Is it safe to continue sertraline and aripiprazole (Abilify) during pregnancy?

Sertraline and Aripiprazole During Pregnancy

Continue both sertraline and aripiprazole during pregnancy if they are required for maternal functioning and mental health stability, as untreated psychiatric illness poses significant risks to both mother and fetus that likely outweigh the modest medication-related risks.

Sertraline in Pregnancy

Safety Profile

Sertraline is one of the preferred SSRIs during pregnancy and breastfeeding 1. The evidence shows:

• Paroxetine and sertraline are the most commonly prescribed antidepressants during breastfeeding due to their favorable safety profiles 1
• Sertraline transfers in low concentrations into breast milk 1
• SSRI treatment should be continued during pregnancy at the lowest effective dose, because withdrawal of medication may have harmful effects on the mother-infant dyad 2

Specific Risks to Monitor

While generally safe, sertraline exposure requires awareness of certain risks:

• Cardiac defects: First-trimester sertraline exposure was associated with increased risk of atrial/ventricular defects (RR 1.34) and craniosynostosis (RR 2.03) 3
• Persistent pulmonary hypertension of the newborn (PPHN): Late pregnancy SSRI exposure linked to PPHN with number needed to harm of 286-351 1
• Neonatal adaptation syndrome: Third-trimester exposure can cause crying, irritability, tremors, poor feeding, hypertonia, tachypnea, sleep disturbance, hypoglycemia, and seizures in neonates 2
  • Onset ranges from hours to days after birth
  • Usually resolves within 1-2 weeks
  • Arrange early follow-up after hospital discharge 2

Critical Context

Depression during pregnancy itself is associated with premature birth and decreased breastfeeding initiation 1. Women who discontinued antidepressants during pregnancy were more likely to experience relapse of major depression 4. The risks of untreated maternal depression must be weighed against medication risks.

Aripiprazole (Abilify) in Pregnancy

FDA Label Information

The FDA label provides the most authoritative guidance 4:

• Overall available data from published epidemiologic studies have not established a drug-associated risk of major birth defects, miscarriage, or adverse maternal outcomes
• A retrospective Medicaid database study of 9,258 women exposed to antipsychotics during pregnancy did not indicate an overall increased risk for major birth defects 4
• Neonates exposed to antipsychotics including aripiprazole during the third trimester are at risk for extrapyramidal and/or withdrawal symptoms (agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, feeding disorder) 4
• Symptoms vary in severity; some neonates recover within hours/days, others require prolonged hospitalization

Research Evidence

Recent studies provide additional reassurance 5:

• Relatively large prospective studies and database studies show no definitive evidence of increased malformation risk
• Aripiprazole is unlikely to pose metabolic risk in pregnancy (no increased gestational diabetes) 6
• However, one study found associations with pregnancy hypertension, lower birth weight, shorter gestation, and higher neonatal admission rates 6 - these findings need replication to rule out confounding

Critical Lactation Concern

A major concern with aripiprazole is lactation failure 7:

• In a study of 35 women continuing aripiprazole postpartum, 74% experienced complete lactation failure and 11% had insufficient milk production
• The FDA label explicitly states: "Aripiprazole exposure during pregnancy may decrease milk supply in the post-partum period" 4
• This lactation issue should be discussed with patients during pregnancy planning

Clinical Management Algorithm

During Pregnancy

1. Continue both medications at the lowest effective dose if required for maternal functioning 2, 4

2. Monitor closely for:

   • Blood pressure (aripiprazole associated with hypertension risk) 6
   • Fetal growth (potential for lower birth weight with aripiprazole) 6
   • Maternal weight gain
   • Blood glucose (though aripiprazole has low metabolic risk) 6

3. Avoid first-trimester discontinuation if possible, as this is when relapse risk is highest and when cardiac malformations occur 1

Peripartum Period

1. Do not discontinue medications before delivery - maintain therapeutic doses 2
2. Prepare neonatal team for potential adaptation syndrome from sertraline and extrapyramidal/withdrawal symptoms from aripiprazole
3. Plan for early neonatal follow-up within first week of life 2

Postpartum/Breastfeeding

1. Sertraline: Safe to continue during breastfeeding - it's a preferred agent 1, 2
2. Aripiprazole:
   • Counsel extensively about high risk of lactation failure (74% complete failure rate) 7
   • Discuss alternative feeding plans if lactation fails
   • Consider whether benefits of continuing aripiprazole outweigh loss of breastfeeding benefits
   • If breastfeeding is a priority, discuss potential medication alternatives with psychiatry

Neonatal Monitoring

Monitor newborns for:

• From sertraline: Crying, irritability, jitteriness, tremors, feeding difficulty, respiratory distress, sleep disturbance 2
• From aripiprazole: Extrapyramidal symptoms, withdrawal symptoms, feeding disorders 4
• Symptoms typically resolve within 1-2 weeks but may require supportive care or brief hospitalization

Key Pitfalls to Avoid

1. Do not discontinue medications abruptly - this increases relapse risk significantly 2, 4
2. Do not assume breastfeeding will be successful on aripiprazole - prepare alternative feeding plans 7
3. Do not fail to arrange early neonatal follow-up - adaptation syndromes require monitoring 2
4. Do not ignore the risks of untreated psychiatric illness - these often exceed medication risks 4

The consensus from guidelines and FDA labeling is clear: treatment with these medications should not be stopped if required for maternal daily functioning 4. The magnitude of documented risks is very low, and untreated psychiatric illness poses substantial risks to both mother and infant.