Effects of antipsychotics on the unborn child: what is known and how should this influence prescribing?

The onset of psychosis during pregnancy presents difficult management decisions. A complete and thorough physical and obstetric examination is always warranted to look for possible physiological precipitants. The treatment of pregnant patients with psychotic symptomatology requires close contacts between family members, non-physician professionals involved in the patient's care (e.g. social workers, case managers and home healthcare nurses), and the physicians overseeing the patient's management (e.g. internists, obstetricians and psychiatrists). In mild and less disabling cases it may be possible to avoid medication intervention but this approach risks adverse behaviour consequences resulting from a possible worsening of the patient's symptomatology. Avoiding medication requires an environment in which the patient has strong social supports. Risks are present whether medication is initiated or not, and treatment decisions require a careful assessment of the risks and benefits involved. Initiating medication raises the possibility of obstetric, teratogenic, neurobehavioural and neonatal toxic effects. Research on the risks imposed by antipsychotic drug use during pregnancy is incomplete and raises questions regarding appropriate management. The first trimester represents a period of increased susceptibility to medication-induced teratogenesis. The use of low potency phenothiazines during the first trimester may increase the risk of congenital abnormalities by an additional 4 cases per 1000 (odds ratio = 1.21, p = 0.04) The pharmacological profiles of antipsychotic medications also present adverse effects which need to be considered during pregnancy (hypotension, sedation, etc.). Less is known about the risk of adverse consequences resulting from the use of newer atypical antipsychotic medications. Electroconvulsive therapy is another treatment modality and its use may circumvent the need to introduce antipsychotic medication during pregnancy. It must be stressed that. given current knowledge, no treatment regimen can be considered completely safe. Ultimately many factors must be evaluated when treating psychosis during pregnancy, however, no decision is risk-free.