Successful Use of Risperidone, Trihexyphenidyl, and Paroxetine in Pregnancy.

Sir,

Use of psychotropic drugs in pregnancy is a matter of concern. The choice of antipsychotic treatment during pregnancy remains subject to controversy, mainly due to a lack of exposure and outcome data that would allow for a meaningful risk estimate.[1]

We report a patient who was exposed to Risperidone, Trihexyphenidyl, and Paroxetine during first trimester of pregnancy.

A 25-year-old female patient with diagnosis of paranoid schizophrenia since 2009 was on treatment from our department since 2012, and she was showing significant improvement on maintenance dose of fixed-dose combination of Risperidone 3mg plus Trihexyphenidyl 2 mg one tablet at night. The patient got married in 2015, and the patient and her family members were explained about need to take contraceptive measures. Paroxetine 25 mg was added in December 2015 for obsessive–compulsive symptoms, and on next follow-up in February 2016, as the patient had no obsessive–compulsive symptoms, paroxetine was reduced to 12.5 mg. On next follow-up after 1 month (March 2016), the patient had no active symptoms and she reported about her pregnancy (she had the last menstrual period in January). Patient and her sister were told about probable teratogenic effects of medicines and they opted to continue medicine. Paroxetine was stopped and fixed-dose combination of Risperidone 3 mg plus Trihexyphenidyl 2 mg was continued at same dose. She was monitored regularly with ultrasonography. The patient delivered a male baby in November 2016. Infant was examined by a pediatrician when he was 3 months old, and no obvious congenital abnormality or delay in milestones was detected. Hence, she received Risperidone and Trihexyphenidyl throughout the pregnancy and paroxetine for approximately 2 months (first trimester)

DISCUSSION

Risperidone exposure is found to cause fetal malformations including Ivemark syndrome, Pierre-Robin syndrome, cardiomyopathy, cleft lip and palate, ear abnormalities, gastroschisis, gestational diabetes, and Turners’ syndrome.[2]

A systematic review of pregnancy exposure to various antipsychotics and risk of congenital malformations reported 22 malformations in 432 pregnancies exposed to Risperidone, resulting in malformation rate of 5.1%.[3] Two studies have shown a doubled or tripled risk of right ventricular outflow tract obstruction associated with paroxetine use.[45] There is a case report of two uncomplicated pregnancies in one woman with sporadic, primary generalized dystonia treated with high dosage Trihexyphenidyl.[6]

Until now, no case report has reported the successful use of a combination of Risperidone, Trihexyphenidyl, and Paroxetine during first trimester of pregnancy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.