Is it safe to continue sertraline (selective serotonin reuptake inhibitor (SSRI)) in a pregnant patient with a history of depression?

Sertraline Safety in Pregnancy: Continuation Recommended

Yes, sertraline should be continued during pregnancy for women with a history of depression, as it is the first-line SSRI with the most favorable safety profile, and discontinuation significantly increases the risk of depressive relapse which poses substantial risks to both mother and infant. 1, 2

Why Sertraline is the Preferred Choice

• Sertraline is specifically recommended as first-line therapy by the American Academy of Pediatrics due to minimal excretion in breast milk, low infant-to-maternal plasma concentration ratios, and the most robust safety data among SSRIs 1, 2

• Large population-based studies have found no increased risk of cardiac malformations with first-trimester sertraline use, unlike paroxetine which carries FDA pregnancy category D classification 1, 2, 3

• The evidence shows sertraline and citalopram have the strongest safety profiles, while paroxetine and fluoxetine have the strongest associations with negative outcomes including significant malformations 3

Critical Risk-Benefit Analysis

• Untreated depression during pregnancy carries substantial documented risks including premature birth, decreased breastfeeding initiation, low birth weight, and harm to the mother-infant relationship 1, 2, 4

• Women who discontinue antidepressants during pregnancy show a significant increase in relapse of major depression, with associated risks of suicide attempts and worsening maternal morbidity 5, 2, 6

• The magnitude of documented medication risks is very low and must be weighed against the well-established harms of untreated maternal depression 1, 2

Dosing Strategy During Pregnancy

• Use the lowest effective dose throughout pregnancy to minimize fetal exposure while maintaining maternal mental health 1, 5, 2, 6

• Continue treatment through pregnancy rather than discontinuing, as the FDA label specifically notes that sertraline should be used during pregnancy when the potential benefit justifies the potential risk 6

• Do not abruptly discontinue—if dose reduction is attempted, taper gradually and monitor closely for depressive symptoms 6

Third-Trimester Considerations and Neonatal Monitoring

• Approximately one-third of exposed newborns may develop neonatal adaptation syndrome with symptoms including irritability, jitteriness, tremors, feeding difficulty, respiratory distress, and sleep disturbance 1, 5

• These symptoms typically appear within hours to days after birth and usually resolve within 1-2 weeks without long-term consequences 1, 5

• Monitor infants for at least 48 hours after birth and arrange for early follow-up after initial hospital discharge 1, 5, 2

• There is a possible association with persistent pulmonary hypertension of the newborn (PPHN) with a number needed to harm of 286-351, representing a very small absolute risk 1, 5, 2

Breastfeeding Continuation

• Sertraline should be continued during breastfeeding as it provides infants less than 10% of the maternal daily dose through breast milk 1, 5, 2

• Sertraline and paroxetine are the most commonly prescribed antidepressants during breastfeeding and are considered suitable first-line agents 1

• Start with low doses (25-50 mg daily) if initiating during breastfeeding and slowly titrate upward while monitoring the newborn for adverse effects 1, 7

Common Pitfalls to Avoid

• Do not discontinue effective SSRI therapy upon discovering pregnancy without careful psychiatric consultation, as relapse risk is high and poses greater danger than medication continuation 2, 4

• Do not avoid treatment altogether due to fear of medication risks, as untreated maternal depression poses greater documented risks to both mother and infant 2

• Do not switch from sertraline to another antidepressant during pregnancy if sertraline is effective, as this introduces unnecessary risk of destabilization 2

• Do not use paroxetine as an alternative, which has FDA pregnancy category D classification due to cardiac malformation concerns 1, 2

Neurodevelopmental Outcomes

• Converging evidence from multiple study designs suggests that observed associations between prenatal antidepressant exposure and neurodevelopmental problems (including autism spectrum disorder and ADHD) are largely due to confounding factors rather than causal medication effects 1

• Several recent reviews have not identified adverse neurodevelopmental outcomes among infants born to women treated with SSRIs during pregnancy 1