Abstract
Adequate treatment of depression during pregnancy is very important for maternal, fetal and neonatal health. Selective serotonin reuptake inhibitors (SSRIs) are commonly used antidepressants. According to one American study, approximately 7% of pregnant women were prescribed an SSRI in 2004–2005. First trimester use of SSRIs, as a group, is unlikely to increase the risk of congenital malformations. Paroxetine may be associated with a small increased risk of cardiac malformations, but evidence remains inconclusive. Fetal exposure to SSRIs closer to time of birth may result in respiratory, motor, central nervous system and gastrointestinal symptoms in about 10% to 30% of newborns (SSRI neonatal behaviour syndrome). These symptoms are usually mild and transient. Persistent pulmonary hypertension of the newborn is an extremely rare consequence of fetal exposure. This information should be used to make individual risk-benefit decisions when considering the treatment of depression during pregnancy. Newborns with late-pregnancy exposure to SSRIs should be observed in hospital for at least 48 h.
Keywords: Depression in pregnancy, Neonatal abstinence, Neonatal behaviour syndrome, Selective serotonin reuptake inhibitors
RECOMMENDATIONS
Based on available evidence, the Canadian Paediatric Society makes the following recommendations:
- Adequate treatment of depression in pregnancy is very important for the health and well-being of both mother and baby. An individual risk-benefit decision must be made concerning SSRI use in pregnancy, bearing in mind the following:
- ○ SSRI neonatal behavioural syndrome is common but usually mild and transient,
- ○ The absolute risk for persistent pulmonary hypertension is negligible,
- ○ There is no evidence that SSRIs as a group increase the risk of congenital malformation; and
- ○ The evidence for association of paroxetine and cardiac malformations remains contradictory (Grade A recommendation).
When women who are taking paroxetine are pregnant or contemplating pregnancy, their care providers may wish to consider switching them to another antidepressant or reducing the dose (Grade B recommendation).
Babies with late-trimester SSRI exposure should be observed in hospital for neurobehavioural or respiratory symptoms for a minimum of 48 h. Families should receive anticipatory guidance on the possible effects of SSRIs on their infant, including the need for observation after birth (Grade A recommendation).
Postpartum use of SSRIs is not a contraindication to breastfeeding, and women who choose to breastfeed should be supported (Grade B recommendation).
Acknowledgments
First drafted by Drs Kim J Burrows and John C LeBlanc for the Canadian Paediatric Society (CPS) Psychosocial Paediatrics Committee, this position statement was revised and completed by the CPS Fetus and Newborn Committee. It was reviewed by the Canadian Psychiatric Association, as well as by the Mental Health and Developmental Disabilities and Drug Therapy and Hazardous Substances Committees of the CPS.
Footnotes
FETUS AND NEWBORN COMMITTEE
Members: Ann L Jefferies MD (Chair), Thierry Lacaze-Masmonteil MD, Abraham Peliowski-Davidovich MD, S Todd Sorokan MD, Richard Stanwick MD (Board Representative), Hilary EA Whyte MD
Liaisons: Michael S Dunn MD, CPS Neonatal-Perinatal Medicine Section; Ms Sandra Dunn MD, Canadian Perinatal Programs Coalition; Andrée Gagnon MD, College of Family Physicians of Canada; Robert Gagnon MD, Society of Obstetricians and Gynaecologists of Canada; Juan Andrés León MD, Public Health Agency of Canada; Patricia A O’Flaherty MN MEd RN-EC, Canadian Association of Neonatal Nurses; Lu-Ann Papile MD, American Academy of Pediatrics, Committee on Fetus and Newborn
Consultant: Robin K Whyte MD
Principal author: Ann L Jefferies MD
The recommendations in this statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. All Canadian Paediatric Society position statements and practice points are reviewed on a regular basis. Please consult the Position Statements section of the CPS website (www.cps.ca) for the full-text, current version.