Is it safe to take sertraline (selective serotonin reuptake inhibitor - SSRI) during pregnancy?

Safety of Sertraline During Pregnancy

Sertraline is considered one of the preferred antidepressants during pregnancy due to its favorable safety profile, and it can be taken during pregnancy when the benefits of treating depression outweigh the potential risks. 1

Benefits of Treating Depression During Pregnancy

• Untreated depression during pregnancy is associated with premature birth, decreased initiation of breastfeeding, and potential harmful effects on the mother-infant relationship 1, 2
• Women who discontinue antidepressant medication during pregnancy show a significant increase in relapse of major depression 3
• The American Academy of Pediatrics recommends that antidepressant treatment should be continued during pregnancy at the lowest effective dose when clinically indicated 2

Potential Risks of Sertraline During Pregnancy

Fetal Development

• FDA pregnancy category C - animal studies have shown adverse effects on the fetus, but there are no adequate well-controlled studies in pregnant women 3
• Sertraline crosses the placenta and can be found in amniotic fluid 4
• No evidence of teratogenicity (birth defects) at any dose level in animal studies 3

Neonatal Adaptation Syndrome

• Approximately one-third of newborns exposed to SSRIs in late pregnancy may experience neonatal adaptation syndrome 2
• Symptoms include crying, irritability, jitteriness, tremors, poor feeding, hypertonia, tachypnea, sleep disturbance, hypoglycemia, and seizures 2
• Symptoms typically begin within hours to days after birth and usually resolve within 1-2 weeks 2

Persistent Pulmonary Hypertension of the Newborn (PPHN)

• Some studies suggest a possible association between SSRI use during pregnancy and PPHN, though evidence is conflicting 1
• The number needed to harm for PPHN with late pregnancy SSRI exposure is approximately 286-351 1, 2

Management Recommendations

Dosing Considerations

• Use the lowest effective dose of sertraline during pregnancy 1, 2
• Sertraline plasma concentrations may decrease during pregnancy, potentially requiring dose adjustments 5
• Patients with certain CYP2C19 genetic variants may be at risk for subtherapeutic sertraline concentrations during pregnancy 5

Monitoring

• Monitor for symptoms of depression throughout pregnancy 1
• Infants exposed to sertraline in utero should be monitored for at least 48 hours after birth 2
• Arrange for early follow-up after hospital discharge for infants exposed to sertraline in the third trimester 1

Breastfeeding Considerations

• Sertraline transfers in low concentrations into breast milk and is considered one of the preferred antidepressants during breastfeeding 1
• Sertraline is minimally excreted in human milk, providing the infant <10% of the maternal daily dose 2

Clinical Decision Algorithm

1. Assess severity of depression and necessity of medication treatment
2. If treatment is indicated, sertraline is a preferred option during pregnancy 1, 6
3. For women already taking sertraline who become pregnant, continuation of treatment is generally recommended if clinically indicated 1
4. Use the lowest effective dose and monitor maternal mental health closely 1, 2
5. Monitor newborns for neonatal adaptation syndrome for at least 48 hours after birth 2
6. Continue sertraline during breastfeeding if clinically indicated 1, 2

Important Considerations

• The overall benefit of treatment with sertraline during pregnancy generally outweighs the potential risks 7
• Sertraline and citalopram should be considered first-line drug treatments for anxiety and depression in pregnant women in the SSRI class 6
• A gradual reduction in dose rather than abrupt cessation is recommended if discontinuation is necessary 3