What are the recommendations for a pregnant patient prescribed bupropion (Bupropion) SR 75 mg daily for depression and anxiety and mirtazapine (Mirtazapine) for sleep and nausea?

Psychoeducation for Bupropion SR and Mirtazapine in Pregnancy

Why These Medications Were Prescribed

Your healthcare provider has prescribed bupropion SR 75 mg daily to treat your depression and anxiety, and mirtazapine to help with sleep and nausea during pregnancy. Both medications can be continued during pregnancy when the benefits of treating your mental health outweigh the small potential risks to your baby 1, 2.

• Untreated depression during pregnancy carries significant risks including premature birth, difficulty bonding with your baby, and decreased likelihood of breastfeeding 3
• Your mental health is essential for both your wellbeing and your baby's development 3

What You Need to Know About Bupropion SR

Safety Profile During Pregnancy

• Bupropion does not increase the overall risk of major birth defects above the baseline rate that occurs in all pregnancies 1, 2
• There is a small absolute increased risk of two specific heart defects: left ventricular outflow tract obstruction and ventricular septal defects (adjusted odds ratio 2.9), though the absolute risk remains low 4, 2
• A possible increased risk for diaphragmatic hernia exists, but this condition is extremely rare (occurring in only 0.012%-0.031% of all births), so the absolute risk remains very small 4, 2
• There may be a possible increased risk of spontaneous abortion, though it's unclear if this is due to the medication or the underlying depression itself 1, 2

Important Safety Information

• Never crush, chew, or divide your bupropion tablets—swallow them whole to prevent seizure risk 5
• Take your bupropion in the morning, with or without food 5
• If you miss a dose, do not take an extra tablet to make up for it; just take your next dose at the regular time 5
• Minimize or avoid alcohol use, as excessive alcohol or abrupt discontinuation can increase seizure risk 5
• Contact your provider immediately if you experience a seizure—you must stop bupropion if this occurs 5

Common Side Effects

• Dry mouth is the most common side effect 6, 7
• You may experience agitation, insomnia, headaches, nausea, or constipation 6
• The medication typically begins working within 2 weeks, with full effect at 4 weeks 6

What You Need to Know About Mirtazapine

Benefits for Pregnancy Symptoms

• Mirtazapine is particularly helpful for nausea and vomiting during pregnancy, which is why your provider chose this medication 8
• It improves sleep quality due to its sedating effects 6, 9
• It can help with anxiety symptoms associated with depression 9
• Symptoms often improve within 1-2 weeks of starting treatment 6, 9

Common Side Effects

• Sedation (drowsiness) is the most common side effect, which can actually be beneficial for sleep 6, 9
• Increased appetite and weight gain may occur 6, 9
• Dizziness may occur initially 6, 9
• Take mirtazapine as a single evening dose to minimize daytime sedation 9

Monitoring During Pregnancy

Your healthcare team will monitor:

• Fetal growth through ultrasounds 4, 2
• Your blood pressure at regular visits 4, 2
• Your weight gain to ensure it's appropriate for pregnancy 4, 2
• A detailed fetal anatomy ultrasound (typically around 18-20 weeks) to check the baby's heart structure 4, 2

Planning for Breastfeeding

Bupropion and Breastfeeding

• Bupropion is present in breast milk at very low levels, sometimes undetectable 1, 2
• In 21 reported cases, generally no adverse events occurred in breastfed infants 2
• There have been 2 case reports of seizures in breastfed infants, though causality is uncertain 2, 3
• If you plan to breastfeed, your baby should be monitored carefully for vomiting, diarrhea, jitteriness, excessive sedation, or seizures 2
• The therapeutic dose should be maintained while breastfeeding rather than reducing it, as undertreated depression poses risks to both you and your baby 2

Mirtazapine and Breastfeeding

• Limited data exists on mirtazapine during breastfeeding 6
• Based on its properties, it will likely be present in breast milk 6
• Your baby should be monitored for adequate weight gain and normal development if you breastfeed while taking mirtazapine 2

Important Warnings

Mental Health Monitoring

• Contact your provider immediately if you experience worsening depression, suicidal thoughts, or unusual changes in mood or behavior 5
• Antidepressants may increase the risk of suicidal thoughts in some individuals, particularly in the first few months of treatment 5
• Pay close attention to sudden changes in mood, behaviors, thoughts, or feelings 5

Medication Interactions

• Do not take any other medications containing bupropion (such as Wellbutrin, Zyban, or Aplenzin) as this increases seizure risk 5
• Inform your provider about all prescription and over-the-counter medications you take, as drug interactions can occur 5

Severe Allergic Reactions

• Discontinue bupropion immediately and seek emergency care if you develop symptoms of a severe allergic reaction (rash, hives, difficulty breathing, swelling) 5

Key Takeaway

The benefits of treating your depression and anxiety during pregnancy significantly outweigh the small potential risks of these medications. Your provider has carefully selected these medications because untreated maternal depression poses substantial documented risks to both you and your baby, including premature birth, impaired mother-infant bonding, and long-term developmental concerns 2, 3. Continue taking your medications as prescribed, attend all prenatal appointments, and maintain open communication with your healthcare team about any concerns.