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Objctive: To contribute to the of treatment of major depressive disorder with psychotic features developing during pregnancy
Case: A 25 year-old, married, female patient was 13 weeks pregnant and diagnosed with major depressive disorder (MDD) with psychotic features. She was a housewife with primary school degree and was admitted to inpatient unit. The obstetrician did not find any fetal anomalies. The patient was put on mirtazapine and olanzapine, doses of which ranged between 15-30mg/day and 5-10 mg/day, respectively during her two months hospitalization. In her follow up, 15 days after discharge, olanzapine dose was decreased to 5 mg/day, but mirtazapine was continued at 30mg/day until delivery. To decrease neural tube defect risk folic acid 5mg/day was prescribed during the treatment, as well. She gave birth to a live and healthy baby on the expected due date during her outpatient treatment. The information regarding the safety of use of mirtazapine and olanzapine during pregnancy primarily rely on case reports. While there were no fetal abnormalities in majority of cases regarding olanzapine use (1,2), there are some reports including hip dysplesia (3), meningocele ve ankyloblepharon (4), atrioventricular channel defect and unilateral pes equinovarus (5). However, more cases and studies are needed to explore, whether these cases were coincidental or due to teratogenic effects of olanzapine. Currently available publications (6,7,8,9) report that major malformation risk in general population does not increase with the use of mirtazapine during pregnancy. The reports from our country are parallel to the reports in the literature (10,11).
Results: Even in majority of cases no fetal abnormalities were reported regarding olanzapine use during pregnancy, large case series are needed to have more evidence for stronger judgments. Also even mirtazapine does not look like a teratogenic agent, is should be used with caution during pregnancy and babies that are exposed to mirtazapine should be followed closely.
References:
1. Littrell KH, Johnson CG, Peabody CD, Hilligoss N. Antipsychotics during pregnancy. Am J Psychiatry 2000; 157(8):1342
2. Mendhekar DN, War L, Sharma JB, Jiloha RC. Olanzapine and pregnancy. Pharmacopsychiatry 2002; 35(3):122-123
3. Spyropoulou AC, Zervas IM, Soldatos CR. Hip dysplasia following a case of olanzapine exposed pregnancy: a questionable association. Arch Womens Ment Health 2006; 9(4):219-222
4. Arora M, Praharaj SK. Meningocele and ankyloblepharon following in utero exposure to olanzapine. Eur Psychiatr 2006; 21(5):345-356 5. Yeshayahu Y. The use of olanzapine in pregnancy and congenital cardiac and musculoskeletal abnormalities. Am J Psychiatry 2007; 164(11):1759-1760
6. Lennestål R, Källén B. Delivery outcome in relation to maternal use of some recently introduced antidepressants. J Clin Psychopharmacol 2007; 27(6):607-613 7. Way CM. Safety of newer antidepressants in pregnancy. Pharmacotherapy 2007; 27(4):546-552
8. Djulus J, Koren G, Einarson TR, Wilton L, Shakir S, Diav-Citrin O, et al. Exposure to mirtazapine during pregnancy: a prospective, comparative study of birth outcomes. J Clin Psychiatry 2006; 67(8):1280-1284
9. Einarson TR, Einarson A. Newer antidepressants in pregnancy and rates of major malformations: a meta-analysis of prospective comparative studies. Pharmacoepidemiol Drug Saf 2005; 14(12):823-827
10. Yaris F, Kadioglu M, Kesim M, Ulku C, Yaris E, Kalyoncu NI, et al. Newer antidepressants in pregnancy: prospective outcome of a case series. Reprod Toxicol 2004; 19(2):235-328
11. Guclu S, Gol M, Dogan E, Saygili U. Mirtazapine use in resistant hyperemesis gravidarum: report of three cases and review of the literature. Arch Gynecol Obstet 2005; 272(4):298-300 Bulletin of Clinical Psychopharmacology 2011;21(Suppl. 2):S190-1