Prescribed psychotropic medication in pregnancy - The neonatal management of infants where mother is

Publication: 15/05/2019  
Next review: 02/05/2022  
Clinical Guideline
CURRENT 
ID: 6000 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

The neonatal management of infants where mother is prescribed psychotropic medication in pregnancy

Background

It is not uncommon for women of child bearing age to be prescribed psychotropic medication during pregnancy. Many of the medications prescribed in pregnancy are shown in Appendix 2.

Diagnosis
Selective Serotonin Reuptake Inhibitors (SSRI) and other antidepressants including Serotonin and Noradrenaline Re-uptake Inhibitors (SNRI) and Tricyclic Anti-depressants (TCAD) can cause a self-limiting Neonatal Behavioural Syndrome (NBS)as a result of a sudden cessation of medication crossing the placenta, leading to infant withdrawal.

Where NBS is identified it can usually be managed with supportive care only.

Medication may be prescribed either in Primary Care or by Specialist Perinatal Mental Health Services. If a woman is known to Leeds and York Partnership NHS Foundation Trust (LYPFT) Perinatal Mental Health Service she will usually have had an antenatal multidisciplinary care planning meeting at 32 weeks when a post-natal plan should have been agreed.
Please see the Pregnancy and Early Postnatal Care Plan (PEPCP) in the mother’s handheld notes. An example of a PEPCP is shown in Appendix 3

This plan should have been shared with all appropriate professionals and with the neonatal team.

These care plans are used for women with the most severe mental health disorders or women who are at risk of relapse or recurrence of severe disorders and therefore will include a neonatal care plan where appropriate.

These PEPCP are not likely to be in place for the majority of women with mild to moderate depression/anxiety/OCD who are often on an SSRI prescribed by the GP or a mental health clinician. There may however be letters from the mental health clinician with details of a diagnosis and a management plan.

Any mother taking psychotropic medication should have a neonatal alert completed by her midwife as per normal practice.

Back to top

Treatment / Management

The vast majority of women on antidepressant medication can be cared for as normal on the post natal ward (PNW) unless expressly stated in the antenatal plan or symptoms/concerns are raised at Newborn Infant Physical Examination (NIPE).

Infants should not be routinely scored unless concerns have been raised and the situation has been discussed with the on call neonatal consultant or there has been a specific antenatal plan to do so

Those infants exposed to opioids or benzodiazepines will generally need TC admission for 72 hours. Scoring and pharmacological treatment may be necessary.

Postnatal Check:

A NIPE should be undertaken within 24 hours.

Before seeing the baby, any antenatal plan, particularly for feeding should be reviewed as this may reduce conflicting advice given to the mother. 

Particular attention should be paid to:

  • Antenatal history and scan results
  • Saturations and respiratory status given increased risk of Persistent Pulmonary Hypertension of the Newborn (PPHN).
  • Symptoms of NBS

It is not the role of the Health Care Profession undertaking the NIPE to give advice regarding mother’s medication – this is the responsibility of the mother's treating clinician.

If significant concerns are raised admission to TC should be considered, otherwise infants can be discharged as per normal practice.

An information leaflet should be given to mothers.
The leaflet in the Pan Thames Document - see Appendix 1 P33. Please print a copy and give to the parents.

Care following discharge:

  • Standard Day 2 visit.
  • NBS may be on-going but self-limiting.
  • A well infant does not any need further action.
  • If an infant is unwell, they should be referred to paediatrics as for any other unwell infant.

Breastfeeding:

Advice on breastfeeding can be complex for women with mental health disorders who are taking psychotropic medication, and needs to be made on a case by case basis.
It is the responsibility of the prescribing clinician (GP or mental health clinician) to advise the mother regarding breastfeeding prior to delivery, in order to allow her to make an informed choice. Conflicting advice post-delivery should be avoided.
Most antidepressant and antipsychotic medications are present in breast milk at too small an amount to be harmful. Further information can be found from the LactMed website (https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm).

Advice may change however if the infant is born prematurely, with a low birth weight or with other neonatal problems. Support for breastfeeding therefore must be given to the mother if safe and in accordance with her informed decision.

Be aware that sleep deprivation can be a trigger for relapse of maternal mental illness. Responsive formula feeding and mixed feeding should also be supported if this is the best way to protect the mother’s well-being as well mothers are better able to care for their infants.

Sedation in the mother due to medication also needs to be taken into account, and there needs to consideration of the practical and emotional support available to the mother in the context of caring for a newborn.

Mothers should not be advised to stop their medication to allow for breastfeeding unless this has already been advised. Discontinuation of medication prescribed to treat or prevent maternal mental illness can be associated with significant risk to the mother and infant.

Mothers should be advised not to abruptly stop breastfeeding as there may be a risk of withdrawal at that point.

There are few absolute contraindications; however women taking Clozapine and Lithium are usually advised not to breastfeed due to a high risk to the infant from these medications.

 

Back to top

Provenance

Record: 6000
Objective:

Aims

  • To provide guidance for healthcare professionals involved in the care of infants born to mothers who have been prescribed psychotropic medication during pregnancy.
  • To have a consistent approach to the assessment of such infants.
  • To ensure infants and their mothers are cared for in the most appropriate location.
  • To avoid unnecessary transitional care (TC) or neonatal unit admission and subsequent unnecessary separation of baby and mother.

The plan for postnatal monitoring will depend on the maternal medication to which the infant has been exposed to in utero.

Further detailed guidance can be found in:

Pan-London Perinatal Mental Health: Guidance for Newborn Assessment – a comprehensive up to date detailed guideline

June 2017

Pan-London Perinatal Mental Health Network and the London Neonatal Operational Delivery Network (Appendix 1).

With grateful thanks to the authors for allowing us to use their guideline


Objectives

To provide evidence-based recommendations for appropriate diagnosis, investigation and neonatal management of newborns at risk of withdrawal symptoms following exposure to prescribed psychotropic medication during pregnancy.


Clinical condition:
Target patient group: Newborns
Target professional group(s): Midwives
Pharmacists
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

C. Expert consensus.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Appendix 1

http://www.londonneonatalnetwork.org.uk/wp-content/uploads/2016/10/FinalNeodoc-v3.pdf

Back to top

Appendix 2 - Medication Classes

Appendix 2. Medication Classes:
(For more detail please refer to Appendix 1)

Antidepressants:

Selective Serotonin Reuptake Inhibitors (SSRI)

Citalopram, escitalopram, fluoxetine, paroxetine, sertraline

Serotonin and Noradrenaline Re-uptake Inhibitor (SNRI)

Venlafaxine, Duloxetine

Tricyclic Antidepressants (TCAs)

Amitriptyline, lofepramine, Imipramine

 

Antipsychotics:

First generation

Haloperidol, chlorpromazine,

Second generation  (“atypicals”)

Aripiprazole, clozapine, quetiapine, olanzapine, risperidone

 

Mood stabilisers:

Lithium

Anti-epileptics - sodium valproate, carbamazepine

 

Others:

Anxiolytics

Benzodiazepines, beta-blockers

Hypnotics

zopiclone, zolpidem or zaleplon,
sedative antihistamines, promethazine

Back to top

Appendix 3 - Pregnancy and Early Postnatal Care Plan

Back to top