What is the first line treatment for schizophrenia during pregnancy?

First-Line Treatment for Schizophrenia During Pregnancy

Second-generation antipsychotics, particularly olanzapine, are the first-line treatment for schizophrenia during pregnancy, as the risks of untreated schizophrenia outweigh the potential risks of medication exposure to the fetus. 1

Rationale for Continuing Antipsychotic Treatment

Untreated schizophrenia during pregnancy is associated with significant risks:

• Higher rates of risky health behaviors
• Delayed antenatal follow-up
• Increased risk of preterm birth (2.31 times higher risk) 2
• Higher rates of pregnancy complications including gestational diabetes, placental abruption, and preeclampsia 2
• Increased risk of infant mortality (2.33 times higher) 2

Medication Selection Algorithm

1. First choice: Olanzapine

   • Well-studied in pregnancy with no definitive association with increased risk of major birth defects 1, 3
   • FDA pregnancy category C 3
   • Animal studies show some fetal toxicities at doses 9-30 times the maximum recommended human dose 3
   • Effective for maintaining psychiatric stability during pregnancy 4

2. Alternative option: Quetiapine

   • FDA pregnancy category C 5
   • Limited published data show no major malformations in exposed infants 5
   • Consider if patient has history of better response or tolerability to quetiapine

Dosing and Monitoring Considerations

• Use the lowest effective dose that maintains psychiatric stability 1

• Schedule early and frequent antenatal visits to monitor:

  • Blood pressure changes
  • Gestational diabetes (2.35 times higher risk in women with schizophrenia) 2
  • Fetal growth
  • Signs of psychiatric relapse 1

• Monitor for metabolic side effects:

  • Weight gain
  • Blood glucose levels (increased risk of gestational diabetes with olanzapine) 1
  • Lipid profiles

Important Precautions

1. Third trimester considerations:

   • Neonates exposed to antipsychotics during the third trimester are at risk for extrapyramidal and/or withdrawal symptoms after delivery 5, 3
   • These may include agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, and feeding disorders 3
   • Symptoms vary in severity; some resolve within hours or days while others require intensive care and prolonged hospitalization 3

2. Breastfeeding considerations:

   • Both olanzapine and quetiapine are excreted in breast milk 5, 3
   • Decision to continue medication during breastfeeding should weigh benefits of treatment against potential risks to the infant

Psychosocial Support

• Provide additional psychosocial interventions alongside pharmacological treatment 1
• Consider mother-baby units for women with low social support 2, 1
• Address common comorbidities in pregnant women with schizophrenia:
  • Tobacco smoking (4.87 times more common) 2
  • Illicit drug use (13.33 times more common) 2
  • Obesity (2.38 times more common) 2

Common Pitfalls to Avoid

1. Discontinuing medication during pregnancy

   • This is likely to lead to relapse during pregnancy or postpartum 6
   • The risk of untreated schizophrenia outweighs the potential risks of medication exposure 1, 6

2. Inadequate monitoring

   • Failing to schedule frequent antenatal visits increases risk of complications 1
   • Women with schizophrenia often have delayed antenatal follow-up 2

3. Neglecting psychosocial support

   • Women with schizophrenia are more frequently socially deprived and without partners 2
   • Lack of support increases risk of poor outcomes after discharge 2

4. Overlooking physical health

   • Women with schizophrenia have higher rates of metabolic comorbidities that require monitoring 2

By following these guidelines, clinicians can optimize outcomes for both mother and baby while managing schizophrenia during pregnancy.