Can olanzapine (olanzapine) and zuclopenthixol (zuclopenthixol) be continued in a patient with schizophrenia who is now pregnant (positive beta-human chorionic gonadotropin (BHCG))?

Management of Antipsychotics in a Pregnant Patient with Schizophrenia

Antipsychotic medications should be continued during pregnancy in a patient with schizophrenia who has a positive pregnancy test (BHCG), as the risks of untreated schizophrenia outweigh the potential risks of medication exposure to the fetus.

Risk-Benefit Assessment

Risks of Discontinuing Antipsychotics

• Untreated schizophrenia during pregnancy is associated with:
  • Increased risk of relapse and hospitalization 1
  • Higher rates of risky health behaviors 2
  • Delayed antenatal follow-up 2
  • Increased risk of preterm birth 2
  • Potential for suicide and/or infanticide 3

Risks of Continuing Antipsychotics

• Olanzapine:

  • No definitive association with increased risk of major birth defects 4
  • Possible increased risk of gestational diabetes 2
  • FDA pregnancy registry data shows placental passage is variable (7-167%) 4

• Zuclopenthixol:

  • Limited specific data available
  • As a conventional antipsychotic, no definitive association with increased risk of birth defects 5

Management Algorithm

1. Immediate Management

• Continue both olanzapine and zuclopenthixol at current effective doses
• Register patient with the National Pregnancy Registry for Atypical Antipsychotics (1-866-961-2388) 4

2. Monitoring During Pregnancy

• Schedule early and frequent antenatal visits 2
• Monitor for:
  • Blood pressure changes
  • Gestational diabetes (particularly with olanzapine)
  • Fetal growth
  • Appropriate maternal weight gain
  • Signs of relapse of schizophrenia

3. Medication Adjustments

• Consider using the lowest effective dose that maintains psychiatric stability
• Do not discontinue medications abruptly as this significantly increases relapse risk 1
• If side effects become problematic, dose adjustments should be made gradually under close supervision

4. Delivery Planning

• Monitor for extrapyramidal and/or withdrawal symptoms in the neonate after delivery 4
• These symptoms may include:
  • Agitation
  • Hypertonia or hypotonia
  • Tremor
  • Somnolence
  • Respiratory distress
  • Feeding disorders

5. Postpartum Care

• Continue antipsychotic treatment postpartum
• Consider mother-baby unit if available, particularly for patients with low social support 2
• Provide additional psychosocial support and interventions 2

Important Considerations

• The FDA notes that there are risks to the mother associated with untreated schizophrenia that may outweigh potential medication risks 4
• Case reports demonstrate that discontinuation of olanzapine during pregnancy has led to relapse requiring hospitalization 1
• While data on antipsychotic use in pregnancy is limited, the consensus is that the risks of untreated psychosis generally outweigh potential medication risks 6
• Women with schizophrenia have higher rates of unplanned pregnancies, making preconception counseling challenging 5

Common Pitfalls to Avoid

1. Abrupt discontinuation of antipsychotics: This significantly increases relapse risk and can lead to hospitalization during pregnancy 1
2. Focusing only on medication risks without considering risks of untreated illness: Untreated schizophrenia poses substantial risks to both mother and fetus 2, 3
3. Inadequate monitoring: Pregnant women with schizophrenia require more intensive monitoring for both psychiatric stability and pregnancy complications 2
4. Neglecting psychosocial support: Women with schizophrenia often have lower social support and may need additional resources during and after pregnancy 2

The evidence strongly supports continuing antipsychotic treatment during pregnancy in women with schizophrenia, with careful monitoring and appropriate dose adjustments as needed.