Perinatal psychopharmacology viva — hierarchy, signals, shared decision

Station structure

Time: 8–10 minutes. Depth: consultant teaching registrar. Expect absolute-risk language, named datasets, and a four-verb plan (continue / switch / stop / dose-adjust).[2][4]

Core questions and model points

1. Why not open with the drug list? Untreated depression (Grote birth outcomes) and bipolar discontinuation recurrence (Viguera) are the first half of every answer.[1][2]

2. Baseline MCM? Roughly 2–3% without drugs — always stated before relative risks.[3]

3. Valproate rank? Highest common ASM MCM (EURAP dose-related) plus NEAD cognitive harm — avoid as routine in pregnancy potential.[5][6]

4. Lithium modern signal? Patorno: small absolute cardiac malformation increase — shared decision with monitoring and neonatal plan.[4]

5. SSRI cardiac after Huybrechts? Association largely attenuates with confounding adjustment; do not scare with unadjusted headlines.[3]

6. Late SSRI neonate? Poor neonatal adaptation commoner mild syndrome; observe; rare PPHN absolute risk small.[7]

7. Antipsychotic metabolic? Gestational diabetes risk with several atypicals — screen and choose by efficacy–metabolic balance.[3]

8. Postpartum? Peak psychosis/mania window (Bergink); prophylaxis and mother–infant safety planning before birth.[8]

9. Lactation? RID framework, lowest effective dose, sertraline often workable among antidepressants; lithium only with specialist infant monitoring culture; no class ban.[4]

10. Process? Document shared decision with obstetrics; never invent foreign legal section numbers; never promise zero risk.[2][8]