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Year : 2010  |  Volume : 52  |  Issue : 1  |  Page : 83-86
Continuing medical education: SSRIs and pregnancy


Department of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bangalore 560 029, India

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Date of Web Publication13-Jan-2010
 

How to cite this article:
Andrade C. Continuing medical education: SSRIs and pregnancy. Indian J Psychiatry 2010;52:83-6

How to cite this URL:
Andrade C. Continuing medical education: SSRIs and pregnancy. Indian J Psychiatry [serial online] 2010 [cited 2014 Sep 20];52:83-6. Available from: http://www.indianjpsychiatry.org/text.asp?2010/52/1/83/58906



   CME Questions Top


In euthymic women with a history of major depression, the planned, voluntary withdrawal of antidepressant medication prior to conception (as compared with the continuation of medication all through pregnancy) is associated with a five-fold increase in the risk of relapse during pregnancy. A longer duration of illness and a larger number of past depressive episodes each predict an increased risk of relapse. About half of the relapses occur during the first trimester. [1]

Untreated depression during pregnancy is itself associated with a large number of adverse maternal and fetal outcomes. These include an increased risk of maternal mortality, [2] poor weight gain, alcohol or illicit drug use, toxemias of pregnancy, and poor mother-child bonding [3],[4] and an increased risk of pre-term delivery, low birth weight, operative delivery, and neonatal ICU admission. [5],[6],[7]

There is now an increasing trend to prescribe selective serotonin reuptake inhibitors (SSRIs) to treat depression during pregnancy; in fact, SSRIs are now first-line antidepressants during pregnancy in Denmark and many other European countries. [8],[9] The epidemiology of SSRI and antidepressant use during pregnancy has been described by Tuccori et al. [10]

With this background, mark True or False against each of the statements in sets A and B:

A) Teratogenicity of SSRIs after first-trimester exposure:

  1. SSRIs increase the overall risk of major congenital malformations
  2. SSRIs increase the overall risk of minor congenital malformations
  3. SSRIs increase the risk of septal heart defects
  4. SSRIs increase the risk of certain specific but rare congenital malformations
B) Other pregnancy outcomes after exposure to SSRIs

  1. SSRIs increase the risk of spontaneous abortions
  2. SSRIs increase the risk of preterm delivery
  3. SSRIs are associated with low Apgar scores after birth
  4. SSRIs are associated with an approximately 500 g decrease in mean birth weight
  5. SSRIs are associated with decreased head circumference in the newborn
  6. SSRIs increase the risk of persistent pulmonary hypertension in the newborn
  7. SSRI exposure during late pregnancy is associated with a neonatal SSRI withdrawal syndrome
C) SSRI-exposed vs. SSRI-unexposed pregnancies in depressed women

  1. It is better to treat depression during pregnancy than to leave it untreated because neonatal outcomes in SSRI-treated depressed women are better than those in untreated depressed women.




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   References Top

1.Cohen LS, Altshuler LL, Harlow BL, Nonacs R, Newport DJ, Viguera AC. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 2006;295:499-507.  Back to cited text no. 1      
2.Brettingham M. Depression and obesity are major causes of maternal death in Britain. BMJ 2004;329:1205.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Kurki T, Hiilesmaa V, Raitasalo R, Mattila H, Ylikorkala O. Depression and anxiety in early pregnancy and risk for preeclampsia. Obstet Gynecol 2000;95:487-90.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Nonacs R, Cohen LS. Assessment and treatment of depression during pregnancy: An update. Psychiatr Clin North Am 2003;26:547-62.   Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Chung TK, Lau TK, Yip AS, Chiu HF, Lee DT. Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes. Psychosom Med 2001;63:830-4.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Bonari L, Pinto N, Ahn E, Einarson A, Steiner M, Koren G. Perinatal risks of untreated depression during pregnancy. Can J Psychiatry 2004;49:726-35.   Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Oberlander TF, Warburton W, Misri S, Aghajanian J, Hertzman C. Neonatal outcomes after prenatal exposure to selective serotonin reuptake inhibitor antidepressants and maternal depression using population-based linked health data. Arch Gen Psychiatry 2006;63:898-906.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Nielsen RE, Stage KB, Christensen PM, Mortensen S, Andersen LL, Damkier P. Medical treatment of depression during pregnancy and breastfeeding. Ugeskr Laeger 2007;169:1442-4.   Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Lund N, Pedersen LH, Henriksen TB. Selective serotonin reuptake inhibitor exposure in utero and pregnancy outcomes. Arch Pediatr Adolesc Med 2009;163:949-54.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Tuccori M, Testi A, Antonioli L, Fornai M, Montagnani S, Ghisu N et al. Safety concerns associated with the use of serotonin reuptake inhibitors and other serotonergic/noradrenergic antidepressants during pregnancy: A review. Clin Ther 2009;31:1426-53.  Back to cited text no. 10      
11.Pedersen LH, Henriksen TB, Vestergaard M, Olsen J, Bech BH. Selective serotonin reuptake inhibitors in pregnancy and congenital malformations: Population based cohort study. BMJ 2009;339:3569.  Back to cited text no. 11      
12.Bar-Oz B, Einarson T, Einarson A, Boskovic R, O'Brien L, Malm H, et al. Paroxetine and congenital malformations: Meta-analysis and consideration of potential confounding factors. Clin Ther 2007;29:918-26.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]  
13.Birard A, Ramos E, Rey E, Blais L, St-Andri M, Oraichi D. First trimester exposure to paroxetine and risk of cardiac malformations in infants: The importance of dosage. Birth Defects Res B Dev Reprod Toxicol 2007;80:18-27.  Back to cited text no. 13      
14.Merlob P, Birk E, Sirota L, Linder N, Berant M, Stahl B, et al. Are selective serotonin reuptake inhibitors cardiac teratogens? Echocardiographic screening of newborns with persistent heart murmur. Birth Defects Res A Clin Mol Teratol 2009;85:837-41.  Back to cited text no. 14      
15.Louik C, Lin AE, Werler MM, Hernandez-Dmaz S, Mitchell AA. First-trimester use of selective serotonin-reuptake inhibitors and the risk of birth defects. N Engl J Med 2007;356:2675-83.   Back to cited text no. 15      
16.Alwan S, Reefhuis J, Rasmussen SA, Olney RS, Friedman JM; National Birth Defects Prevention Study. Use of selective serotonin-reuptake inhibitors in pregnancy and the risk of birth defects. N Engl J Med 2007;356:2684-92.   Back to cited text no. 16  [PUBMED]  [FULLTEXT]  
17.Rahimi R, Nikfar S, Abdollahi M. Pregnancy outcomes following exposure to serotonin reuptake inhibitors: A meta-analysis of clinical trials. Reprod Toxicol 2006;22:571-5.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]  
18.Chambers CD, Hernandez-Diaz S, Van Marter LJ, Werler MM, Louik C, Jones KL, et al. Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med 2006;354:579-87.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]  
19.Kallen B, Olausson PO. Maternal use of selective serotonin re-uptake inhibitors and persistent pulmonary hypertension of the newborn. Pharmacoepidemiol Drug Saf 2008;17:801-6.  Back to cited text no. 19      
20.Andrade SE, McPhillips H, Loren D, Raebel MA, Lane K, Livingston J, et al. Antidepressant medication use and risk of persistent pulmonary hypertension of the newborn. Pharmacoepidemiol Drug Saf 2009;18:246-52.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]  
21.Wichman CL, Moore KM, Lang TR, St Sauver JL, Heise RH Jr, Watson WJ. Congenital heart disease associated with selective serotonin reuptake inhibitor use during pregnancy. Mayo Clin Proc 2009;84:23-7.   Back to cited text no. 21  [PUBMED]  [FULLTEXT]  
22.Moses-Kolko EL, Bogen D, Perel J, Bregar A, Uhl K, Levin B, et al. Neonatal signs after late in utero exposure to serotonin reuptake inhibitors: Literature review and implications for clinical applications. JAMA 2005;293:2372-83.   Back to cited text no. 22  [PUBMED]  [FULLTEXT]  
23.Sanz EJ, De-las-Cuevas C, Kiuru A, Bate A, Edwards R. Selective serotonin reuptake inhibitors in pregnant women and neonatal withdrawal syndrome: A database analysis. Lancet 2005;365:482-7.  Back to cited text no. 23  [PUBMED]  [FULLTEXT]  
24.Levinson-Castiel R, Merlob P, Linder N, Sirota L, Klinger G. Neonatal abstinence syndrome after in utero exposure to selective serotonin reuptake inhibitors in term infants. Arch Pediatr Adolesc Med 2006;160:173-6.  Back to cited text no. 24  [PUBMED]  [FULLTEXT]  

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Correspondence Address:
Chittaranjan Andrade
Department of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bangalore 560 029
India
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DOI: 10.4103/0019-5545.58906

PMID: 20174529

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