Is sertraline (selective serotonin reuptake inhibitor) safe to use during pregnancy?

Sertraline Safety During Pregnancy

Sertraline is considered a preferred first-line antidepressant option during pregnancy when medication treatment is necessary, as its established safety profile shows benefits that generally outweigh potential risks. 1

Benefits vs. Risks Assessment

Benefits of Treating Depression During Pregnancy

• Untreated depression during pregnancy is associated with:
  • Premature birth
  • Decreased breastfeeding initiation
  • Increased risk of depression relapse 1
• Women who discontinue antidepressants during pregnancy show significant increase in major depression relapse compared to those who remain on medication 2

Potential Risks of Sertraline During Pregnancy

1. Fetal Development Effects:

   • No evidence of teratogenicity in animal studies at clinical doses 2
   • Delayed ossification observed in animal studies at doses equivalent to 0.5 times the maximum recommended human dose 2
   • Unlike paroxetine (FDA category D), sertraline has not been associated with significant cardiac malformation risk 1

2. Third Trimester Exposure Risks:

   • Neonatal adaptation syndrome may occur, characterized by:
     • Irritability, tremors, jitteriness
     • Respiratory distress
     • Feeding difficulties
     • Sleep disturbance
     • Hypoglycemia 1, 2
   • Small increased risk of persistent pulmonary hypertension of the newborn (PPHN)
     • Number needed to harm: 286-351 1

Clinical Recommendations

During Pregnancy

1. First-line non-pharmacological approach:

   • Cognitive Behavioral Therapy (CBT) is recommended as initial treatment for anxiety disorders during pregnancy 1

2. When medication is necessary:

   • Sertraline is a preferred SSRI option due to its established safety profile 1
   • Start with lowest effective dose and monitor closely
   • Sertraline clearance may be reduced by 42% in CYP2C19 poor metabolizers 3

3. Monitoring during pregnancy:

   • Regular assessment of maternal mental health status
   • Fetal growth monitoring through standard prenatal care

Delivery Planning

• Inform pediatric team about sertraline exposure
• Plan for monitoring of potential neonatal adaptation syndrome, particularly in the first week of life 1

Postpartum and Breastfeeding

• Sertraline is considered one of the safest antidepressants during breastfeeding 4
• Only small amounts transfer into breast milk:
  • Median daily infant dosage approximately 0.95% of weight-adjusted maternal dose 3
  • Milk-to-plasma ratio is influenced by milk fat content 3
• Monitor breastfed infants for:
  • Irritability
  • Poor feeding
  • Sleep disturbances 1

Important Clinical Considerations

• FDA Classification: Sertraline is FDA category C, meaning it should be given only if potential benefits justify potential risks to the fetus 1

• Balancing Decision Factors: The decision to use sertraline during pregnancy requires weighing maternal mental health needs against potential fetal risks 1, 2

• Special Caution Populations:

  • Premature infants
  • Low birth weight infants
  • CYP2C19 poor metabolizers 3, 4

• Avoid Common Pitfalls:

  • Don't discontinue effective treatment abruptly during pregnancy due to fear of fetal effects
  • Don't overlook the significant risks of untreated maternal depression
  • Don't switch from another effective antidepressant to sertraline during pregnancy without careful risk-benefit analysis 4