Treatment

There is no doubt that women and clinicians are in an evidence-free zone when it comes to the risks of treating women with antipsychotic medications (APs) during pregnancy. In this study, Gentile attempts to provide an update of evidence on the safety of APs in pregnancy using a systematic review. Better care and use of fewer hyperprolactinaemic medications have seen increasing fertility in women with psychotic disorders and the majority will have children. Treating pregnant and breastfeeding women with antipsychot-ics requires weighing clinical effectiveness against risk of toxicity to mother, fetus and children. Withholding antipsychotic treatment may expose mother and fetus to more harm than benefi t (i.e. behavioural disturbance may put both at risk and may result in poorer mother-infant interaction after birth and physiological changes associated with psychosis could affect feto-placental integrity and central nervous system development). The problem, of course, is that systematic review is only as robust as the evidence it collates. The ghastly trail of studies cited by Gentile with an n=1 and the pitiful few large enough to deliver reliable evidence stands out all the more when around 2 % of women live with non-affective psychosis, and a large percent-age of women with bipolar disorder are also treated with APs. The impact of neuroleptic medication on maternal health during pregnancy and on fetal development remains unclear primarily because no randomised controlled trials have evaluated their use in pregnancy. This review was submitted in 2008, but at present we remain without suffi cient evidence to educate women or clinicians about risks, or to inform their decision making. The value of the review lies in its breadth of survey and its timely reminder that these drugs do not have evidence to suggest that they are safe and that gestational diabetes and maternal obesity are emer-gent and potent adverse risk factors for fetal devel-opment. Clinicians need to pay special attention to women of reproductive age who are receiving APs and to consider a wider range of risk to pregnant women and their offspring than congenital malformation