From the Guidelines
Selective serotonin reuptake inhibitors (SSRIs) considered relatively safer during pregnancy include sertraline (Zoloft) and citalopram (Celexa), with sertraline often being the first-line choice, as supported by the most recent evidence 1. The decision to use SSRIs during pregnancy should balance the risks of untreated depression against potential medication risks. While SSRIs are generally considered to have acceptable safety profiles in pregnancy, they are not completely risk-free. Some studies suggest a small increased risk of certain complications like persistent pulmonary hypertension of the newborn (PPHN) and minor cardiac defects, though absolute risks remain low, as noted in a study published in the American Family Physician 1. Women should never abruptly discontinue these medications during pregnancy without medical consultation, as untreated depression poses significant risks to both mother and baby, including poor prenatal care, inadequate nutrition, increased substance use, and potential for self-harm. Typical starting doses are sertraline 25-50mg daily, citalopram 10-20mg daily, with adjustments made based on response and side effects, and fluoxetine (Prozac) is also considered acceptable but has a longer half-life, as discussed in the Journal of Child Psychology and Psychiatry and Allied Disciplines 1. It is essential to consider the potential risks and benefits of SSRI use during pregnancy, including the risk of neonatal drug withdrawal, as described in the Pediatrics journal 1. Ultimately, the choice of SSRI during pregnancy should be made on a case-by-case basis, taking into account the individual patient's medical history, the severity of their depression, and the potential risks and benefits of treatment, as emphasized in the most recent study 1.
Key considerations for SSRI use during pregnancy include:
- The potential risks of untreated depression, including poor prenatal care and increased substance use
- The risks of SSRI use, including PPHN and minor cardiac defects
- The importance of gradual dose reduction or discontinuation to minimize the risk of withdrawal symptoms
- The need for close monitoring of the mother and baby during pregnancy and after delivery
- The importance of considering alternative treatments, such as psychotherapy or other medications, for women who are pregnant or planning to become pregnant.
In terms of specific SSRIs, sertraline and citalopram are generally considered to be safer options during pregnancy, while fluoxetine is also considered acceptable but has a longer half-life, as noted in the American Family Physician 1. Paroxetine is not recommended during pregnancy due to the potential risk of congenital cardiac malformations, as discussed in the Pediatrics journal 1. Ultimately, the choice of SSRI during pregnancy should be made on a case-by-case basis, taking into account the individual patient's medical history and the potential risks and benefits of treatment, as emphasized in the most recent study 1.
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 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
The FDA drug label does not answer the question of what SSRI's are safe for pregnancy, but it does provide information about the potential risks and benefits of using sertraline during pregnancy.
- Sertraline should only be used during pregnancy if the potential benefit justifies the potential risk to the fetus.
- There is an increased risk of persistent pulmonary hypertension of the newborn (PPHN) associated with SSRI use in pregnancy.
- The decision to use sertraline during pregnancy should be made on a case-by-case basis 2.
From the Research
SSRI Safety in Pregnancy
The safety of Selective Serotonin Reuptake Inhibitors (SSRIs) during pregnancy is a concern due to potential risks to the fetus. According to 3, exposure to SSRIs in pregnancy has been associated with miscarriage, premature delivery, neonatal complications, birth defects, and neurodevelopmental disorders in childhood.
Individual SSRI Risks
Studies have shown that individual SSRIs have different risk profiles:
- Paroxetine and fluoxetine have a higher risk of negative outcomes, including birth defects and neonatal complications 4.
- Sertraline and citalopram have a mixed association with negative outcomes, but are generally considered safer than paroxetine and fluoxetine 4.
- There is limited data on the safety of escitalopram and fluvoxamine during pregnancy 4, 5.
Treatment Recommendations
Based on the available evidence:
- Sertraline and citalopram are recommended as first-line treatments for anxiety and depression in pregnant women 4.
- Pregnant women exposed to SSRIs in early pregnancy should be offered prenatal diagnosis and monitoring to detect potential birth defects 3.
- The decision to use SSRIs during pregnancy should be made on a case-by-case basis, weighing the risks and benefits of treatment against the risks of untreated depression 3, 6.
Key Considerations
- Untreated maternal depression can have adverse effects on maternal-fetal health and postpartum care 5, 7.
- Large-scale, population-based studies are needed to comprehensively assess the safety of SSRIs in pregnancy 7.
- Consultation with specialists experienced in treating depression may be helpful when treating pregnant women with SSRIs 7.