Teratogenicity with Olanzapine
Ms. A, a 25-year-old married lady presented in the hospital's Walk-in clinic with the symptoms of suspiciousness and hearing voices. The symptoms had been present for about 5 years. She was very irritable and was unable to sleep. She also suffered few episodes suggestive of dissociative spells in which she would call herself “Goddess Kali.” There was also occasional history of disinhibition in the form of taking of her clothes in front of her family members.\nDetailed evaluation revealed delusions of persecution and second person auditory hallucination. There were no features suggestive of a mood disturbance or organicity. She was diagnosed as having unspecified non-organic psychosis on International Classification of Diseases, tenth edition.[] Olanzapine was started and gradually increased to 15 mg/day. The psychotic symptoms were controlled over a period of 2 months with olanzapine. After 1 month of treatment with olanzapine, the patient became pregnant (this was her first pregnancy) and sought consultation for safety of medications during the 2nd month of gestation. Considering the severity of the symptoms in the past and duration of illness, on mutual discussions, it was decided to continue olanzapine. She was referred to the obstetrics service of the hospital to keep a close watch for any untoward event. She followed-up there regularly as advised by the obstetrician. A discussion with the consulting obstetrician and review of records revealed no major untoward event during pregnancy. Careful history revealed absence of fever, rashes or other skin lesions. Antibody titers for herpes simplex, varicella, cytomegalovirus, toxoplasma and rubella were conducted and found to be normal. Fasting and postprandial blood glucose levels performed at the time of first consultation and repeated in the 2nd and 3rd trimesters were found to be in the normal range. On follow-up, the fetus was detected to have microcephaly on ultrasonography. No other major anomalies were detectable.\nMs. A delivered a female baby weighing 3.4 kg with microcephaly and congenital anopthalmos (bilateral) at full term. The head circumference was 30.5 cm at birth, which falls below the third percentile.[] The baby was seen at department of pediatrics, genetics and ophthalmology. B scan ultrasound revealed absence of ocular tissue. No additional causative factors could be elicited despite the above mentioned specialist referrals. However, detailed imaging and genetic investigations could not be done due to cost limitations. She was not on any other medication known to cause teratogenicity during the period. There was no history of any substance use or family history of congenital anomalies. Patient had adequate nutrition and rest during her pregnancy. There was no history of trauma or exposure to radiation either. The history was corroborated by the patient's mother as well as husband Although this adverse event scored only three on the the Naranjo et al. adverse drug reaction probability scale,[] the lower scores were due to non-applicability of some questions to this situation. For instance, the issue of improvement on discontinuation of drug or administration of antagonist obviously does not apply to this case. Similarly, re-administration and replication of the adverse effect also cannot be done in this case for ethical reasons.