the risk increases further when medications are changed or discontinued. At present, patients are advised to continue their medication intake during pregnancy due to the risk of developing complications related to the discontinuation of psychotic disorder treatment. In the absence of studies on the effects of atypical anti-psychotics on pregnancy, the general guidelines for drug use during pregnancy must be strictly followed. Psychotic disorder patients must be intensively monitored, even after birth. Assessments of the patients’ abilities to nurture their children, child development, and patient-child attachment are needed to understand interactions between the patient and the child.