Published: September 2010

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The use of antidepressants in pregnancy

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Prescriber Update 31(3): 23
September 2010

In 2008 Medsafe provided advice on the use of Selective Serotonin Reuptake Inhibitors (SSRIs) in pregnancy.¹

Since that time further epidemiological studies have been published.^2-5 The Medicines Adverse Reactions Committee (MARC) has reviewed these studies investigating the association between SSRI or serotonin noradrenaline reuptake inhibitor (SNRI) treatment and congenital anomalies. The MARC concluded that there is a small increased risk of congenital cardiac defects associated with fluoxetine, similar to that seen with paroxetine.⁶ The possibility of a class effect for all SSRIs or a similar effect with SNRIs could not be excluded.

In addition to the risk of congenital anomalies SSRIs and SNRIs have been associated with an increase in risk of pre-term birth, persistent pulmonary hypertension of the newborn (PPHN) and neonatal withdrawal symptoms when the mother is treated until the birth of the baby. There is less information on the use of tricyclic antidepressants (TCA) in pregnancy. However, a recent epidemiological study indicated that TCAs may also be associated with an increased risk of congenital anomalies, pre-term birth and neonatal withdrawal symptoms.⁷

It is important to remember that untreated antenatal depression has also been associated with adverse outcomes for both mother and foetus. The decision to treat a pregnant woman with antidepressant medicines can only be made on an individual basis in collaboration with the patient. The risks associated with ineffective treatment need to be balanced with the small increase in risk of congenital abnormalities, pre-term birth and neonatal withdrawal symptoms.

Healthcare professionals should be aware of the use of antidepressants in pregnancy and should closely observe neonates exposed to antidepressants for signs of withdrawal symptoms or PPHN.

References

1. Medsafe. 2008. SSRI use in pregnancy - collaborative decision-making is key. Prescriber Update. Vol 29(1):78. www.medsafe.govt.nz/profs/PUArticles/SSRIPreg.htm
2. A review of studies up to 2009 has been published: Tuccori M, Testi A, Antonioli L et al 2009 'Safety concerns associated with the use of serotonin reuptake inhibitors and other serotonergic/ noradrenergic antidepressants during pregnancy: a review' Clin Therap 31: 1426-1453.
3. Pederson LH, Henriksen TB, Vestergaard M et al 2009 'Selective serotonin reuptake inhibitors in pregnancy and congenital malformation: population based cohort study' BMJ 339: b3569
4. Merlob P, Birk E, Sirota L et al 2009 'Are selective serotonin reuptake inhibitors cardiac teratogens? Echocardiographic screening of newborns with persistent heart murmur' Birth Defects Res (A) 85: 837-841.
5. Wisner KY, Sit DKY, Hanusa BH et al 2009 'Major depression and antidepressant treatment: impact on pregnancy and neonatal outcomes' Am J Psychiatry 166 557-566.
6. MARC minute item for serotonin reuptake inhibitors and risk of congenital abnormalities. Available at: http://www.medsafe. govt.nz/profs/adverse/Minutes141.htm#3.1
7. Reis M and Kallen B 2010 'Delivery outcome after maternal use of antidepressant drugs in pregnancy: an update using Swedish data' Psychological Med doi:10.1017/S0033291709992194