SSRI use during pregnancy
Do antidepressants’ benefits outweigh the risks?
You may need to increase SSRI dosages as pregnancy progresses. Increased metabolism and weight gain during pregnancy can lower SSRI serum levels, allowing depressive symptoms to re-emerge in the third trimester. Counsel the patient to continue taking the antidepressant for at least 12 months postpartum, then re-evaluate the need for medication based on her history.
Paroxetine precautions. If your patient is taking paroxetine and wishes to become pregnant, consider switching to another SSRI (using a slow cross-taper) unless paroxetine has been the only effective medication (Table 4). When discussing risks of any SSRI, explain that the baseline risk for congenital malformations is 3%. Paroxetine might increase this risk by 1% and other SSRIs by less.
If a woman becomes pregnant while taking paroxetine, often the time when cardiac defects occur is passed or will be before you slowly taper the medication to avoid withdrawal. If the patient’s depression has been severe, the risk of shifting her to an untested SSRI is probably higher than the possible 1% increased risk of fetal malformation. If she has taken paroxetine during the first-trimester, refer for ultrasound to monitor for cardiac anomalies.
Table 4
Recommendations for managing paroxetine risk during pregnancy
| Patient status | Recommendation |
|---|---|
| Taking paroxetine and planning pregnancy | Advise of possible 1% increase in risk of fetal malformation |
| Switch to another SSRI unless paroxetine has been the only successful therapy for depression | |
| If stopping paroxetine, slowly taper to avoid withdrawal symptoms | |
| Taking paroxetine and is pregnant | Advise of possible 1% increase in risk of fetal malformation |
| Continue paroxetine; a slow taper probably could not be completed before the first-trimester period associated with increased risk of fetal cardiac defects | |
| If any paroxetine exposure in first trimester, order ultrasound to monitor for fetal malformations |
- California Teratogen Information Service (CTIS). Pediatric department, University of California San Diego Medical Center. www.otispregnancy.org/ctis.html
- MGH Center for Women’s Mental Health, Massachusetts General Hospital. Psychiatric disorders during pregnancy and postpartum. www.womensmentalhealth.com
- MOTHERISK Web site. Teratogen information and updates on reproductive risk research. The Hospital for Sick Children, University of Toronto. www.motherisk.org
- Citalopram • Celexa
- Escitalopram • Lexapro
- Fluoxetine • Prozac
- Paroxetine • Paxil
- Sertraline • Zoloft
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
