II. Epidemiology
- Pregnancy is not protective against Major Depression
- Perinatal depression Prevalence: 12%
III. Risk Factors
IV. Adverse Effects: Untreated Depression
- Untreated Depression risks
- Suicide
- Adverse effects on family functioning
- Increased risk of Intrauterine Growth Retardation and low birth weight
- Increased risk of preterm birth
- Concurrent adverse habit risks
V. Adverse Effects: Medications
- See Psychiatric Medications in Pregnancy
- SSRIs appear to be safe as a class in pregnancy
-
Paroxetine (Paxil)
- Made Category D in 2005
- See Paxil for details
- Associated with cardiac defects with first trimester exposure
- Atrial and Ventricular Septal Defects
- Right Ventricular Outflow Obstruction
- Other associated risks
- Anencephaly
- Gastroschisis
- Omphalocele
- Neonatal antedepressant withdrawal risk
-
Fluoxetine
- Well studied in pregnancy, but data in 2015 showed association with cardiac defects
- Association with VSD, right ventricular outflow tract obstruction cardiac defects
- Also associated with Craniosynostosis
- Avoid in Lactation due to increased Fluoxetine levels in Breast Milk
- Berard (2015) Br J Clin Pharmacol +PMID:26613360 [PubMed]
- Persistent Pulmonary Hypertension
- Increased risk by 6 fold if SSRIs used after 20 weeks
- Number needed to harm: 286-351
- Grigoriadis (2014) BMJ 348:f6932 [PubMed]
- Studies that show no longterm newborn effects
- Some reports of short-term neonatal withdrawal
- Weak cry, mild Tachypnea, jitteriness, Tremors
- Wisner (1999) JAMA 282:1264-9 [PubMed]
- SSRIs that have shown mixed or weak associations with Autism (as one of many contributing factors)
VI. Management
- Treat Major Depression in Pregnancy
- Avoid medications during first trimester if possible
- Indications to continue Antidepressants started before pregnancy
- Severe or recurrent depression history with high risk of relapse
- Informed Consent regarding medication risks and benefits
- Consult mental health counseling
- Psychotherapy (esp. CBT) is preferred first-line therapy over medication
- However, untreated depression is associated with low birth weight, preterm-birth, C-Section
- Select SSRI Antidepressants with most safety data
- Sertraline (Zoloft)
- Most commonly used SSRI in pregnancy, and preferred agent
- May be continued into Lactation (poorly secreted into Breast Milk)
- Citalopram (Celexa)
- Escitalopram (Lexapro)
- Sertraline (Zoloft)
- Avoid agents associated with adverse effects
- Avoid Fluoxetine (Prozac)
- Best studied in pregnancy, but see adverse effects above
- Avoid Paroxetine (Paxil) due to higher fetal risk
- Avoid Fluoxetine (Prozac)
- Avoid agents with insufficient efficacy and safety data in pregnancy
- Avoid Docosahexaenoic Acid
- Avoid St. John's Wort
- Severe, refractory major Depression in Pregnancy
- Electroconvulsive Therapy for severe Depression