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05. SSRI Treatment During Pregnancy: A Clinical Case

Published on January 1, 2025 Certification expiration date: January 1, 2028

Amanda Koire, M.D.

Attending Psychiatrist - Brigham and Women's Hospital

Key Points

SSRIs as a class are not consistently associated with increased risk of congenital malformations above baseline risk.
Switching from an effective SSRI to another during pregnancy may disrupt maternal mood stability and result in unnecessary fetal exposures.
Tapering or discontinuing SSRIs prior to delivery does not consistently reduce the risk of postnatal adaptation syndrome, which is generally self-limited.

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Slides and Transcript

Slide 1 of 7

Let’s now discuss another clinical case in which we manage SSRI treatment during pregnancy.

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Ms. B is a G2 P1 with history of generalized anxiety disorder requesting consultation about management of fluoxetine 20 mg during pregnancy. She is at 6 weeks gestational age and is concerned about the risks of the medication to the fetus as she has read that SSRIs may cause heart defects and withdrawal symptoms after birth. She asks if she should discontinue entirely, asked the PCP prescribing her medication about switching to sertraline and/or taper during the third trimester. She does plan to breastfeed. She wonders, are SSRIs associated with malformations? Should I switch to sertraline? And should I discontinue my antidepressant in the third trimester to prevent withdrawal in the neonate? Let’s now address all those points.

SSRI Treatment During Pregnancy: A Clinical Case Slide 2 of 7

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SSRIs as a class have not been consistently associated with an elevated risk of congenital malformations above baseline risk. If fluoxetine is already effective for her, there is risk in switching to another SSRI. The new medication may not work as well to maintain her mood stability and put her at risk of a mood episode.

References:

Huybrechts, K. F., Palmsten, K., Avorn, J., Cohen, L. S., Holmes, L. B., Franklin, J. M., Mogun, H., Levin, R., Kowal, M., Setoguchi, S., & Hernández-Díaz, S. (2014). Antidepressant use in pregnancy and the risk of cardiac defects. New England Journal of Medicine, 370(25), 2397-2407. https://doi.org/10.1056/NEJMoa1312828
Wisner, K. L., Oberlander, T. F., & Huybrechts, K. F. (2020). The association between antidepressant exposure and birth defects-are we there yet? JAMA Psychiatry, 77(12), 1215-1216. https://doi.org/10.1001/jamapsychiatry.2020.1512

SSRI Treatment During Pregnancy: A Clinical Case Slide 3 of 7

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When she is asking a question about withdrawal symptoms after birth, it’s likely that she is referring to postnatal adaptation syndrome. Postnatal adaptation syndrome occurs in up to 25% of newborns born to women who took SSRIs during pregnancy compared to about 10% of newborns if their mothers were not taking SSRIs during pregnancy. So it can occur in either case. It is best described as taking a little bit more time to adapt to life outside the womb, sometimes increased irritability and jitteriness. Postnatal adaptation syndrome does not represent withdrawal or a discontinuation syndrome. It is generally self-limited and resolves in a few days on its own.

References:

Warburton, W., Hertzman, C., & Oberlander, T. F. (2010). A register study of the impact of stopping third trimester selective serotonin reuptake inhibitor exposure on neonatal health. Acta Psychiatrica Scandinavica, 121(6), 471-479. https://doi.org/10.1111/j.1600-0447.2009.01490.x
Suri, R., Hellemann, G., Stowe, Z. N., Cohen, L. S., Aquino, A., & Altshuler, L. L. (2011). A prospective, naturalistic, blinded study of early neurobehavioral outcomes for infants following prenatal antidepressant exposure. Journal of Clinical Psychiatry, 72(7), 1002-1007. https://doi.org/10.4088/JCP.10m06135

SSRI Treatment During Pregnancy: A Clinical Case Slide 4 of 7

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Slide 5 of 7

There is not any consistently demonstrated benefit in tapering or discontinuing medication prior to delivery in terms of the risk of postnatal adaptation syndrome. However, there is an increased risk to maternal mood destabilization. If the patient is already on an effective SSRI, don’t switch to another medication which may not work as well. There’s no specific benefit in doing so. Both fluoxetine and sertraline are considered generally safe in pregnancy and lactation.

References:

Cohen, L. S., Altshuler, L. L., Harlow, B. L., Nonacs, R., Newport, D. J., Viguera, A. C., Suri, R., Burt, V. K., Hendrick, V., Reminick, A. M., Loughead, A., Vitonis, A. F., & Stowe, Z. N. (2006). Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA, 295(5), 499-507. https://doi.org/10.1001/jama.295.5.499
Warburton, W., Hertzman, C., & Oberlander, T. F. (2010). A register study of the impact of stopping third trimester selective serotonin reuptake inhibitor exposure on neonatal health. Acta Psychiatrica Scandinavica, 121(6), 471-479. https://doi.org/10.1111/j.1600-0447.2009.01490.x

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To wrap up, here are some key points for this section. SSRI use in pregnancy is not considered to increase risk of congenital malformations. If an SSRI is clinically effective for an individual, avoid switching medications during pregnancy as this may disrupt maternal euthymia and result in unnecessary fetal exposures.

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Slide 7 of 7

Postnatal adaptation syndrome occurs at higher rates in newborns who are SSRI-exposed in utero but discontinuing or tapering prior to birth does not consistently reduce this risk.

SSRI Treatment During Pregnancy: A Clinical Case Slide 7 of 7

Next Section

06. Valproate in Pregnancy: Key Considerations

Learning Objectives:

After completing this activity, the learner will be able to:

Describe the prevalence and barriers to treatment of perinatal mental health conditions.
Explain how pregnancy affects medication efficacy through physiological changes and recognize when dose adjustments may be needed for common psychiatric medications
Evaluate and discuss the risks and benefits of continuing versus discontinuing psychiatric medications during pregnancy, incorporating evidence-based data to inform shared decision-making with patients

Original Release Date: January 1, 2025
Expiration Date: January 1, 2028

Expert: Amanda Koire, M.D.
Medical Editor: Flavio Guzmán, M.D.

Relevant Financial Disclosures:
None of the faculty, planners, and reviewers for this educational activity have relevant financial relationships to disclose during the last 24 months with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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Artificial Intelligence (AI) Use DisclosureArtificial intelligence (AI) tools may have been used in limited stages of developing this activity (e.g., drafting or language refinement). The specific tool, version, and date of use are documented internally.AI does not determine clinical recommendations. All content is reviewed, verified, and approved by the listed faculty and medical editors, and reflects independent human clinical judgment consistent with ACCME Standards for Integrity and Independence in Accredited Continuing Education.