The safety of second-generation antipsychotics (SGAs) during pregnancy is a nuanced issue, as there is limited data from randomized controlled trials. However, many SGAs are commonly prescribed to pregnant patients when the benefits outweigh potential risks. Treatment decisions should be individualized, weighing the severity of the mother’s condition and the risks of untreated psychiatric illness against the potential risks to the fetus.
SGAs Commonly Considered Safe (Relatively)
The following SGAs are generally considered to have a better safety profile during pregnancy, based on current evidence:
1. Quetiapine (Seroquel)
• Often considered a safer option for use during pregnancy due to relatively limited association with adverse outcomes. It is frequently prescribed because of its lower risk of metabolic side effects and limited evidence of teratogenicity.
2. Lurasidone (Latuda)
• Lurasidone is classified as Category B by the FDA (meaning no evidence of risk in animal studies, but limited human data). It is preferred for treating bipolar depression during pregnancy because of its favorable safety profile.
3. Aripiprazole (Abilify)
• Preliminary data suggest aripiprazole may have a relatively low risk of teratogenicity. It’s sometimes used during pregnancy, particularly in cases of mood stabilization or psychosis, where other options are less suitable.
4. Risperidone (Risperdal)
• Risperidone has more extensive data available and is generally considered relatively safe for use in pregnancy, though it may carry a slightly higher risk of metabolic and extrapyramidal side effects compared to some other SGAs.
SGAs with Caution Advised
Some SGAs have limited data or a potentially higher risk profile, and caution is advised when prescribing them during pregnancy:
1. Olanzapine (Zyprexa)
• While not contraindicated, olanzapine is associated with higher risks of metabolic effects, including weight gain and gestational diabetes, which could impact pregnancy outcomes. It may still be used if benefits outweigh risks.
2. Clozapine (Clozaril)
• Clozapine is generally avoided during pregnancy unless absolutely necessary due to risks of agranulocytosis, metabolic effects, and potential neonatal complications.
3. Ziprasidone (Geodon)
• There is limited data on ziprasidone, so its use is less common during pregnancy unless other options are unsuitable.
4. Paliperidone (Invega)
• Paliperidone, a metabolite of risperidone, has very limited data regarding safety during pregnancy. Caution is advised.
Risks and Considerations
• Congenital Malformations: Most studies on SGAs do not show a strong link to major congenital malformations, but more data are needed.
• Neonatal Effects: Use of SGAs, particularly late in pregnancy, has been associated with neonatal complications such as sedation, withdrawal symptoms, and extrapyramidal side effects.
• Metabolic Risks: Some SGAs (e.g., olanzapine, risperidone) may increase the risk of gestational diabetes or other metabolic issues, which should be monitored closely.
• Placental Transfer: SGAs cross the placenta, so potential fetal exposure must always be considered when prescribing.
General Recommendations for Prescribing SGAs in Pregnancy
1. Risk-Benefit Assessment
• Carefully assess the necessity of antipsychotic treatment during pregnancy. The risk of untreated psychiatric conditions, such as psychosis, bipolar disorder, or severe depression, may outweigh the potential risks of medication.
2. Lowest Effective Dose
• Use the lowest effective dose to minimize fetal exposure.
3. Monitoring and Follow-Up
• Monitor for metabolic complications (e.g., gestational diabetes) and fetal development through regular ultrasounds and prenatal check-ups.
• Postnatal monitoring for neonatal complications such as withdrawal symptoms or sedation.
4. Avoid Polypharmacy
• Limit the use of additional medications, especially those that may interact with SGAs, to reduce the risk of compounded side effects.
5. Consultation with Specialists
• Involve a perinatal psychiatrist or maternal-fetal medicine specialist to ensure comprehensive care and monitoring.
Conclusion
While no SGA is completely without risk during pregnancy, quetiapine, lurasidone, and aripiprazole are generally preferred based on current evidence. However, treatment decisions should always be individualized, with ongoing monitoring and collaboration between psychiatry and obstetrics to ensure the safety of both the mother and the fetus.
