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Pregnancy.....Quetiapine

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Hi Colleagues,

One of my outpatients(early 20 something yr old female Caucasian) ,diagnosed:Paranoid Schizo/Cannabis misuse is currently on Quetaipine(approx.700mg/day).

She just found out last week that she is 7weeks pregnant(wants to keep the baby).I was told this info by the care coordinator casually in the corridor. What is the best way foward? Do I see her immediately in OP? Do I have to immediately switch over to a typical eg:Stelazine or Haloperidol???

Never been in this clinical situation before and would greatly value any advice......

thanks...

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Hi You don’t need to be panic. Discuss with your consultant, patient, and even the Quetiapine drug rep. Find out what is the chance of teratogenicity with Quetiapine. I do not think there is any evidence but the Maudsley guideline suggest Older typical or at least Olanzapine. There is no medication absolutely safe in first trimester and we do not recommend but final decision is for patient to make and we assist during that process. It is very very important you meet this patientASAP and document everything.  I had a patient whom we treated in second trimester with 6 mg of Risperidone but your is different case

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Also have a look at the Maudsley Guidelines, and Bazire's Psychotropic Drug Directory. Both have good information on prescribing in pregnancy.

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There is an article that was published in the Schiz bulletin... a systematic review... published in September 2008.

They say that metabolic complications are more common in patients who have been started newly on SGA... But those already on an SGA could be continued on the same...

It is the most uptodate systematic review...

I would suggest you present the case at the local journal club along with this article... If you cant access it through your athens account, just pm me... and I will email you the article...

http://schizophreniabulletin.oxfordjournals.org/cgi/reprint/sbn107v1

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[highlight]She just found out last week that she is 7weeks pregnant(wants to keep the baby[/highlight]

damage is already done if any, i dont see changing to any other medication is relevant.

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Hi Colleagues,

 One of my outpatients(early 20 something yr old female Caucasian) ,diagnosed:Paranoid Schizo/Cannabis misuse is currently on Quetaipine(approx.700mg/day).

 She just found out last week that she is 7weeks pregnant(wants to keep the baby).I was told this info by the care coordinator casually in the corridor. What is the best way foward? Do I see her immediately in OP? Do I have to immediately switch over to a typical eg:Stelazine or Haloperidol???

  Never been in this clinical situation before and would greatly value any advice......

thanks...

I was in a similar situation in the recent past.

Answering the question like an old styled PMP

It is important to involve both the mother and the partner in the decision making process. Care co ordinator needs to monitor her closely and a close liaison with the mid wife will be necessary from an early stage. Is she taking just cannabis or something more? ,

Like Wetrain said, the damage is done but it is important for you to convey this information to her in a milder tone as that is the fact.

What is the pattern of her illness?

How severe is her illness?, Has she engaged in serious , risk taking behaviours if she is unwell, has she been sectioned before etc etc./ This will give you an account of the seriousness of her illness if she relapses which could be disastrous for her baby. Has medication reduction ever been attempted?, how successful was it?

Have a meeting, preferably multi disciplinary , make sure that important parts of your discussion are well documented.

Take into account the above mentioned risk factors . Explain the risk of stopping tablets which as you know is relapse and that she might need more doses of antipsychotics to control her symptoms which may not be good for her and her baby .

Benefit---- She has already taken anti psychotics for a good part of her first trimester . The only benefit will be being off antipsychotics for the remainder of five weeks which may or may not make a difference.

I think our role is to explain the risk and benefits and make our patients make an informed choice .

If she wants to stop medication, usage of a low dose of antipsychotic , preferably typical but as Chris said, check out the Maudsley. Make sure you tell her that she will be monitored well by her care co ordinator and your team . This may give her the much needed confidence to take this decision.

If she wants to continue with Quetiapine , a reduction of the dosage atleast till the start of second trimester will not be a bad idea if she insists that she wants to remain on quetiapine.

I have no thoughts on stopping antipsychotics. It is a brave idea though.

Whatever you do, explain the risks , benefits. Know about alternatives. Ensure good support from midwife , CPN .

Keep your consultant fully informed . Very important.

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Wet train...

I am sorry to be pedantic... Unlike popular belidf, all is not over at 7 weeks... The whole process is complicated because we dont know excactly what period in the mice correspond to human nervous system development....

I will post a graph of development in humans...

Summary of timing of neurobiological processes in the telencephalon during human ontogeny. W = weeks PMA, M = postnatal months, Y = years, P = onset of puberty, A = onset of adulthood. In the upper part of the figure, a broken line means that the process is active, a bold line indicates that the process is very active.

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Just to reiterate.... the graph above is in humans...

As you can see, most processes only start after 10 weeks and are mostly active after 20 weeks... So even the first trimester theory is not really completely that simple... I would say as far as neurodevelopment is concerned, all trimesters are important... not just the first, the second and third may be more important...

Although I completely agree with your conclusion of staying on the same medication, I beg to disagree on the rationale behind reaching that decision....

The rationale behind my conclusion of staying on the same medication is the fact that there is not enough evidence to say that SGAs are better than FGAs as far as teratogenecity is concerned, and the old axiom.... 'dont rock the stable boat'...

If the lady has been on Qtip for a long time and has not developed a metabolic syndrome, then there is no need to worry... there is a risk of development of gestational diabetes and foetal overweight in the population, but if the patient has not become overweight before, it is less likely for her to develop that during thepregnancy...

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excellent peice of work dorian.thank you for the great information.

could you please expand PMA.

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excellent peice of work dorian.thank you for the great information.

could you please expand PMA.

Cheers

PMA - postmenstrual age

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thank you dorian. keep the good work going.

SP

p.s: we might have met before. did u take your exams in doncaster?

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thank you dorian. keep the good work going.

SP

p.s: we might have met before. did u take your exams in doncaster?

Nope... I took my exam in Lancaster... pm me SP...

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oops.i meant Lancaster. hope i am not dementing.will PM you soon.

SP

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I dont know if this is resolved, but involving the local medicines helpline/ pharmacy service can get you good evidence on medication in pregnancy. Also involving or liaising with the perinatal services (including midwives and obs consultants with interest/experience in mental health) may be further good practice to plan future course of action. Also is there any need of informing social services regarding risks to baby? Hope this helps.

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Just to reiterate.... the graph above is in humans...

As you can see, most processes only start after 10 weeks and are mostly active after 20 weeks... So even the first trimester theory is not really completely that simple... I would say as far as neurodevelopment is concerned, all trimesters are important... not just the first, the second and third may be more important...  

Although I completely agree with your conclusion of staying on the same medication, I beg to disagree on the rationale behind reaching that decision....

The rationale behind my conclusion of staying on the same medication is the fact that there is not enough evidence to say that SGAs are better than FGAs as far as teratogenecity is concerned, and the old axiom.... 'dont rock the stable boat'...

If the lady has been on Qtip for a long time and has not developed a metabolic syndrome, then there is no need to worry... there is a risk of development of gestational diabetes and foetal overweight in the population, but if the patient has not become overweight before, it is less likely for her to develop that during thepregnancy...

Thanks Dorian,

This information has given some room for revising our views about some commonly held theories.

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Hi Colleagues,

 One of my outpatients(early 20 something yr old female Caucasian) ,diagnosed:Paranoid Schizo/Cannabis misuse is currently on Quetaipine(approx.700mg/day).

 She just found out last week that she is 7weeks pregnant(wants to keep the baby).I was told this info by the care coordinator casually in the corridor. What is the best way foward? Do I see her immediately in OP? Do I have to immediately switch over to a typical eg:Stelazine or Haloperidol???

  Never been in this clinical situation before and would greatly value any advice......

thanks...

You don't HAVE to do anything.

You should not SWITCH her to anything.

you should discuss with your consultant and pharmacist asap.

You should also see her asap.

When you see her you should be giving her info and letting her make the choice.

As far as choice of drugs go -

- it should be her choice not yours.

- none of them have been shown to be teratogenic.

- there is more evidence that the older drugs are not teratogenic than the newer drugs.

- a change of drug may precipitate a relapse which may be more harmful than the potential yet undemonstarted higher risk of teratogenicity of quetiapine than an older drug.

- changing drug after she has found out she is pregnant may not reduce the risk of teratogenicity.

- from the point of view of teratogenicity no drug is possibly safer than any drug at this point even if she conceived on a drug (though as above relapse may be more harmful than the low risk that antipsychotics may have).

- there is a potentially relevant NICE guideline and you should read it and take it into account before providing info to her.

- remember it should be her choice not yours.

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I recently had one person with Bipolar on Quetiapine. Explained to patient. A single mother, wanted to be on it. She had just come out of hypomania, which had a serious attempt to end life.. perhaps mixed affective at least at some point.

Stopped using illicit drugs.

Quetiapine had good effect, found out pregnant while on it.

Contacted Pharmacist, Drug company for most recent studies and advice.

explained lack of evidence, risks of relapse if wanted to stop, risks of being on two medications if wanted to change. Told her happy to support any decision.

She wanted to continue. Umbilical blood concentration is the lowest for Quetiapine among the antipsychotics.

will provide links in couple of days.

She is now on 100mg which keeps her sleep cycle and energy levels okay. She was under crisis team. we discharged her. Hope community psychiatrists liaises with Obstetrician.

I wrote letters to GP and Obstetrician wondering how often she wanted to do scans to look for any abnormality. Discharged her to community psychiatrists.

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