COMMENTARY

For the most part, this timely review addresses the authors’ objectives. The findings suggest that women with schizophrenia have increased risks during pregnancy that other women do not have, including preterm deliveries, other obstetrical complications and increased possibility of a psychotic breakdown during pregnancy or the post-partum period. With increased use of atypical antipsychotics, which are less likely to cause hyperprolactinemia induced infertility, more women with schizophrenia are likely to become pregnant, especially with unplanned pregnancies. The available evidence suggests that these drugs are relatively safe to use during pregnancy and lactation.

The main problem with this review is that the authors’ conclusions somewhat contradict their findings, specifically regarding the safety of typical antipsychotic drugs during pregnancy and lactation. The authors do not present compelling evidence that these drugs are harmful in pregnancy or lactation, and even caution about abruptly discontinuing them. These drugs have been on the market for more than forty years. There is no convincing evidence that any of them increase the baseline rate for major malformations or other long term neuro-developmental problems.^1,2 The amount of drugs excreted in breastmilk is also minimal. There have been only occasional reports of sedation in exposed babies.³

Patton et el used limited search terms. For example, the key word “phenothiazines” was absent, resulting in the omission of two important papers. If included, these may have altered the conclusions of the review and implications for clinical practice. One of the omitted papers was the largest study from the Collaborative Perinatal Project, involving 1309 children exposed to phenothiazines during pregnancy. This study found no adverse effects on physical or mental development.⁴ The other omitted study was a review of phenothiazines used for nausea and vomiting in pregnancy. Here again, there was no increased risk of birth defects.⁵

The authors suggest that antipsychotic medications should be avoided in the first trimester if possible. This may be difficult, as more than 50% of pregnancies are unplanned in the general population, and probably an even higher proportion in people with schizophrenia. It is therefore likely that many women with schizophrenia will be on medication when they become pregnant, exposing the fetus during the first trimester.

We feel that a pregnant or lactating woman with schizophrenia should be treated with these drugs if indicated, after being given evidence-based information to assist in her decision making. Withholding the medication could impair the mother’s mental health and limit her potential to care for and interact appropriately with her baby.