Continuing medical education: SSRIs and pregnancy

Abstract

Byline: Chittaranjan. Andrade CME Questions 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.[sup] [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,[sup] [2] poor weight gain, alcohol or illicit drug use, toxemias of pregnancy, and poor mother-child bonding[sup] [3],[4] and an increased risk of pre-term delivery, low birth weight, operative delivery, and neonatal ICU admission.[sup] [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.[sup] [8],[9] The epidemiology of SSRI and antidepressant use during pregnancy has been described by Tuccori et al .[sup] [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: *SSRIs increase the overall risk of major congenital malformations *SSRIs increase the overall risk of minor congenital malformations *SSRIs increase the risk of septal heart defects *SSRIs increase the risk of certain specific but rare congenital malformations B) Other pregnancy outcomes after exposure to SSRIs *SSRIs increase the risk of spontaneous abortions *SSRIs increase the risk of preterm delivery *SSRIs are associated with low Apgar scores after birth *SSRIs are associated with an approximately 500 g decrease in mean birth weight *SSRIs are associated with decreased head circumference in the newborn *SSRIs increase the risk of persistent pulmonary hypertension in the newborn *SSRI exposure during late pregnancy is associated with a neonatal SSRI withdrawal syndrome C) SSRI-exposed vs. SSRI-unexposed pregnancies in depressed women *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. View Answer CME Answers A) Teratogenicity of SSRIs after first-trimester exposure: 1. False; 2. False; 3. True. 4. True Pedersen et al ,[sup] [11] describe a large, population-based, retrospective cohort study of the teratogenicity of SSRIs using data extracted from four nationwide registers in Denmark. Major and minor congenital malformations were studied in live born children in whom these malformations were detected within a year of birth. Data were excluded if women had used non-SSRI psychotropic drugs or drugs for a variety of medical indications. There were 1370 infants who had been exposed to SSRIs and 493,113 infants who had not been exposed. In this connection, exposure was defined as the redemption of at least two prescriptions for SSRIs from 28 days before conception to 112 days after conception; the assumption was that filling repeated prescriptions implied that the women were actually taking their medications. The risks of teratogenicity with SSRIs were calculated after adjusting for maternal age, marital status, income, smoking, and other variables. This is because women who used SSRIs were more likely to have risk factors such as greater age, living alone, unmarried status, smoking etc. Pedersen et al ,[sup] [11] found that the risk of major malformations in SSRI-exposed vs. unexposed infants was 4.0% vs. …