Antepartum Depression

Aka: Antepartum Depression, Depression in Pregnancy, Depression Management in Pregnancy, Antidepressants in Pregnancy

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II. Epidemiology

  1. Pregnancy is not protective against Major Depression
  2. Perinatal depression Prevalence: 12%
    1. Woody (2017) J Affect Disord 219:86-92 [PubMed]

III. Risk Factors

  1. See Peripartum Depression

IV. Adverse Effects: Untreated Depression

  1. Untreated Depression risks
    1. Suicide
    2. Adverse effects on family functioning
    3. Increased risk of Intrauterine Growth Retardation and low birth weight
    4. Increased risk of preterm birth
  2. Concurrent adverse habit risks
    1. Tobacco Abuse
    2. Alcohol Abuse
    3. Illicit Drug abuse
      1. See Substance Abuse in Pregnancy

V. Adverse Effects: Medications

  1. See Psychiatric Medications in Pregnancy
  2. SSRIs appear to be safe as a class in pregnancy
  3. Paroxetine (Paxil)
    1. Made Category D in 2005
    2. See Paxil for details
    3. Associated with cardiac defects with first trimester exposure
      1. Atrial and Ventricular Septal Defects
      2. Right Ventricular Outflow Obstruction
    4. Other associated risks
      1. Anencephaly
      2. Gastroschisis
      3. Omphalocele
      4. Neonatal antedepressant withdrawal risk
  4. Fluoxetine
    1. Well studied in pregnancy, but data in 2015 showed association with cardiac defects
    2. Association with VSD, right ventricular outflow tract obstruction cardiac defects
    3. Also associated with Craniosynostosis
    4. Avoid in Lactation due to increased Fluoxetine levels in Breast Milk
    5. Berard (2015) Br J Clin Pharmacol +PMID:26613360 [PubMed]
  5. Persistent Pulmonary Hypertension
    1. Increased risk by 6 fold if SSRIs used after 20 weeks
    2. Number needed to harm: 286-351
    3. Grigoriadis (2014) BMJ 348:f6932 [PubMed]
  6. Studies that show no longterm newborn effects
    1. Addis (2000) Psychol Med 30:89-94 [PubMed]
    2. Hendrick (2003) Am J Obstet Gynecol 188:812-5 [PubMed]
  7. Some reports of short-term neonatal withdrawal
    1. Weak cry, mild Tachypnea, jitteriness, Tremors
    2. Wisner (1999) JAMA 282:1264-9 [PubMed]
  8. SSRIs that have shown mixed or weak associations with Autism (as one of many contributing factors)
    1. Boukhris (2016) JAMA Pediatr 170(2):117-2 +PMID:26660917 [PubMed]
    2. Harrington (2014) Pediatrics 133:e1241-8 +PMID:24733881 [PubMed]
    3. Hviid A (2013) N Engl J Med 369:2406-15 [PubMed]
    4. Rai (2013) BMJ 346:f2059 [PubMed]

VI. Management

  1. Treat Major Depression in Pregnancy
  2. Avoid medications during first trimester if possible
  3. Indications to continue Antidepressants started before pregnancy
    1. Severe or recurrent depression history with high risk of relapse
    2. Informed Consent regarding medication risks and benefits
  4. Consult mental health counseling
    1. Psychotherapy (esp. CBT) is preferred first-line therapy over medication
    2. However, untreated depression is associated with low birth weight, preterm-birth, C-Section
  5. Select SSRI Antidepressants with most safety data
    1. Sertraline (Zoloft)
      1. Most commonly used SSRI in pregnancy, and preferred agent
      2. May be continued into Lactation (poorly secreted into Breast Milk)
    2. Citalopram (Celexa)
    3. Escitalopram (Lexapro)
  6. Avoid agents associated with adverse effects
    1. Avoid Fluoxetine (Prozac)
      1. Best studied in pregnancy, but see adverse effects above
    2. Avoid Paroxetine (Paxil) due to higher fetal risk
  7. Avoid agents with insufficient efficacy and safety data in pregnancy
    1. Avoid Docosahexaenoic Acid
    2. Avoid St. John's Wort
  8. Bipolar Depression preferred agents in pregnancy
    1. Quetiapine
    2. Lamotrigine
      1. Dose increase may be need in pregnancy due to increased clearance
      2. Decrease dose after delivery
  9. Acute mania preferred agents in pregnancy
    1. Haloperidol
    2. Atypical Antipsychotics (e.g. Risperidone, Quetiapine)
    3. Lithium
      1. Requires close monitoring by psychiatry
      2. Risk of fetal cardiac defects
    4. Avoid Valproic Acid in all trimesters
    5. Avoid Carbamazepine and Oxcarbazepine in first trimester
  10. Severe, refractory major Depression in Pregnancy
    1. Electroconvulsive Therapy for severe Depression

VII. Prevention

  1. See Peripartum Depression

VIII. References

  1. Langan (2016) Am Fam Physician 93(10):852-8 [PubMed]
  2. (2025) Presc Lett 32(9): 52-3

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