From the Guidelines
Paroxetine (Paxil) is generally avoided during pregnancy due to a slightly increased risk of heart defects in newborns, particularly when used in the first trimester. When considering the use of SSRIs in pregnancy, it's essential to weigh the potential risks and benefits, prioritizing both the mother's mental health and the fetus's well-being 1. The evidence suggests that while no SSRI is completely safe, some carry higher risks than others.
Key Considerations
- Fluoxetine (Prozac) and sertraline (Zoloft) are often preferred options during pregnancy as they have more extensive safety data.
- Citalopram (Celexa), escitalopram (Lexapro), and fluvoxamine have less extensive pregnancy safety data but haven't shown strong evidence of harm.
- All SSRIs carry a small risk of persistent pulmonary hypertension in newborns when used late in pregnancy, and some babies may experience temporary withdrawal symptoms after birth.
Balancing Risks and Benefits
The decision to use any SSRI during pregnancy should balance the mother's mental health needs against potential risks to the developing baby. Untreated depression during pregnancy carries its own significant risks, including poor prenatal care, inadequate nutrition, increased substance use, and potential for self-harm. Women taking SSRIs who become pregnant should not stop medication abruptly but should consult their healthcare provider to discuss individual risk-benefit considerations 1.
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 For women who intend to become pregnant or are in their first trimester of pregnancy, paroxetine should only be initiated after consideration of the other available treatment options. Infants exposed to SSRIs in late pregnancy may have an increased risk for persistent pulmonary hypertension of the newborn (PPHN) Prozac should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus Neonates exposed to Prozac 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.
SSRIs that may be unsafe in pregnancy include:
- Paroxetine: due to the potential harm to the fetus, and increased risk of persistent pulmonary hypertension of the newborn (PPHN) 2
- Fluoxetine: due to the potential risk to the fetus, and increased risk of PPHN 3 Key considerations:
- The benefits of the SSRI to the mother should be weighed against the potential risks to the fetus
- Alternative treatments should be considered for women who intend to become pregnant or are in their first trimester of pregnancy
- Physicians should carefully consider both the potential risks and benefits of treatment when prescribing SSRIs to pregnant women, especially during the third trimester 2 3
From the Research
SSRI's and Pregnancy
- The use of certain SSRI's during pregnancy has been associated with an increased risk of congenital cardiac defects 4, 5, 6.
- Paroxetine, in particular, has been linked to an increased risk of major cardiac malformations, especially when used at high doses (>25 mg/day) during the first trimester 5, 6.
- A systematic review and meta-analysis found that first trimester use of paroxetine was associated with an increased risk of any major congenital malformations and major cardiac malformations 6.
- Other SSRI's, such as sertraline, have not been found to have a significant association with cardiac defects 4.
- The risk of major cardiac malformations associated with paroxetine use during the first trimester of pregnancy is increased, with a pooled odds ratio of 1.28 (95% CI 1.11,1.47) 6.
Specific SSRI's and Their Risks
- Paroxetine: associated with an increased risk of major cardiac malformations, especially when used at high doses (>25 mg/day) during the first trimester 5, 6.
- Sertraline: no significant association with cardiac defects found 4.
- Fluoxetine and escitalopram: showed a numerically higher prophylactic efficacy than paroxetine and sertraline, but the difference was statistically insignificant 7.