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Schizophrenia, Antipsychotic Medications and Birth Defects Jensea Chauvin, RNC, MN, BC-CNS Women’s and Children’s Clinic

Schizophrenia, Antipsychotic Medications and Birth Defects Jensea Chauvin, RNC, MN, BC-CNS Women’s and Children’s Clinical Nurse Specialist Salem Hospital 2013. Schizophrenia, Antipsychotic Medications, and Birth Defects.

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Schizophrenia, Antipsychotic Medications and Birth Defects Jensea Chauvin, RNC, MN, BC-CNS Women’s and Children’s Clinic

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  1. Schizophrenia, Antipsychotic Medications and Birth Defects Jensea Chauvin, RNC, MN, BC-CNS Women’s and Children’s Clinical Nurse Specialist Salem Hospital 2013

  2. Schizophrenia, Antipsychotic Medications, and Birth Defects Objectives: At the end of this course, the participant will be able to: Identify signs and symptoms of schizophrenia Discuss fetal develop and impact of medications Identify common medications and side effects Identify possible birth defects associated with schizophrenia Identify nursing care during antepartum, intrapartum, and postpartum admissions

  3. Case Presentation: Mother: 29 yr old G 3 P2, Spontaneous Vaginal Delivery at 39w 3d BMI 38.2 ,5’3, 215 lbs, Plans breast and formula feeding DSH Hold Social history: + for tobacco, alcohol and lV drug abuse Past Medical History: - Musculo-skeletal system disorder - Anxiety -STD - Migraines - Unspecified mental or behavioual disorder - Asthma - Postpartum depression - Schizophrenia - Scoliosis with spinal fusion

  4. Case continued: • Current Medications: • Fluoxetine ( Prozac) • Folic Acid • Ibuprofen • olanzapine(Zyprexa) • perphanazine (Trilafon) • quetiapine • riseridone(Risperdal) • acyclovir

  5. Baby: Girl, 7’ 13”, APGARS 8 and 9 Failed hearing screening X 2 CMV ordered Head- shallow midfacies with somewhat frontal bossing Hands- simian crease on right, the left has a simian crease that is interrupted. Labs: Urine drug screen- negative Meconium drug screen-negative CMV- not detected Discharged to foster care on day 2.

  6. Frontal Bossing Simian Crease

  7. Schizophrenia • Is a chronic, disabling brain disorder • Affects about 1% of Americans • Is NOT dissociative identity disorder( multiple personality disorder). • Symptoms: • Hallucinations- Auditory or visual • Delusions- Wildly false beliefs • Paranoia

  8. Schizophrenia • Often have abnormal ways of thinking • Have trouble organizing thoughts or making logical connections • May feel like their mind is racing from one unrelated thought to another • Sometimes experience “thought blocking”, a feeling that thoughts are removed form their head

  9. Schizophrenia • Causes a wide range of behaviors: • May speak incoherently • May make up words • May act agitated or appear stone-faced • May have trouble maintaining basic hygiene or order in homes • May display repetitive behaviors, such as pacing

  10. Schizophrenia Epidemiology • Affects men at slightly greater rates than women (1.4 : 1) • Crosses all ethnic groups • Symptoms typically begin between ages 6 and 30 years • Women tend to be diagnosed later in life than men • Rarely begins in childhood or after age 45 • Runs in families

  11. Schizophrenia Etiologies • Unknown • Genes and environment may play a role… multifactorial? • Levels of the chemical messengers dopamine and glutamate may be out of balance • Brain structures may be abnormal

  12. Schizophrenia Diagnosis • Based on clinical history and symptoms • In teenagers, a combination of family history and behaviors which might include withdrawing from social groups and expressing unusual suspicions.

  13. Schizophrenia Treatments • Long term medications • Psychosocial therapies • Rehabilitation

  14. Schizophrenia Goals • To help people with schizophrenia stay employed and maintain as much independence as possible • Relapse prevention

  15. Psychosis- A Psychiatric Emergency in Pregnancy • Psychosis in Pregnancy: is a loss of contact with reality, presence of hallucinations, delusions, or thought disorganization • Psychotic Disorders include: • Primary thought disorders including schizophrenia or schizoaffective disorder • Secondary disorders including mood disorders or substance induced

  16. Schizophrenia • Fertility and Pregnancy: • Fertility is reduced, estimated to be 30% to 80% of the general population • Factors contributing to decreased fertility • Psychotropic medications/tranquillizers-suppress ovulation through the effects on the hypothalamus • Untreated psychotic episodes may interfere with the menstrual cycle • Lack of opportunity • Difficulty forming relationships

  17. Schizophrenia: Pregnancy • Denial of pregnancy common • Complications: • Insufficient prenatal care • Alcohol or substance abuse • Prematurity • Longer NICU stays • Breech presentations • Deliveries outside of hospitals • Neonaticide

  18. Schizophrenia: Pregnancy • Other Risks: • Intrauterine growth restriction increased twofold • Stillbirth quadrupled • Treatment: • Antipsychotic medications • No medications FDA approved for use during pregnancy

  19. Schizophrenia: Pregnancy Placenta Anatomy

  20. Fetal Development Weeks 1 and 2 Getting Ready for fertilization. Weeks 3 Fertilization Week 4 Implantation- blastocyst. The inner group of cells will become the embryo and the outer upon contact with the uterus will burrow into the uterine wall and form the placenta. 4 Weeks Gestation

  21. Fetal Development Week 5 Embryonic Period Formation begins for the: Ectoderm Brain Spinal Cord Heart Other Organs Skin Central and Peripheral Nervous System Eyes, Inner Ear, Connective Tissues Mesoderm Heart and Circulatory System Foundation of bones, muscles, kidneys, and reproductive system. Endoderm Lungs, Intestines, bladder 5 Weeks Gestation

  22. Fetal Development Week 6 Period of rapid growth. Neural tube is closing Heart is beating Basic facial features appear. Week 7 Brain and face rapidly developing Baby is about the size of a pencil eraser. Week 8 Arms and Legs are getting longer Ears are forming. Eyes are visible Upper lip and nose have formed 8 Weeks Gestation

  23. Fetal Development Week 9 Arms grow, develop bones and bends at the elbow. Toes form ¾ inch long Week 10 Baby’s head is rounding Neck begins to develop Eyelids begin to close Week 11 Officially now a fetus. RBC’s are beginning to form in the liver. External genital start developing. 2 inches long Week 12 Developing fingernails. 2 ½ inches long 14 grams 10-12 Weeks Gestation

  24. Schizophrenia Medications • Antipsychotic medications • Fetal exposure to antipsychotics may vary due to differences in placental permeability to these drugs. • The placental passage ratios were as follows: • Olanzapine – 72% (ZyPREXA) • Haloperidol – 66% (Haldol) • Risperidone – 49% (RisperDAL) • Quetiapine – 24% (SEROquel)

  25. Schizophrenia Medications Olanzapine – pregnancy class C In breastfeeding infants, sedation has been seen but no short-term effects. Risperidone- pregnancy class C evidence of embryolethality but no teratogenicity Women should not breastfeed. Quetiapine- pregnancy class C In animal studies evidence of embryo, fetal and maternal toxicity. Breastfeeding not recommended. perphanazine (Trilafon)- has not been assigned a category Is excreted in breast milk. Monitor infant for excessive drowsiness and for developmental milestones.

  26. Schizophrenia Medications • Haloperidol- pregnancy class C • Has the most data on safety in pregnancy • Some cases of limb reduction malformations

  27. Schizophrenia Medications Neonatal toxicity and withdrawal — Chronic administration of antipsychotics during the third trimester may cause symptoms of neonatal toxicity and withdrawal, including: Abnormal movements (dyskinesia) Abnormally increased or decreased muscle tone Motor restlessness Hyper-reflexia Agitation Hyperactivity Tremor Sedation Irritability Crying Tachycardia Hypotension Difficulty breathing Difficulty feeding Gastrointestinal dysfunction (eg, functional bowel obstruction) May be mild or severe requiring intensive care support and prolonged hospitalization

  28. Schizophrenia Medications • Haloperidol: Neonatal Effects While Breastfeeding • Limited Information: • is found in low levels in breast milk • does not seem to effect the infant in short or long term • used in combination with other antipyschotic medications can negatively affect development.

  29. Schizophrenia Medications Haloperidol Adverse Reactions in the Mother: - Cardiovascular: arrhythmia, hyper-/hypotension, sudden death, tachycardia, torsade de pointes - Endocrine & metabolic: hyper-/hypoglycemia,

  30. Schizophrenia • Common Side Effects of Antipsychotics • Extrapyramidal syndrome- psuedoparkinsonism, symptoms may present as bradykinesia, rigidity, tremor, and masked fascies. • Akathisia- a subjective sense of restlessness which can mimic worsening agiation. • Dystonias- can be severe, painful, dysfiguring and frightening. • Laryngospasms can be life threatening • Occulogyric can end in blindness due to retinal ischemia caused by kinking of the retinal artery that runs through the optic nerve when the eye is dramatically deviated beyond its typical range of motion. • 4. Tardive dyskinsia- a permanent movement disorder associated with long term use. Typically seen in the muscle of the mouth and face.

  31. Schizophrenia • Interventions: • In patients with history of neuroleptic use and presenting with symptoms: • Supportive care- hydration, electrolyte stabilization, cooling, airway protection • Immediate cessation of medications • Transfer to ICU • Electronic fetal monitoring • Possible drug therapy • Dantrolene • Bromocriptine • lorazopan

  32. Schizophrenia Medications • Benzodiazepines • Useful in treating psychotic agitation • Does not provide antipsychotic benefits • May worsen psychosis through dis-inhibition and further disorganization of thoughts

  33. Schizophrenia Medications Summary: We don't think schizophrenia itself causes birth defects but the medications have the potential to, and because the etiology of schizophrenia is likely multifactorial with some of the suspected causes (eg, maternal illness/infection like Toxo) having the potential for fetal effects independent of schizophrenia, we can't know the answer. There are no clear birth defects that are "classic" for schizophrenia. Dr Susan Tran Maternal Fetal Medicine

  34. Schizophrenia Medications How to have a conversation with a patient with schizophrenia: 1. Know that many schizophrenics have a delay in processing information, so give them plenty of time to take in what is being said- the response is often delayed, sometimes significantly. 2. Know they often have auditory hallucinations in their head that compete with your conversation. Lori Kessler, RN Nurse Manager Psychiatric Patient Services

  35. Antipsychotic Medications and Birth Defects Resources • http://www.webmd.com/schizophrenia/ss/slideshow-schizophrenia-overview • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2153578/pdf/canfamphys00221-0105.pdf • Foley,M., Strong, T., Garite,T. (2011). Obstetric intensive Care Manual. #rd Edition. McGraw Hill. Pg. 255-257.Hendrick, V. MD. (2012).Bipolar disorder in adults: Teratogenic and postnatal risks of pharmacotherapy. UptoDate

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