What are the recommendations for Selective Serotonin Reuptake Inhibitor (SSRI) use during pregnancy?

From the Guidelines

The use of SSRIs during pregnancy is recommended when the benefits outweigh the potential risks, and the lowest effective dose should be used to minimize risks to the fetus and the mother. When considering SSRI use during pregnancy, it is essential to weigh the potential risks and benefits, as untreated maternal mental health conditions can pose significant risks to both mother and baby 1. Common SSRIs prescribed during pregnancy include sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), and fluoxetine (Prozac), with sertraline often considered first-line due to its favorable safety profile 1. Some key points to consider when prescribing SSRIs during pregnancy include:

• The potential risks of SSRI use, such as a small increased risk of persistent pulmonary hypertension of the newborn (PPHN), neonatal adaptation syndrome, and possibly a slight increase in preterm birth 1
• The importance of individualized treatment decisions through shared decision-making between the patient and healthcare providers, taking into account the severity of current symptoms, previous mental health history, and patient treatment preferences 1
• The need to monitor infants for signs of drug toxicity or withdrawal over the first week of life and arrange for early follow-up after the initial hospital discharge 1
• The consideration of breastfeeding, as antidepressants transfer in low concentrations into breast milk, and paroxetine and sertraline are the most commonly prescribed antidepressants during breastfeeding 1. Overall, the decision to use SSRIs during pregnancy should be made on a case-by-case basis, with careful consideration of the potential risks and benefits, and the lowest effective dose used to minimize risks to the fetus and the mother.

From the FDA Drug Label

There are no adequate and well-controlled studies in pregnant women. Sertraline hydrochloride should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus Neonates exposed to sertraline and other SSRIs or serotonin and norepinephrine reuptake inhibitors (SNRIs), late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. Infants exposed to SSRIs in pregnancy may have an increased risk for persistent pulmonary hypertension of the newborn (PPHN). Physicians should also note the results of a prospective longitudinal study of 201 pregnant women with a history of major depression, who were either on antidepressants or had received antidepressants less than 12 weeks prior to their last menstrual period, and were in remission Women who discontinued antidepressant medication during pregnancy showed a significant increase in relapse of their major depression compared to those women who remained on antidepressant medication throughout pregnancy When treating a pregnant woman with sertraline, the physician should carefully consider both the potential risks of taking an SSRI, along with the established benefits of treating depression with an antidepressant. The decision can only be made on a case by case basis

The recommendations for Selective Serotonin Reuptake Inhibitor (SSRI) use during pregnancy are:

• Use only if necessary: Sertraline should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
• Consider the risks: Neonates exposed to SSRIs may develop complications, and infants may have an increased risk for persistent pulmonary hypertension of the newborn (PPHN).
• Case-by-case decision: The decision to use sertraline during pregnancy should be made on a case-by-case basis, considering the potential risks and benefits of treatment.
• Monitor for relapse: Women who discontinue antidepressant medication during pregnancy may have a significant increase in relapse of their major depression. 2

From the Research

Recommendations for SSRI Use During Pregnancy

The use of Selective Serotonin Reuptake Inhibitors (SSRIs) during pregnancy is a complex issue, with various studies highlighting the potential risks and benefits associated with their use. Some key points to consider include:

• The risk of birth defects, particularly cardiac defects, is slightly higher with maternal fluoxetine and paroxetine use 3
• Antenatal depression itself is associated with adverse perinatal outcomes, and discontinuing antidepressant treatment during pregnancy is associated with a high risk of relapse of depression 3, 4
• The use of SSRIs in the third trimester has been linked to various perinatal complications, including respiratory distress, irritability, and feeding problems 5
• The risk of not receiving adequate antidepressant treatment in the third trimester when indicated may outweigh the risks of adverse events in the infant 5

Risk-Benefit Assessment

When assessing the risk-benefit balance of SSRI use during pregnancy, the following factors should be considered:

• The risks associated with SSRI use, including potential birth defects and perinatal complications 3, 5
• The risks associated with untreated depression, including adverse perinatal outcomes and relapse of depression 3, 4
• The therapeutic benefits of SSRI treatment, including improved maternal mental health and reduced risk of relapse 4, 6
• Alternative treatment strategies, including non-pharmacological interventions and other antidepressant medications 4, 7

Clinical Guidelines

Based on the available evidence, the following clinical guidelines can be suggested:

• Pregnant women exposed to any SSRI in early pregnancy should be offered options for prenatal diagnosis through ultrasound examinations and fetal echocardiography to detect the presence of birth defects 3
• Tapering off or switching to other therapy in early pregnancy may be considered on a case-by-case basis 3
• In women suffering from major depression and responding to a pharmacological treatment, introduction or continuation of an SSRI should be encouraged to prevent maternal complications and preserve maternal-infant bonding 4
• The choice of the right drug depends on individual patient characteristics, such as prior treatment response, diagnoses, and comorbid conditions 4