What is the appropriate management of an acute sertraline overdose in a woman in her third trimester of pregnancy?

Management of Acute Sertraline Overdose in Third Trimester Pregnancy

Manage sertraline overdose in the third trimester with standard supportive care—ensure adequate airway, oxygenation, and ventilation; monitor cardiac rhythm and vital signs; consider gastric lavage with airway protection if performed soon after ingestion; administer activated charcoal; and provide general supportive measures, as forced diuresis and dialysis are ineffective due to sertraline's large volume of distribution. 1

Immediate Overdose Management

The FDA-approved approach to sertraline overdose applies regardless of pregnancy status, as the primary concern is maternal stabilization 1:

• Ensure adequate airway, oxygenation, and ventilation as the first priority 1
• Monitor cardiac rhythm and vital signs continuously, as overdose can cause tachycardia, bradycardia, bundle branch block, QT-interval prolongation, hypertension, hypotension, and rarely Torsade de Pointes 1
• Perform gastric lavage with a large-bore orogastric tube with appropriate airway protection if the patient presents soon after ingestion or is symptomatic 1
• Administer activated charcoal to reduce absorption 1
• Do not induce emesis, as this is not recommended for sertraline overdose 1

Expected Clinical Presentation

Understanding the typical overdose presentation helps guide monitoring intensity:

• The most common symptoms in non-fatal sertraline overdose are somnolence, vomiting, tachycardia, nausea, dizziness, agitation, and tremor 1
• Less common but serious manifestations include convulsions, coma, delirium, hallucinations, serotonin syndrome, stupor, syncope, and pancreatitis 1
• In a prospective study of 40 sertraline overdoses, isolated sertraline ingestion (without co-ingestants) resulted in no significant morbidity, with tremor, lethargy, and nausea being the most common findings 2
• The largest known ingestion of 13.5 grams resulted in complete recovery, though a 2.5-gram ingestion in another patient was fatal, highlighting the unpredictable nature of overdose outcomes 1

Ineffective Interventions to Avoid

• Do not attempt forced diuresis, dialysis, hemoperfusion, or exchange transfusion, as these are unlikely to be beneficial due to sertraline's large volume of distribution 1
• No specific antidotes for sertraline exist 1

Pregnancy-Specific Monitoring Considerations

While managing the overdose with standard protocols, add pregnancy-specific surveillance:

• Monitor fetal heart rate and uterine activity continuously during the acute phase, as maternal hemodynamic instability can compromise placental perfusion
• Arrange obstetric consultation immediately to assess fetal well-being and determine if delivery should be expedited if maternal condition deteriorates
• After maternal stabilization, plan for enhanced neonatal monitoring at delivery, as the infant will have had acute high-dose sertraline exposure on top of any chronic therapeutic exposure 3, 4

Post-Overdose Neonatal Considerations

If the pregnancy continues to delivery after overdose recovery:

• Anticipate neonatal adaptation syndrome in approximately one-third of infants exposed to SSRIs in late pregnancy, with symptoms including irritability, jitteriness, tremors, feeding difficulty, respiratory distress, and sleep disturbance appearing within hours to days after birth 3, 4
• Monitor the newborn for at least 48 hours after birth and arrange early follow-up after hospital discharge 4
• In severely affected infants with persistent symptoms, consider a short-term course of chlorpromazine, which has provided measurable relief 3, 4

Critical Pitfalls to Avoid

• Do not delay standard overdose management due to pregnancy concerns—maternal survival is the priority, and standard interventions (gastric lavage, activated charcoal) do not pose significant fetal risk 1
• Do not assume benign outcome based on stated ingestion amount alone, as a 2.5-gram ingestion proved fatal while a 13.5-gram ingestion resulted in recovery 1
• Consider co-ingestants carefully, as benzodiazepines and alcohol are frequently taken with sertraline in overdose and complicate the clinical picture 2
• Contact a poison control center for additional guidance on managing any overdose 1

Disposition and Follow-Up

• Admit patients for 24-hour observation if symptomatic, have taken a large ingestion, or have co-ingestants 2
• For asymptomatic patients with small ingestions and no co-ingestants, observation in the emergency department for 3-4 hours may be sufficient before discharge 2
• Continue routine prenatal care with enhanced fetal surveillance after maternal recovery, including serial ultrasounds for fetal growth 3