Should you discontinue Zoloft (sertraline) during pregnancy?

Sertraline (Zoloft) During Pregnancy: Continuation vs. Discontinuation

Sertraline should not be discontinued during pregnancy as discontinuation is associated with a high risk of depression relapse, which can negatively impact both maternal and fetal outcomes. 1

Risk-Benefit Assessment

Risks of Discontinuation

• Women who discontinue antidepressants during pregnancy have a significantly higher risk of depression relapse (68%) compared to those who maintain treatment (26%) 2
• Abrupt discontinuation can lead to serious adverse effects including:
  • Physical and psychological withdrawal symptoms
  • Suicidal ideation requiring hospitalization in some cases 3
  • Increased risk of relapse particularly in women with severe or recurrent depression 4

Safety Profile of Sertraline in Pregnancy

• Sertraline is considered a preferred first-line option during pregnancy due to its established safety profile 1
• FDA categorizes sertraline as pregnancy category C, meaning it should be used when benefits outweigh potential risks 1
• The FDA drug label notes that while animal studies showed delayed ossification at high doses, there was no evidence of teratogenicity 5

Management Recommendations

For Women Currently on Sertraline

1. Continue medication throughout pregnancy if clinically indicated
2. Consider dosage modification if needed, as this approach shows similar risk of depression as non-users 6
3. Monitor closely throughout pregnancy for:
   • Depression symptoms
   • Need for dosage adjustments

Potential Risks to Monitor

• Neonatal adaptation syndrome may occur with third-trimester exposure, characterized by:
  • Irritability, tremors, poor feeding, respiratory distress, and other symptoms 1, 5
  • These symptoms are typically self-limiting and manageable
• Small increased risk of persistent pulmonary hypertension of the newborn (PPHN), with a number needed to harm of 286-351 1

Special Considerations

Severity of Depression

• Women with histories of severe or recurrent depression are at particularly high risk of relapse if medication is discontinued 4
• For women with mild depression, non-pharmacological approaches may be considered as adjuncts, but not necessarily as replacements for medication

Tapering vs. Abrupt Discontinuation

• If discontinuation is absolutely necessary (which is rarely the case), medication should be gradually tapered rather than abruptly discontinued 7
• Abrupt discontinuation can lead to withdrawal symptoms and significantly increased risk of relapse 3

Common Pitfalls to Avoid

1. Assuming pregnancy is "protective" against depression - Research clearly shows this is not the case 2
2. Making decisions based on unfounded fears rather than evidence - Many women and healthcare providers discontinue medication due to fear rather than scientific evidence 7, 3
3. Failing to consider the risks of untreated depression - Depression during pregnancy is associated with premature birth, decreased breastfeeding initiation, and other adverse outcomes 1

The decision to continue sertraline during pregnancy should be based on scientific evidence that supports its relative safety, balanced against the well-documented risks of discontinuation and untreated depression.