Questions Related to Pregnancy & My Meds
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Q:  Questions Related to Pregnancy and My Meds


I am a 25 y/o female with BP I D/O.  I take 800mg tid of Neurontin and 
150 mg qd of Zoloft.  I am medically compliant and have had no relapse since first diagnosed 2 years ago.  I am thinking of conceiving a child with my husband, but do not want to be on meds while pregnant.  I also would like to breast feed.  I am very in-tuned with my body and alert my doctor right away if I am feeling hypomanic (has only happened once, and with the addition of 25 mg Benadryl qhs x one week, I was fine.)My psychiatrist states that my drugs are class C; I am advised to take them, as the benefit outweighs the risk. I work in pediatric rehab, and most of my clientele have PDD, or Autism.  My questions are: 1) What are the teratogenic effects of my meds on a developing fetus 2) Are there any studies on children (not infants) whose mothers took my meds while pregnant? 3)Is there a correlation between children with an Autistic Spectrum diagnosis and a bipolar parent? 4) What is the rate of a puerperal incident in mothers who are not medicated during pregnancy?  Thank you so much for your time.  I know I asked many questions.  I want to prevent any possible disorders/ diseases in my future children.  I am so scared that I will cause them to be less than healthy.  I am seriously considering adoption.  I do realize that a majority of my anxiety exists because the children I am exposed to on a daily basis are all special-needs.



Dear Ms. M' -- 
That was  a well written question.  You probably also understand from your work that this kind of thing is often addressed by a specialist, a genetic risk counselor.  It would be nice to find such a person who was really knowledgeable about these particular medications -- better yet to have a psychiatrist who had that knowledge.  In my area there are a few psychiatrists who have trained themselves particularly on issues such as this (I have not).  Getting a consultation from such a person would be ideal.  

In the interim, I'll take a stab at the parts of your question I have some confidence to address.  In case somebody's reading who hasn't read up on pregnancy safety categories like you: 

Category A: Controlled human studies have demonstrated no fetal risk
Category B: Animal studies indicate no fetal risk, but no human studies OR adverse effects in animals , but not in well-controlled human studies
Category C: No adequate human or animal studies.OR adverse fetal effects in animal studies, but no available human data.
Category D:Evidence of fetal risk, but benefits outweigh risks.
Category X: Evidence of fetal risk. Risks outweigh any benefits.

First of all, as you know, Category C means "we don't know", not "it's probably safe".  It  is dramatically more difficult to say that a medication is safe (how many cases does one have to have monitored?) than that a medication is unsafe (where only a few clear-cut cases of an association could be sufficient to make it category X).  

That's how we should look at Neurontin, for example: close to unknown.  In my view there ought to be something more dramatic than "Category C", for things we know so little about -- like "Category Z", meaning almost X until we know more.  

Zoloft is listed as Category B, which is interesting, because so is Prozac -- but there is a growing database on Prozac that to my knowledge is much more extensive so far than Zoloft.  In particular, as you may have learned, Prozac is the only "SRI" antidepressant (to my knowledge) that meets the test you suggest -- i.e. your question #2.  There was at least one big study: 

Kids exposed to Prozac

that looked at kids exposed to Prozac in utero, following their development compared to a control group of kids.  Note that we're talking about 50 kids followed until age 7.  This study is probably continuing and if so goes another 4 years -- no big report of new problems emerging.  

There were numerous previous studies that answer the easier question about kids exposed, and how they looked right after birth (i.e. more on the subject of malformations than developmental problems), such as this one: 

Prozac in pregnancy

OK, so question #3 (these keep me on my toes, force me to go look at the literature again, so don't feel badly for asking): autism and Bipolar.  I keep hearing these two conditions mentioned "in the same breath" but have never seen some direct evidence linking the two; and when I took a look around (Pub Med search, "autism bipolar"; Google search; Dr. Ivan's site) again I find them mentioned close to one another but not associated to one another as such.  You may know more about this one than I (write me about that).  

Finally, question #4: rate of "puerperal incident" in mothers -- do you mean with known bipolar disorder? -- unmedicated during pregnancy.  There is a considerable literature on this.  Here's an example of one of the more prominent such studies.  In general, the risk of postpartum depression in bipolar women not on med's is usually quoted as 50%.   Here's another good review, though older.

Whew, that was a good workout.  Keep asking good questions, and good luck with your difficult decision making. . 

Dr. Phelps  


Published October, 2001

 

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