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Journal of Clinical and
Basic Psychosomatics Safe psychotropic drug use: Pregnancy checklist

Table 1. A 10-point checklist of key considerations when prescribing/deprescribing psychotropic medications before or during
pregnancy
No. Consideration/risk description
1 Pre-pregnancy counseling: Balancing risks and benefits
The primary concern when prescribing psychotropic drugs during pregnancy is finding a balance between managing the mental health
condition and minimizing potential harm to the fetus. Leaving a mental health condition untreated can also have serious consequences for both
the mother and the developing fetus. 3
Unplanned pregnancies in women taking psychotropic medications are common, resulting in fetal exposure during the first trimester. Pre-
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pregnancy counseling, involving shared decision decision-making with the patient about the risks and benefits of proposed continuation,
termination, or amendment of a current medication regimen, is preferable to having this first discussion during pregnancy. 3
2 Potential risks to the fetus:
• Teratogenicity: Some psychotropic drugs have been associated with increased teratogenicity when taken during specific stages of pregnancy.
These have varying levels of risk. For example, mood stabilizers such as valproate and lithium have well-known teratogenic risks (e.g., neural
tube defects and cardiovascular malformations, respectively), while antidepressants (e.g., SSRIs and TCAs associated with heart defects)
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are considered low risk. It is essential to examine the specific drug’s safety profile. Second-generation antipsychotics may increase the risk
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of gestational diabetes. Lithium is contraindicated in breastfeeding and poses a risk of congenital heart defects. However, lithium is the gold
standard treatment for bipolar disorder, with demonstrated efficacy in the prophylaxis of postpartum relapse, and should be considered for
women with severe bipolar disorder. If lithium is used during pregnancy, fetal echocardiography, and ultrasonography are recommended. 11
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• Neonatal withdrawal syndrome: Certain psychotropic drugs, particularly selective SSRIs, can lead to withdrawal symptoms in newborns if
taken during late pregnancy, as well as opioids. Fetal exposure, particularly in the last trimester, may result in respiratory, motor, central
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nervous system, and gastrointestinal symptoms in about 10%–30% of newborns (Poor Neonatal Adaptation Syndrome). 13
*N.B.: Not all teratogens or drug interactions have been discussed –each medication in question should be individually reviewed by the treating
practitioner.
3 Maternal well-being
Untreated mental health conditions during pregnancy can have adverse effects on the mother’s well-being and health, potentially leading
to difficulties with bonding, prenatal care, self-care, and an inclination to engage in dangerous behavior. Activities of daily life, including
employment, social obligations, caring for other children, and other daily responsibilities, need to be considered, along with the previous dosage
history and success.
As discussed by Ward et al., “The patient’s diagnosis, severity of previous episodes, the necessity for medication, and responsiveness to
medication are strong predictors of the need for medication to maintain remission.” 14 (p635]])
The patient’s past level of function when not taking medication must be explored. 14
A comprehensive history should, at a minimum, include:
• Previous psychiatric hospitalization(s), which likely suggest severe previous dysfunction 14
• Suicidality
• Self-destructive thoughts or behaviors
• Assessment of the patient’s ability to meet home, educational, and occupational responsibilities 11
If there have been previous pregnancies, the pattern of prior dysfunction and symptoms present is greatly useful. 14
4 Consultation/collaboration
Prescribing psychotropic drugs during pregnancy should ideally involve a collaborative approach with a team of healthcare providers, including
obstetricians, psychiatrists, and mental health specialists. 3,15
According to Coffman et al.
“The first, most important thing to do is to change nothing; that is, do not recommend to your patient that they immediately stop or taper off
[their] psychotropic medication.” 15(p380)
This decision needs to be made in consultation with a psychiatrist and the deprescription needs to follow normal safety protocols. A specialist
perinatal psychiatrist can be particularly helpful in making informed decisions. There should be a conversation (preferably face-to-face) with
3,15
the patient discussing the risks of continuing the psychotropic medication versus tapering off.
Maternal-fetal medicine services, a subspecialty of obstetrics that focuses on identified high-risk pregnancies, can provide pre-conception
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counseling for high-risk patients, counseling for fetal complications, first-trimester ultrasounds, and other tests that may be relevant. It is
worthwhile considering if a high-risk patient satisfies referral criteria for their local service.
5 Medication selection
The choice of medication is crucial. Some psychotropic drugs may be considered safer during pregnancy or have fewer side effects than
others. Healthcare providers should carefully evaluate the risks and benefits of each drug and consider non-pharmacological treatments when
appropriate.
Additional care and attention are required in the case of polypharmacy and whether to continue or amend the existing medication regimen. 5,14
6 Dose adjustment
Adjusting the dosage of psychotropic drugs may be necessary during pregnancy. Pregnant patients may metabolize medications differently, and
dose adjustments may help minimize potential risks while maintaining therapeutic benefits. Pregnancy is a hypermetabolic state; accordingly,
drug doses may need to increase to achieve the same result before pregnancy. 12

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Volume 2 Issue 3 (2024) 3 https://doi.org/10.36922/jcbp.2978