Tuesday, November 10, 2009

Pregnancy Anxiety Depression SSRI's

There has been a great deal of uncertainty in the last several years about the risks of the selective serotonin reuptake inhibitors (SSRI's) in pregnancy. These medications which include Prozac, Zoloft, Paxil, Celexa, Luvox, and Lexapro are used to treat both depression and anxiety disorders. All of them are considered Category C medications which mean there are not adequate well controlled studies in women to answer the question of safety to the developing child, that caution is advised, and that the benefits of the medication may outweigh the potential risks of not using the medication. As you can see this guideline is extremely vague and doesn't really help the clinician in knowing what to do with a pregnant woman with depression or an anxiety disorder.

There are several areas of concerns for a pregnant woman. First, does the medication cause any congenital malformations? Secondly does the medication increase the risks of low birth weight or preterm delivery? Are there ill effects on the newborn such as lower Apgar scores, withdrawal symptoms, or increased need for Neonatal Intensive Care (NICU) services and finally what is the effect on the developing brain of the fetus when medications are used during pregnancy and how might that affect the cognitive and emotional development of the child? These are a lot of questions and we don't have clear answers. I will leave aide the issue of nursing for now.

What is known at this time is that SSRI's put infants at risk of low preterm birth, lower 5 minute Apgar scores and increased risk of admission to the NICU. Paxil has been associated with a slightly higher risk of congenital abnormalities than in the general population. A number of infants will develop some withdrawal symptoms of increased irritability and poor muscle tone, seizures and respiratory problems. On the other hand untreated depression is linked to preterm birth, lower birth weights, and lower Apgar scores indicating that untreated depression has an adverse effect on the developing fetus as well. Pregnant women with untreated depression ate also at significantly higher risk of alcohol use and abuse (which clearly causes fetal problems) and failure to receive adequate prenatal care. In all the studies it has also been unclear whether the adverse effects are due to the SSRI's themselves or that the SSRI use is not simply linked to women who experience significant depression who develop more problems.

A recent study published in the November issue of Paediatric and Perinatal Epidemiology does give us some new information about untreated anxiety in pregnancy. 763 women were assessed and followed during the course of pregnancy which indicated that mild or moderate anxiety is not associated with any adverse fetal effects but that high levels of anxiety were associated with smaller birth weights and risk of preterm delivery. This does not necessarily help us with the medication issue though. It does tell us that anxiety needs to be assessed and addressed in pregnancy but there are non medication means of reducing anxiety.

So, little by little we are gaining more knowledge but for now the clinician and soon to be mother have to decide in each individual case whether it is better to continue ore use antidepressant medication during pregnancy.

Thought for the day

There are not always easy answers in medicine.

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