Haldol's been around longer so we can be more sure of its relative safety. We basically say these meds are ok to use based on an absence of evidence of teratogenicity so a longer time period for this absence of evidence means something.
Whoa you guys. There have now been a sufficiently large number of controlled observational studies of psychotropics in pregnancy that we do not need to rely on accumulated years of clinical use in the absence of controlled studies. None of the potential negative effects from these drugs are common or obvious enough that a single clinician would be likely to notice them without a rigorously chosen comparison group, hence 'years of clinical use' really does not mean very much.
Haldol has actually not been as well studied in pregnant women as the older SGAs, although it was the go-to for pregnant women in past decades based pretty much solely on this 'clinical-use' thing. FGAs as a class have been clearly associated with preterm birth and reduced birth weights however. (Newham et al. BJP 192:333, Reis et al. J Clin Psychopharm 28:279, Habermann et al. J Clin Psychopharm 33(4):453, Lin et al., Schizophrenia Res 2010; 116: 55–60 )
We do have quite a bit of info on the older SGAs (olanzapine, risperidone, quetiapine) in this population and although most of the available studies are underpowered to rule out small increases in MCM rates, most recently, a study of 1.3 million pregnant women on Medicaid with 9K on antipsychotics confirmed the suggestion of older, smaller studies that congenital malformations are not increased with either FGA or SGA, although a possible small increase with risperidone was flagged for the first time. (Huybrechts et al., JAMA Psychiatry Aug 2017)
All other things being equal my go-to mood stabilizers in pregnant women are lamotrigine (good evidence going out to 6 years of absolutely normal cognitive development in babies exposed antenatally to lamotrigine: Meador et al.
New England Journal of Medicine,
360(16), 1597-1605 and
The Lancet Neurology 12, no. 3 (2013): 244-252)
and Seroquel (because of evidence of lower rates of placental passage with this than with other atypicals and Haldol (Newport et al. AJP 164:8, 2007)).
But all other things are rarely equal and in general one should privilege whatever medication has been shown to be helpful for the particular individual. No point in putting someone on lamotrigine if it's going to be insufficient to control their rampant mania resulting in multiple undesirable pregnancy outcomes. Polypharmacy should be avoided insofar as possible as adverse outcomes when they occur are almost always linked to women using multiple psychotropics at once (Sadowski et al., BMJ Open 2013;3:e003062).
If using for maintenance why haldol over lurasidone or some other atypical monotherapy?
There has never been a single study of lurasidone (or the other newer SGAs like asenapine, iloperidone) in pregnant women and I therefore never use them in this population. Absence of evidence of harm is not evidence of absence of harm.
Overall I would like to point out that the perinatal psychiatry literature is extremely complex to interpret because RCTs are not a possibility. A close reading of the methods is essential to understand whether any given study yields important information or just bunk, and it's often very difficult to interpret the literature without a good grasp of what has been published in the past and how new work fits into that framework. It's hard to attain or maintain this level of familiarity without at least some formal training in this area.
For general psychiatrists, unless you have had explicit training in perinatal psychiatry I would strongly recommend getting a consultation from someone who specializes in this if you need to treat a pregnant patient.
