Second-generation antipsychotics in pregnancy linked to more gestational diabetes

Design

Systematic review and random-effects meta-analysis of observational studies

Population

21 studies of pregnant women with or without psychotropic exposure

Primary outcome

Gestational diabetes

Effect

Second-generation antipsychotics RR 1.6 (1.23 to 1.97); antidepressants RR 1.19 (1.10 to 1.27)

This meta-analysis pooled 21 observational studies, searched to June 2025, of gestational diabetes after antidepressant or antipsychotic exposure in pregnancy. Adjusted relative risks were 1.43 (95% CI 1.17 to 1.69) for any antipsychotic and 1.19 (1.10 to 1.27) for antidepressants. Second-generation antipsychotics carried the clearest signal, RR 1.6 (1.23 to 1.97); first-generation agents showed no significant association.

Psychiatrists are often the doctors who know a woman is pregnant and on olanzapine or quetiapine before the antenatal team has the full drug history. The finding makes the psychiatrist's letter a place to flag metabolic risk, so glucose testing is planned rather than left to routine timing.

The response is surveillance, not withdrawal. Relapse of severe mental illness in pregnancy and the postpartum period is dangerous for mother and baby, and stopping an effective drug to avoid a modest rise in glucose risk is rarely justified. Where a woman is planning pregnancy, the metabolic profile can be one factor in choosing between equally effective options.

• Tell the antenatal team in writing that a pregnant patient takes a second-generation antipsychotic or antidepressant.
• Ask that glucose testing is planned, and consider early testing where obesity or family history adds risk.
• Record baseline weight and, where available, HbA1c or fasting glucose before or early in pregnancy.
• Do not stop an effective antipsychotic or antidepressant for this reason alone.
• Include metabolic profile in preconception discussions about which drug to use.

Why it matters

The prescriber who knows about the drug is best placed to make sure the glucose test happens.

Don't overread it

Observational data cannot show the drugs cause gestational diabetes, or that switching drugs would prevent it.

The statistics, in plain English

An RR of 1.6 means about 60% more gestational diabetes in exposed women. All intervals sit above 1.0. Because the studies are observational, the higher risk may partly reflect weight, diet and illness severity rather than the drugs themselves.

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