What about using Selective Serotonin Reuptake Inhibitors (SSRIs) during pregnancy?

SSRIs During Pregnancy: Risks and Benefits

SSRIs during pregnancy should be used when the benefits outweigh the risks, with sertraline being the preferred option due to its favorable safety profile for both maternal depression treatment and minimal fetal exposure.

Risks of SSRI Use During Pregnancy

Neonatal Effects

• SSRIs used during pregnancy can cause neonatal adaptation syndrome in approximately one-third of exposed newborns, with symptoms including irritability, jitteriness, tremors, poor feeding, and respiratory issues that typically resolve within 1-2 weeks 1
• Neonates exposed to SSRIs late in the third trimester may develop complications requiring prolonged hospitalization, respiratory support, and tube feeding 2, 3
• Clinical findings in affected neonates include respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulties, hypoglycemia, and neurological symptoms 2

Persistent Pulmonary Hypertension of the Newborn (PPHN)

• There is a possible association between SSRI use during pregnancy and PPHN, though evidence is conflicting 4, 5
• A meta-analysis indicated a number needed to harm of 286-351 for PPHN with late pregnancy SSRI exposure 4, 5
• The absolute risk remains small, with PPHN occurring in 1-2 per 1,000 live births in the general population 2, 3

Neurodevelopmental Concerns

• Recent evidence provides reassurance that antidepressant use during pregnancy is unlikely to substantially increase the risk of autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) 4
• Many observational studies have documented associations between prenatal antidepressant exposure and ASD and ADHD, but these findings are inconsistent and confounded by maternal depression itself 6
• Studies using paternal antidepressant use as a negative control suggest that observed associations with maternal use may be due to familial confounding rather than direct medication effects 6

Benefits of Treatment

• Untreated depression during pregnancy is associated with premature birth, decreased initiation of breastfeeding, and potential harmful effects on the mother-infant relationship 4, 5
• Women who discontinue antidepressant medication during pregnancy show a significant increase in relapse of major depression 2, 3
• The American Academy of Pediatrics recommends that SSRI treatment should be continued during pregnancy at the lowest effective dose when clinically indicated 1

Medication Selection

• Sertraline is one of the most commonly prescribed and preferred antidepressants during pregnancy due to its favorable safety profile 5
• Sertraline and paroxetine transfer to breast milk in lower concentrations than other antidepressants, making them preferred options during breastfeeding 4, 5
• Paroxetine has been associated with a small but higher risk for birth defects, particularly cardiac defects, compared to other SSRIs 7, 8

Management Recommendations

• Use the lowest effective dose of SSRI during pregnancy 1, 5
• Monitor for symptoms of depression throughout pregnancy 4, 5
• Infants exposed to SSRIs in utero should be monitored for at least 48 hours after birth for signs of neonatal adaptation syndrome 1, 9
• Arrange for early follow-up after hospital discharge for infants exposed to SSRIs in the third trimester 1, 5
• For women already taking SSRIs who become pregnant, continuation of treatment is generally recommended if clinically indicated, especially with a history of severe depression 4, 2

Breastfeeding Considerations

• Sertraline, paroxetine, and fluvoxamine are minimally excreted in human milk and provide the infant <10% of the maternal daily dose 1
• Sertraline and paroxetine are considered to have more favorable profiles during breastfeeding due to lower infant-to-maternal plasma concentration ratios 1, 4

Clinical Decision Algorithm

1. Assess severity of depression and necessity of medication treatment 4
2. For mild depression with recent onset, consider non-pharmacological approaches first 4
3. For moderate-to-severe depression or history of relapse, consider pharmacological treatment 4
4. If SSRI treatment is indicated, sertraline is a preferred option during pregnancy 4, 5
5. Monitor maternal mental health closely throughout pregnancy 4, 5
6. Plan for neonatal monitoring for at least 48 hours after birth 1
7. Continue appropriate SSRI during breastfeeding if clinically indicated 1, 4