Maternal Mental

Health
Pregnancy and Postpartum
Jacklyn Gries, PharmD & Amanda Schoettmer, PharmD

March 17, 2022

A little bit about me...
About Amanda ☺
Learning Objectives

Identify teratogenic psychiatric medications.

1.
Choose a safe medication option for pregnant
2. women with various psychiatric conditions.

Select a safe medication for a breast-feeding

3. mother with a psychiatric disorder.
Pregnancy
Epidemiology
Teratogenic Medications
Recommended Medications
Epidemiology and Facts
20% of women suffer from mood or anxiety disorders during pregnancy.
•Women with a history of psychiatric illness are particularly vulnerable.

Depression and anxiety during pregnancy have been associated with adverse
pregnancy outcomes.

Women who suffer from psychiatric illness during pregnancy are:

•Less likely to receive adequate prenatal care
•More likely to use alcohol, tobacco, and other substances
Several studies have described low birth weight and fetal growth retardation in
children born to depressed mothers.

Preterm delivery is another potential pregnancy complication among women

experiencing distress during pregnancy.

MGH Center for Women’s Mental Health.

Do mental disorders during pregnancy impact
birth outcomes?
Retrospective observational study

Location: Germany

Time period: One-year (Jan 2008 – Dec 2008)

Population: 38,174 pregnant women

•Four diagnostic groups: depression, anxiety disorders, somatoform/dissociative disorders, acute

stress reactions

Main outcome measures:

•prevalence of mental disorders during pregnancy

•performed cesarean sections
•infants born underweight

Arch Gynecol Obstet. 2019;299(3):755-763.

Continued...

16,639 cases with at least one diagnosis from the four mental
disorder diagnostic groups were identified:
• 9.3% cases of depression
• 16.9% cases with an anxiety disorder
• 24.2% cases with a somatoform/dissociative disorder
• 11.7% cases of acute stress reactions

Women diagnosed with a mental disorder were more likely to

deliver their child by cesarean section.

Infants of women diagnosed with depression during pregnancy

were more likely to be underweight and/or delivered preterm.

Arch Gynecol Obstet. 2019;299(3):755-763.

Rates of Relapse
Depression (prospective study)

• 82 women who maintained antidepressant therapy during pregnancy

---- 26% relapsed
• 65 of the women who discontinued antidepressant therapy during
pregnancy ---- 68% relapsed

Bipolar Disorder (prospective study)

• 70.8% of women experienced at least one mood episode during

pregnancy
• Risk of recurrence was significantly higher in women who
discontinued treatment with mood stabilizers (85.5%) than those
who maintained treatment (37.0%)

MGH Center for Women’s Mental Health.

Pregnancy Complications

Maternal depression and anxiety

Operative
Pre-eclampsia
delivery

Infant
admission to
NICU

Respiratory
Hypoglycemia Prematurity
distress

MGH Center for Women’s Mental Health.

So, it is very important to do...

RISK-
BENEFIT
ANALYSIS

with all mothers on psychiatric medications

and/or with psychiatric conditions.
Weighing the Risks

Receiving Abruptly stop

Unplanned
medication for taking
pregnancy
psych disorder medication

Risk of relapsing
Risk vs. Benefit
and/or
analysis
withdrawal
FDA Pregnancy Categories: 1979-2015

Drugs.com.
 Pregnancy and Lactation Labeling Final Rule
(PLLR) went into effect on June 30, 2015

Pregnancy Lactation Females and

• Pregnancy exposure • Risk summary Males of
registry • Clinical Reproductive
• Risk summary considerations Potential
• Clinical • Data • Pregnancy testing
considerations
• Contraception
• Data
• Infertility

Link for Pregnancy categories: https://online.lexi.com/lco/action/doc/retrieve/docid/fc_briggs/5712224

Drugs.com.
What are the Risks of Medication Exposure?

Risk of Teratogenesis

Risk of Neonatal Symptoms

Risk of Long-Term Effects

MGH Center for Women’s Mental Health.

Teratogenic
Psych
Medications
Where does this data come from?

For obvious ethical reasons, it is not possible to

conduct randomized placebo-controlled studies on
medication safety in pregnant and lactating women.
Most of the information about the reproductive safety
of drugs is derived from case reports, case series, and
retrospective studies.
Very few studies involve prospective design. Hence,
knowledge regarding the risks of prenatal exposure to
psychotropic medications remains far from complete.

Indian J Psychiatry. 2015;57(Suppl 2):S308-S323.

Parents Life. January 14, 2020. https://parents-life.com/teratogens-in-pregnancy/
 Anxiolytics and Hypnotics
Drug/Drug Class Old Category New Category

Benzodiazepines D Human and Animal Data Suggest Risk

Buspirone B Limited Human Data—Animal Data Suggest Low Risk

Eszopiclone C No Human Data—Animal Data Suggest Low Risk

Zolpidem B Human Data Suggest Risk

Zaleplon C Human Data Suggest Low Risk

Hydroxyzine C Human Data Suggest Low Risk

Am Fam Physician. 2008 Sep 15;78(6):772-778.

Lexicomp (Briggs Drugs in Pregnancy and Lactation).
 Antiepileptics and Mood Stabilizers
Drug Old Category New Category

Carbamazepine D Compatible—Maternal Benefit >> Embryo–Fetal Risk

Lamotrigine C Compatible—Maternal Benefit >> Embryo–Fetal Risk

Lithium D Human Data Suggest Risk

Levetiracetam C Limited Human Data—Animal Data Suggest Risk

Valproic Acid D Human Data Suggest Risk

Phenytoin D Compatible—Maternal Benefit >> Embryo–Fetal Risk

Phenobarbital D Human Data Suggest Risk

Topiramate C Human and Animal Data Suggest Risk

Am Fam Physician. 2008 Sep 15;78(6):772-778.
Lexicomp (Briggs Drugs in Pregnancy and Lactation).
Drugs in Pregnancy. Drugs_Pregnancy.pdf
Drugs in Pregnancy. Drugs_Pregnancy.pdf
Drugs in Pregnancy. Drugs_Pregnancy.pdf
Drugs in Pregnancy. Drugs_Pregnancy.pdf
 Antidepressants
Drug/Drug Class Old Category New Category

Tricyclics C Human Data Suggest Low Risk

SSRIs^ C Human Data Suggest Risk in 3rd Trimester

Paroxetine* D* Human Data Suggest Risk

SNRIs^ C Human Data Suggest Risk in 3rd Trimester

Bupropion B Limited Human Data Suggest Low Risk

Mirtazapine C Limited Human Data—Animal Data Suggest Moderate Risk

Trazodone C Limited Human Data—Animal Data Suggest Low Risk

^= also maintenance treatment for GAD Am Fam Physician. 2008 Sep 15;78(6):772-778.
Lexicomp (Briggs Drugs in Pregnancy and Lactation).
 Antipsychotics
Drug/Drug Class Old Category New Category

Aripiprazole C Human Data Suggest Low Risk

Chlorpromazine C Compatible

Clozapine B Compatible—Maternal Benefit >> Embryo–Fetal Risk

Haloperidol C Limited Human Data—Animal Data Suggest Moderate Risk

Olanzapine C Compatible—Maternal Benefit >> Embryo–Fetal Risk

Compatible—Maternal Benefit >> Embryo–Fetal Risk

Quetiapine C

Am Fam Physician. 2008 Sep 15;78(6):772-778.

Lexicomp (Briggs Drugs in Pregnancy and Lactation).
 Antipsychotics
Drug/Drug Class Old Category New Category

Paliperidone C No Human Data—Animal Data Suggest Low Risk

Pimozide C Limited Human Data—Animal Data Suggest Low Risk

Risperidone C Compatible—Maternal Benefit >> Embryo–Fetal Risk

Thioridazine C Limited Human Data—No Relevant Animal Data

Trifluoperazine C Limited Human Data—Animal Data Suggest Low Risk

Ziprasidone C Limited Human Data—Animal Data Suggest Risk

Am Fam Physician. 2008 Sep 15;78(6):772-778.

Lexicomp (Briggs Drugs in Pregnancy and Lactation).
Preferred Medications in each
Psychiatric Disorder
Tips for all psychiatric medication use during pregnancy
Non-pharmacologic preferred

• Try CBT first whenever possible

If medication is required, pregnant women should be prescribed …

• Lowest effective dosage

• Minimum amount of time

Keep doses low close to the time of delivery

• Minimizes withdrawal and adverse effects in newborn

Abrupt discontinuation of medications is not recommended

• Taper off the medication with adjunctive CBT

Women who have avoided medications during pregnancy should

consider resumption postpartum
• The postpartum period is a high risk for relapse

J Clin Psychiatry. 1998;59 Suppl 2:18-28.

 Anxiety Disorders (GAD, Panic Disorder)
 Nonpharmacologic treatment such as cognitive-behavioral therapy or interpersonal psychotherapy
should be employed whenever possible

 Benzos may cause physiological dependence and withdrawal in the newborn

 First-trimester exposure increases the infant's risk for oral cleft (≤ 0.7%)
 Use of SSRI is first-line treatment for anxiety disorders because of the data supporting efficacy and
low side effect profile
 Excluding paroxetine
 Venlafaxine XR and mirtazapine are options for patients who are unresponsive to, or intolerant
of SSRIs
 Not enough human data on the safety of buspirone in pregnancy, so it is not recommended.
 Hydroxyzine may be used in the second and third trimesters of pregnancy, but it should not be used
during or just prior to labor.
 Use of hydroxyzine during labor may increase seizure risk in infants, decrease fetal heart rate,
and increase side effects when combined with narcotics.
J Clin Psychiatry. 1998;59 Suppl 2:18-28.
NAMI: National Alliance on Mental Illness. 2021.
Major Depression Disorder
Mild Depression

• First-line: Nonpharmacologic (Cognitive behavioral therapy, interpersonal therapy,

bright light therapy, etc.)
• Second-line: SSRIs (excluding paroxetine)

Moderate to severe depression:

• First-line: Nonpharmacologic + SSRIs (excluding paroxetine due to its cardiac effects)

• Although preferred, there is a warning regarding SSRI use during pregnancy and the
potential risk of persistent pulmonary hypertension of the newborn
• Other options:
• TCAs: nortriptyline and desipramine are preferred during pregnancy (fewer
anticholinergic side effects and are less likely to exacerbate orthostatic hypotension)
• SNRIs: Venlafaxine is preferred due to having more human data to support its use in
pregnancy
• Data regarding the safety of mirtazapine, bupropion, and trazodone in pregnancy is
not extensive
• Of the studies available, all of these caused an increased risk of spontaneous
abortions compared to nonteratogens

Am Fam Physician. 2008 Sep 15;78(6):772-778.

Treatment of Depression During Pregnancy. U.S. Pharmacist. 2007.
Bipolar Disorder and Schizophrenia
 Mood Stabilizers and Antiepileptics:
 Lithium
 Data on lithium in pregnancy continues to be refined
 Studies dating back to the 1970s have displayed increased risk for cardiovascular
malformations (0.05%-1%)
 Two recent studies (2017 and 2018) found no significant difference in major cardiac
malformations between the lithium-exposed group (0.5%-3.7%) and the reference group (1.0%-
2.1%).
 Appears to be safe in 2nd and 3rd trimesters (avoid in 1st trimester if possible)
 Monitor levels

 Lamotrigine
 Appears to be more favorable than other antiepileptics
 In multiple studies (Newport et al., Cunnington et al., Holmes et al.), ~2-3% of newborns
experienced major birth defects

MGH Center for Women’s Mental Health. 2018.

Indian J Psychiatry. 2015;57(Suppl 2):S308-S323.
Bipolar Disorder and Schizophrenia Continued
 Antipsychotics: the reproductive safety data on atypical
antipsychotics is limited
 The most frequently used antipsychotics in pregnancy are
olanzapine, risperidone, and quetiapine
 Do not appear to cause consistent, congenital harm to fetus
 No patterns of fetal limb or organ malformation related to these drugs
 Relation between antipsychotic use in pregnancy and...
 Gestational diabetes
 Increased neonatal respiratory distress and withdrawal symptoms
Clozapine—Rating B?
•Crosses the placenta and may increase the risk of agranulocytosis in infants
•Limitations of the available safety data regarding perinatal clozapine use due to having only a few
studies

Expert Opin Pharmacother. 2015;16(9):1335-1345.

Substance Use Disorder

Opioid use disorder Alcohol use disorder

• Methadone • Naltrexone?
• Buprenorphine • Limited Human Data—
Animal Data Suggest
Moderate Risk

National Institute on Drug Abuse. July 1, 2017.

Lexicomp - Briggs Drugs in Pregnancy and Lactation
Postpartum
Epidemiology and Statistics

20% of women experience mental health conditions after delivery

•75% go untreated

Suicide and overdose are the leading cause of death in the first
year postpartum

Women may be at increased risk of maternal mental health (MMH)

conditions if they:
•have a personal or family history of mental illness
•lack social support
•experienced a traumatic birth or previous trauma
• have a baby in the NICU

Women living in poverty and women of color are MORE likely to

experience MMH conditions and LESS likely to get help

Maternal Mental Health Leadership Alliance.

Maternal Mental Heatlh (MMH) Fact Sheet.
Background
 Caused by a combination of changes in biology, psychology, and environment
 MMH conditions commonly present during pregnancy or within the first year
after birth
 Consequences
Mother more likely to: Child at higher risk for:

• Not manage their own heatlh; have
poor nutrition
• Use substances (alcohol, tobacco,
drugs)
• Experience physical, emotional, or
sexual abuse
• Be less responsive to baby's cues
• Have fewer positive interactions
with baby
• Experience breast feeding
challenges
• Question their competence as
mothers
• Longer stays in the NICU
• Excessive crying
• Impaired parent-child interactions
• Behavioral, cognitive, emotional
delays
• Adverse Childhood Expereince (ACE),
impacting the long-term health of
the child
Maternal Mental Health Leadership Alliance.
Maternal Mental Heatlh (MMH) Fact Sheet.
Mental Health America. Maternal Mental Health.
Baby Blues
A normal period of transition involving mood swings, emotional
sensitivity, weepiness, and/or feeling overwhelmed

Onset usually occurs

Affects up to 85% of
3 to 5 days after
new mothers
delivery

Resolve Ater 2 to 3
weeks without
NOT considered a
treatment as
MMH condition
hormones begin to
stabilize
Maternal Mental Health Leadership Alliance. Maternal Mental
Heatlh (MMH) Fact Sheet.
Mental Health America. Pregnancy and Postpartum Disorders.
Types of MMH Conditions

Obsessive
Depression Anxiety compulsive
disorder

Post-traumatic Substance use

Bipolar illness
stress disorder disorders

Maternal Mental Health Leadership Alliance.

Maternal Mental Heatlh (MMH) Fact Sheet.
Postpartum Depression

Major form of depression

• Begins any time after delivery and can last up to a year

• Less common than baby blues
• Affects 10% to 20% of new mothers

Symptoms

• Specific fears such as preoccupation with the child's health or intrusive

thoughts of harming the baby
• Drastic change in motivation appetite, or mood

Diagnosis

• Symptoms must be present for >2 weeks following childbirth

Mental Health America. Pregnancy and Postpartum Disorders.

Postpartum Depression
Contributing Factors

Hormonal Situational Life

changes risks stressors

Mental Health America. Pregnancy and Postpartum Disorders.

Treatment of Postpartum Depression

Therapy
Social
Self-Care and Medication
Support
Counseling

Mental Health America. Pregnancy and Postpartum Disorders.

Medications in Postpartum Depression

Refractory
First-line Second-line
treatment
• SSRI • SNRI • Brexanolone
• Mirtazapine

Stewart DE, et al. Annu Rev Med. 2019;71:183-96.

Brexanolone (Zulresso®)
MOA: synthetic formulation of allopregnanolone, a positive
allosteric modulator of GABA receptors

FDA-approved for postpartum depression

Administered as a 60-hour continuous infusion

Boxed Warning for excessive sedation and sudden loss of

consciousness
• Only available under Risk Evaluation and Mitigation Strategy (REMS) Program

Brexanolone. Lexi-Drugs.
Payne JL, et al. Front Neuroendocrinol. 2019;52:165-80.
How to choose an antidepressant

Prior treatment Side Patient

history effects preference

Infant Exposure
Through
Lactation

Stewart DE, et al. Annu Rev Med. 2019;71:183-96.

Lactation Safety with Antidepressants
SSRIs
• All SSRIs pass minimally into breastmilk at a level
considered compatible with breastfeeding

Sertraline and • Most minimal passage into breastmilk

• PREFERRED when newly starting therapy
paroxetine
• May be a reasonable alternative to
Citalopram sertraline and paroxetine

Escitalopram and • Fewer studies in nursing infants compared to

other SSRIs
fluoxetine • Used less often for initial treatment

Larsen ER, et al. Acta Psychiatr Scand Suppl. 2015;(445):1-28.

Stewart DE, et al. Annu Rev Med. 2019;71:183-96.
Lactation Safety with Antidepressants

SNRIs and Mirtazapine

• Minimal passage into breastmilk

Tricyclic Antidepressants
• Greater passage into breastmilk than SSRIs
• Nortriptyline considered to have the best safety profile
• Doxepin is considered CONTRAINIDCATED
Bupropion
• AVOID if possible due to case reports of infant seizure

Adjunctive psychotropic medications

• Hypnotics, benzodiazepines, antipsychotics

Stewart DE, et al. Annu Rev Med. 2019;71:183-96.

Determining Medication Safety in
Lactation
Drug Transfer from Mother to Baby

Orally Absorbed Able to cross

available to into mother's into
mother bloodstream breastmilk

Orally Absorbed
available to into baby's
baby bloodstream
Relative Infant Dose (RID)

The dose received

via breast milk A medication is
(mg/kg/day) Expressed as a generally
relative to the percentage considered safe if
mother's dose the RID <10%
(mg/kg/day)

Hotham N, et al. Aust Prescr. 2015;38(5):156-9.

Hale's Lactation Risk Category

L1 L2 L3 L4 L5

• Compatible • Probably • Probably • Potentially • Hazardous

Compatible Compatible Hazardous
(but limited
data)

Hale's Medications & Mother's Milk. Dr.

Hale's Lactation Risk Categories.
Antidepressants
Class RID Hale's Risk Category Infant Effects
SSRIs Sertraline (1.3%) L2 Probably Compatible Sedation, irritability, poor
Paroxetine (2%) feeding, weight gain
Citalopram (4.5%)
Escitalopram (6.6%)
Fluoxetine (8.1%)
SNRIs Venlafaxine (7.5%) L2 Probably Compatible Sedation, irritability, poor
feeding, weight gain
Duloxetine (0.6%) L3 Probably
Desvenlafaxine (7.6%) Compatible
TCAs Amitriptyline (1.9%) L2 Probably Compatible Sedation, irritability, dry
Nortriptyline (2.5%) mouth, urinary retention,
constipation
Doxepin L5 Hazardous Sedation, difficulty
breathing
Others Bupropion (1.1%) L3 Probably Compatible Sedation, irritability, poor
Mirtazapine (4.0%) feeding, weight gain,
seizures (bupropion)

Hale's Medications & Mother's Milk.

Anxiolytics and Hypnotics
Class RID Hale's Risk Category Infant Effects
Benzodiazepines Clonazpam (2.8%) L3 Probably Compatible Sedation, slowed
Lorazepam (2.8%) respiratory rate, poor
Diazepam (4.0%) feeding
Alprazolam (8.5%)
Sedative-Hypnotics Zaleplon (0.4%) L2 Probably Compatible Sedation, slowed
respiratory rate, dry
Zolpidem (0.1%) L3 Probably Compatible
mouth
Others Hydroxyzine (not L2 Probably Compatible Sedation, dry mouth,
reported) constipation, urinary
retention
Buspirone (not L3 Probably Compatible Behavioral changes,
reported) feeding problems, weight
gain

Hale's Medications & Mother's Milk.

Antiepileptics and Mood Stabilizers
Class RID Hale's Risk Category Infant Effects
1st Generation Phenytoin (4.2%) L2 Probably Compatible Sedation, irritability, poor
Antiepileptics Carbamazepine (4.9%) feeding, weight gain
Valproate (3.3%) L4 Possibly Hazardous Sedation, irritability, poor
Phenobarbital (24%) feeding, weight gain,
apneas (phenobarbital)
2nd Generation Levetiracetam (5.6%) L2 Probably Compatible Sedation, irritability, poor
Antiepileptics Gabapentin (6.6%) feeding, vomiting, tremor,
Lamotrigine (27.5%) rash
Topiramate (40.2%) L3 Probably Compatible Sedation, irritability, poor
Oxcarbazepine feeding, diarrhea, weight
(not reported) gain (oxcarbazepine) or
loss (topiramate)
3rd Generation Pregabalin (7.2%) L3 Probably Compatible Sedation, irritability, poor
Antiepileptics Lacosamide (not feeding, weight gain,
reported) tremor
Mood Stabilizers Lithium (4.1%) L4 Possibly Hazardous Drowsiness, irritability, dry
mouth or excessive
salivation, tremor

Hale's Medications & Mother's Milk.

Antipsychotics

Class RID Hale's Infant Effects

Risk Category
1st Generations Chlorpromazine (0.3%) L3 Probably Sedation, irritability,
Haloperidol (6.1%) Compatible poor feeding, apnea,
EPS
2nd Generations Quetiapine (0.1%) L2 Probably Sedation, irritability,
Ziprasidone (0.6%) Compatible poor feeding, apnea,
Olanzapine (1.3%) tremor, EPS
Risperidone (6.0%)
Lurasidone (0.4%) L3 Probably
Clozapine (1.4%) Compatible
Aripiprazole (3.6%)
Paliperidone (not reported)

Hale's Medications & Mother's Milk.

Drugs for Substance Use Disorders

Class RID Hale's Infant Effects

Risk Category
Alcohol use Naltrexone (1.4%) L1 Compatible Opioid withdrawal
Disulfiram (not L5 Hazardous Consumption of small
reported) amounts of alcohol
could cause severe
reaction in infants
Opioid use Buprenorphine (1.3%) L2 Probably Sedation, apnea,
Methadone (4.2%) Compatible pallor, constipation,
poor feeding

Hale's Medications & Mother's Milk.

 Resources

Pregnancy
 Briggs Drugs in Pregnancy
and Lactation
 DART (Developmental and
Reproductive Toxicology)
via PubMed
 Package inserts
Lactation
 LactMed database
 Hales Medications and
Mother's Milk
 Briggs Drugs in Pregnancy
and Lactation
 Package inserts
References
1. New FDA Pregnancy Categories Explained. Drugs.com. Accessed March 10, 2022.
https://www.drugs.com/pregnancy-categories.html
2. Health MC for WM. Psychiatric Disorders During Pregnancy. MGH Center for Women’s Mental Health. Accessed
March 10, 2022. https://womensmentalhealth.org/specialty-clinics/psychiatric-disorders-during-pregnancy/
3. Grover S, Avasthi A. Mood stabilizers in pregnancy and lactation. Indian J Psychiatry. 2015;57(Suppl 2):S308-S323.
doi:10.4103/0019-5545.161498
4. Wallwiener S, Goetz M, Lanfer A, et al. Epidemiology of mental disorders during pregnancy and link to birth
outcome: a large-scale retrospective observational database study including 38,000 pregnancies. Arch Gynecol
Obstet. 2019;299(3):755-763. doi:10.1007/s00404-019-05075-2
5. Armstrong, C. ACOG Guidelines on Psychiatric Medication Use During Pregnancy and Lactation. Am Fam
Physician. 2008 Sep 15;78(6):772-778.
6. Lexicomp (Briggs Drugs in Pregnancy and Lactation). Accessed March 12, 2022.
7. Cohen LS, Rosenbaum JF. Psychotropic drug use during pregnancy: weighing the risks. J Clin Psychiatry. 1998;59
Suppl 2:18-28.
8. Carroll DG. Drugs in Pregnancy. Drugs_Pregnancy.pdf
9. Teratogens in pregnancy can cause birth defects. Parents Life. January 14, 2020. https://parents-
life.com/teratogens-in-pregnancy/
10. Health MC for WM. Treatment for Anxiety During Pregnancy. MGH Center for Women’s Mental Health. Published
April 30, 2015. Accessed March 15, 2022. https://womensmentalhealth.org/posts/anxiety-during-pregnancy-
options-for-treatment/
11. Mental Health Medications | NAMI: National Alliance on Mental Illness. 2021. Accessed March 15, 2022.
https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-
Medication/Hydroxyzine-(Vistaril-Atarax)
References
1. Michigan CF PharmD, BCPS Assistant Professor Ferris State University, College of Pharmacy Kalamazoo. Treatment of Depression
During Pregnancy. U.S. Pharmacist. 2007. Accessed March 15, 2022. https://www.uspharmacist.com/article/treatment-of-
depression-during-pregnancy
2. Health MC for WM. Options for treatment of bipolar disorder during pregnancy. MGH Center for Women’s Mental Health. 2018.
Accessed March 16, 2022. https://womensmentalhealth.org/obgyn/options-for-treatment-of-bipolar-disorder-during-pregnancy/
3. Kulkarni J, Storch A, Baraniuk A, Gilbert H, Gavrilidis E, Worsley R. Antipsychotic use in pregnancy. Expert Opin Pharmacother.
2015;16(9):1335-1345. doi:10.1517/14656566.2015.1041501
4. Maternal Mental Health Leadership Alliance. Maternal Mental Heatlh (MMH) Fact Sheet. Accessed March 14,
2022. https://www.mmhla.org/wp-content/uploads/2020/07/MMHLA-Main-Fact-Sheet.pdf.
5. NIDA. Treating Opioid Use Disorder During Pregnancy. National Institute on Drug Abuse website.
https://nida.nih.gov/publications/treating-opioid-use-disorder-during-pregnancy. July 1, 2017 Accessed March 16, 2022.
6. Mental Health America. Maternal Mental Health. Accessed March 14, 2022. https://www.mhanational.org/maternal-mental-health.
7. Mental Health America. Pregnancy and Postpartum Disorders. Accessed March 14,
2022. https://www.mhanational.org/conditions/pregnancy-and-postpartum-disorders.
8. Stewart DE, Vigod SN. Postpartum depression: pathophysiology, treatment, and emerging therapeutics. Annu Rev Med. 2019;71:183-
96.
9. Payne JL, Maguire J. Pathophysiological mechanisms implicated in postpartum depression. Front Neuroendocrinol. 2019;52:165-80.
10. Brexanolone. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed March 14, 2022. http://online.lexi.com.
11. Larsen ER, Damkier P, Pedersen LH, Fenger-Gron J, Mikkelsen RL, Nielsen RE, et al. Use of psychotropic drugs during pregnancy
and breast-feeding. Acta Psychiatr Scand Suppl. 2015;(445):1-28.
12. Hotham N, Hotham E. Drugs in breastfeeding. Aust Prescr. 2015;38(5):156-9.
13. Hale's Medications & Mother's Milk. Dr. Hale's Lactation Risk Categories. Accessed March 16,
2022. https://www.halesmeds.com/mnemonics/47704?resource=true.
14. Multiple Drugs. Hale's Medications and Mother's Milk. Accessed March 16, 2022. http://halesmeds.com.