Psykofarmaka och amning

Behandling med antidepressiva
under första trimestern

<= span style=3D'font-family:Arial'>•Ing= en säkerställd ökad risk för missbildningar

•Unda= ntag - sannolikt något ökad risk för hjärtmissbildning efter paroxetinbehandling

Läkemedel

N (publicerade

studier)

(

GSK

studie

)

N (Svenska

födelseregistret)

Tricykliska

>1000

>300

1300

Fluoxetin

>2000

1178

920

Citalopram

400

298

2663

Sertralin

>200

705

1866

Paroxetin

>400

704

950

Venlafaxin

>100

215

505

Mirtazapin

150

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file:///C:/2AC75235/file5781-filer/slide0190_image047.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhAgAVAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAAAAAB ABQAgAAAAAAAAAIEjI+ZBQA7 ------=_NextPart_01C636D8.67376FC0 Content-Location: file:///C:/2AC75235/file5781-filer/slide0190_image048.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhAgAVAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAAAAAB AAEAgAAAAAECAwICRAEAOw== ------=_NextPart_01C636D8.67376FC0 Content-Location: file:///C:/2AC75235/file5781-filer/slide0004.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Psykofarmaka och amning

Låg födelsevikt och prematuritet?

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Låg födelsevikt enligt några studier=

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Prematuritet enligt enstaka studier&= #13;

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Adaptationsstörningar

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Har beskrivits för serotonerga medel=

ökad skrikighet, sprittighet, agitation, ökad muskeltonus, hyperaktiva reflexer, = 3D"*"

I mer uttalade fall: muskulär hypoto= ni, bristfällig sugförmåga, takypne =

I sällsynta fall: cyanos, kramper= 3;

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Långtidspåverkan?

Få och små humanstudie= r

Metodologiskt svårt område

Djurstudier- betydelse= för humansituationen? =

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Begränsad konklusivite= t

Mer studier behövs!= 3;

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5Z5LMTOMQzd8D30Aq/CpTzOMk6SWqzcgh5PC8kY2/Ur2hah+K4Dlzojzd203R6eKiA0D4vYQ87o+ CzXjQOQBEsmzvnaEbcxjCzbxOU8KevS3FoH+eRXeegaK8EFc8PGjlQ/0LcJgE3XZkGAZ+lHY3BN/ cAjid5hsGKIZC5bIRAEAOw== ------=_NextPart_01C636D8.67376FC0 Content-Location: file:///C:/2AC75235/file5781-filer/slide0179.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Psykofarmaka och amning

Behandling med bensodiazepiner=
under graviditeten

Inga säkra hållpunkter för missbildningar -något ökad risk för läppgomspalt har dock antytts i enstaka studier.

•

Andra missbi= ldningar har föreslagits men sådana fynd har inte kunnat reproduceras i = andra studie= r<= /span>

•

Användning i= tredje trimestern har associerats med neonatala utsättnings-<= span style=3D'position:absolute;top:91.0%;left:12.17%;width:79.4%;height:6.0%'>= symptom (flo= ppy infant syndrom)

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Behandling med zolpidem och zopiklon under graviditeten <= /span>

Begränsad erfarenhet

<= span style=3D'font-size:88%'>Inga missbil= dningar har dokumenterats
I MFR hade 3= 44 respektive 435 barn exponerats i tidig graviditet - utfallet var inte anmärkningsv= ärt = Användning i= tredje trimestern kan medföra hypotoni, påverkan på andningsfunktion och hypotermi.

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Behandling med ”= mood stabilisers”
under första trimestern

= Litium

lNågot ökad risk för hjärtmissbildningar <= /span>

= Karbamazepin

lSpina bifida 1%

= Valproat

lSpina bifida 1-2%, hjä= rtfel, hypospadi, läppgom spalt

lSannolikt störst risk för strukturella missbildningar= av alla antiepileptika.

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”Mood stabilisers” under senare delen av graviditeten

•Neonatala symptom

Litium

lCyanos, hypotoni, hypotermi= 3;

Karbamazepin, valpr= oat

l= Något högre risk för tidig födsel, låg födelsevikt = och tillväxthämning

lHepatotoxicitet? = Utsättningss= ymptom?

•Långtidseffekter

Karbamazepin, valproat

l= Lindrig störning av mentala utvecklingen? <= /div>
lAutism har föreslagits.

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Behandling med antipsykotika
under första trimestern

Inga säkra hållpunkter= för en kliniskt signifikant ökat risk för strukturella missbildningar.
•<= span style=3D'mso-hansi-font-family:Arial;font-size:88%;display:none'>
• En metaanalys av 5 studier påvisade en marginellt ökad risk för missbildningar vid användning av fentiazi= ner av ffa hög dos typ.
•

Invändn= ingar.

Brett konfidensintervall (95%KI: 1:110 – 1 :5000)

Inte kontrollerat för rö= kning

Orsakad av läkemedlen eller av psykossjukdomen?

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Antipsykotika under senare delen = av gravidite= ten

•Neonatala symptom

Konventionella = antipsyko= tika

lEPS, sugproblem, sedation, hypotonicitet har beskrivits.

Atypiska antipsykot= ika

lBegränsat med <= /span>humandata - = risker går inte att värdera ännu.

lKlozapin teoretiskt ri= sk för agranulo= cytos.

•Långtidseffekter
Inga säkra hållpunkter för sådana effekter dock = mycket lite humandata

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Amning och psykofar= maka Individue= ll nytta-risk värdering

Att amma sitt barn har en mängd väldokumenterade fördelar.
<= span class=3DBB>Exponeringen är oftast rel= ativt liten.
Begränsad information för = att värdera risken av läkemedelsexponering via bröstmjölk.

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Amning och psykofarmaka

<= span lang=3DSV style=3D'mso-hansi-font-family:Arial;font-size:63%'>TCA OK <= /span>

SSRI OK möjl= igen bör man undvika fluoxetin och högdos citalopram =

<= span lang=3DSV style=3D'mso-hansi-font-family:Arial;font-size:63%'>Venlafaxin O= K?

<= span lang=3DSV style=3D'mso-hansi-font-family:Arial;font-size:63%'>Undvik övriga AD

•

<= span lang=3DSV style=3D'mso-hansi-font-family:Arial;font-size:63%'>Oxapam är att föredra framför andra bensodiazepiner

<= span lang=3DSV style=3D'mso-hansi-font-family:Arial;font-size:63%'>Zolpidem och zopiklon är att föredra framför bensodiazepiner

<= span lang=3DSV style=3D'mso-hansi-font-family:Arial;font-size:63%'>Undvik litiu= m

•

<= span lang=3DSV style=3D'mso-hansi-font-family:Arial;font-size:63%'>Karbamazepin= och valproat kan användas med försiktighet

<= span lang=3DNO-BOK style=3D'mso-hansi-font-family:Arial;font-size:63%'>Antipsyk= otiska läkemedel - inga generella rekommendationer kan ges<= /span>

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<= span style=3D'font-size:88%'>Individuell nytta-risk värdering

<= span style=3D'font-size:88%'>Hänsyn bör tas till kv= innans egen vilja

<= span style=3D'font-size:88%'>Multidisciplinär approach
Vid farmakologiska behandling använd lägsta möjliga dos Följ gärna läkemedelskoncentrationen hos modern
<= span style=3D'font-size:88%'>Hjälp med beslutsunder= lag: LIC / janusinfo.se

Allmänna rekommendationer
farmakologisk behandling und= er graviditet och amning

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‹sidhuvud›

‹datum/tid›

Klikk for å redigere tekststiler i malen

Andre nivå

Tredje nivå

Fjerde nivå

Femte nivå

‹sidfot›

‹#›

Ofta Inte kontrollerat f<= /span>ör rökning

Orsakad av läkemedlet eller av depressionen i sig= ?

Sannolikt inte kliniskt signifikant

Debut: de första timmerna till det första dygnet efter förlossningen

Försvinner i allmänhet under första veckan

Abstinens eller serotonerg toxicitet?

Invändningar.

Brett konfidensintervall (95%KI: 1:110 – 1 :5000)

Inte kontrollerat för rökning

Orsakad av läkemedlen eller av psykossjukdomen?

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var sld=3DGetObj("SlideObj") if( !g_supportsPPTHTML ) { =09 sld.style.visibility=3D"visible" return } if( MakeNotesVis() ) return runAnimations =3D _InitAnimations(); =09 if( IsWin("PPTSld") ) parent.SldUpdated(GetSldId()) g_origSz=3DparseInt(SlideObj.style.fontSize) g_origH=3Dsld.style.posHeight g_origW=3Dsld.style.posWidth g_scaleHyperlinks=3D(document.all.tags("AREA").length>0) if( g_scaleHyperlinks ) InitHLinkArray() if( g_scaleInFrame||(IsWin("PPTSld") && parent.IsFullScrMode() ) ) document.body.scroll=3D"no" _RSW() if( IsWin("PPTSld") && parent.IsFullScrMode() ) FullScrInit(); =09 MakeSldVis(); ChkAutoAdv() if( runAnimations ) { if( document.all("NSPlay") ) document.all("NSPlay").autoStart =3D false; if( sld.filters && sld.filters.revealtrans ) setTimeout( "document.body.start()", sld.filters.revealtrans.duration * = 1000 ); else document.body.start(); } } function MakeSldVis()=20 { var fTrans=3Dg_showAnimation && SldHasTrans() if( fTrans )=09 { if( g_bgSound ) { idx=3Dg_bgSound.indexOf(","); pptSound.src=3Dg_bgSound.substr( 0, idx ); pptSound.loop=3D -(parseInt(g_bgSound.substr(idx+1))); } SlideObj.filters.revealtrans.Apply()=09 } SlideObj.style.visibility=3D"visible" if( fTrans ) SlideObj.filters.revealtrans.Play() } function MakeNotesVis()=20 { if( !IsNts() ) return false=20 SlideObj.style.display=3D"none" nObj =3D document.all.item("NotesObj") parent.SetHasNts(0) if( nObj ) {=20 nObj.style.display=3D"" parent.SetHasNts(1) } return 1 } function ChkAutoAdv() { if(SldHasTrans()) SlideObj.onfilterchange=3DAutoAdv else AutoAdv() } function AutoAdv() { if(!IsWin("PPTSld") || !gUseSldTimings )return var sld=3DGetCurSld() if( (sld.mAdvDelay>0) && !parent.IsFramesMode() ) setTimeout("parent.GoToNextSld()",sld.mAdvDelay) } function GetObj(id) { if(g_supportsPPTHTML) return document.all(id); else return document.getElementById(id); } function SldHasTrans() { return SlideObj.style.filter !=3D ""; } function GetSldId() { return sId=3Dlocation.href.substring(location.href.la= stIndexOf('/')+1) } function HideMenu() { if( frames["PPTSld"] && PPTSld.document.all.item("ctx= tmenu") && PPTSld.ctxtmenu.style.display!=3D"none" ) { PPTSld.ctxtmenu.styl= e.display=3D'none'; return true } return false } function IsWin( name ) { return window.name =3D=3D name } function IsNts() { return IsWin("PPTNts") } function IsSldOrNts() { return( IsWin("PPTSld")||IsWin("PPTNts") ) } function SupportsPPTAnimation() { return( navigator.platform =3D=3D "Win32"= && navigator.appVersion.indexOf("Windows")>0 ) } function SupportsPPTHTML() { var appVer=3Dnavigator.appVersion, msie=3DappVer.indexOf("MSIE "), ver=3D0 if( msie >=3D 0 ) ver=3DparseFloat( appVer.substring( msie+5, appVer.indexOf(";",msie) ) ) else ver=3DparseInt(appVer) return( ver >=3D 4 && msie >=3D 0 ) } function _RSW() { if( !g_supportsPPTHTML || IsNts() || ( !g_scaleInFrame && (!IsWin("PPTSld") || !parent.IsFullScrMode()) ) ) return var padding=3D0; if( IsWin("PPTSld") && parent.IsFramesMode() ) padding=3D6 cltWidth=3Ddocument.body.clientWidth-padding cltHeight=3Ddocument.body.clientHeight-padding factor=3D(1.0*cltWidth)/g_origW if( cltHeight < g_origH*factor ) factor=3D(1.0*cltHeight)/g_origH newSize =3D g_origSz * factor if( newSize < 1 ) newSize=3D1 s=3DSlideObj.style s.fontSize=3DnewSize+"px" s.posWidth=3Dg_origW*factor s.posHeight=3Dg_origH*factor s.posLeft=3D(cltWidth-s.posWidth+padding)/2 s.posTop=3D(cltHeight-s.posHeight+padding)/2 if( g_scaleHyperlinks ) ScaleHyperlinks( factor ) } function _InitAnimations() { animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined'; isFullScreen =3D (window.name =3D=3D "PPTSld") && !parent.IsFramesMode(); g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc= reen && parent.IsSldVisited()); if( g_animUseRuntime ) { collSeq =3D document.all.tags("seq"); if( collSeq !=3D null ) { for(ii=3D0;ii numSlds ) gSldJumpIdx =3D numSlds; if ( gSldJumpIdx >=3D 0 ) { if ( gSldJumpIdx =3D=3D 0 ) gSldJumpIdx =3D 1; var jumpTo =3D parseInt(gSldJumpIdx); gSldJump =3D 0; gSldJumpIdx =3D ""; win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref ) } } } function _KDH() { if( event.keyCode =3D=3D 8 ) { event.returnValue =3D 0; parent.GoToPrevSld(); } } function DocumentOnClick() { if( IsNts() || parent.HideMenu() ) return; if( ( g_allowAdvOnClick && !parent.IsFramesMode() ) || (event && (event.keyCode=3D=3D32) ) ) parent.GoToNextSld(); } var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""= , g_bgSound=3D"", g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser = =3D 0, gLoopCont =3D 0, gUseSldTimings =3D 1; var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w= indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va= r g_animManager =3D null; var g_animUseRuntime =3D false; var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime; var g_animMainSequence =3D null; var ENDSHOW_MESG=3D"Bildspelet är slut, klicka för att avsluta.", SCREEN_MO= DE=3D"Frames", gIsEndShow=3D0, NUM_VIS_SLDS=3D16, SCRIPT_HREF=3D"script.js"= , FULLSCR_HREF=3D"fullscreen.htm"; var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO= tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true window.gPPTHTML=3DSupportsPPTHTML() var gMainDoc=3Dnew Array(new hrefList("slide0103.htm",1,-1,1),new hrefList(= "slide0104.htm",1,-1,1),new hrefList("slide0091.htm",1,-1,1),new hrefList("= slide0190.htm",1,-1,1),new hrefList("slide0004.htm",1,-1,1),new hrefList("s= lide0005.htm",1,-1,1),new hrefList("slide0105.htm",1,-1,1),new hrefList("sl= ide0179.htm",1,-1,1),new hrefList("slide0180.htm",1,-1,1),new hrefList("sli= de0172.htm",1,-1,1),new hrefList("slide0188.htm",1,-1,1),new hrefList("slid= e0155.htm",1,-1,1),new hrefList("slide0189.htm",1,-1,1),new hrefList("slide= 0178.htm",1,-1,1),new hrefList("slide0185.htm",1,-1,1),new hrefList("slide0= 007.htm",1,-1,1)); /********************************************* Frameset functions These functions control slide navigation and state of the frameset. **********************************************/ function FullScrInit() { g_allowAdvOnClick =3D GetCurSld().mAdvOnClk document.body.style.backgroundColor=3D"black" document.oncontextmenu=3Dparent._CM; document.onkeydown =3D _KDH; document.ondragstart=3DCancel document.onselectstart=3DCancel self.focus() } function Redirect( frmId ) {=09 var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId() if(idx>=3D0) str=3Dstr.substr(1); if( window.name !=3D frmId && ( sId !=3D str) ) { obj =3D GetObj("Main-File") window.location.href=3Dobj.href+"#"+sId return 1 } return 0 } var MHTMLPrefix =3D CalculateMHTMLPrefix();=20 function CalculateMHTMLPrefix() { if ( document.location.protocol =3D=3D 'mhtml:') {=20 href=3Dnew String(document.location.href)=20 Start=3Dhref.indexOf('!')+1=20 End=3Dhref.lastIndexOf('/')+1=20 if (End < Start)=20 return href.substring(0, Start)=20 else=20 return href.substring(0, End)=20 } return ''; } function GetTags(base,tag) { if(g_supportsPPTHTML) return base.all.tags(tag); else return base.getElementsByTagName(tag); } function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP= refix+GetHrefObj( gCurSld ).mNtsHref ) } function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() } function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() } function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() } function SetHasNts( fVal ) { if( gHasNts !=3D fVal ) { gHasNts=3DfVal UpdNavPane() } } function ToggleOtlText() { gOtlTxtExp=3D!gOtlTxtExp UpdOtlPane() } function ClearMedia() { // Clear any sounds playing before launching another browser window. Other= wise, // in fullscreen mode, you'll continue to hear the sound in the frames mod= e. if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0; } function FullScreen() {=20 if ( PPTSld.g_animUseRuntime ) PPTSld.document.body.pause(); ClearMedia(); var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF = : FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref; if(PPTNav.event.ctrlKey) { var w =3D (window.screen.availWidth * 1.0) / 2.0 var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top= =3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } else { win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" ); if( win.document.body && PPTSld.g_animUseRuntime ) win.document.body.PPTSldFrameset=3Dwindow; } } function ToggleVNarration() { rObj=3DPPTSld.document.all("NSPlay") if( rObj && !PPTSld.g_animUseRuntime ) { if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) ) rObj.Play() else if( rObj.playState =3D=3D 2 ) rObj.Pause() else return; } else if( PPTSld.g_animUseRuntime ) { narObj =3D PPTSld.document.all("narrationID") if( narObj ) narObj.togglePause() } } function GetCurSldNum() { =20 obj=3DGetHrefObj(gCurSld) if( obj.mOrigVis =3D=3D 1 ) return obj.mSldIdx else =20 return gCurSld } function GetNumSlds() { =20 if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 ) return GetSldList().mNumVisSlds; else return GetSldList().mList.length } function GetSldNum( href ) { for(ii=3D0; ii 1 ) PopSldList(); else if( !IsFramesMode() ) { if( gLoopCont ) GoToFirst() else EndShow() } } function GoToPrevSld() { ii=3DgCurSld-1 if( ii > 0 ) { obj=3DGetHrefObj(ii) while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) ) obj=3DGetHrefObj(--ii) if( ii =3D=3D 0 ) ii=3D1 GoToSldNum(ii) } } function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) } function GoToLast() { ii=3DGetSldList().mList.length if( ii !=3D gCurSld ) GoToSld( GetHrefObj(ii).mSldHref ) } function GoToSldNum( num ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue obj =3D GetHrefObj( num ) obj.mVis=3D1 gPrevSld=3DgCurSld gCurSld =3D num; PPTSld.location.replace(MHTMLPrefix+obj.mSldHref) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function GoToSld( href ) { if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue GetHrefObj( GetSldNum(href) ).mVis=3D1 PPTSld.location.replace(MHTMLPrefix+href) } function SldUpdated( id ) { if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return gPrevSld=3DgCurSld gCurSld=3DGetSldNum(id) if( IsFramesMode() ) { UpdNavPane(); UpdOtlPane(); UpdNtsPane() } } function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) } function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO= bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) } function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) } function CloseWindow() { if( HideMenu() ) return; =09 var event =3D PPTSld.event; if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D= =3D32 || event.type=3D=3D"click" ) ) window.close( self ); CatchNumKeys( self, event ); } function Unload() { gIsEndShow=3D0; } function SetupEndShow() { gIsEndShow=3D1; PPTSld.document.body.scroll=3D"no"; PPTSld.document.onkeypress=3DCloseWindow; PPTSld.document.onclick=3DCloseWindow; PPTSld.document.oncontextmenu=3D_CM; } function EndShow() { if( IsFramesMode() ) return if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue doc=3DPPTSld.document var dir =3D doc.body.dir if( dir !=3D "rtl" ) dir =3D "ltr"; doc.open() doc.writeln('

' + ENDSHOW_MESG + '
') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 0) { PushSldList(sldList,fEnd); gCurSld =3D 1; } else if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue } function PushSldList(arr,fEnd) { var ii =3D gSldStack.length; gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd); GoToSld( gSldStack[ii].mList[0].mSldHref ); } function PopSldList() { if (gSldStack[gSldStack.length-1].fEndShow) EndShow() else { gCurSld =3D gSldStack[gSldStack.length-1].mCurSld; gSldStack[gSldStack.length-1] =3D null; gSldStack.length--; var sldList =3D gSldStack[gSldStack.length-1]; GoToSld( sldList.mList[gCurSld - 1].mSldHref ); } } var custShowList=3Dnew Array(); /********************************************* Navigation button implementation There are 2 types of buttons: ImgBtn, TxtBtn implemented as function objects. They share a similiar interface so the event handlers can call SetActive, for example, on a button=20 object without needing to know exactly=20 what type of button it is. **********************************************/ //---------------------------------- function ImgBtn( oId,bId,w,action ) //---------------------------------- { var t=3Dthis t.Perform =3D _IBP t.SetActive =3D _IBSetA t.SetInactive=3D _IBSetI t.SetPressed =3D _IBSetP t.SetDisabled=3D _IBSetD t.Enabled =3D _IBSetE t.ChangeIcon =3D null t.UserAction =3D action t.ChgState =3D _IBUI t.mObjId =3D oId t.mBorderId=3D bId t.mWidth =3D w t.mIsOn =3D t.mCurState =3D 0 } function _IBSetA() { if( this.mIsOn ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _IBSetI() { if( this.mIsOn ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0=20 } } function _IBSetP() { if( this.mIsOn ) { obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 ) obj.style.posLeft+=3D1; obj.style.posTop+=3D1 } } function _IBSetD() { =20 obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 ) obj.style.posTop=3D0=20 } function _IBSetE( state ) { var t=3Dthis GetObj( t.mBorderId ).style.visibility=3D"visible" if( state !=3D t.mIsOn ) { t.mIsOn=3Dstate if( state ) t.SetInactive() else t.SetDisabled() } } function _IBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( t.ChangeIcon ) { obj=3DGetObj(t.mObjId) if( t.ChangeIcon() ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth else obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth } t.SetActive() } =20 } function _IBUI( clr1,clr2,nextState ) { var t=3Dthis SetBorder( GetObj( t.mBorderId ),clr1,clr2 ) obj=3DGetObj( t.mObjId ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj= .style.posTop t.mCurState=3DnextState return obj } //----------------------------------------- function TxtBtn( oId,oeId,action,chkState ) //----------------------------------------- { var t=3Dthis t.Perform =3D _TBP t.SetActive =3D _TBSetA t.SetInactive=3D _TBSetI t.SetPressed =3D _TBSetP t.SetDisabled=3D _TBSetD t.SetEnabled =3D _TBSetE t.GetState =3D chkState t.UserAction =3D action t.ChgState =3D _TBUI t.mObjId =3D oId t.m_elementsId=3D oeId t.mIsOn =3D 1 } function _TBSetA() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gHiliteClr,gShadowClr,0,0 ) } function _TBSetI() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) } function _TBSetP() { if( this.mIsOn ) this.ChgState( gShadowClr,gHiliteClr,1,1 ) } function _TBSetD() { =20 this.ChgState( gFaceClr,gFaceClr,0,0 ) this.mIsOn =3D 0 } function _TBSetE() { var t=3Dthis if( !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) else t.ChgState( gShadowClr,gHiliteClr,1,1 ) t.mIsOn =3D 1 } function _TBP() { var t=3Dthis if( t.mIsOn ) {=20 if( t.UserAction !=3D null ) t.UserAction() if( !t.GetState ) return if( t.GetState() ) t.SetPressed() else t.SetActive() } =20 } function _TBUI( clr1,clr2,lOffset,tOffset ) { SetBorder( GetObj( this.mObjId ),clr1,clr2 ) Offset( GetObj( this.m_elementsId ),lOffset,tOffset ) } function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle= ft } function SetBorder( obj, upperLeft, lowerRight ) { s=3Dobj.style; s.borderStyle =3D "solid" s.borderWidth =3D 1=20 s.borderLeftColor =3D s.borderTopColor =3D upperLeft s.borderBottomColor=3D s.borderRightColor =3D lowerRight } function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] } function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() } function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() } function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() } function BtnOnUp() { b=3DGetBtnObj() if( b !=3D null ) b.Perform() else Upd() } function GetNtsState(){ return parent.gNtsOpen } function GetOtlState(){ return parent.gOtlOpen } function GetOtlTxtState(){ return parent.gOtlTxtExp } function NtsBtnSetFlag( fVal ) { s=3Ddocument.all.item( this.m_flagId ).style s.display=3D"none" if( fVal ) s.display=3D"" else s.display=3D"none" } function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etActive() } function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etInactive() } function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etPressed() } function _BSetA_BorderImg() {=20 b =3D gBtnArr[this.mBorderId]=20 if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _BSetI_BorderImg() {=20 b =3D gBtnArr[this.mBorderId] if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"= THREEDFACE" var gBtnArr =3D new Array() gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan= e,GetOtlState ) gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt= lPane,GetOtlState ) gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN= tsPane ) gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg; gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg; gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.= ToggleNtsPane,GetNtsState ) gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To= ggleNtsPane,GetNtsState ) gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n= b_prevBorder",30,parent.GoToPrevSld ) gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n= b_nextBorder",30,parent.GoToNextSld ) gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent= .FullScreen ) gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa= rent.FullScreen,null ) gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border; gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent= .FullScreen,null ) gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border; gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice= ","nb_voiceBorder",18,parent.ToggleVNarration ) gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT= xt","nb_otlTxtBorder",23,parent.ToggleOtlText ) gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts" gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState /********************************************* Context menu implementation _CM() is the function that's hooked up to the oncontextmenu event. Once we're asked to show the menu, we first build it by creating DIVs on-the-fly. Then we position it=20 within the screen area so it doesn't get clipped. Creating the DIVs using createElement() means we don't have to write out any extra HTML into the slide HTML files. **********************************************/ var sNext=3D"Nästa",sPrev=3D"Föregående",sEnd=3D"Avsluta bildspel",sFont=3D= "Arial",sArrow=3D"Pil",sFreeform=3D"Frihandsfigur",sRect=3D"Rektangel",sOva= l=3D"Ellips" function ShowMenu() { BuildMenu(); var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y= =3DPPTSld.event.clientY+doc.scrollTop m =3D PPTSld.document.all.item("ctxtmenu") m.style.pixelLeft=3Dx if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) ) m.style.pixelLeft=3Dx-m.scrollWidth m.style.pixelTop=3Dy if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) ) m.style.pixelTop=3Dy-m.scrollHeight m.style.display=3D"" } function _CM() { if( !parent.IsFullScrMode() ) return; if(!PPTSld.event.ctrlKey) { ShowMenu() return false } else HideMenu() } function BuildMenu() { if( PPTSld.document.all.item("ctxtmenu") ) return var mObj=3DCreateItem( PPTSld.document.body ) mObj.id=3D"ctxtmenu" mObj.style.visibility=3D"hidden" var s=3DmObj.style s.position=3D"absolute" s.cursor=3D"default" s.width=3D"120px" SetCMBorder(mObj,"menu","black") var iObj=3DCreateItem( mObj ) SetCMBorder( iObj, "threedhighlight","threedshadow" ) iObj.style.padding=3D2 CreateMenuItem( iObj,sNext,M_GoNextSld,M_True ) CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld ) =09 CreateSeparator( iObj ) CreateMenuItem( iObj,sEnd,M_End,M_True ) mObj.style.visibility=3D"visible" } function Cancel() { window.event.cancelBubble=3Dtrue; 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charset="windows-1252" Psykofarmaka och amning ------=_NextPart_01C636D8.67376FC0 Content-Location: file:///C:/2AC75235/file5781-filer/outline.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252"

An= teckningar

Bildspel<= /div>

Disposition

1

Behandling med psykofarmaka
under graviditet
Nytto/risk aspekter

Docent/öl Staffan Hägg

Spec. klinisk farmakologi och allmän psykiatri

Avdelning för klinisk farmakologi

Universitetssjukhuset, Linköping

2

3

Evidensbaserad behandling vid depression

Lätt till måttlig depression:

Allmänt kliniskt omhändertagande. Extra psykosocialt stöd.

Antidepressiva läkemedel

Psykologisk behandling

Kognitiv terapi, kognitiv beteende terapi, interpersonell psykotera= pi, psykodynamisk korttidsterapi.

Svår depression

Antidepressiva läkemedel

ECT

4

Behandling med antidepressiva
under första trimestern

5

Låg födelsevikt = och prematuritet?

Låg födelsevikt enligt några studier

Prematuritet enligt enstaka studier

6

Adaptationsstörn= ingar

Har beskrivits för serotonerga medel

ökad skrikighet, sprittighet, agitation, ökad muskeltonus, hyperakti= va reflexer,

I mer uttalade fall: muskulär hypotoni, bristfällig sugförmåga, taky= pne

I sällsynta fall: cyanos, kramper

7

Långtidspåverkan= ?

Få och små humanstudier

Metodologiskt svårt område

Djurstudier- betydelse för humansituationen?

Begränsad konklusivitet

Mer studier behövs!

8

Behandling med b= ensodiazepiner
under graviditeten

Inga säkra hållpunkter för missbildningar -något ökad risk för läppgomspalt har dock antytts i enstaka studier.

Andra missbildningar har föreslagits men sådana fynd har inte kunnat reproduceras i andra studier

Användning i tredje trimestern har associerats med neonatala utsättnings-symptom (floppy infant syndrom)

9

Behandling med z= olpidem och zopiklon under graviditeten

Begränsad erfarenhet

Inga missbildningar har dokumenterats

I MFR hade 344 respektive 435 barn exponerats i tidig graviditet - utfallet var inte anmärkningsvär= t

Användning i tredje trimestern kan medföra hypotoni, påverkan på andningsfunktion och hypotermi.

10

Behandling med = ”mood stabilisers”
under första trimestern

Litium

Något ökad risk för hjärtmissbildningar

Karbamazepin

Spina bifida 1%

Valproat

Spina bifida 1-2%, hjärtfel, hypospadi, läppgom spalt

Sannolikt störst risk för strukturella missbildningar av alla antiepileptika.

11

”Mood stabilisers” under senare delen av graviditeten

Neonatala symptom

Litium

Cyanos, hypotoni, hypotermi

Karbamazepin, valproat

Något högre risk för tidig födsel, låg födelsevikt och tillväxthämn= ing

Hepatotoxicitet? Utsättningssymptom?

Långtidseffekter

Karbamazepin, valproat

Lindrig störning av mentala utvecklingen?

Autism har föreslagits.

12

Behandling med antipsykotika
under första trimestern

Inga säkra hållpunkter för en kliniskt signifikant ökat risk för strukturella missbildningar.

En metaanalys av 5 studier påvisade en marginellt ökad risk för missbildningar vid användning av fentiaziner av ffa hög dos typ.

13

Antipsykotika under senare delen av graviditeten

Neonatala symptom

Konventionella antipsykotika

EPS, sugproblem, sedation, hypotonicitet har beskrivits.

Atypiska antipsykotika

Begränsat med humandata - risker går inte att värdera ännu.

Klozapin teoretiskt risk för agranulocytos.

Långtidseffekter

Inga säkra hållpunkter för sådana effekter dock mycket lite humandat= a

14

Amning och psyk= ofarmaka Individuell nytta-risk värdering

Att amma sitt barn har en mängd väldokumenterade fördelar.

Exponeringen är oftast relativt liten.

Begränsad information för att värdera risken av läkemedelsexponering= via bröstmjölk.

15

Amning och psyk= ofarmaka

TCA OK

SSRI OK möjligen bör man undvika fluoxetin och högdos citalopram

Venlafaxin OK?

Undvik övriga AD

Oxapam är att föredra framför andra bensodiazepiner

Zolpidem och zopiklon är att föredra framför bensodiazepiner

Undvik litium

Karbamazepin och valproat kan användas med försiktighet

Antipsykotiska läkemedel - inga generella rekommendationer kan ges

16

"Individue= ll nytta-risk värdering"

Individuell nytta-risk värdering

Hänsyn bör tas till kvinnans egen vilja

Multidisciplinär approach

Vid farmakologiska behandling använd lägsta möjliga dos

Följ gärna läkemedelskoncentrationen hos modern

Hjälp med beslutsunderlag: LIC / janusinfo.se

------=_NextPart_01C636D8.67376FC0 Content-Location: file:///C:/2AC75235/file5781-filer/filelist.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C636D8.67376FC0--


	Ofta Inte kontrollerat för rö= kning
	Orsakad av läkemedlet eller av depressionen i sig?
	Sannolikt inte kliniskt signifikant


	Debut: de första timmerna till det första dygnet efter förlossningen
	Försv= inner i allmänhe= t under först= a veckan
	Abstinens eller serotonerg toxicitet?


	Invändn= ingar.
	Brett konfidensintervall (95%KI: 1:110 – 1 :5000)
	Inte kontrollerat för rö= kning
	Orsakad av läkemedlen eller av psykossjukdomen?

1	Behandling med psykofarmaka under graviditet Nytto/risk aspekter Docent/öl Staffan Hägg Spec. klinisk farmakologi och allmän psykiatri Avdelning för klinisk farmakologi Universitetssjukhuset, Linköping
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3	Evidensbaserad behandling vid depression Lätt till måttlig depression: Allmänt kliniskt omhändertagande. Extra psykosocialt stöd. Antidepressiva läkemedel Psykologisk behandling Kognitiv terapi, kognitiv beteende terapi, interpersonell psykotera= pi, psykodynamisk korttidsterapi. Svår depression Antidepressiva läkemedel ECT
4	Behandling med antidepressiva under första trimestern
5	Låg födelsevikt = och prematuritet? Låg födelsevikt enligt några studier Prematuritet enligt enstaka studier
6	Adaptationsstörn= ingar Har beskrivits för serotonerga medel ökad skrikighet, sprittighet, agitation, ökad muskeltonus, hyperakti= va reflexer, I mer uttalade fall: muskulär hypotoni, bristfällig sugförmåga, taky= pne I sällsynta fall: cyanos, kramper
7	Långtidspåverkan= ? Få och små humanstudier Metodologiskt svårt område Djurstudier- betydelse för humansituationen? Begränsad konklusivitet Mer studier behövs!
8	Behandling med b= ensodiazepiner under graviditeten Inga säkra hållpunkter för missbildningar -något ökad risk för läppgomspalt har dock antytts i enstaka studier. Andra missbildningar har föreslagits men sådana fynd har inte kunnat reproduceras i andra studier Användning i tredje trimestern har associerats med neonatala utsättnings-symptom (floppy infant syndrom)
9	Behandling med z= olpidem och zopiklon under graviditeten Begränsad erfarenhet Inga missbildningar har dokumenterats I MFR hade 344 respektive 435 barn exponerats i tidig graviditet - utfallet var inte anmärkningsvär= t Användning i tredje trimestern kan medföra hypotoni, påverkan på andningsfunktion och hypotermi.
10	Behandling med = ”mood stabilisers” under första trimestern Litium Något ökad risk för hjärtmissbildningar Karbamazepin Spina bifida 1% Valproat Spina bifida 1-2%, hjärtfel, hypospadi, läppgom spalt Sannolikt störst risk för strukturella missbildningar av alla antiepileptika.
11	”Mood stabilisers” under senare delen av graviditeten Neonatala symptom Litium Cyanos, hypotoni, hypotermi Karbamazepin, valproat Något högre risk för tidig födsel, låg födelsevikt och tillväxthämn= ing Hepatotoxicitet? Utsättningssymptom? Långtidseffekter Karbamazepin, valproat Lindrig störning av mentala utvecklingen? Autism har föreslagits.
12	Behandling med antipsykotika under första trimestern Inga säkra hållpunkter för en kliniskt signifikant ökat risk för strukturella missbildningar. En metaanalys av 5 studier påvisade en marginellt ökad risk för missbildningar vid användning av fentiaziner av ffa hög dos typ.
13	Antipsykotika under senare delen av graviditeten Neonatala symptom Konventionella antipsykotika EPS, sugproblem, sedation, hypotonicitet har beskrivits. Atypiska antipsykotika Begränsat med humandata - risker går inte att värdera ännu. Klozapin teoretiskt risk för agranulocytos. Långtidseffekter Inga säkra hållpunkter för sådana effekter dock mycket lite humandat= a
14	Amning och psyk= ofarmaka Individuell nytta-risk värdering Att amma sitt barn har en mängd väldokumenterade fördelar. Exponeringen är oftast relativt liten. Begränsad information för att värdera risken av läkemedelsexponering= via bröstmjölk.
15	Amning och psyk= ofarmaka TCA OK SSRI OK möjligen bör man undvika fluoxetin och högdos citalopram Venlafaxin OK? Undvik övriga AD Oxapam är att föredra framför andra bensodiazepiner Zolpidem och zopiklon är att föredra framför bensodiazepiner Undvik litium Karbamazepin och valproat kan användas med försiktighet Antipsykotiska läkemedel - inga generella rekommendationer kan ges
16	"Individue= ll nytta-risk värdering" Individuell nytta-risk värdering Hänsyn bör tas till kvinnans egen vilja Multidisciplinär approach Vid farmakologiska behandling använd lägsta möjliga dos Följ gärna läkemedelskoncentrationen hos modern Hjälp med beslutsunderlag: LIC / janusinfo.se