Use of antipsychotic medications during pregnancy may be necessary for several reasons and is a challenging topic for clinicians. Clinical trials are limited due to ethical reasons, making it challenging to develop definite guidelines. The best practices used so far have been, around considering risk versus benefit for both mother and the baby. In this article, we are going to discuss the antipsychotic medications and their use in pregnancy along with a case presentation of a primigravida with bipolar disorder who received Aripiprazole during her pregnancy.

Antipsychotic medications, both Typical and Atypical, are used to treat Schizophrenia spectrum disorder, affective psychosis, and bipolar disorder. The rate of pregnancy in schizophrenia and bipolar disorder are reported to be less than the general population in most studies. But since these illnesses begin at an early age and many of these patients are in their reproductive age, there is still a substantial amount of such patients who get pregnant. Often such pregnancy is unplanned, adding more risk to the unborn baby.

Untreated illness could be harmful to both mother and foetus and should be avoided according to FDA. Although some population-based studies found pregnancy as a protective factor against relapse of their illness, others find high recurrence rate, once treatment is discontinued in both schizophrenia and bipolar disorder.

Foetal complications of untreated schizophrenia are found to be low birth weight, preterm delivery, intrauterine growth retardation, stillbirth as well as infant death within the first year of birth. Recently, several studies have been published regarding the safety of antipsychotic drugs during pregnancy. Most of these studies are retrospective studies. The typical antipsychotic medications seem to have more complications like teratogenicity, while both typical and atypical antipsychotics have shown low birth weight, preterm delivery and some neonatal motor and behavioural symptoms after birth. Choosing the best antipsychotic medication for pregnant women is an ongoing challenge and the best option is to carefully weigh risk versus benefit. Some studies also looked into the placental transfer of antipsychotic medications and one study looked into Aripiprazole in particular. Knowing the placental transfer rate will be helpful in choosing the right medication.

We present a case of a 23 year old female who was diagnosed with bipolar disorder and was finally stabilized on Aripiprazole after trial of several other medications. Although she has a remote history of drug and alcohol use she was abstinent of drugs and alcohol for a few years, got a stable job and had a stable relationship with her boyfriend. She was maintained on Aripiprazole 20 mg prescribed by her psychiatrist. She has not seen a psychiatrist for quite some time since her psychiatrist moved. She came for a psychiatric appointment at 20th week of pregnancy. She found out about her pregnancy about 6 weeks after conception. After she found about her pregnancy, she reduced her doses to 15 mg a day after discussing with her pharmacist. This was her first pregnancy and her first-trimester ultrasound was unremarkable. The pros and cons of using antipsychotic medications during this period were discussed with patient, along with reviewing available articles with her.

After the informative session, she chose to continue the medication on a lower dose. She was maintained on Aripiprazole 10 mg a day, in her second-trimester. Along with the change in medication dose, she was also monitored closely for symptom relapse and foetal wellbeing by both psychiatrist and obstetrician. She attended her antenatal check-ups regularly. She had good support from her mother, who ensured her sleep, hygiene and diet. She planned to breastfeed her baby, and as Aripiprazole is excreted in breast milk, she was gradually weaned off of Aripiprazole, 2 weeks prior to the expected date of delivery. She was referred to attend perinatal mental health groups.

Delivery: Patient had an uncomplicated vaginal delivery at term under epidural anaesthesia. She delivered a healthy male child with normal scores. He did not have any abnormal movements, tremor or any withdrawal or EPS symptoms at birth. There was no congenital abnormality.

Although the patient had planned to breastfeed her baby, she had difficulty with lactation. After few weeks of delivery, her mother noticed some hypomanic symptoms, namely, decreased sleep, increased energy and goal-directed activity. This prompted the patient’s mother to bring her to the hospital to restart her on Aripiprazole. Breastfeeding was discontinued.

Pregnancy in each woman, her mental state and need for treatment is unique and should be carefully considered based on risks versus benefits of using certain medications. The best approach is to use the minimal effective dose and close monitoring.

Few things are important to keep in mind while making a management plan:

• How is her current mental health?
• Is she stable or acutely ill?
• What works for her?
• Is the medication safe for the baby?
• How is her support system?
• How can we minimize her triggers and prevent a possible relapse during pregnancy and/or after     delivery?

Other things to consider:

• More close monitoring than non-pregnant woman.
• A team approach, liaison with Obstetrician and community mental health team.

Disclosure
No relevant association or funding to disclose.