Trastorno bipolar en embarazo y lactancia
Análisis de las pautas de tratamiento según las Guías de Práctica Clínica
DOI:
https://doi.org/10.37536/RIECS.2017.2.2.45Keywords:
Trastorno bipolar, Embarazo, Tratamiento, Lactancia, FarmacologíaAbstract
El trastorno bipolar (TB) es una enfermedad psiquiátrica crónica, caracterizada por fluctuaciones del humor, desde la manía hasta la depresión bipolar. Dado que suele debutar en adultos jóvenes, afecta a mujeres en edad fértil y embarazadas. El TB se asocia con mayor riesgo de efectos adversos en el embarazo, incluyendo aquellos relacionados con la medicación y posibles recaídas de la enfermedad. El objetivo de esta revisión sistemática es analizar la bibliografía reciente y de calidad sobre el tratamiento farmacológico del TB. Para ello se realizó una búsqueda sistemática en PubMed de artículos publicados entre 2012 y 2017, seleccionando aquellos de mayor calidad siguiendo los criterios de la guía PRISMA. Los psicotrópicos empleados en el TB, que incluyen principalmente litio, algunos antiepilépticos, antipsicóticos, antidepresivos y benzodiacepinas, se han asociado con efectos adversos tales como malformaciones congénitas, anomalías cardiacas, afectación del neurodesarrollo, síndrome de adaptación neonatal, abortos espontáneos y parto pretérmino, entre otros. Las recomendaciones de las Guías de Práctica Clínica (GPC) deben interpretarse con cautela, ya que tienen grados variables de evidencia y gran parte de los datos disponibles necesitan mayor investigación en futuros estudios. En conclusión, para manejar el TB durante el embarazo y lactancia, se debe utilizar el fármaco con mejor perfil de seguridad, con la mínima dosis eficaz, y en monoterapia si es posible, y es obligado monitorizar estrechamente la evolución de la mujer y de su hijo. Las GPC proporcionan un apoyo apropiado y necesario, pero siempre se debe individualizar el tratamiento
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2. Grande I, Berk M, Birmaher B, Vieta E. Bipolar disorder. The Lancet 2016 Apr 9;387(10027):1561-1572.
3. Boden R, Lundgren M, Brandt L, Reutfors J, Andersen M, Kieler H. Risks of adverse pregnancy and birth outcomes in women treated or not treated with mood stabilisers for bipolar disorder: population based cohort study. BMJ 2012 Nov 8;345: e7085
4. Taylor CL, Stewart R, Ogden J, Broadbent M, Pasupathy D, Howard LM. The characteristics and health needs of pregnant women with schizophrenia compared with bipolar disorder and affective psychoses. BMC Psychiatry 2015 Apr 17;15:88
5. Di Florio A, Forty L, Gordon-Smith K, Heron J, Jones L, Craddock N, et al. Perinatal episodes across the mood disorder spectrum. JAMA Psychiatry 2013 Feb;70(2):168-175.
6. Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. The Lancet 2014 Nov 15;384(9956):1789-1799.
7. Wesseloo R, Kamperman AM, Munk-Olsen T, Pop VJ, Kushner SA, Bergink V. Risk of Postpartum Relapse in Bipolar Disorder and Postpartum Psychosis: A Systematic Review and Meta-Analysis. Am J Psychiatry 2016 Feb 1;173(2):117-127.
8. Bergink V, Bouvy PF, Vervoort JS, Koorengevel KM, Steegers EA, Kushner SA. Prevention of postpartum psychosis and mania in women at high risk. Am J Psychiatry 2012 Jun;169(6):609-615.
9. Westin AA, Brekke M, Molden E, Skogvoll E, Aadal M, Spigset O. Changes in drug disposition of lithium during pregnancy: a retrospective observational study of patient data from two routine therapeutic drug monitoring services in Norway. BMJ Open 2017 Mar 1;7(3):e015738
10. Marengo E, Martino DJ, Igoa A, Scapola M, Fassi G, Baamonde MU, et al. Unplanned pregnancies and reproductive health among women with bipolar disorder. J Affect Disord 2015 Jun 1;178:201-205.
11. Man SL, Petersen I, Thompson M, Nazareth I. Antiepileptic drugs during pregnancy in primary care: a UK population based study. PLoS One 2012;7(12): e52339
12. Goodwin GM, Haddad PM, Ferrier IN, Aronson JK, Barnes T, Cipriani A, et al. Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2016 Jun;30(6):495-553.
13. 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 Mar;20(23):1-176.
14. Gui?a de Pra?ctica Cli?nica sobre Trastorno Bipolar. 1ªed. Madrid: Ministerio de Sanidad, Servicios Sociales e Igualdad; 2012. Disponible en: http://www.sepsiq.org/file/Enlaces/GPC_510_Trastorno_Bipolar_compl.pdf
15. NICE (National Institute for Clinical Excellence). Clinical Guideline 192. Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance. London: NICE; 2014. Disponible en: https://www.nice.org.uk/guidance/cg192
16. Oruch R, Elderbi MA, Khattab HA, Pryme IF, Lund A. Lithium: a review of pharmacology, clinical uses, and toxicity. Eur J Pharmacol 2014 Oct 5;740:464-473.
17. Diav-Citrin O, Shechtman S, Tahover E, Finkel-Pekarsky V, Arnon J, Kennedy D, et al. Pregnancy outcome following in utero exposure to lithium: a prospective, comparative, observational study. Am J Psychiatry 2014 Jul;171(7):785-794.
18. Bergink V, Kushner SA. Lithium during pregnancy. Am J Psychiatry 2014 Jul;171(7):712-715.
19. van der Lugt NM, van de Maat JS, van Kamp IL, Knoppert-van der Klein EAM, Hovens JGFM, Walther FJ. Fetal, neonatal and developmental outcomes of lithium-exposed pregnancies. Early Hum Dev 2012 6;88(6):375-378
20. Bogen DL, Sit D, Genovese A, Wisner KL. Three cases of lithium exposure and exclusive breastfeeding. Arch Womens Ment Health 2012 Feb;15(1):69-72.
21. Pacchiarotti I, Leon-Caballero J, Murru A, Verdolini N, Furio MA, Pancheri C, et al. Mood stabilizers and antipsychotics during breastfeeding: Focus on bipolar disorder. Eur Neuropsychopharmacol 2016 Oct;26(10):1562-1578
22. Meador KJ, Loring DW. Developmental effects of antiepileptic drugs and the need for improved regulations. Neurology 2016 Jan 19;86(3):297-306.
23. Nanau RM, Neuman MG. Adverse drug reactions induced by valproic acid. Clin Biochem 2013 Oct;46(15):1323-1338.
24. Cohen MJ, Meador KJ, Browning N, May R, Baker GA, Clayton-Smith J, et al. Fetal antiepileptic drug exposure: Adaptive and emotional/behavioral functioning at age 6 years. Epilepsy & Behavior 2013 11;29(2):308-315.
25. Meador KJ, Baker GA, Browning N, Cohen MJ, Bromley RL, Clayton-Smith J, et al. Breastfeeding in children of women taking antiepileptic drugs: cognitive outcomes at age 6 years. JAMA Pediatr 2014 Aug;168(8):729-736.
26. Comunicado de la FDA sobre la seguridad de los medicamentos: Productos con valproato para las convulsiones están contraindicados para la prevención de migrañas en mujeres embarazadas debido a disminución en puntajes de cociente intelectual (IC) en niños expuestos. [online]. Disponible en: https://www.fda.gov/Drugs/DrugSafety/ucm351985.htm
27. Christensen J, Gronborg TK, Sorensen MJ, Schendel D, Parner ET, Pedersen LH, et al. Prenatal valproate exposure and risk of autism spectrum disorders and childhood autism. JAMA 2013 Apr 24;309(16):1696-1703.
28. Dolk H, Wang H, Loane M, Morris J, Garne E, Addor MC, et al. Lamotrigine use in pregnancy and risk of orofacial cleft and other congenital anomalies. Neurology 2016 May 3;86(18):1716-1725.
29. Clark CT, Klein AM, Perel JM, Helsel J, Wisner KL. Lamotrigine dosing for pregnant patients with bipolar disorder. Am J Psychiatry 2013 Nov;170(11):1240-1247.
30. Davanzo R, Dal Bo S, Bua J, Copertino M, Zanelli E, Matarazzo L. Antiepileptic drugs and breastfeeding. Ital J Pediatr 2013 Aug 28;39:50
31. 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 May;125(5):1224-1235.
32. Sorensen MJ, Kjaersgaard MI, Pedersen HS, Vestergaard M, Christensen J, Olsen J, et al. Risk of Fetal Death after Treatment with Antipsychotic Medications during Pregnancy. PLoS One 2015 Jul 10;10(7): e0132280.
33. Sadowski A, Todorow M, Yazdani Brojeni P, Koren G, Nulman I. Pregnancy outcomes following maternal exposure to second-generation antipsychotics given with other psychotropic drugs: a cohort study. BMJ Open 2013 Jul 13;3(7): e003062
34. Kulkarni J, Worsley R, Gilbert H, Gavrilidis E, Van Rheenen TE, Wang W, et al. A prospective cohort study of antipsychotic medications in pregnancy: the first 147 pregnancies and 100 one year old babies. PLoS One 2014 May 2;9(5): e94788
35. Johnson KC, LaPrairie JL, Brennan PA, Stowe ZN, Newport DJ. Prenatal antipsychotic exposure and neuromotor performance during infancy. Arch Gen Psychiatry 2012 Aug;69(8):787-794.
36. Mehta TM, Van Lieshout RJ. A review of the safety of clozapine during pregnancy and lactation. Arch Womens Ment Health 2017 Feb;20(1):1-9.
37. 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 May 13;350: h2298
38. Uguz F. Second-Generation Antipsychotics During the Lactation Period: A Comparative Systematic Review on Infant Safety. J Clin Psychopharmacol 2016 Jun;36(3):244-252
39. Ban L, West J, Gibson JE, Fiaschi L, Sokal R, Doyle P, et al. First trimester exposure to anxiolytic and hypnotic drugs and the risks of major congenital anomalies: a United Kingdom population-based cohort study. PLoS One 2014 Jun 25;9(6): e100996
40. Bellantuono C, Tofani S, Di Sciascio G, Santone G. Benzodiazepine exposure in pregnancy and risk of major malformations: a critical overview. Gen Hosp Psychiatry 2013 Jan-Feb;35(1):3-8.
41. Odsbu I, Skurtveit S, Selmer R, Roth C, Hernandez-Diaz S, Handal M. Prenatal exposure to anxiolytics and hypnotics and language competence at 3 years of age. Eur J Clin Pharmacol 2015 Mar;71(3):283-291.
42. Radojcic MR, El Marroun H, Miljkovic B, Stricker BH, Jaddoe VW, Verhulst FC, et al. Prenatal exposure to anxiolytic and hypnotic medication in relation to behavioral problems in childhood: A population-based cohort study. Neurotoxicol Teratol 2017 May;61: 58-65
43. Oyebode F, Rastogi A, Berrisford G, Coccia F. Psychotropics in pregnancy: safety and other considerations. Pharmacol Ther 2012 Jul;135(1):71-77.
44. El Marroun H, Jaddoe VW, Hudziak JJ, Roza SJ, Steegers EA, Hofman A, et al. Maternal use of selective serotonin reuptake inhibitors, fetal growth, and risk of adverse birth outcomes. Arch Gen Psychiatry 2012 Jul;69(7):706-714.
45. Hayes RM, Wu P, Shelton RC, Cooper WO, Dupont WD, Mitchel E, et al. Maternal antidepressant use and adverse outcomes: a cohort study of 228,876 pregnancies. Am J Obstet Gynecol 2012 Jul;207(1):49.
46. Kjaersgaard MI, Parner ET, Vestergaard M, Sorensen MJ, Olsen J, Christensen J, et al. Prenatal antidepressant exposure and risk of spontaneous abortion - a population-based study. PLoS One 2013 Aug 28;8(8):e72095
47. Ross LE, Grigoriadis S, Mamisashvili L, Vonderporten EH, Roerecke M, Rehm J, et al. Selected pregnancy and delivery outcomes after exposure to antidepressant medication: a systematic review and meta-analysis. JAMA Psychiatry 2013 Apr;70(4):436-443.
48. Stephansson O, Kieler H, Haglund B, Artama M, Engeland A, Furu K, et al. Selective serotonin reuptake inhibitors during pregnancy and risk of stillbirth and infant mortality. JAMA 2013 Jan 2;309(1):48-54.
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