Considerations for antidepressant use in pregnancy

If an antidepressant is required during pregnancy, consider the:

principles of psychotropic use during pregnancy
amount of data on the antidepressant (see below)
risk of teratogenicity, miscarriage and preterm birth, poor neonatal adaptation, persistent pulmonary hypertension of the neonate and neurodevelopmental disorders
patient’s risk of gestational hypertension, postpartum haemorrhage—low-quality data have associated antidepressant use during pregnancy with an increased risk of gestational hypertension and postpartum haemorrhage.

Antidepressant safety data in pregnancy are limited—selective serotonin reuptake inhibitors (SSRIs) have the largest amount of pregnancy safety data of all antidepressants.

If an antidepressant is required for the first time during pregnancy, use an SSRI other than paroxetine because of its association with cardiac malformations and miscarriage. Sertraline is most commonly used because it has the most safety data. If the patient intends to breastfeed, avoid starting fluoxetine during pregnancy because, of the SSRIs, it has the highest reported concentrations in breastmilk.

If a patient is already taking paroxetine or fluoxetine, the evidence of harm is not sufficiently strong to warrant switching to a different SSRI. Discuss the concerns so that the patient can make an informed decision about treatment—see Principles of psychotropic use during pregnancy.

Although less data are available to support its use in pregnancy, venlafaxine appears to have a similar risk profile to SSRIs in terms of teratogenicity and poor neonatal adaptation. The risk of miscarriage is similar to that of paroxetine.

Very limited data suggest use of mirtazapine or a tricyclic antidepressant (TCA) is not associated with congenital malformations. Cases of neonatal adaptation problems have been reported.

The safety during pregnancy of agomelatine, desvenlafaxine, duloxetine, mianserin, moclobemide, phenelzine, reboxetine, tranylcypromine and vortioxetine has not been adequately studied. Only continue or start these drugs in pregnancy if the harm–benefit analysis supports it.

The association of antidepressant use with low birth weight/small-for-gestational age infants is controversial. Studies do not adequately control for depression, which has been shown to contribute to low birth weight/small-for-gestational-age infants.

If a decision is made to switch or stop the antidepressant, see Switching antidepressants or Stopping an antidepressant.