Abstract
Lyn-May Lim, St Vincent's Hospital, Victoria, Australia:
Caring for the pregnant psychotic woman presents special problems for the clinician. Management involves carefully balancing the risks and benefits of medicating both mother and the unborn child. Limited literature is available to guide psychiatrists in the management of this cohort of patients. Randomised controlled studies comparing different therapeutic modalities in this setting are lacking. A literature search revealed data regarding the use of traditional antipsychotics in pregnancy [1] but only a sparse number of anecdotal reports about the use of atypical agents in pregnancy. To date only three cases have reported the use of olanzapine in pregnancy [2–4] although in one of these the woman opted for a therapeutic abortion.
Ms B was a 37-year-old woman with a 7-year history of paranoid schizophrenia. The mainstay of her previous treatment had been depot flupenthixol decanoate injections. Compliance was poor in the setting of extrapyramidal side-effects and residual psychotic symptoms.
Ms B unintentionally fell pregnant. At that time she had not been medicated with antipsychotics for 3 months. She described persecutory delusions and auditory hallucinations and had started to respond aggressively to these symptoms. She was commenced on olanzapine in the 8th gestational week. This was chosen because of its lesser side-effects compared with the traditional depot antipsychotics. The daily dose was titrated to 25 mg over the subsequent 3 months before there was resolution of her psychotic symptoms. At the 32nd gestational week Ms B decided to cease taking olanzapine against medical advice as she regarded herself as well and no longer in need of treatment. She maintained her decision despite the risk of relapse of psychosis being explained to her. Ms B agreed to be reviewed for the remainder of the pregnancy in her unmedicated state.
The pregnancy was uncomplicated and tests reported no foetal abnormalities. A healthy 3 kilogram baby boy was delivered by elective Caesarean section at 39 weeks gestation. The Apgar score at 1 minute was nine and at 5 minutes was 10. Ms B did not experience an exacerbation of her psychiatric illness in gestation, labour or delivery.
There is an increasing use of atypical antipsychotics due to their preferable side-effect profile and their increased efficacy in treating the negative symptoms of schizophrenia. This indicates a pressing need for more evidence about the safety of the use of these drugs in pregnancy. The challenge lies in treatment of the woman's psychiatric illness without compromising the course of the pregnancy or the health of the foetus [5]. This case involving the use of olanzapine describes an uncomplicated pregnancy and a healthy outcome for both mother and baby. More case reports are needed to contribute to the existing body of knowledge on this topic.