Information for Providers on Antidepressants During Pregnancy and Breast Feeding - September 2011

This chart is produced by the University of Illinois at Chicago (UIC) Perinatal Mental Health Project as a summary of research on antidepressants in human pregnancy and breastfeeding.

• Pregnancy data: Data summarized here are from controlled studies in human pregnancy. The Food and Drug Administration (FDA) Pregnancy Risk Categories, as found in the Physicians' Desk Reference1, are based on both animal and human studies. No antidepressants are yet specifically FDA-approved for use during pregnancy. All antidepressants cross the placenta, so there are none that are 'Category A' ("no risk"). Medications that are non-teratogenic in animal studies but have never been studied in humans are classified as 'Category B'. Since teratogenicity does not generalize across species, a 'Category B' classification does not imply greater safety in human pregnancy than a 'Category C' or 'D' classification. Several medications have been shifted from 'Category B' to 'Category C' or 'Category D' as their risks became better known.

• Breastfeeding data: Data about antidepressant effects on breastfeeding babies are predominantly from case reports and case series. For medications with no reported side effects, that does not necessarily mean the medication is "safe"; often it means there are few case reports available. Reported percents of maternal dose to breastfeeding babies are weight-adjusted estimates that include the agent and its active metabolite(s).

*Specific references are available on request.

• Optimal treatment is based on individual patient characteristics and clinical judgment, especially weighing medication risks against risks of untreated illness. Risks of untreated perinatal depression may include preterm birth and other obstetric complications, increased risk of infection and difficult temperament in the infant, impaired parenting, and psychological effects such as impaired cognitive development, emotional and behavioral problems and increased reactivity to stress in children.

• Increased risk of preterm birth and lower gestational age at birth, but without adverse effects on birth weight or Apgar scores

• Increased risk of miscarriage, but rates within norms of the general population

• Neonatal side effects, including respiratory distress, excessive crying, changes in sleep and behavioral state, difficulty sleeping, increased or decreased muscle tone, hyperreflexia, seizures, and/or cardiac arrhythmias.

• Most studies have found no increased risk of gestational hypertension. One retrospective study2 found a possible increased risk of gestational hypertension.

• Possible increased risk of persistent pulmonary hypertension in the newborn with exposure later in pregnancy.

• Most studies have found no increased risk of birth defects. One retrospective study3 found a possible increased risk of anencephaly, craniosynostosis, and omphalocele; another4 found an increased risk of anomalies in general, although absolute risks were small.

• Delay in lactation, however the delay was only for 14 hours on average.

• Kaiser Study showed 2-fold increased risk for Autism spectrum disorder with use of SSRI within one year of delivery and 3-fold increased risk with SSRI use in first trimester.

* Findings from one study at variance with other data, perhaps due to methodological flaws 

© 2011 The Board of Trustees of the University of Illinois, UIC Perinatal Mental Health Project. All rights reserved.

 For questions, references, or permission to reprint, call the UIC Perinatal Mental Health Project at 1-800-573-6121

 1. Physician's Desk Reference. Thomson Reuters. Montvale, NJ. 2. Toh et al. Selective serotonin reuptake inhibitor use and risk of gestational hypertension. Am J Psychiatry. 2009 Mar;166(3):320-8. 3. Alwan, S. et al. Use of selective serotonin-reuptake inhibitors in pregnancy and the risk of birth defects. N Engl J Med. 2007 Jun 28; 356(26):2684-92. 4. Wogelius et al. Maternal use of selective serotonin reuptake inhibitors and risk of congenital malformations. Epidemiology. 2006 Nov;17(6):701-4. 5. Suri et al. Effects of Antenatal Depression and Antidepressant treatment on gestationl age at birth and risk of preterm birth. Am J Psychiatry. 2007 Aug; 164:1206-1213. 6. Figueroa. Use of antidepressants during pregnancy and risk of Attention-Deficit/Hyperactivity Disorder in the offspring. JDBP. 2010 Oct. Vol 31, No.8. 7. Alwan et al. Maternal use of Bupropion and risk of congenital heart defects. Am J Obstet Gynecol 2010.