A while back I saw a patient for a first prenatal visit who had a major psychiatric diagnosis (she was bipolar) and was on two medications, Prozac and Lamictal. The medications were making her life much better -- she was functioning well and had a stable relationship with the father of the baby. It was an unplanned pregnancy -- she wasn't taking folic acid and was still smoking a pack of cigarettes a day. She didn't know how far along she was, but she seemed to be about 8 to 10 weeks.
Prozac is in a class of drugs called selective serotonin reuptake inhibitors, or SSRIs, which includes Zoloft, Celexa, Paxil, Lexapro, and many of the other commonly used antidepressants. Most of these drugs fall into the "probably safe" category when it comes to birth defects, with a less than 1 percent risk, although there is some debate about their safety late in pregnancy.
Lamictal, which also goes by the generic name lamotrigine, was developed to treat epilepsy and also turned out to be effective for a variety of psychiatric disorders. But in sporadic cases, Lamictal may cause cleft palate or cleft lip, which distorts a baby's face and typically requires several surgeries during the first few years of its life. Some babies have feeding problems from orofacial clefts as well. And cigarette smoking is another risk factor for cleft lip and palate also.
The embryo's structure and organs form during the earliest part of pregnancy -- starting about two weeks after conception (around the time of the missed period). The lip and mouth are formed seven weeks after conception, or about nine weeks from the last period. Although cleft lip and palate are usually random events, they occur more commonly when mothers are smokers or take certain medications.
In a perfect world, we would know how all medicines (and all other factors) would affect this baby, and exactly what to do to prevent problems. But my patient needed her medications for her well-being. A major psychiatric breakdown during pregnancy might be more risky for her than continuing to take these medications. Plus, since we weren't sure how far along she was, the fetal mouth may already have formed. I wasn't sure if she and the baby would be better off stopping the medicines, or continuing to take them. I asked my patient to call her psychiatrist for advice. I don't know yet about the outcome of the pregnancy.
If you take medicine, it's always best to plan your pregnancies, so you can figure out ahead of time what medicine you really need and what can be omitted if there is risk. Even medications that are known to cause birth defects (like some epilepsy drugs) do so only sporadically. Women on epilepsy drugs have about a 90 percent chance that the baby will be free from major problems. It is not advisable to take yourself off necessary medications if you become pregnant, since sometimes the underlying disease is more dangerous than the medications. Planning ahead with your medical doctors and obstetrician can help you get the best outcomes for you and your baby.
