Planning A Medicated Pregnancy: Dr. P

Nathan and I went to Manhattan last Thursday to meet Dr. P; my psychiatrist had referred me to Dr. P for her expertise in perinatal mental health (translation: medication and mental health during pregnancy and the postpartum period). We talked about my history, my symptoms, the triggers for those symptoms; I explained that because transitions are the worst trigger for my anxiety and out-of-control anxiety triggers depression, I do not see a way through pregnancy and childbirth (the biggest transition ever) without medication. She asked which medications I take. I told her. She asked Nathan how he felt about me taking medication during pregnancy (100% in favor).

Dr. P: In an ideal world, when would you start trying to conceive?

Me: January.

Dr. P: This January?

Me: Yep.

Dr. P: Two months! Wow, that’s… a little soon. I’m not saying wait a year, but definitely more than two months…

Me: You said “ideal.”

Then came the science. In sum, the good news is this: the drugs that have worked best for me, Effexor XR and Klonopin, are prescribed often, have been taken by many pregnant women and many of these pregnancies and the children born have been tracked by doctors. The bad news is that because it’s not ethical to run “randomized controlled studies” (proper drug trials) on pregnant ladies. You see, we don’t actually know that pregnant women will harm a fetus by taking your average prescription medication, but we’d have to risk a whole lot of harm in order to find out. Animal trials are useful because they let us test out chemicals in highly controlled environments. So how do we know anything about pregnant women and drugs? Researchers get women who are already pregnant and already taking a drug like Klonopin to take tests and document as many details as possible about their pregnancies and the health of their children. An example of one problem with gathering information this way: recently, the New York Times published an article about a study linking antidepressant use to increased rates of Autism. Dr. P mentioned this study and said that because all it shows is a possible correlation (link, connection) and doesn’t tell us anything about causation, there’s no way of knowing if that link to autism is because of the medication or because of depression. Catch that? If you take antidepressants while pregnant, you might put your child at a higher risk for autism. But there’s also a pretty good chance that if you don’t take your meds and you become depressed, only then is there a higher risk that your child will be autistic. There’s definitely a correlation between age and autism, so you also have to factor in all the women in that study who are, oh, no one knows, maybe over 35? Oh, and Effexor is similar to Zoloft, but not exactly the same, so there’s really no way of knowing whether that study does, in fact, apply to me. But don’t worry, the risk is still small. (Feel better? Me neither.)

So here’s what Dr. P told us to think about: what if we are in fact the couple who has the child with, say, autism? If you are that family, the fact that the odds are tiny tend to matter, well, not at all. Will we be able to cope with the knowledge that my medication may have contributed to that child’s illness? or birth defect? Yes, and I’ll tell you why: no one will ever know whether my medication did anything specific except make a significant contribution to my own mental well-being.

I know, I was surprised, too. But check this out:

[quote]Based on experimental animal studies, venlafaxine [Effexor] … [is] not anticipated to increase the risk of congenital abnormalities. A study published in abstract has suggested an increase in some malformations based on small numbers of exposed individuals. Transient and usually mild neonatal complications have been reported for venlafaxine and other serotonergic antidepressants. –Reprotox database of potential teratogens [/quote]

Translation: The drug doesn’t cause birth defects in rat or rabbit babies. As for human beings, one study (for real, just one–the National Birth Defects Prevention Study, 2010) found some (very few) cases of cleft palate, limb defects, gastroschisis and heart defects.

And this is about Klonopin, the benzodiazepine that I thought was too dangerous to take during pregnancy:

“Based on experimental animal studies and human pregnancy experience, clonazepam [Klonopin] therapy is not anticipated to increase the risk of congenital malformations. The risk of mild transient neonatal complications may be increased when this drug is used in combination with selective serotonin reuptake inhibitors. –Reprotox database of potential teratogens”

Translation: We don’t see any birth defects when Klonopin is the only medication used. In combination with an SSRI (I take an SNRI, but they’re very similar), it might cause problems for babies just after they’re born. The “complications” are mild because they mostly include feeling mild withdrawal after birth. There have been babies born with birth defects to mothers who took Klonopin during the first trimester (when “physical abnormalities” occur). It’s not clear that Klonopin exposure caused those birth defects. Here’s an example: one study in Hungary looked at 22,865 babies exposed to one of five benzodiazepines, including Klonopin, in the first trimester and found 57 “affected” infants. Out of 38,151 babies not exposed, 75 were “affected.” Reprotox says that “These data … showed no increased teratogenic risk associated with benzodiazepine exposures.” And so on.

I have another appointment with Dr. P in two weeks to discuss “a timeline” and plan when exactly it’s a good idea to start trying to conceive. In the meantime, I am no longer taking BuSpar, because my psychiatrist and I think it was actually making me feel worse, and I’m about to start a prenatal vitamin regimen.  Oh, and Nathan and I are disgustingly mushy about this whole baby possibility. Our conversation over brunch at Alice’s Teacup after the appointment was too ridiculous to repeat!

So there’s no way to know for sure, but it seems like combining Effexor XR (generic) and Klonopin (also generic) will be safer than my other options. That’s the plan. It might change, but it’s a thoughtful plan. And yes, I do have a headache.