Safety of antidepressants in pregnancy and breastfeeding

 

This information is not intended as a substitute for professional medical advice, diagnosis or treatment.

Introduction to antidepressants and pregnacy

Decisions about the use of antidepressants in pregnancy and breastfeeding need to be made with care. After all, antidepressants, like most drugs, might carry some risks when taken by a pregnant woman. While this information is designed to help you to make an informed decision about the use of antidepressants at this time, it is not meant to replace a detailed discussion with your doctor. Furthermore, our knowledge in this area remains limited and new information is constantly coming to light on this topic. Ideally, discussions with your doctor would take place before planning a pregnancy and, if possible, with your partner present. The risks and benefits need to be weighed up before decisions can be made about stopping or (re)starting an antidepressant in pregnancy and when breastfeeding.

The risks of untreated depression in pregnancy and postnatally

Depression in pregnancy and after childbirth occurs in about 10 percent of women. When depression is severe it may be associated with suicidal behaviour, poor self-care, inadequate nutrition, excessive use of alcohol and cigarettes and poor antenatal clinic attendance. All of these can put the foetus at risk. Some studies suggest that maternal depression is associated with increased rates of prematurity, low birth weight and irritability in newborns. Finally, women who cease antidepressants early in pregnancy or pre-conception have a five-fold increased chance of relapse into depression by the time they deliver.

Mothers who are depressed after the birth will find it harder to adjust to parenting, thus potentially impacting on their care of the baby and the mother-baby relationship.

While untreated depression at this time may have significant adverse effects for both mother and baby, there is also considerable concern on the part of women, their partners and doctors about foetal and infant exposure to antidepressants.

Exposure to antidepressants in pregnancy and breastfeeding

A significant amount (probably between 20-100%) of antidepressants crosses into the baby’s system in pregnancy. The amount is generally less than 1-5% in breast milk. We do not know how exposure to antidepressants in pregnancy might affect the developing foetal brain, but two small studies suggest no negative impact on cognitive function, while a small 2007 study suggests no behavioural impact in pre-school children.
Much work remains to be done in this area.

Early pregnancy antidepressant exposure and birth defects and miscarriage

1) Birth defects:

There are now a number of studies examining several thousand infants, suggesting that there is no increased risk of overall birth defects or malformations above the general population risk (which is 2-3%, a third of which are heart defects) with early pregnancy exposure to the serotonin-acting SSRI antidepressants (Prozac, Zoloft, Cipramil and Luvox) and the older Tricyclic antidepressants. There is now significant evidence from a meta-analysis (2007) of combined data on 2,752 infants exposed to Aropax, to suggest that exposure to this particular SSRI may be associated with an increase in heart defects. This is also supported by another large study published in 2007. The most common heart defects are called Ventricular Septal Defect (colloquially known as a ‘hole in the heart’). Most of these heart defects, however, are known to resolve spontaneously as the baby grows. The risk of birth defects with the SNRI, Efexor, is far less studied, but the small amount of data available would suggest there is not an increased risk above the norm. There is as yet no information available on the newer antidepressants Avanza or Edronax in relation to birth defects.

2) Miscarriage and mild prematurity:

There appears to be slightly increased risk of such events with the use of SSRIs. Late pregnancy exposure and risk of newborn ‘withdrawal.’ There have been recent reports of withdrawal syndromes in babies exposed to the SSRI antidepressants (as well as to the older tricyclic antidepressants such as Prothiaden) in the last few weeks of pregnancy. Based on much smaller numbers from a 2007 publication, this also seems to apply to Efexor.
Withdrawal symptoms are usually mild, mostly begin on day one or within four days of birth and they usually last for two to three days. Newborns will initially need to be monitored in hospital for such symptoms. Withdrawal symptoms include mild breathing problems, irritability, difficulty in settling and feeding, and - very occasionally - the baby may have a seizure. No babies have died from late pregnancy SSRI exposure. More recent reports also suggest an increased, but minimal, chance of more severe breathing problems with SSRI exposure in late pregnancy. These findings are yet to be confirmed. As noted above, this is an evolving field of research and new information is continually coming to light such that no definitive statements can be made about the absolute safety of the SSRIs, whether the exposure is early or late in pregnancy. Ultimately the decision is made after discussion between the doctor and the patient and her family, by balancing out the risks of untreated depression versus the impact of these drugs on the foetus.

Breastfeeding and antidepressants

While a small number of studies suggest that antidepressants are not harmful to your baby in terms of its developmental milestones and preschool performance, there is still very little known in this area. What we do know is that, compared to the use of antidepressants in pregnancy, less than five percent of SSRIs pass into breast-milk. The decision on whether to breastfeed is an individual one but a significant number of women have done so whilst on antidepressants and do not report adverse effects in their babies.

Key points to remember

It is important to balance the mental health needs of the mother and the safety issues for the infant in the treatment of depression in pregnancy.

• Aropax may be associated with heart defects and an echocardiogram can be done at 18 weeks gestation to exclude such defects if the foetus has been exposed to this drug. Overall, Aropax is probably best avoided in pregnancy
• Other SSRIs: While the data are still not completely clear about the risk of other (non-cardiac) birth defects related to SSRIs, any such reported risk appears to be relatively minor and must be weighed against the benefits of treatment if the mother is unwell

Please consult with your doctor for more detailed information about medication use in pregnancy and breastfeeding.

Where to get more information

Black Dog Institute

Hospital Road,
Prince of Wales Hospital

www.blackdoginstitute.org.au

Australia

Mothersafe:  NSW state-wide telephone service (http://www.sesiahs.health.nsw.gov.au/Mothersafe/

Phone: 02 9382 6539 or 1800 647 848
9am-5pm.

 

Black Dog Institute

www.blackdoginstitute.org.au

Ph: (02) 9382 4530 / (02) 9382 4523

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Canada

Canadian service which provides information on medications and medical conditions in pregnancy and also medication in the breastfeeding mother.

Motheriskhttp://www.motherisk.org/women/index.jsp

 

 

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