Can a Pregnant Patient Continue Taking Zoloft (Sertraline)?
Yes, pregnant patients can and often should continue taking sertraline during pregnancy, as the benefits of treating maternal depression typically outweigh the potential risks, and discontinuing treatment may cause significant harm to both mother and infant. 1, 2
Primary Recommendation
The American Academy of Pediatrics explicitly states that SSRI treatment, including sertraline, should be continued during pregnancy at the lowest effective dose, because withdrawal of medication may have harmful effects on the mother-infant dyad. 1 The FDA drug label confirms that sertraline should be used during pregnancy when the potential benefit justifies the potential risk to the fetus. 2
Risk-Benefit Analysis
Risks of Untreated Depression
- Discontinuing antidepressants during pregnancy leads to significant increases in relapse of major depression compared to continued treatment 2
- The decision must weigh both the potential risks of taking an SSRI against the established benefits of treating depression 2
Fetal and Neonatal Considerations
Third Trimester Effects:
- Neonates exposed to sertraline late in the third trimester may develop transient complications including: crying, irritability, tremors, poor feeding, hypertonia, tachypnea, sleep disturbance, hypoglycemia, and rarely seizures 1, 2
- These symptoms typically resolve within 1-4 weeks and are generally mild 1
- The FDA label specifically notes these complications may require prolonged hospitalization, respiratory support, and tube feeding in some cases 2
Developmental Outcomes:
- Multiple reviews have not identified adverse neurodevelopmental outcomes among infants born to women treated with SSRIs during pregnancy 1
- Recent literature reviews indicate that sertraline has a more favorable safety profile compared to paroxetine and fluoxetine, with mixed and generally unsubstantiated associations with negative outcomes when controlled for maternal depression 3
Dosing Considerations During Pregnancy
Pharmacokinetic Changes
- Sertraline clearance increases by up to 143% at 40 weeks gestational age due to pregnancy-related physiological changes 4
- Mean sertraline concentration-to-dose ratios decrease by 22% in late pregnancy compared to postpartum levels 5
- The interindividual variation in maternal concentrations is 10-fold, suggesting some women may require dose adjustments 6
Practical Dosing Approach
- Use the lowest effective dose throughout pregnancy 1, 2
- Consider therapeutic drug monitoring, particularly in the third trimester, to identify poor metabolizers at risk for subtherapeutic levels 5, 6
- Women with poor or intermediate CYP2C19 activity may experience 51% decreases in sertraline levels during pregnancy and may require dose increases 5
Clinical Management Algorithm
When treating pregnant women with sertraline in the third trimester:
- Carefully consider potential risks and benefits before making treatment decisions 2
- Continue treatment at the lowest effective dose rather than discontinuing 1
- Arrange early follow-up after delivery as infants are at risk for withdrawal or toxicity symptoms over the first week of life 1
- Monitor infants carefully for irritability, feeding difficulties, and respiratory symptoms 1
- Inform pediatric team about maternal sertraline use so they can anticipate and manage neonatal adaptation syndrome if it occurs 1
Important Caveats
- Avoid abrupt discontinuation: If stopping sertraline is necessary, use gradual dose reduction to minimize withdrawal symptoms in both mother and potentially the neonate 2
- Paroxetine should be avoided in pregnancy when possible, as it has stronger associations with negative outcomes compared to sertraline 7, 3
- Sertraline is compatible with breastfeeding as placental passage is low (25-33% of maternal levels) and breast milk concentrations are very low 3, 6
- The clinical significance of animal studies showing decreased pup survival at supratherapeutic doses is unknown and should not drive clinical decision-making 2