Recent reports have raised questions regarding the use of selective serotonin reuptake inhibitors (SSRI) during pregnancy. To date, no professional medical association has issued formal guidelines regarding the use of SSRIs during pregnancy. However, in December the American College of Obstetricians and Gynecologists ACOG published an opinion paper on this topic that is noteworthy for its clarity and balanced review of the existing data on the reproductive safety of SSRI antidepressants (Obstetrics and Gynecology 2006;108:1601-3). The ACOG report addressed the following issues:
Two unpublished reports have suggested a 1.5 to 2.0-fold increase in the risk of cardiovascular malformations (atrial and ventricular septal defects) among children exposed to paroxetine (Paxil) during the first trimester of pregnancy. These findings prompted a change in Paxil’s labeling from Pregnancy Category C to D (see April 2006 Newsletter). The ACOG Committee on Obstetric Practice notes that this increase in risk has not been observed with any other SSRIs and makes the following recommendation: “At this time, paroxetine use among pregnant women and women planning pregnancy should be avoided, if possible.”
Also referenced in the opinion are multiple reports indicating that exposure to SSRIs late in pregnancy may be associated with neonatal complications, including jitteriness, mild respiratory distress, weak cry, poor muscle tone, and admission to a special care nursery (see December 2005 Newsletter). The report also commented on a single study documenting an increased risk of a more serious complication, persistent pulmonary hypertension of the newborn (PPHN), in infants exposed to SSRIs after 20 weeks of gestation (see April 2006 Newsletter).
The report reminds us that while these reports have raised concerns regarding SSRI use during pregnancy, depression is common during pregnancy, affecting approximately 1 in 10 women. Furthermore, the ACOG Committee notes that women who discontinue treatment with an antidepressant are five times to experience a depressive relapse than women who maintain treatment. “The potential risk of SSRI use throughout pregnancy must be considered in the context of the risk of relapse of depression if maintenance treatment is discontinued,” the report states. “Untreated depression may increase the risk of low weight gain, sexually transmitted diseases, and alcohol and substance abuse, all of which have maternal and fetal health implications.”
Most importantly, the report recommends an individualized approach to treating women who are either pregnant or planning pregnancy while taking an SSRI or selective norepinephrine reuptake inhibitor: “Decisions about treatment of depression should incorporate the clinical expertise of the mental health clinician and obstetrician, and the process should actively engage the patient’s values and perceptions when framing the discussion of the risks and benefits of treatment.” When it comes to prescribing SSRIs during pregnancy, patients must collaborate with their treaters in order to make the best decision under circumstances in which we have imperfect estimates of risk on both sides of the risk-benefit equation. As in any other clinical situation, treatment must be individually tailored based on the patients’ particular clinical scenario and her own personal wishes.
Ruta Nonacs, MD PhD
Lee S. Cohen, MD
*This post was originally published as an article in our November 2007 Newsletter