Antipsychotics in pregnancy and breastfeeding

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. You can read more about this in our long-acting injectable (depot) antipsychotics resource.

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. 

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.  

•  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. 

• Your risk of becoming unwell again during pregnancy and after birth
• The care and support available for you and your family 

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 defects^3-4.  

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

Stillbirth

Birth weight

Longer term

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.

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. 

• Best Use of Medicines in Pregnancy - www.medicinesinpregnancy.org 
  
• Bipolar UK - www.bipolaruk.org/FAQs/leaflets-bipolar-disorder-pregnancy-and-childbirth 
  
• Action on Postpartum Psychosis Network - www.app-network.org 

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.

• 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