Sertraline During Pregnancy: Continuation Recommended
Yes, continue sertraline during pregnancy at the lowest effective dose that maintains remission of depressive symptoms. 1, 2 Discontinuing antidepressant medication during pregnancy significantly increases the risk of maternal depression relapse, which poses substantial documented risks to both mother and infant including premature birth, decreased breastfeeding initiation, and harm to the mother-infant relationship. 1, 2, 3
Why Sertraline Should Be Continued
Sertraline is the first-line SSRI for pregnancy due to its favorable safety profile, minimal breast milk excretion, and low infant-to-maternal plasma concentration ratios. 1 The American Academy of Pediatrics specifically recommends sertraline as preferred therapy during pregnancy and lactation. 1
Evidence Supporting Continuation
No increased risk of cardiac malformations has been demonstrated with first-trimester sertraline use in large population-based studies. 1, 2
Neurodevelopmental outcomes are reassuring: Multiple recent reviews have not identified adverse neurodevelopmental outcomes (including autism spectrum disorder or ADHD) among infants born to women treated with SSRIs during pregnancy. 4, 1
Untreated depression carries greater risks than medication treatment, including premature birth, decreased breastfeeding, and impaired mother-infant bonding. 1, 2, 3
Women who discontinue antidepressants during pregnancy show a significant increase in relapse of major depression compared to those who continue treatment. 5, 3
Risks to Discuss and Monitor
Third-Trimester Neonatal Adaptation Syndrome
Approximately one-third of exposed newborns may develop neonatal adaptation syndrome with symptoms including irritability, jitteriness, tremors, feeding difficulty, sleep disturbance, respiratory distress, and rarely seizures. 1, 5
Symptoms typically appear within hours to days after birth and usually resolve spontaneously within 1-2 weeks without intervention. 1, 5
In severely affected infants with persistent symptoms, a short-term course of chlorpromazine has provided measurable relief. 1, 5
Persistent Pulmonary Hypertension of the Newborn (PPHN)
Late pregnancy SSRI exposure has a possible association with PPHN, though evidence remains conflicting. 1, 2
The number needed to harm is 286-351, indicating this is a rare complication. 1, 2
The absolute risk remains very low (PPHN occurs in 1-2 per 1000 live births in the general population). 3
Practical Management Algorithm
Dosing Strategy
Continue current sertraline dose if depression is well-controlled and the patient is tolerating the medication. 1
Use the lowest effective dose throughout pregnancy, but prioritize maintaining remission over minimizing dose. 1, 5, 3
Be aware that sertraline plasma concentrations may decrease during pregnancy (by approximately 22% in late pregnancy compared to postpartum) due to increased drug elimination, potentially requiring dose adjustment to maintain efficacy. 6, 7
Monitoring Requirements
Monitor maternal depressive symptoms throughout pregnancy to ensure continued remission. 2, 8
Arrange for early follow-up after hospital discharge for the infant to monitor for neonatal adaptation syndrome. 1, 5
Infants should be monitored for at least 48 hours after birth for signs of drug toxicity or withdrawal including respiratory distress, feeding difficulties, irritability, and temperature instability. 1, 5, 3
Postpartum Considerations
Continue sertraline during breastfeeding as it transfers in very low concentrations into breast milk (providing the infant less than 10% of maternal daily dose). 1, 2
Sertraline is one of the two most commonly prescribed antidepressants during breastfeeding due to its favorable safety profile. 1, 2
Dose adjustment may be needed postpartum as drug elimination returns to non-pregnant state. 6
Common Pitfalls to Avoid
Do not discontinue sertraline due to fear of medication risks alone, as untreated maternal depression carries substantial documented risks that often exceed medication risks. 1, 2
Avoid switching to paroxetine, which has FDA pregnancy category D classification due to cardiac malformation concerns. 1
Do not abruptly discontinue if dose adjustment is needed; gradual tapering is recommended to avoid withdrawal symptoms. 3
Do not delay treatment in women with moderate-to-severe depression or those with history of severe depression who previously responded to antidepressants. 4