Večinoma je potrebno z zdravljenjem shizofrenije med nosečnostjo in po porodu nadaljevati.
Nezdravljena psihoza je močan psihološki stresor in prinaša vedenjske spremembe, ki ogro-žajo tako žensko kot plod in pomembno vpliva na navezovanje med dojenčkom in materjo po porodu. Antipsihotiki so skupaj s psihološkimi intervencami prva izbira pri zdravljenju shizofrenije (36). Splošno navodilo je, da je tipični antipsihotik najmanj škodljiva izbira za nosečnice, ki še nikoli niso jemale antipsihotikov. Če zanosi ženska, ki jih že jemlje, naj bi z njimi nadaljevala (37).
Večina najpogosteje predpisanih atipičnih antipsihotikov v nosečnosti (olanzapin, kvetiapin in risperidon) ne poveča tveganja za prirojene malformacije ploda (38). Glavna ugotovitev nedavne italijanske sistematične pregledne študije o atipičnih antipsihotikih v nosečnosti je, da je najbolj razumna in najmanj škodljiva izbira zdravljenja shizofrenije (in bipolarne mo-tnje) pri nosečnicah še varen najnižji odmerek zdravila, ki ga že jemlje (39). Po podatkih za ZDA se je v zadnjih letih močno povečalo število nosečnic s predpisanim atipičnim antipsi-hotikom, s 3 na 1000 nosečnosti v letu 2001 na 8 na 1000 v letu 2007. Uporabljajo se namreč tako pri nosečnicah s shizofrenijo, kot pri tistih z bipolarno motnjo, unipolarno depresijo in drugimi psihiatričnimi motnjami (40, 41).
Z njihovo uporabo so povezane metabolne motnje pri nosečnici, predvsem gestacijski diabe-tes in debelost (37), ki pa bi se verjetno pojavile tudi, če ženska ne bi bila noseča. Incidenca gestacijskega diabetesa je pri nosečnicah, ki jemljejo antipsihotike, večja kot pri nosečnicah, ki jih ne jemljejo (4,2 % proti 1,7 %) (14). Metabolne motnje, ne glede na vzrok, povečajo tveganje za porodniške zaplete.
Zaenkrat še nobena raziskava ni dokončno potrdila vzročne povezanosti med izpostavlje-nostjo antipsihotiku in izidi nosečnosti. Izpostavljenost antipsihotikom naj ne bi povečala tveganja za prevelikega novorojenčka, mrtvorojenost in spontani splav. Potrebno pa je skrbno spremljanje nosečnice in zmanjševanje ostalih dejavnikov tveganja. V metaanalizah pogosto naletijo na pomembne begajoče spremenljivke, kot so kajenje, zloraba psihoaktivnih snovi, debelost in socialno-ekonomski status (42).
Tipični in atipični antipsihotiki so lipofilni in prehajajo skozi placentarno krvno bariero. Od-stotki prehajanja iz seruma matere za posamezne antipsihotike znašajo 72,1 % za olanzapin, 65,5 % za haloperidol, 49,2 % za risperidon in 24,1 % za kvetiapin (43). V Španiji so opisali
primer nosečnice s shizoafektivno motnjo, ki je prejemala dolgo delujoči preparat palipe-rodon palmitat, ki ni imel neželenih učinkov ne na nosečnost, ne na otroka (44). Podatki o varnosti klozapina v obporodnem obdobju so na voljo le iz posameznih objavljenih primerov.
Ne potrjujejo povečanega tveganja za prirojene malformacije pri izpostavljenem plodu, ven-dar imajo nosečnice dvakrat večje stopnje gestacijskega diabetesa. Akumulira se v serumu ploda in je lahko vzrok za sindrom ohlapnega novorojenčka, zmanjša variabilnost plodovega srčnega utripa, pri dojenčku lahko sproža krče. Prehaja placentarno krvno bariero, akumulira se v mleku in pri dojenem otroku poveča tveganje za agranulocitozo (45).
Zaključek
Ženske s shizofrenijo imajo že zaradi same bolezni veliko tveganje za zaplete v nosečnosti in za večjo umrljivost novorojenčkov (46). Pri nosečnicah so pogostejše preeklampsije, slabša rast ploda, prezgodnji porod, nizka porodna teža ter mrtvorojenost in večja umrljivost novo-rojenčkov. Za boljši dolgoročni izid nosečnosti je pomembno že pred zanositvijo čim bolj zmanjšati dejavnike tveganja (povečana telesna teža, kajenje, zloraba psihoaktivnih substanc, zdrav življenjski slog) in prilagoditi psihiatrično terapijo. Splošno priporočilo za zdravljenje shizofrenije v nosečnosti je nadaljevanje z antipsihotikom (ki po možnosti ne povzroča meta-bolnih motenj) v najnižjem še učinkovitem odmerku.
Glede na to, da je večina žensk vključenih v sistem prenatalne oskrbe in da jih večina rodi v porodnišnici, je to obdobje idealno za vključitev psihiatričnih in socialnih služb v obravnavo in vzpostavitev terapevtskega odnosa z njimi. Multidisciplinarna obravnava namreč pripo-more k dolgoročnemu okrevanju in zdravemu prehodu v starševstvo (47).
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