Psychotropic drug treatment during pregnancy and lactation in obsessive compulsive disorder

According to recent studies, obsessive compulsive disorder(OCD) is one of the leading cause of disability and the prevalence of OCD is found to be 0.2-3.5% in pregnancy and 2.7-9% in the postpartum period.

The efficacy and tolerability of SSRIs and SNRIs in the treatment of OCD are well-determined in many double-blind randomized controlled trials. Despite the fact that it is well known that OCD patients may benefit from antiobsessional therapy during pregnancy and the postpartum period, very little data are available about the efficacy of the treatment and no evidence suggests that patients would react differently to these drugs. Hence, OCD women who are pregnant and in the postpartum period might be treated using standardized treatment approaches.

During pregnancy and the postpartum period, the treatment of OCD should clinically take the risks and benefits of several treatment modalities and the expectations of the patient into account. While cognitive-behavioral therapy (CBT) is the leading choice in non-pharmacological treatment of OCD, pharmacoterapy might be used if necessary.

If CBT is inadequate and pharmacotherapy is needed, during pregnancy, şuoxetine, and during the lactation period, paroxetine, are proposed to be the first line treatments. Although evidence is limited, other SSRIs are acceptable as alternative treatment options.

All of the antidepressant drugs are transferred to the nursing infant during breastfeeding. The American Academy of Pediatrics classifies psychotropic drugs as "drugs whose effects are unknown, but may be of concern." The best way of determining the exposure to the drug is measuring the drug concentration in the plasma of the baby. Clinical evaluation is important to identify any side effects while monitoring the baby.

There is no evidence indicating an increase in the rates of intrauterine death or malformation in the case of exposure to tricyclics or SSRIs. Whether exposure to SSRIs causes a decrease in birth weight or an increase in premature births is not certain and the evidence is controversial. Nonetheless, The Food and Drug Administration (FDA) has determined that first trimester exposure to paroxetine might cause an increase in the risk for congenital malformations particularly cardiac defects. Therefore, the FDA has changed paroxetine's pregnancy category from C (risk can not be ruled out) to D (positive evidence of human fetal risk).

A "withdrawal syndrome," consisting of symptoms in the locomotor, central nervous, respiratory and gastrointestinal systems may occur in newborns exposed to SSRIs in the third trimester. Although monitoring is required in an exposed newborn, this syndrome is relatively mild, can be managed with supportive therapy and diminishes within 2 weeks. Some evidence points out an increase in the rates of persistent pulmonary hypertension in infants exposed to SSRIs during the third trimester. Before delivery, lowering the dosage of the mother's drugs that might have been augmented due to the symptom severity of OCD, is recommended.

References:

1. Clinical Management Guidelines for Obstetrician-Gynecologists Use of Psychiatric Medications During Pregnancy and Lactation. ACOG Practice Bulletin, (Reprinted with permission from Obstetrics & Gynecology 2008; 111:1001–1020)
2. Brandes M, Soares CN, Cohen LS. Postpartum onset obsessive-compulsive disorder: diagnosis and management. Arch Womens Ment Health 2004; 7:99–110
3. Use of Psychoactive Medication During Pregnancy and Possible Effects on the Fetus and Newborn Amerikan Academy of Pediatrics Committee on Drugs Pediatrics 2000; 105; 880-887
4. Koran LM, Hanna GL, Hollander E et al. Practice Guidline for theTreatment of Patients with Obsessive-Compulsive Disorder. Copyright 2010, American Psychiatric Association.
5. McGuinness M. OCD in the Perinatal Period: Is Postpartum OCD (ppOCD) a Distinct Subtype? A Review of the Literature. Behavioural and Cognitive Psychotherapy 2011, 39, 285–310