Can a pregnant woman take trazodone and Zoloft (sertraline) during pregnancy?

Can a Pregnant Woman Take Trazodone and Zoloft During Pregnancy?

Yes, sertraline (Zoloft) can be continued during pregnancy at the lowest effective dose, and trazodone may be used if needed, though sertraline has more robust safety data. 1, 2

Sertraline (Zoloft) in Pregnancy

The American Academy of Pediatrics recommends continuing SSRI treatment, including sertraline, during pregnancy at the lowest effective dose, because withdrawal of medication may have harmful effects on the mother-infant dyad. 1

Key Safety Data for Sertraline:

• Sertraline is one of the most commonly prescribed antidepressants during pregnancy and breastfeeding, with a well-established safety profile 3
• Multiple reviews have not identified adverse neurodevelopmental outcomes among infants born to women treated with SSRIs during pregnancy 1
• Sertraline and citalopram should be first-line SSRI treatments for anxiety and depression in pregnant women based on their favorable risk profiles 4

Specific Risks to Monitor:

• Late third-trimester exposure may cause transient neonatal complications including crying, irritability, tremors, poor feeding, hypertonia, tachypnea, sleep disturbance, hypoglycemia, and rarely seizures, which typically resolve within 1-4 weeks and are generally mild 1
• There is a possible association with persistent pulmonary hypertension of the newborn (PPHN) with late pregnancy SSRI exposure, with a number needed to harm of 286 to 351 3
• Conflicting findings exist regarding whether SSRIs can cause PPHN, and the FDA revised its advisory in 2011 to reflect this uncertainty 3

Trazodone in Pregnancy

Trazodone can be used during pregnancy when clinically indicated, though the evidence base is more limited than for sertraline. 2, 5

Safety Profile for Trazodone:

• The FDA label states that published prospective cohort studies, case series, and case reports over several decades have not identified any drug-associated risks of major birth defects, miscarriage, or adverse maternal or fetal outcomes 2
• The largest comparative study (221 trazodone-exposed pregnancies) found no significant difference in the risk of major congenital anomalies (0.6% vs 2.6% in SSRI group) 6
• A systematic review found no consistent evidence linking trazodone to increased risks of congenital malformations, stillbirths, or low birth weight 5
• A multicentre prospective study of 147 pregnancies found no statistically significant increase in major malformations (1.6%), which is within the baseline rate of 1-3% 7

Potential Concerns:

• Some studies suggest a possible association with increased risk of spontaneous and therapeutic abortions, though data are limited and varied 5
• Animal studies showed increased fetal resorption and congenital anomalies at doses 7.3 to 22 times the maximum recommended human dose 2

Combined Use of Sertraline and Trazodone

When both medications are needed, there is a theoretical risk of serotonin syndrome from combining two serotonergic agents, though this is rare at therapeutic doses 3

Monitoring for Serotonin Syndrome:

• Watch for signs including tremor, diarrhea, delirium, neuromuscular rigidity, and hyperthermia 3
• This risk is primarily a concern with overdose or when combining with other serotonergic medications 3

Clinical Management Algorithm

During Pregnancy:

• Continue sertraline at the lowest effective dose rather than discontinuing, as untreated depression carries significant risks including poor prenatal care adherence, substance use, and adverse pregnancy outcomes 1
• Trazodone can be continued if required for daily functioning (often prescribed for insomnia in this population) 2, 5
• Monitor for signs of preeclampsia and ensure appropriate weight gain throughout pregnancy 1
• Arrange early follow-up after delivery, as infants are at risk for withdrawal or toxicity symptoms over the first week of life 1

Neonatal Monitoring:

• Inform the pediatric team about maternal medication use so they can anticipate and manage neonatal adaptation syndrome if it occurs 1
• Monitor infants carefully for irritability, feeding difficulties, respiratory symptoms, tremors, and need for NICU admission 1
• These symptoms typically resolve within 1-4 weeks and are generally mild 1

Important Caveat:

• The risk of untreated maternal depression must be weighed against medication risks - women who discontinued antidepressants during pregnancy were more likely to experience relapse of major depression 2
• Untreated depression during pregnancy is associated with premature birth and decreased initiation of breastfeeding 3