What selective serotonin reuptake inhibitors (SSRIs) are safe during pregnancy?

From the Guidelines

Sertraline (Zoloft) is considered the safest SSRI during pregnancy, due to its relatively low risk of adverse effects and extensive study in pregnant women. When considering the use of SSRIs during pregnancy, it is essential to weigh the potential risks and benefits, as untreated depression can have severe consequences for both the mother and the fetus 1. The American Academy of Pediatrics recommends continuing SSRI treatment during pregnancy at the lowest effective dose, as withdrawal of medication may have harmful effects on the mother-infant dyad 1.

Some key points to consider when prescribing SSRIs during pregnancy include:

• Sertraline (Zoloft) is often the first-choice medication due to its relatively low risk of adverse effects and extensive study in pregnant women 1
• Citalopram (Celexa) and escitalopram (Lexapro) are also considered relatively safe during pregnancy, although the evidence is not as extensive as for sertraline 1
• Fluoxetine (Prozac) is considered acceptable but has a longer half-life, which may increase the risk of adverse effects in the fetus 1
• Typical starting doses for these medications are sertraline 25-50mg daily, citalopram 10-20mg daily, escitalopram 5-10mg daily, or fluoxetine 10-20mg daily, with adjustments based on response 1
• The risks of untreated depression, such as poor prenatal care, inadequate nutrition, increased substance use, and potential self-harm, often outweigh the minimal risks associated with these medications 1

It is crucial to note that while SSRIs are considered relatively safe during pregnancy, they may still pose some risks, such as a small increased risk of persistent pulmonary hypertension of the newborn (1-2 per 1,000 versus 1-2 per 2,000 in the general population) and potential mild, transient neonatal adaptation syndrome (irritability, feeding difficulties) when used in late pregnancy 1. Therefore, treatment decisions should always involve weighing the mother's mental health needs against potential medication risks in consultation with healthcare providers.

From the FDA Drug Label

If a patient becomes pregnant while taking paroxetine, she should be advised of the potential harm to the fetus. Unless the benefits of paroxetine to the mother justify continuing treatment, consideration should be given to either discontinuing paroxetine therapy or switching to another antidepressant 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

The safe use of SSRIs in pregnancy is not established.

• Sertraline and paroxetine have been studied in pregnant animals, but there is no conclusive evidence of their safety in humans.
• The FDA drug labels for sertraline 2 and paroxetine 3 do not provide sufficient information to determine their safety in pregnancy.
• Physicians should carefully consider the potential risks and benefits of treating pregnant women with SSRIs.
• The decision to use SSRIs in pregnancy should be made on a case-by-case basis.

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 developing fetus.

• Studies have associated SSRI exposure with miscarriage, premature delivery, neonatal complications, birth defects, and neurodevelopmental disorders in childhood 4, 5.
• The risk of birth defects is higher with maternal fluoxetine and paroxetine use, although the excess absolute risk is small 4.
• Antenatal depression itself is associated with adverse perinatal outcomes, and discontinuing antidepressant treatment during pregnancy can lead to a high risk of relapse of depression 4.

Recommended SSRIs in Pregnancy

• Sertraline and citalopram are recommended as first-line drug treatments for anxiety and depression in pregnant women in the SSRI class, as they have a lower association with negative outcomes 6.
• Sertraline can be continued in breast-feeding, as the concentration found in breast milk is very low and has not been linked to infant complications 6.
• There is limited evidence on the safety of escitalopram and fluvoxamine, and further research is needed to determine their safety profiles 6, 7.

Risk-Benefit Assessment

• The decision to use SSRIs during pregnancy should be based on a careful risk-benefit assessment, considering the potential risks of treatment against the risk of untreated depression for both the mother and the child 4, 5.
• 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 4.
• Tapering off or switching to other therapy in early pregnancy may also be considered on a case-by-case basis 4.