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prices (to the disadvantage of other general practition-ers and patients) are therefore disappearing. Thenational tariff should also reduce transaction costs. Pri-mary care trusts will act as the contracting agent forcommissioners in practices, streamlining the processand reducing costs still further and the additional costs

of practice based commissioning will be funded fromsavings against the budget. Unlike fundholdingdoctors, the new practice based commissioners will not

be legally autonomous and will remain under the aegisof primary care trusts. This will provide an opportunityto marry the dynamism of devolution with the strategicplanning and public accountability of primary caretrusts. Practices that commission services in the newscheme are less likely to be seen as wild cards as they

were in the 1990s.12

Nor will the patients of these new commissionersenjoy access to a far wider range of services. There arenow guarantees of greater choice for all patients and,from 2008, patients will have unrestricted choices to

see any provider meeting minimum quality standardsand the NHS price tariff.1 Furthermore, since thedemise of fundholding, the NHS has worked todecrease variation in services across the country.National service frameworks, guidelines from theNational Institute for Clinical Effectiveness,inspections

by the Healthcare Commission, and new national coreand developmental quality standards are all aiming toregulate the services available to NHS patients. This

new environment might allay the fears of all save themost hardened critics of fundholding.

Richard Q Lewis visiting fellow

Kings Fund, London W1G 0AN(R.lewis@kingsfund.org.uk)

Competing interests: The author has advised NHS organisa-tions on practice based commissioning as a paid consultant.

1 Department of Health.NHS improvement planputting people at the heart ofpublic services. London: DoH, 2004.

2 Department of Health. Practice based commissioning. Engaging practices incommissioning. London: DoH, 2004. (http://www.dh.gov.uk/assetRoot/04/09/03/59/04090359.pdf (accessed 6 Oct 2004).

3 Lewis R. Primary care led commissioningharnessing the power of theprimar y c ar e front l ine. London: K ings Fund, 2004.

www.kingsfund.org.uk/pdf/practiceledcommissioning.pdf (accessed 1Oct 2004).

4 Commissionfor Health Improvement.What CHI has found in primary caretrustssector report. London:CHI,2004.

5 Department of Health. Reforming NHS financial flows. Introducing paymentby results. London:DoH, 2002.

6 NHS Alliance/Primary Care Report. Clinician engagement: a nationalsurvey. Retford: NHS Alliance, 2003.

7 HM Treasury. Public service agreements 2004. www.hm-treasury.gov.uk/spending_review/spend_sr04/psa/spend_sr04_psaindex.cfm (accessed1 October 2004).

8 Goodwin N. GP fundholding. In: Le Grand J, Mays N, Mulligan, JA, eds.Learning from the NHS internal marketa review of the evidence. London:Kings Fund, 1998.

9 Propper C, Croxson B, Shearer A. Waiting times for hospital admissions:theimpact of GP fundholding. CMPO Working Paper Series No 00/20, 2000.

10 Dusheiko M, Gravell H, Jacobs R, Smith P. The effects of budgets on doctorbehaviour:evidence from a natural experiment,discussion paper. York: Depart-ment of Economics, University of York, 2003.

11 Baxter K, Bachmann M, Bevan G. Primary care groups: trade-offs inmanaging budgets and risk.Public Money Manage2000;Jan-Mar:53-62.

12 Glennerster H, Matsaganis M, Owens P. Implementing GP fundholding:wild card or winning hand? In: Robinson R, Le Grand J, eds. Evaluatingthe NHS reforms. London:Kings Fund,1994.

Safety of antipsychotic drugs for pregnant and

breastfeeding women with non-affective psychosisMulticentre cohort studies are needed as randomised trials are impractical

Around 2% of women develop a non-affective

psychotic disorder, and more than half ofthem have children.1 2 Women with non-

affective psychoses are less fertile than controls, partly because of hyperprolactinaemia secondary to anti-psychotic drugs.3 4 The use of atypical drugs such asclozapine and olanzapine, which do not have thiseffect, may increase fertility rates. Weighing risksagainst benefits in treating pregnant and breastfeeding

women with antipsychotics requires assessment ofclinical effectiveness versus risk of toxicity to mother,fetus, newborn, and the developing child. Withholdingantipsychotic treatment may expose mother and fetusto more harm than benefit as, in addition to

behavioural disturbance which may put both at risk,physiological changes associated with psychosis couldaffect fetoplacental integrity and development of thecentral nervous system. Subsequently, poor clinicaloutcomes for mothers may result in poorer interaction

between mother and infant.5 But the impact of antipsy-chotic medication on the fetus is also unclear as norandomised controlled trials have evaluated the use ofantipsychotics in pregnancy.6

The only large controlled studies of antipsychoticsin pregnancy have been conducted on women withhyperemesis gravidarum. Much lower doses of

medication (generally drugs such as phenothiazines)are used for these patients than for patients withschizophrenia, and residual confounding is common-place. Conclusions are therefore limited. A meta-analysis reported that exposure to low potencyantipsychotics during the first trimester was associated

with a small additional risk of congenital anomalies. 7

Antipsychotics can also produce toxic effects innewborn infants medicated in the womb, including

respiratory depression and neonatal behaviouralabnormalities such as extrapyramidal movementsand difficulty with oral feeding, although theseeffects usually resolve within days. The few smallstudies examining longer term neurobehaviouraleffects in children exposed to antipsychotics in the

womb have reported no behavioural or intellectualabnormalities.

Even less is known about any adverse effects ofatypical antipsychotics. On comparing case registrydata (n= 37) with historical controls the rates ofadverse effects with olanzapine during pregnancy werenot found to be higher.8 However, data from theNational Teratology Information Service indicate an

increased incidence of malformations of 10% (com-pared with an expected incidence of 2-3%).9 However,as only three cases were seen, no clear relation can be

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established.9 One survey of pregnant women takingclozapine reported a higher than expected rate of mal-formations (five cases in 61 pregnancies).10 Reduced

variability of the fetal heart rate before and duringlabour has also been noted in one woman takingclozapine.11 Case reports and data from the National

Teratology Information Service do not indicate a prob-lem with quetiapine and risperidone during preg-nancy. No data are available on newer drugs such asaripiprazole. An increased risk of neural tube defectshas also been proposed as many atypical antipsychoticsare associated with weight gain and subsequent folatedeficiency.12 This association has not been investigatedempirically.

Thus very little evidence exists regarding the use ofantipsychotics during pregnancy. When a woman withschizophrenia presents pregnant, wanting to come offmedication, many psychiatrists will be concernedabout the high risk of relapse during pregnancy ifmedication is discontinued. Most will suggest that ide-

ally she should be maintained on the lowest possibledose of antipsychotic during and after pregnancy, withfetal screening throughout pregnancy. The woman islikely to be concerned about the risk of medication tothe fetus. But neither the psychiatrist nor the pregnant

woman will be able to find data on the size of the effectof these risks.

Pharmacological treatment after delivery dependson the mothers symptoms and whether she is breastfeeding. Antipsychotic drugs are excreted in breastmilk, but to date breast fed infants have not shownsigns of toxicity or impaired development in most casereports of antipsychotics, although manufacturersadvise avoidance of these drugs during breast feeding.Recent recommendations from the World HealthOrganization and the UK government, stressing thedesirability of breast feeding exclusively for six months,make it imperative that women know whether they cando this safely while on medication.

Little is known about the effect of newerantipsychotics; preliminary experience shows noadverse effects attributable to olanzapine, but longterm data are required.10 13 Dev and Krupp reported onfour infants breast feeding from mothers takingclozapineone developed excess sleepiness andanother agranulocytosis, which resolved with dis-continuation of breastfeeding.10 Mothers on clozapineshould thus not breast feed. The evidence for prescrib-ing antipsychotic medication while breast feeding is

therefore based on even fewer reports. Althoughmothers are advised to continue the same medicationgiven during pregnancy when breast feeding, to avoiddrugs with a long half life, and to time feeds to coincide

with trough concentrations of drugs in breast milk, thisis based on common sense and not on any high levelevidence.

The lack of evidence is partly attributable to ethicalconstraints restricting randomisation of pregnant and

breastfeeding women. In addition, drug companies donot usually sanction the evaluation of antipsychotics inpregnant or breastfeeding women in randomised con-trolled trials. This raises ethical and clinical dilemmasregarding appropriate management of an already vul-nerable group of women.

Many women are likely to be taking atypical anti-psychotic drugs at conception. This provides anopportunity to investigate short and long term adverseeffects of antipsychotic drugs on pregnant women andtheir offspring, including neurobehavioural outcomesin these children. Although randomised controlled tri-als may be impractical, coordinated multicentreprospective cohort studies could provide goodevidence. Obstetricians, psychiatrists, and generalpractitioners need robust evidence on which to baseprescribing of antipsychotic drugs for pregnant and

breastfeeding women, and women must be providedwith dependable information to support them in deci-sions about medication during pregnancy and after the

birth.Louise Howard senior lecturer

Health Services Research Department, Institute of Psychiatry, LondonSE5 8AF(l.howard@iop.kcl.ac.uk)

Roger Webb research fellow

(roger.webb@man.ac.uk)

Kathryn Abel senior lecturer

(kathryn.m.abel@man.ac.uk)

Centre for Womens Mental Health Research, University ofManchester, Manchester M13 9PL

Competing interests: None declared.

1 McCormick A, Fleming D, Charlton J.Morbidity statistics from general prac-tice: 4th national study 1991-1992. Series MB5, no 3. London: HMSO,1995.

2 Howard LM,Kumar C,Thornicroft G.The psychosocialcharacteristicsofmothers with psychotic disorders.Br J Psychiatry 2001;178:427-32.

3 Howard LM, Leese M, Kumar C, Thornicroft G. The general fertility ratein women with psychotic disorders. Am J Psychiatry 2002;159:991-7.

4 Smith SM, OKeane V, Murray R. Sexual dysfunction in patients takingconventional antipsychotic medication.Br J Psychiatry 2002;181:49-55.

5 Riordan D, Appleby L, Faragher B. Mother-infant interaction in postpar-tum women with schizophrenia and affective disorders. Psychol Med1999;29:991-5.

6 Webb R, Howard L, Abel K. Antipsychotic drugs for non-affectivepsychosis during pregnancy and postpartum. Cochrane Database Syst Rev2004;(2):CD004411

7 Altshuler LL, Cohen L, Szuba MP, Burt VK, Gitlin M, Mintz J. Pharmaco-logic management of psychiatric illness during pregnancy: dilemmas andguidelines.Am J Psychiatry 1996;153:592-606.

8 Goldstein DJ, Corbin LA, Fung MC. Olanzapine-exposed pregnanciesand lactation: early experience. J Clin Psychopharmacol 2000;20:399-403.

9 University of Newcastle upon Tyne, NHS. National teratology informationservice. (NTIS) www.nyrdtc.nhs.uk/Services/teratology/teratology.html(accessed 29 Jul 2004).

10 Dev VJ, Krupp P. Adverse event profile and safety of clozapine. Rev Con-temp Pharmacother1995;6:197-208.

11 Yogev Y, Ben-Haroush A, Kaplan B. Maternal clozapine treatment anddecreased fetal heart rate variability.Int J Obs Gyn2002;79:259-60.

12 Koren G, Cohn T, Chitayat D, Kapur B, Remington G, Reid DM, et al.Useof atypical antipsychotics during pregnancy and the risk of neural tubedefects in infants.Am J Psychiatry 2002;159:136-7.

13 Gardiner SJ, Kristesnsen JH, Begg EJ, Hackett LP, Wilson DA, Ilett KF, etal.Transfer of olanzapineinto breast milk,calculation of infantdrug dose,and effect on breast-fed infants. Am J Psychiatry 2003;160:1428-31.

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