SSRIs during pregnancy

Be careful with fluoxetine. It reaches high levels in breast milk and recent data suggest birth-defect risks may be higher than once thought....

Women will ask you whether they should stop taking SSRIs during pregnancy due to recent headlines about autism risk. They're hearing about a new study that suggests taking SSRIs in the second or third trimester is linked to a higher risk of autism.

But this study has flaws and does not prove antidepressants CAUSE autism and other studies have NOT found a link. Plus stopping an antidepressant may have downsides. For example, UNtreated depression may contribute to low birth weight, postpartum depression, etc. And new evidence suggests that SSRI therapy is related to a LOWER risk of preterm birth and C-section.

Help weigh the risks and benefits of antidepressants in pregnancy. Recommend psychotherapy when possible but add an SSRI if needed. Lean toward sertraline. It doesn't seem to be strongly linked to birth defects and is generally safe in breastfeeding.

Be careful with fluoxetine. It reaches high levels in breast milk and recent data suggest birth-defect risks may be higher than once thought. Also try to avoid paroxetine in the first trimester due to a possible higher risk of heart defects. Try to switch antidepressants ideally BEFORE pregnancy to help minimize risks. Consider bupropion for a woman who's also trying to quit smoking risks during pregnancy seem low. Be aware the jury's still out on SNRIs. Duloxetine doesn't seem to be a problem but venlafaxine might increase preeclampsia risk. See our note, "Medication safety and drug exposure in pregnancy".

References

Boukhris T, Sheehy O, et al. Antidepressant Use During Pregnancy and the Risk of Autism Spectrum Disorder in Children. JAMA Pediatr. 2016 Feb;170(2):117-24.
Reefhuis J, Devine O, Friedman JM, Louik C, Honein MA; National Birth Defects Prevention Study. Specific SSRIs and birth defects: Bayesian analysis to interpret new data in the context of previous reports. BMJ. 2015 Jul 8;351:h3190.
Malm H, Sourander A, Gissler M, et al. Pregnancy Complications Following Prenatal Exposure to SSRIs or Maternal Psychiatric Disorders: Results From Population-Based National Register Data. Am J Psychiatry. 2015 Dec;172(12):1224-32.