Prof Jayashri Kulkarni’s Tips On Prescribing Antipsychotics in Pregnancy

Posted on August 14, 2016

Prof Jayashri Kulkarni takes us through the key points for clinicians to remember in prescribing antipsychotics in women of childbearing age and pregnant women.


  1. Second Generation Antipsychotics (SGA’s) are used in a wide variety of conditions such as Schizophrenia, Bipolar Affective Disorder, Anxiety Disorders (e.g., low dose quetiapine), etc. The TGA has given all SGA’s a category ‘C’ rating, but there is no global data for clinicians and pregnant women to rely on.
  2. The Central Nervous System (CNS) development in a fetus occurs at 3-4 weeks, and hence medication effects on the CNS may have taken place even before the patient knows they are pregnant in an unplanned pregnancy.
  3. The National Register of Antipsychotic Medication in Pregnancy (NRAMP) was created to study mother and baby (up to 12 months) outcomes. Some aims are to assist clinicians in making informed decisions, formulate evidence-based guidelines, improve treatment options and safer outcomes for mother and baby.
  4. Of all the SGA’s, Quetiapine is the most widely used and the most common outcome is live births.
  5. “We are not seeing a thalidomide drug signal.....None of the SGA’s have got the particular concern of congenital birth defects or congenital organ anomalies.
  6. The level of miscarriages is not out of the normal population range.
  7. Neonatal Respiratory Distress (NRD) is an important outcome that occurs at a higher rate than the normal population. 34% of babies in the NRAMP cohort has NRD. These babies had poor APGAR scores at birth but have done well at 12 months.
  8. “For this reason, we are very clear when we have a woman who is taking an antipsychotic during pregnancy that she should deliver her baby in a big hospital which has good paediatric and neonatal intensive care or special care nursery facilities.”
  9. Neonatal Abstinence Syndrome (NAS) is another important outcome, and the clinical presentation can be similar to an opiate abstinence syndrome in the newborn.
  10. There is an increased risk of prematurity: 8.3% in the general population (AIHW, 2011) vs. 15% in the NRAMP cohort.
  11. Small for gestational age babies: 6.3% in the general population (AIHW, 2011) vs. 19% in the NRAMP cohort.
  12. There is a greater risk of maternal weight gain in pregnancy which is defined as a greater than 15 kg of weight gain. 31% of the NRAMP cohort showed increased weight gain. This can increase the risk of Gestational diabetes.
  13. Gestational diabetes in the NRAMP cohort was 20% vs. 5.6% in the normal population. Recommendations are to consider an oral Glucose Tolerance Test (GTT) at 10 weeks.
  14. It is essential to have not only the “contraception conversation,” but also the “childbearing conversation” in young females because if we can plan it, we are in a better situation to prevent the “CNS assault” in the 3 weeks fetus.



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