Is sertraline (Zoloft) safe to use during pregnancy?

Safety of Sertraline During Pregnancy

Sertraline is generally considered safe during pregnancy, with the benefits of treating maternal depression typically outweighing the potential risks to the fetus. 1

Benefits vs. Risks Assessment

• Depression during pregnancy is associated with premature birth and decreased breastfeeding initiation, making treatment important for maternal and fetal wellbeing 1
• Untreated depression during pregnancy can have harmful effects on the mother-infant relationship 1, 2
• The American Academy of Pediatrics recommends that antidepressants should be continued during pregnancy at the lowest effective dose when clinically indicated 3, 1

Potential Risks

• Neonatal adaptation syndrome may occur in infants exposed to sertraline in the third trimester, characterized by symptoms such as irritability, jitteriness, tremors, and feeding difficulties 4
• These symptoms typically appear within hours to days after birth and most resolve within 1-2 weeks 2
• Some studies suggest a possible association between SSRI use during pregnancy and persistent pulmonary hypertension of the newborn (PPHN), though evidence is conflicting 1, 4
• The FDA label notes that infants exposed to SSRIs in pregnancy may have an increased risk for PPHN, which occurs in 1-2 per 1,000 live births 4

Pharmacokinetics During Pregnancy

• Sertraline plasma concentrations may decrease during pregnancy, with a 22% difference between late pregnancy and postpartum periods 5
• The interindividual variation in maternal concentrations during pregnancy can be significant (up to 10-fold), which may affect therapeutic efficacy 6
• Placental transfer of sertraline to the infant is relatively low, with infant concentrations typically 25-33% of maternal levels 6

Management Recommendations

• Use the lowest effective dose of sertraline during pregnancy 1, 4
• For women already taking sertraline who become pregnant, continuation of treatment is generally recommended if clinically indicated 1, 4
• Monitor maternal mental health closely throughout pregnancy, as discontinuation of antidepressants during pregnancy is associated with significant risk of depression relapse 4
• Arrange for early follow-up after hospital discharge for infants exposed to sertraline in the third trimester to monitor for neonatal adaptation syndrome 3, 1

Breastfeeding Considerations

• Sertraline is considered one of the safest antidepressants during breastfeeding 1, 7
• Sertraline is minimally excreted in breast milk, providing the infant <10% of the maternal daily dose (normalized for weight) 3, 8
• Recent research indicates a median daily infant dosage of approximately 0.95% of the weight-adjusted maternal dose through breast milk 9
• The American Academy of Pediatrics notes that sertraline is one of the preferred SSRIs during breastfeeding due to its low transfer into breast milk 3, 8

Clinical Decision Algorithm

1. Assess severity of depression and necessity of medication treatment 1
2. If treatment is indicated, sertraline is a preferred option during pregnancy 1, 10
3. Use the lowest effective dose and monitor maternal mental health closely 1, 4
4. For women in the third trimester, plan for neonatal monitoring after delivery 3, 4
5. Continue sertraline during breastfeeding if clinically indicated 8, 7

Common Pitfalls and Caveats

• Abrupt discontinuation of sertraline during pregnancy may lead to depression relapse, which poses significant risks to both mother and fetus 4
• CYP2C19 poor metabolizers may have reduced sertraline clearance (by approximately 42%), potentially requiring dose adjustments 9, 5
• When initiating sertraline postpartum in breastfeeding women, start with low doses and slowly increase while monitoring the infant for adverse effects 7