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Am Fam Physician. 2007;76(4):587

ACOG Releases Guidelines on the Use of SSRIs During Pregnancy

Guideline source: American College of Obstetricians and Gynecologists

Literature search described? No

Evidence rating system used? No

Published source: Obstetrics & Gynecology, December 2006

Depression is common among women of reproductive age, and approximately one in 10 women will have major or minor depression during pregnancy and the postpartum period. Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat depression. Recently, however, there have been concerns that the use of paroxetine (Paxil) during the first trimester of pregnancy may increase the risk of congenital cardiac malformations. Additionally, transient neonatal complications, including mild respiratory distress, transient tachypnea of the newborn, a weak cry, and poor tone, have been associated with SSRI use late in pregnancy. To address this risk, the American College of Obstetricians and Gynecologists (ACOG) has released a committee opinion on the use of SSRIs during pregnancy, which was published in the December 2006 issue of Obstetrics & Gynecology.

Although the benefits of paroxetine may outweigh the risks, physicians should consider whether a patient could have a relapse of depression if treatment is discontinued. Left untreated, depression could increase the risk of low weight gain, sexually transmitted diseases, and alcohol and substance abuse.

Therefore, ACOG recommends that the use of SSRIs and selective norepinephrine reuptake inhibitors be individualized in pregnant women. If possible, however, paroxetine should be avoided in patients who are pregnant or want to become pregnant. If a patient is exposed to paroxetine in early pregnancy, fetal echocardiography should be considered.

The committee recommends that treatment decisions involve the expertise of a mental health professional to assess the benefits. Ideally, this shared decision making would occur before the patient becomes pregnant. However, because nearly 50 percent of pregnancies are unplanned, preconception care for women with depression may not always occur.

When discontinuing paroxetine, patients should follow the instructions outlined in the prescribing information, because abrupt discontinuation may lead to withdrawal symptoms.

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