Prozac During Labor
Continue Prozac through labor and delivery if the patient has been taking it during pregnancy, as the benefits of maintaining maternal mental health stability typically outweigh the potential risks of neonatal adaptation syndrome, which is generally self-limited and manageable.
Key Clinical Considerations
FDA Labeling Position
The FDA label states that fluoxetine should be used during labor and delivery only if the potential benefit justifies the potential risk to the fetus, noting that fluoxetine crosses the placenta and may have adverse effects on the newborn 1. However, this must be interpreted in the context of the risks of abrupt discontinuation.
Neonatal Adaptation Syndrome
- Neonates exposed to SSRIs late in the third trimester commonly develop complications requiring prolonged hospitalization, respiratory support, and tube feeding 2
- Clinical findings include respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying 1
- The syndrome typically begins within hours to days after birth and resolves within 1-2 weeks 2
- Third-trimester exposure increases risk of premature delivery (relative risk 4.8), special-care nursery admission (relative risk 2.6), and poor neonatal adaptation including respiratory difficulty and jitteriness (relative risk 8.7) 3
Risks of Discontinuation
- Discontinuing psychiatric medications during pregnancy leads to worse mental health outcomes and significant functional impairment 2
- Women who discontinued antidepressants during pregnancy were more likely to experience relapse of major depression than those who continued treatment 1
- The postpartum period represents the highest-risk time for mood and anxiety disorder relapse 2
Clinical Algorithm for Labor Management
If Patient Has Been on Prozac Throughout Pregnancy:
- Continue the medication through labor and delivery at the current therapeutic dose 2, 1
- Alert the neonatal team about SSRI exposure for monitoring purposes 1
- Prepare for potential neonatal adaptation syndrome with appropriate monitoring and supportive care 2, 1
If Patient Discontinued Prozac Earlier in Pregnancy:
- Do not restart during active labor given the timing would not prevent neonatal adaptation syndrome but could complicate the clinical picture 1
- Plan for immediate postpartum resumption if indicated for maternal mental health 2
Neonatal Monitoring Protocol:
- Observe for signs of adaptation syndrome: respiratory distress, feeding difficulties, temperature instability, jitteriness, irritability 1
- Most symptoms are self-limited and respond to supportive care 2
- The absolute risk remains manageable compared to the risks of untreated maternal depression 2, 4
Critical Pitfall to Avoid
Do not abruptly discontinue Prozac when a patient presents in labor. The medication has already crossed the placenta throughout the third trimester, so stopping it during labor will not prevent neonatal adaptation syndrome but will destabilize maternal mental health at a critical time when postpartum relapse risk is highest 2, 1.