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Psychosis During Pregnancy

Note: The Pregistry website includes expert reports on more than 2000 medications, 300 diseases, and 150 common exposures during pregnancy and lactation. For the topic Psychosis, go here. These expert reports are free of charge and can be saved and shared.
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Psychosis is a phenomenon in which thoughts and emotions are disrupted to such an extent that the person is out of touch with reality. Psychosis is the principle feature of several conditions that are known collectively as psychotic disorders. Together, psychotic disorders affect approximately 3.5 percent of people worldwide. Researchers have found the incidence of psychotic disorders varies widely between different countries and is highest in younger men and racial and ethnic minorities. However, psychosis also occurs in young and middle aged women and can happen particularly in association with pregnancy. While a growing number of women with psychotic conditions, such as schizophrenia, are getting pregnant, research also has revealed that it is fairly common for women to suffer what are called psychotic-like experiences (subclinical episodes that seem psychotic but typically are less extreme than actual psychosis) during pregnancy, or just after giving birth.

In psychosis, the disconnection from reality presents with symptoms that include delusions and hallucinations. A delusion is a belief or idea that a person maintains, even when it is contradicted by reasoning that is accepted by virtually everybody else, or when it is different from what is accepted by people as a whole. Hallucinations are perceptions within a person’s mind of things that are not really there and they can involve any of the senses.

There are different categories of delusions:

  • Paranoid delusions are delusions in which the underlying disconnection from reality is that everyone else is part of conspiracy organized against him, or her.
  • Visual hallucinations are false perceptions that the person is seeing something that is not there.
  • Auditory hallucinations are false perceptions that the person is hearing something, for instance a voice.

Other psychotic features include disorganized speech and disorganized behavior.

Diagnosis of psychosis and psychotic disorders is made clinically. This works by way of a psychiatric evaluation that includes the person’s history and demonstration of features, such as hallucinations, delusions, disorganized speech, or disorganized behavior. These features are assessed in terms of criteria that are listed in Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Based on the presence of psychotic features, the amount of time the features have been present, and the degree to which the condition affects the person’s function, an examiner can determine if the person meets the requirements for any of several psychotic conditions, such as schizophrenia, brief psychotic disorder, or substance-induced psychotic disorder. If a woman suffers a brief psychotic disorder that begins within four weeks of giving birth, the DSM-V diagnosis would be “brief psychotic disorder with postpartum onset”. This is what used to be called “postpartum psychosis”.

Psychosis during pregnancy entails increased risk that the mother will experience problems, such as a need for cesarean delivery or induction of labor, or bleeding (hemorrhage) before or after delivery. One possible cause of hemorrhage before delivery is a serious condition called placental abruption, in which the placenta detaches from the wall of the uterus, thereby cutting off blood flow to the fetus, but also leading the mother to lose a lot of blood.

Psychosis in a pregnant woman puts the fetus at elevated risk of poor growth in the uterus, fetal distress (the fetus is not doing well, usually because the placenta is not receiving enough blood flow, or oxygen), premature rupture of membranes (“water breaking” too early) and preterm birth, birth defects, and stillbirth, due to reduced blood flow from the uterus, placental abruption, and other causes.

Many different medications are used to treat psychosis. These drugs are characterized into different groups based on how they are thought to work and based on how old or how new they are. Older drugs, known as first generation antipsychotic agents, include phenothiazines and butyrophenones. While these groups have been used only occasionally to treat psychosis in pregnancy, they have been given to pregnant women more often to treat nausea, including a severe condition of nausea and vomiting called hyperemesis gravidarum. One powerful, commonly used butyrophenone called haloperidol has been subject to controversy as to whether it increases the risk of birth defects. There was a report that when given during the first trimester the drug caused abnormalities in the limbs of babies, but this was contradicted by studies involving larger numbers or pregnancies, leading researchers to conclude that haloperidol is probably relatively safe in pregnancy. There also is some concern that a commonly used, lower-potency phenothiazine called chlorpromazine may slightly increase the risk of birth defects when given during the first trimester. There is also some concern that exposure to chlorpromazine, haloperidol, or other first generation antipsychotic drugs in the womb may cause temporary problems for the baby involving movement, feeding, the intestines, or jaundice (yellowing of the skin). Some concern also surrounds second generation antipsychotic agents, which include olanzapine, risperidone, clozapine, amisulpride, aripiprazole, and ziprasidone, but more studies are needed to understand the risks.

Safety limits for antipsychotic medications in nursing mothers have not been established, but tiny amounts entering breast milk are not thought to be dangerous to full term infants. More caution is recommended for mothers with preterm infants who take these medications, since there are knowledge gaps concerning how easily the drugs enter breast milk. To be absolutely safe, if you are on antipsychotic medication, you can avoid breastfeeding, regardless of the maturity of your infant, by avoiding breastfeeding and choosing an infant formula under the direction of your pediatrician. However, there is currently a shortage of infant formula in the United States.

Antipsychotic medications are the gold standard, the main treatment, for  psychosis. When very severe, however, “brief psychotic disorder with postpartum onset” is often treated with a procedure called electroconvulsive therapy (ECT). Usually, this is the choice, after medication proves to be inadequate, so ECT is not really an alternative to medication.

David Warmflash
Dr. David Warmflash is a science communicator and physician with a research background in astrobiology and space medicine. He has completed research fellowships at NASA Johnson Space Center, the University of Pennsylvania, and Brandeis University. Since 2002, he has been collaborating with The Planetary Society on experiments helping us to understand the effects of deep space radiation on life forms, and since 2011 has worked nearly full time in medical writing and science journalism. His focus area includes the emergence of new biotechnologies and their impact on biomedicine, public health, and society.

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