What are the considerations for using Haldol (haloperidol) in a 30-week pregnant female patient?

Haloperidol Use at 30 Weeks Gestation

Haloperidol can be used during the third trimester of pregnancy when the potential benefit justifies the risk to the fetus, but neonates exposed during this period are at significant risk for extrapyramidal symptoms and withdrawal complications requiring intensive monitoring after delivery. 1

Critical FDA Safety Information

The FDA drug label explicitly warns that neonates exposed to antipsychotic drugs during the third trimester face risks for:

• Extrapyramidal symptoms (agitation, hypertonia, hypotonia, tremor) 1
• Withdrawal symptoms 1
• Somnolence, respiratory distress, and feeding disorders 1
• Complications varying from self-limited to requiring intensive care unit support and prolonged hospitalization 1

At 30 weeks gestation, this patient is in the third trimester, placing her fetus in the highest-risk category for neonatal complications. 1

Risk-Benefit Framework for Decision-Making

When Haloperidol May Be Justified:

• Severe psychotic symptoms causing hemodynamic instability that threatens fetal perfusion 2
• Treatment-resistant psychosis where clozapine is the only effective agent and haloperidol is added for acute exacerbation 3
• Life-threatening maternal psychiatric condition where no safer alternative exists 1

Preferred Alternatives to Consider First:

The evidence suggests exploring other antipsychotic options with more pregnancy data before using haloperidol, though the FDA label notes haloperidol should only be used "if the potential benefit justifies the potential risk to the fetus." 1

Clinical Management Algorithm if Haloperidol Must Be Used

Maternal Monitoring:

• Use the minimal effective dosage 3
• Monitor for neuroleptic malignant syndrome (hyperpyrexia, muscle rigidity, altered mental status, autonomic instability) 1
• Assess for falls risk due to somnolence and postural hypotension 1
• Avoid alcohol and other CNS depressants 1

Fetal Considerations:

• Recognize that haloperidol plasma concentration is higher in the fetus compared to the mother 3
• Document maternal overdose cases showing temporary fetal akinesia and prolonged fetal neuromuscular depression 4
• One case at 34 weeks showed nonreactive nonstress test and biophysical profile not reaching 10 until 5 days post-exposure 4

Delivery Planning:

Arrange delivery at a facility prepared to monitor, evaluate, and treat neonatal extrapyramidal symptoms and withdrawal syndrome. 1 This is non-negotiable given the FDA warning about potential need for intensive care support. 1

Neonatal Preparation:

• Anticipate possible need for intensive care unit support 1
• Monitor for agitation, hypertonia, hypotonia, tremor, somnolence 1
• Assess respiratory function and feeding ability 1
• Be prepared for prolonged hospitalization if complications develop 1

Important Contraindications and Warnings

Absolute Contraindications:

• Breastfeeding (haloperidol is present in maternal milk) 3
• Combined use with lithium due to risk of irreversible encephalopathic syndrome 1

Critical Drug Interactions:

• Avoid opioid agonist/antagonists (nalbuphine, butorphanol) which can precipitate withdrawal 2
• Exercise extreme caution with any CNS depressants due to additive effects 1

Comparison to Other Psychiatric Medications in Pregnancy

While haloperidol has been used historically, the evidence base is limited compared to some alternatives. Classic antipsychotics like haloperidol, perphenazine, and trifluoperazine can be added to clozapine for psychotic exacerbation, but this represents adding one risk to another. 3 The key distinction is that haloperidol lacks the extensive safety data available for some other agents, yet the FDA explicitly permits its use when benefits justify risks. 1

Common Pitfalls to Avoid

• Never assume "just a little" haloperidol is safe - even therapeutic doses cause the third-trimester complications described in the FDA label 1
• Never discharge without arranging specialized delivery facility - this is explicitly required by the safety profile 1
• Never combine with lithium - the risk of irreversible brain damage is documented 1
• Never continue into breastfeeding - haloperidol presence in breast milk contraindicates nursing 3