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depression during pregnancy

Epidemiology: a) 14% of women [1] b) peak incidence at 32 weeks of gestation c) pregnancy NOT protective for women with depression [3] Complications: - women with severe recurrent major depression who stop pharmacotherapy are at high risk for relapse Special laboratory: - depression during pregnancy associated with enriched DNA methylation patterns in cord blood, lymphocytes, & hippocampi (post-mortem) of offspring involving genes that regulate immune function & stress reactivity [8] Management: 1) general a) adequate treatment of depression is essential, ideally beginning before conception b) clinicians & patients should make decisions about pharmacotherapy collaboratively c) psychiatric referral for patients with severe depression, acute suicidality, psychosis, or bipolar disorder [6] d) both maternal depression & prenatal antidepressants can affect offspring [8] 2) psychotherapy (preferably cognitive-behavioral therapy or interpersonal psychotherapy) is recommended for treatment of mild-to-moderate depression during pregnancy [6] 3) antidepressant use during pregnancy is safe [10] - depression during pregnancy associated with preterm birth & low Apgar score regardless of antidepressant use [10] - neither depression nor antidepressant use associated with low birth weight or small for gestational age delivery [10] 4) pharmacologic agents (antidepressants) a) selective serotonin re-uptake inhibitor (SSRI)* [2,4] - may be risk to fetus, but absolute risks are small [9] - sertraline probably safest for fetus - not associated with septal defects [9] - citalopram may increase risk of - septal heart defects when used early in pregnancy [5] - probably not [9] - marginal link with neural tube defects [9] - fluoxetine (Prozac) is associated with - ventricular septal defects - right ventricular outflow tract obstruction cardiac defects - craniosynostosis - paroxetine (Paxil) is associated with - anencephaly - atrial septal defects - right ventricular outflow tract obstruction cardiac defects - gastroschisis - omphalocele - neonatal withdrawal, neonatal pulmonary hypertension [4] b) tricyclic antidepressants c) a few reports of irritability, respiratory problems & seizures in infants born to women taking SSRIs or Effexor [2] d) electroconvulsive therapy is an option in severe depression [6] * preferred agents

Related

major depression perinatal depression

General

depression pregnancy disorder; obstetric disorder; pregnancy complication

References

  1. Journal Watch 21(19):156-7, 2001 Evans et al BMJ 323:257, 2001
  2. Prescriber's Letter 11(8): 2004 Treatment of Antenatal and Postpartum Depression Detail-Document#: 200810 (subscription needed) http://www.prescribersletter.com
  3. Cohen LS et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 2006 Feb 1; 295:499-507. PMID: 16449615
  4. Levinson-Castiel R et al, Neonatal abstinence syndrome after in utero exposure to selective serotonin reuptake inhibitors in term infants. Arch Pediatr Adolisc Med 2006; 160:173 PMID: 16461873 - Chambers CD et al, Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med 2006; 354:579 PMID: 16461545
  5. Pedersen LH et al Selective serotonin reuptake inhibitors in pregnancy and congenital malformations: population based cohort study BMJ 2009;339:b3569 PMID: 19776103 http://www.bmj.com/cgi/content/full/339/sep23_1/b3569 - Chambers C Selective serotonin reuptake inhibitors and congenital malformations BMJ 2009;339:b3525 http://www.bmj.com/cgi/content/extract/339/sep23_1/b3525
  6. Yonkers KA et al The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry. 2009 Sep-Oct;31(5):403-13. PMID: 19703633 - Yonkers KA et al The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists Obstet Gynecol. 2009 Sep;114(3):703-13. PMID: 19701065 - Yonkers KA et al Typical somatic symptoms of pregnancy and their impact on a diagnosis of major depressive disorder. Gen Hosp Psychiatry. 2009 Jul-Aug;31(4):327-33. Epub 2009 Apr 15. PMID: 19555792
  7. Prescriber's Letter 16(10): 2009 Treatment of Depression in Pregnancy Detail-Document#: 251006 (subscription needed) http://www.prescribersletter.com
  8. Nemoda Z et al. Maternal depression is associated with DNA methylation changes in cord blood T lymphocytes and adult hippocampi. Transl Psychiatr 2015 Apr 7; 5:e545. PMID: 25849984 http://www.nature.com/tp/journal/v5/n4/full/tp201532a.html - Brandlistuen RE et al. Behavioural effects of fetal antidepressant exposure in a Norwegian cohort of discordant siblings. Int J Epidemiol 2015 Apr 14 PMID: 25873178 http://ije.oxfordjournals.org/content/early/2015/04/14/ije.dyv030
  9. Reefhuis J et al Specific SSRIs and birth defects: bayesian analysis to interpret new data in the context of previous reports. BMJ 2015;351:h3190 PMID: 26156519 http://www.bmj.com/content/351/bmj.h3190
  10. Vlenterie R, van Gelder MMHJ, Anderson HR et al. Associations between maternal depression, antidepressant use during pregnancy, and adverse pregnancy outcomes: An individual participant data meta-analysis. Obstet Gynecol 2021 Oct; 138:633-646. PMID: 34623076 https://lww.com/pages/results.aspx?txtKeywords=10.1097%2fAOG.0000000000004538