Please help me

[Ainara]

Hi, I'm currently 25 weeks pregnant. Have had Bipolar disorder type II since my early 20s (I'm 32 yo), previously was stable taking Seroquel, my last dosage was 400mg, and Ambien for sleep, stopped treatment back in February '08 when we started TTC our youngest baby. Did great during the pregnancy and still nursing him (he is 2yo), no meds so far, only Ambien when needed.

I have started feeling depressed for a few weeks now, it doesn't seem to go away, and all my tricks (more physical activities, sticking to my routine even more, etc) are failing, I'm very worried the doctor will put me back on Seroquel (have an appointment in three days), I'm terrified of taking meds while pregnant, and even more terrified of not being able to nurse my baby.

Is Seroquel safe to take in the third trimester? How about nursing? Their website says that a woman should either take Seroquel OR breastfeed, not both. Is there any other medicine safer to take while nursing a tiny baby? I know Depakote has been approved for breastfeeding by the APA but is not safe while pregnant, is that so for the third (almost) trimester also or only for the beginning of the pregnancy?

I want to go see my psych. armed with all kinds of info regarding bipolar meds and nursing, I won't take a "you cannot nurse your infant" answer. Am I right to assume I can have mental health AND nurse my baby or should I just realize the risk is too high? God just thinking about it makes me more depressed....

Thank you for your help,

Ainara.

[cpride]

Dear Ainara

Quetiapine (Seroquel) is an atypical antipsychotic medication used for the treatment of schizophrenia and bipolar disorder. There have been a limited number of studies conducted during pregnancy. The amount of quetiapine that transfers to the fetus through the placenta is small compared to other medications such as olanzapine (Zyprexa), haloperidol (Haldol), and risperidone (Risperdal). There does not appear to be an increased incidence of birth defects with quetiapine, but there is a risk of neonatal poor adaptation syndrome. The newborn should be observed closely for the first 48 hours of life for low muscle tone, decreased feeding, and weak cry. We do not have data on long-term effects of this medication. You can talk with your obstetrician about the risks and benefits of using this medication during pregnancy. Another medication you can talk with your doctor about is lamotrigine (Lamictal). Lamotrigine has been used in the treatment of bipolar disorder and appears to have a low incidence of birth defects. Valproic acid (Depakote) is not recommended for use during pregnancy even in the third trimester as it has been linked to long term neurological deficits in children.
For breastfeeding, we have good data showing that only 0.07% to 0.1% of quetiapine passes into breast milk, which is negligible. The time that quetiapine is most concentrated in your milk will be at one and one-half hours after your dose so avoid that feeding time, if possible, to further decrease the amount of drug in your milk. No adverse effects were noted in the infants studied. The typical adult dose of quetiapine is 300 mg to 400 mg daily. The authors of one study suggested monitoring quetiapine blood levels in the infant. You should speak with your pediatrician about monitoring the baby's blood levels in the first months of life. Side effects to observe for are low blood pressure, sedation, seizures, and muscle twitches although not likely since such a small amount is transferred into breast milk. Lamotrigine can also be used during breastfeeding but levels are much higher in breast milk, 9.2 % to 18.3 %. Again, your infant’s blood levels of lamotrigine should be monitored routinely by your pediatrician. The time lamotrigine is highest in milk would be one to four hours after the dose. The typical adult dose is 150 mg to 250 mg twice daily. Side effects to observe your infant for are sedation, tremor, and vomiting. Remember that untreated depression itself can have adverse effects on your pregnancy and breastfeeding infant. Talk with your physicians about the risks and benefits of these medications. Let me know if you have further questions.

Sincerely,
Cindy Pride, MSN, CPNP
TTUHSC InfantRisk Center

[Ainara]

Thank you so much for your help, I started feeling much better on Sunday and I think I came out of the woods for now, but obviously keeping an eye on it, I also started taking fish oil and it seems to be helping.

Today I went to see my psychiatrist and his position was what I imagined, he won't recommend nursing while on treatment but the decision is ultimately mine, then I realized I don't need anybody validating my reasons, I feel I can breastfeed on meds, your answer just reassured me even more, you are an angel. It seems is not a question of if but of when, and I will be back on Seroquel when the time comes, hopefully the baby won't have any side effects.

I just emailed your answer to my husband and will be printing it for my ob, pedi and psych.

[mynameismandab]

I completely relate to your post, although lucky you for having a diagnosis so far in advance--my son was 13 months old when I was finally diagnosed with Bipolar II. I ended up on a 100 mg dose before now weaning myself off due to a nasty side effect (rapid hair thinning/loss). Except for the hair loss (and initially the CONSTANT fear of getting the deadly, skin-eating rash), I LOVED this medication because its anti-depressant properties cannot be beat--it boosted my energy level way up so that I could get a lot more done, and I lost weight quickly because I was moving and sweating so much more. I wish I didn't have to stop, but for me the hair loss was the deal-breaker. The only advice I have is to watch out for the deadly skin-eating rash (Stevens-Johnson or TENS) on either your baby or yourself and get help IMMEDIATELY (straight to the ER) if you do notice it. (Although not all Lamictal rashes are The Rash).

[Martha]

For breastfeeding, we have good data showing that only 0.07% to 0.1% of quetiapine passes into breast milk, which is negligible.

Would you mind sharing your sources? I take 200 mg a day and am 27 weeks pregnant and my midwifes do not want me to breastfeed. I would like to be able to show them the hard data.

[cpride]

Dear Martha,

The references Dr. Hale used for quetiapine in his book Medications and Mothers' Milk, 2010 Ed. are as follows:

1. Pharmaceutical Manufacturer Prescribing Information, 1999.
2. Lee A, Giesbrecht B, Dunn E, Ito S. Excretion of Quetiapine in Breast Milk. Am J Psychiatry 2004; 161 (9): 1715-6.
3. Misri S, Corral M, Wardrop AA, Kendrick K. Quetiapine Augmentation in Lactation: A Series of Case Reports. J Clin Psychopharmacol 2006; 26 (5): 508-511.
4. Rampono J, Kristensen JH, Ilett KF, Hackett P, Kohan R. Quetiapine and Breast Feeding. Ann Pharmacother 2007; 41: 711-714.

Sincerely,
Cindy Pride, MSN, CPNP
TTUHSC InfantRisk Center