Between 14 and 23 percent of women struggle with some symptoms of depression during pregnancy, according to The American Congress of Obstetricians and Gynecologists.
Pregnant women are at risk of high blood pressure (preeclampsia), an increased chance of having a C-section, and continued depression after delivery (postpartum depression) if these mental disorders are left untreated. In severe cases, these conditions may lead to pregnancy termination and suicide.
Untreated depression and anxiety disorders in pregnant women pose risks to developing babies, including:
- Premature birth (before 37 weeks)
- Low birth weight
- Respiratory distress and jitteriness outside the womb
- Lower health of newborns after delivery (APGAR score)
- Birth defects and other complications related to a mother’s substance abuse (drugs, alcohol and tobacco use)
A range of emotions often triggered during pregnancy may make it more difficult to cope with depression and anxiety disorders for women previously diagnosed with these conditions.
Selective serotonin reuptake inhibitors, known as SSRIs, have become the standard for antidepressant treatment during pregnancy. The drugs work by preventing receptors in the brain from reabsorbing already released serotonin, a neurotransmitter thought to be a contributor to feelings of happiness and well-being.
Studies suggest women who take SSRIs while pregnant are at higher risk of having a baby born with birth defects or developmental disorders
Unfortunately, some studies suggest women who take SSRIs while pregnant are at higher risk of having a baby born with several physical birth defects as well as autism spectrum or developmental disorders.
Pregnant women dealing with depression or anxiety face a difficult decision. They can risk potential harm to their babies by taking SSRIs or face other possible dangers to themselves and their babies if the disease is left untreated.
The U.S. Food and Drug Administration (FDA) urges women to carefully weigh the benefits and risks of taking antidepressants to treat depression during pregnancy.
Common SSRIs Prescribed During Pregnancy
SSRIs are the most common class of antidepressants prescribed to pregnant women, according to a study from the National Center on Birth Defects and Developmental Disabilities (NCBDDD) at the Centers for Disease Control and Prevention (CDC).
Most SSRIs fall under the FDA’s Category C pregnancy risk, meaning animal reproduction studies have shown adverse effects to animal fetuses, but there are insufficient studies of damage to human fetuses.
The one exception, Paxil (paroxetine), carries a Category D warning, which notates positive evidence of human fetal risk based on clinical studies. However, doctors can still prescribe Paxil to pregnant women if they feel the need outweighs the risk.
A 2015 study published in the British Medical Journal found that birth defects occur 2 to 3.5 times more frequently among newborns of women treated with Paxil and Prozac early in pregnancy. The study analyzed 17,952 mothers of infants with birth defects and 9,857 mothers of infants without birth defects.
A separate study published the same year in JAMA Pediatrics showed mothers who take SSRIs during the second and third trimester have a significant increased risk of having a baby with autism spectrum disorder.
Other studies refute these findings, suggesting untreated depression and anxiety disorders put mothers at equal or higher risk of serious complications. Most experts believe that while SSRIs can increase the risk of birth defects, the chance of giving birth to child with a congenital disorder remains low.
Heart, Abdominal Defects Are Most Common
The NCBDDD study reassessed 12 years of data from the National Birth Defects Prevention Study, one of the largest collaborative case-control studies focused on factors that increase birth defects.
Using Bayesian analysis, researchers analyzed pregnant women taking SSRIs between 1997 and 2009 at 10 sites in the U.S., comparing women who had a baby with a birth defect to those who did not.
Researchers confirmed two reported links between Prozac and birth defects and five reported links between Paxil and certain birth defects.
The links between these drugs and birth defects are:
Heart Defects: Specifically ventricular tract obstruction, where either the right or left ventricular outflow tract of the heart is blocked or obstructed.
Craniosynostosis: One or more fibrous joints in an infant’s skull fuse together.
Anencephaly: Causes a baby to be born missing a portion of the skull, brain and scalp.
Atrial Septal Defect: A hole in the heart wall between the heart’s upper chambers.
Ventricular Tract Obstruction: Outflow tract of the heart is blocked.
Gastroschisis: The baby’s intestines stick outside the body through a hole near the belly button.
Omphalocele: Occurs when some of the bowels herniate out into the umbilical cord and remain outside the abdomen after birth.
The NCBDDD study did not confirm previously reported links between Zoloft — the SSRI used most often in the study — and birth defects. Celexa (citalopram) and Lexapro (escitalopram), two similar SSRIs manufactured by Forest Laboratories, were the least commonly used antidepressants in the study population, and researchers did not find any definitive link to birth defects to confirm previous reports.
Other Birth Defects Associated with SSRIs
The association between SSRIs and developmental disorders remains controversial, with numerous conflicting studies.
There have been countless lawsuits filed against drugmakers by families alleging SSRIs are responsible for their children’s congenital anomalies. In 2010, GlaxoSmithKline, maker of Paxil, settled approximately 800 birth defect lawsuits for $1.14 billion.
Aside from heart and abdominal wall defects, some of the most common birth defects associated with SSRIs include persistent pulmonary hypertension of the newborn (PPHN), respiratory distress and cleft palate or lip. Some studies have also linked autism to SSRI use.
Persistent Pulmonary Hypertension of the Newborn
In a baby born with PPHN, the circulatory system doesn’t switch over to breathing air. Instead, the blood flow continues to bypass the lungs, depriving the vital organs of oxygen.
Common symptoms of PPHN include quick breathing (tachypnea), rapid heart rate (tachycardia), sluggish behavior and a blue tint to the skin (cyanosis).
In 2006, the FDA issued a Public Health Advisory warning of the potential risk of PPHN in babies of mothers who took antidepressants during pregnancy. But the agency issued a follow-up in 2011, noting subsequent studies had clouded the PPHN issue and that health care professionals should not alter their current clinical practice of treating depression during pregnancy.
A 2014 study published in the British Medical Journal found more evidence that SSRIs taken during pregnancy increase the risk of PPHN. Specifically, researchers found that babies exposed to this class of antidepressants during the late stages of pregnancy were at increased risk of PPHN.
In general, about 7 percent of newborn babies experience respiratory distress syndrome (RDS), or trouble breathing. But for babies born to mothers who took an antidepressant during the third trimester, the number can escalate.
Doctors can treat babies with RDS by increasing the oxygen levels either through a nasal tube or a ventilator. Both methods have to be closely monitored because too much oxygen can cause blindness and too much pressure can further damage the baby’s lungs. Drugs used to treat respiratory distress, called surfactants, can also be administered through a tube in the baby’s windpipe.
Severe respiratory distress could be a symptom of a PPHN.
In its prescribing information, the manufacturer of Prozac — Eli Lilly & Company — actually warns patients that babies exposed to the antidepressant in the third trimester have developed respiratory distress.
Other reported complications include:
- Temperature instability
- Feeding difficulty
- Bluish discoloration of skin (Cyanosis)
Cleft Lip and Palate
Exposure to antidepressants can inhibit fetal growth, especially in the first two months when the baby’s head forms. During this process, the upper lip develops before the palate, or roof of the mouth.
When an antidepressant crosses the placenta and interferes with the normal growth of a fetus, it can result in a cleft lip or cleft palate, facial gaps that are produced when structures do not fully fuse.
The CDC estimates that around 7,000 babies are born with either of cleft lip or cleft palate each year in the U.S.
A case study of SSRIs from 2011 reported links from that class of drugs taken during the first trimester of pregnancy to birth defects related to serotonin-related genes. Cleft palate is one of those related defects.
Researchers are studying not only physical birth defects, but also the long-term neurological effects of SSRIs on fetuses. Autism diagnoses are on the rise in the U.S. and doctors are now studying how medications affect a baby’s development in the womb.
The association between the use of SSRI drugs during pregnancy and autism spectrum disorder (ASD) in offspring remains highly contested.
A 2015 study published in JAMA Pediatrics by Anick Berard of the University of Montreal found that SSRIs increase the risk of babies developing autism by up to 200 percent when taken during pregnancy, specifically the final two trimesters. All types of antidepressants increased the risk by 87 percent.
However, critics of the report claim the study doesn’t take into consideration that parental psychiatric illness itself is associated with an increased risk of ASD. Two studies published in 2013 controlling for these factors found no significant association between parental exposures to antidepressants and ASD.
Discontinuing Antidepressants During Pregnancy
Studies show that women with severe depression and anxiety disorders who suddenly stop using SSRIs or other antidepressants during pregnancy may experience serious consequences.
In a 2006 study, 68 percent of women who discontinued use of SSRIs experienced a relapse of major depression, compared to 26 percent of pregnant women who maintained their medication throughout their pregnancy.
Discontinuing SSRIs or other antidepressants can lead to withdrawal symptoms including fatigue, severe headaches, poor coordination, disorientation and stomach cramps.
In severe cases of discontinuation syndrome, pregnant women may experience worsening depression, suicidal thoughts or behaviors and even thoughts of terminating a previously desired pregnancy. Doctors may choose to slowly wean pregnant women with a history of antidepressant use off the medication to avoid these withdrawal symptoms.
If you are pregnant or plan to become pregnant and use SSRIs, it is important to consult with your doctor to understand and carefully weigh the benefits of the medications with the potential risks.