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Am Fam Physician. 2007;75(12):1851

Background: The highest prevalences of depressive disorders occur in women of reproductive age. Pregnancy is linked to depression, with an estimated one in 10 women suffering from clinical depression during pregnancy or puerperium. Although selective serotonin reuptake inhibitors (SSRIs) are first-line therapy for many depressive conditions and are commonly used during pregnancy, information about potential adverse fetal effects remains controversial. The two major areas of concern are congenital abnormalities and transient neonatal complications. An expert opinion paper from the Committee on Obstetric Practice of the American College of Obstetricians and Gynecologists (ACOG) summarizes the current data and recommends clinical strategies for SSRI use during pregnancy.

Untreated depression is associated with adverse effects on the mother, including low weight gain, alcohol and substance abuse, and increased vulnerability to sexually transmitted diseases. In one study of 201 women with a history of major depression, approximately 67 percent of those who discontinued antidepressants experienced relapse during pregnancy compared with 26 percent of women who continued antidepressants. Most women in this study used SSRIs.

Data from a Swedish national registry of congenital malformations and a database of U.S. insurance claims suggest an increased risk of atrial and ventricular septal defects associated with exposure to paroxetine (Paxil) during the first trimester. This increased risk (about 1.5- to 2.0-fold) was specific to paroxetine and not to other SSRIs. The U.S. Food and Drug Administration pregnancy category for paroxetine was recently changed from C to D.

Several studies have linked the use of SSRIs during late pregnancy to transient adverse neonatal effects including weak cry, mild respiratory distress, tachypnea, and jitteriness. An increased rate of admission to neonatal intensive care units also was reported. A large case-control study found that babies born to mothers who used SSRIs after 20 weeks' gestation had a sixfold increase in persistent pulmonary hypertension.

Recommendations: The ACOG Committee on Obstetric Practice recommends that decisions about SSRI treatment during pregnancy be individualized and made with full information about potential benefits and risks of the therapy and availability of alternatives. Paroxetine should be avoided during pregnancy and in women who may become pregnant. Abrupt discontinuation of paroxetine can produce withdrawal syndromes; therefore, stopping use of the medication should be done slowly for the safety of the mother and fetus. Fetal echocardiography should be performed on women who used paroxetine during early pregnancy to detect septal defects.

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Copyright © 2007 by the American Academy of Family Physicians.

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