Antipsychotics in pregnancy and breastfeeding

This page may be helpful if you are taking an antipsychotic medication – or need to start it - and you:

  • Want to get pregnant
  • Are already pregnant
  • Want to breastfeed.

We also hope it will be useful for partners, family and friends.

Disclaimer

This webpage provides information, not advice. You should read our full disclaimer before reading further.

This information reflects the best available evidence at the time of writing. We aim to review our mental health information every three years, and update critical changes more regularly.

©  November 2018 Royal College of Psychiatrists 
These are medicines used to treat several types of mental illness. They are most often used for Schizophrenia and Bipolar Disorder, less often for severe Anxiety or Depression. 
 
They can also be used to prevent and treat Postpartum Psychosis, a severe type of mental illness which starts soon after birth. See our page on Postpartum Psychosis for more information.
 

There are many different antipsychotic medications. These are from two main groups:

Older - “Typical” or “First Generation” antipsychotics

Available since 1950s

Examples include:

  • Haloperidol
  • Chlorpromazine
  • Trifluoperazine 

Newer - “Atypical” or “second generation” antipsychotics

Available since 1990s

Examples include:

  • Olanzapine
  • Quetiapine
  •  Risperidone
  • Aripiprazole

Antipsychotics are most often prescribed as tablets but they can also be given as an injection. You can also take them as a long acting injection (sometimes called a “depot”). This can be given weekly, fortnightly or monthly.

See our page on antipsychotics for more information about these medicines.

You may need to take medication (for physical problems as well as mental health ones) before, during and after pregnancy. If you want to get pregnant you will need to decide whether to continue, stop or change any medication you take. It’s just the same with antipsychotic medication. You may have to decide about medication after you find you are pregnant – many pregnancies aren’t planned.

It can be difficult to decide about taking a medication in pregnancy. We often don’t have enough information to say that a medication is 100% safe in pregnancy. What you can do is weigh up the risks and benefits, for you, of taking or not taking a medication.  You may have to think about:

  • How often and how severe your episodes of illness have been.
  • Medications which have helped, made no difference or caused side effects.
  • How you and your baby might be affected if you become unwell while pregnant or after birth.
  • How antipsychotics and other medications might affect your baby. 

See our pages on Planning a Pregnancy and Mental Health in Pregnancy for more information about decision making.

If you have already had an episode of severe mental illness, it’s important to think carefully about the risks of stopping or changing medication, because it can make you unwell again. Pregnancy can be a wonderful time in your life – but it does not protect against mental illness. You will have a higher risk getting unwell in pregnancy, or after you have had your baby if you have had a diagnosis of:

  • Bipolar Disorder.
  • Schizoaffective Disorder.
  • Other psychotic illnesses.
  • Severe Depression. 

The National Institute for Health and Care Excellence (NICE) guidelines1 recommends that you should continue an antipsychotic if, without it, you are likely to become unwell again. 

You may not have had an antipsychotic before, but may have to start it for the first time when trying to get pregnant, during pregnancy or when breastfeeding. Do talk to your GP or psychiatrist about the medication decisions you need to make. If possible, your GP should refer you to a perinatal psychiatrist - an expert in caring for women who have mental health problems in pregnancy, and after birth. 

 

 

Talk to your psychiatrist, if you have one, or ask your GP to refer you. Your GP or psychiatrist can refer you for a pregnancy planning appointment with a perinatal psychiatrist.  He or she can help you to decide whether it is best for you to continue, change or stop a medication. The benefits of continuing antipsychotic medication will often outweigh the risks, both for you and your baby. But you will need to talk over the different issues involved with your psychiatrist before making your decision.  

If you do decide to stop your antipsychotic medication, make sure that:
 
  •  You don’t do it suddenly - this may make you unwell again.
  • You see someone from the psychiatric team regularly, so they can keep a close eye on your mental health.
  • You, and your family, know how to get help if do you become unwell. 
 

At the pregnancy planning appointment you can also discuss other issues including:

  • Your risk of becoming unwell again during pregnancy and after birth
  • The care and support available for you and your family 
See our page on Planning a Pregnancy for more information
Some of these medications can increase the level of a hormone called prolactin – and this can make it harder to get pregnant2. Your doctor will usually should check your prolactin levels at least yearly if you are taking an antipsychotic medication.  If you are finding it hard to get pregnant, ask your doctor to check your prolactin level.
 
If you do have a high prolactin level, you may be able to switch to one of the antipsychotics that is less likely to raise your prolactin – such as Olanzapine, Quetiapine and Aripiprazole.
 
If you find out you are pregnant, talk to your psychiatrist or GP as soon as possible.  If you stop an antipsychotic in pregnancy, you are quite likely to get unwell again – even more so if you stop the medication suddenly. So, talk to your doctor before you decide what to do about this. 
 
Your GP should refer you to a perinatal mental health service for specialist care during your pregnancy. The psychiatrist on the team can help you to think through the risks and benefits of medication, both for you, and your baby. They can also give you an idea about how likely you are to become unwell again, both during your pregnancy, and in the weeks after the birth (If you have had a diagnosis of Bipolar Disorder, Schizoaffective Disorder, or another psychotic illness, you have a higher risk of having a Postpartum Psychosis - see our page on Postpartum Psychosis for more information). 
 
Talking therapies can be helpful. You may be able to see a psychologist during your pregnancy. However, if you have had a psychotic illness, you will still need to take an antipsychotic medication to stay well. A talking therapy can help, but it does not mean that you should stop your medication. Talk to your psychiatrist or GP about what is best for you.
 
If you do decide not to take medication during pregnancy, think about re-starting your antipsychotic within 24 hours of the birth. This can lower your risk of having a postpartum psychosis. 
 
 
Whatever you decide, do make sure that you see someone from the mental health team regularly, so that they can keep a close eye on your mental health. And make sure that you and your family know how to get help and support quickly if you start to become unwell.
 
As many as 1 in 5 pregnancies end in miscarriage even when a woman has not taken any medication.  The evidence we have suggests that antipsychotics do not increase the risk of miscarriage3 – but we need more research to be sure about this.

About 3 in every 100 babies are born with a birth defect even when their mother has not taken any medication in pregnancy. Birth defects usually happen during the first 12 weeks of pregnancy when the baby’s internal organs are developing. Studies looking at outcomes for over 10,000 women who used antipsychotic medication in pregnancy have not found an overall increased risk of birth defects3-4.  

There is no good evidence that any one antipsychotic is the safest to use in pregnancy. However, one large study, which found no increased risk of birth defects for antipsychotics in general, did show a small increased risk with Risperidone4. In this study the risk of birth defects increased from 3 in every 100 babies not exposed to medication to around 4 in 100 babies of mothers who used Risperidone. But – this has not been shown in other studies. So, we need more research to be sure about this apparent increase in risk. If you are taking Risperidone and are concerned, see a specialist perinatal psychiatrist for advice.

Many other things can harm babies. It is not good for the baby if you smoke, drink alcohol or are overweight. Studies that adjust for these factors show that the babies of women who take antipsychotics in pregnancy usually do just as well as women who do not take these medications3

However - antipsychotics can make you more likely to be overweight, and to develop diabetes. If you have any of these problems, get advice about healthy eating and try not to put on too much weight during your pregnancy.

Gestational Diabetes

There is a type of diabetes that starts in pregnancy - Gestational Diabetes. It affects around 2 in every 100 pregnant women. Some early research suggested that antipsychotic medication doubled this risk, to 4 in every 100 women taking an antipsychotic. However, we now know that women with a psychotic illness who do not take antipsychotic medication in pregnancy also have this higher risk6,7. This suggests that it is the mental health problem, rather than the medication, that increases the chance of Gestational Diabetes. 
 

Stillbirth

Although one study has found a small increase in the risk of stillbirth5, others have not found this8.
 

Birth weight

Women who take antipsychotics can have babies who have slightly lower or slightly higher birthweight, but the risks are small3
 

Longer term

We do not know enough about how babies do in the longer term to be sure about whether they are affected by an antipsychotic medication taken by their mother.
 

Ultrasounds

All women have ultrasound scans in pregnancy at around 12 weeks and 20 weeks. Your baby will be checked for heart and other birth defects at these scans. You should not need any extra scans during pregnancy just because you are taking antipsychotic medication.

 

Gestational diabetes

All women have screening for Gestational Diabetes (high blood sugar) in pregnancy. If you take antipsychotics in pregnancy, your blood glucose will be tested more regularly. Ideally you should also have a test called an Oral Glucose Tolerance Test. You have a blood test after not eating or drinking overnight. You then have a glucose drink and another blood test after 2 hours. If you do develop Gestational Diabetes don’t worry. You will have specialist care to make sure any risk to you or your baby is made as small as possible. It will usually get better after you have given birth.

 

Heart

Anyone who starts antipsychotic medication for the first time, even when they are not pregnant, will have an ECG (a heart tracing) and some routine blood tests, before they start the medication. You will need the same tests if you start antipsychotic medication in pregnancy. Some of the results are affected by pregnancy (for example cholesterol levels are raised during pregnancy).
 

If you are referred to a Perinatal Mental Health Team they will usually work closely with your midwife, obstetrician and health visitor. If not, make sure your midwife and obstetrician know what medication you are taking.

Your psychiatrist will help you make a Perinatal Mental Health Care Plan. This is a plan for your care during pregnancy, birth and the postnatal period. It helps to include your family and the other professionals involved when making this plan. This means that they all know what they can do to help you stay as well as possible. This Care Plan should include any planned changes to your medication during pregnancy and after you have given birth. It should also include any blood tests you may need. The plan will be shared with your midwife and obstetrician to make sure that you and your baby get the care you need. The neonatologist (a doctor who specializes in the care of newborn babies) should also be told about any medication you have taken during pregnancy. When they see your baby soon after birth they can advise you about anything you need to look out for. They will also tell you what to do if you have any concerns.

Again, it’s a case of having to weigh up the risks and benefits of medication for you, as an individual. Talk to your psychiatrist or perinatal psychiatrist.
 
All antipsychotics pass into breastmilk, but mostly in small amounts. The level of antipsychotics which pass to the baby through breastmilk is lowest for Olanzapine and Quetiapine. This does not mean that you can’t breastfeed with other antipsychotics. 
 
Aripiprazole can reduce levels of the hormone prolactin. For some women this can mean that they don’t produce enough breast milk. 
 
Guidelines recommend that women should not breastfeed when taking Clozapine. This is because of the possible risk of agranulocytocis (a serious problem affecting white blood cells) and seizures. 
 
The decision about whether to breastfeed or bottle feed is not just about medication. Breastmilk has many benefits for babies. However, breastfeeding may mean that you don’t get enough sleep and this can increase your risk of relapse. Your partner, or a relative or friend, could help with bottle feeds at night to allow you to get enough sleep. 
 
You may worry that bottle-feeding will affect your relationship with your baby. You can still hold your baby and have skin to skin contact when you bottle feed, an important part of bonding with your baby. 
 
Some women feel guilty if they don’t breastfeed, but nobody should feel like this. Looking after your mental health means you are doing the best thing for your baby. You need to choose the feeding method that works best for you and your baby. 
 
However you decide to feed your baby, you should not sleep in the same bed as your baby. Bed sharing increases the risk of sudden infant death syndrome (cot death). This risk is increased if you are taking sedating medication, such as some antipsychotics. 
 
Talk to your midwife and health visitor if you have any questions about breastfeeding. Ask your psychiatrist or GP if you have any concerns about how antipsychotic medication may be affecting your baby.
 
  1. National Institute for Health and Care Excellence (2014) Antenatal and postnatal mental health: Clinical management and service guidance. NICE Guidelines CG192. Available at: www.nice.org.uk/guidance/CG192 
  2. Haddad PM, Wieck A. Antipsychotic-induced hyperprolactinaemia: mechanisms, clinical features and management. Drugs. 2004 ;64 :2291-314
  3. McAllister-Williams RH, Baldwin DS, Cantwell R, Easter A, Gilvarry E, Glover V  et al. British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum.  J Psychopharmacol. 2017; 31: 519-552.
  4. Huybrechts KF, Hernández-Díaz S, Patorno E,Desai RJ, Mogun H, Dejene SZ et al. Anti-psychotic Use in Pregnancy and the Risk for Congenital Malformations JAMA Psychiatry. 2016; 73:938-46.
  5. Sørensen MJ,  Kjaersgaard MIS, Pedersen HS, Vestergaard M, ChristensenJ ,  Olsen J et al. Risk of Fetal Death after Treatment with Antipsychotic Medications during Pregnancy. PLoS One. 2015; 10: e0132280.
  6. Petersen I, McCrea RL, Sammon CJ, Osborn DP, Evans SJ, Cowen PJ et al. Risks and benefits of psychotropic medication in pregnancy: Cohort studies based on UK electronic primary care health records Health Technol Assess. 2016;20:1-176. 
  7. Vigod SN, Gomes T, Wilton AS, Taylor VH, Ray JG. Antipsychotic drug use in pregnancy: High dimensional, propensity matched, population based cohort study. BMJ. 2015;350:h2298
  8. Coughlin CG, Blackwell KA, Bartley C, Hay M, Yonkers KA, Bloch MH. Obstetric and neonatal outcomes after antipsychotic medication exposure in pregnancy. Obstet Gynecol. 2015;125: 1224-35. 

The ‘Building Capacity, Psychiatry Leadership in Perinatal Mental Health Services’ project was commissioned by NHS England in partnership with Health Education England and delivered by the Royal College of Psychiatrists.

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  • Expert review: Dr Zeyn Green-Thompson, Dr Angelika Wieck and Dr Lucinda Green
  • Service user review: Action on Postpartum Psychosis Network
  • Series Editor: Dr Phil Timms  
  • Series Manager: Thomas Kennedy
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