There appears to be a slightly raised risk of breathing difficulties among babies of women taking antidepressants in late pregnancy, new research suggests.
Dr. Sophie Grigoriadis of Sunnybrook Health Sciences Center, Toronto, Canada, and her team say that women taking antidepressants during pregnancy may need extra attention. Many factors must be weighed, they write in the British Medical Journal.
“One potential adverse effect to be considered may be persistent pulmonary hypertension (PPHN) of the newborn,” they write. This condition is relatively rare, but causes high blood pressure in the lungs and can lead to low oxygen levels. It can also be more severe if it occurs alongside other conditions.
The team examined the risk by analysing seven previous studies. Reliable information was only available for the class of antidepressant known as selective serotonin reuptake inhibitors (SSRIs).
“Exposure to SSRIs in early pregnancy was not associated with PPHN of the newborn,” they report. But exposure in late pregnancy was linked to more than double the normal risk. This equates to one extra case for every 286 to 351 women taking SSRIs in late pregnancy. It was not possible to see how the risk was altered by cesarean section, body mass index, or preterm delivery, they add.
They conclude, “The risk of PPHN of the newborn seems to be increased for infants exposed to SSRIs in late pregnancy, independent of the potential moderator variables examined. Clinically, the absolute risk of PPHN of the newborn remained low even in the context of late exposure to SSRIs.”
Although the risk is still low, they call for pregnant women with depression to be counseled about the small risk of the lung condition, and informed that it can usually be managed successfully. An awareness of the symptoms of PPHN is important, especially as the symptoms can vary in severity.
They add that decisions about treatment for depression during pregnancy must take into account the potential risks to both the mother and the unborn baby. But they also state, “Depression during pregnancy must not be left untreated, as the potential for untoward effects is not negligible and can extend into the postpartum period.”
On the subject of untreated depression, the authors point out that suicide is no less common during pregnancy than at other times, and may even be the leading cause of death among pregnant women in the U.K..
Among pregnant women who die from suicide, one study found that 68 percent had a major mental illness such as severe depression. Further studies have also found that psychiatric illness is a leading cause of death among pregnant women.
“It is imperative that the mother’s health be weighed heavily in treatment decisions,” write the experts. It is now necessary for research to be carried out to see whether other classes of antidepressants have a similar association, the experts say, as well as the impact of cesarean section, obesity, and preterm delivery.
Commenting on the study, Adam C. Urato, M.D., of Tufts University School of Medicine pointed out that several animal studies support a link between antidepressants during pregnancy and PPHN in offspring.
Urato said the protective effect of SSRIs on suicide risk is unclear, to the extent that the FDA has placed a “black box warning” on SSRI packaging.
“Depressed pregnant women deserve good treatment and care,” he writes. However, given that the SSRIs are associated with pregnancy complications such as PPHN, and antidepressants are not guaranteed to help all patients with depression, “it is clear that the first-line approach to most pregnant women with depression should be with nondrug treatments.”
Responding to Dr. Urato’s comments, the research team agrees there is “limited” evidence from animal studies to support the link, but state, “the clinical relevance of animal research has been questioned.”
They add that they intended to “highlight the potentially negative and serious consequences of untreated major depressive disorder,” rather than “juxtapose the death rate in infants with SSRI-induced PPHN to maternal suicide rates.” But they end by saying, “We do want to highlight that as clinically appropriate, nondrug treatments should be an integral component in the decision-making process.”
A 2006 study comparing babies affected by PPHN with unaffected babies found that significantly more mothers of babies with this syndrome had reportedly used SSRIs in late pregnancy. But a range of later studies produced conflicting results.
Grigoriadis, S. et al. Prenatal exposure to antidepressants and persistent pulmonary hypertension of the newborn: systematic review and meta-analysis. BMJ, 15 January 2013 doi: 10.1136/bmj.f6932