Which antidepressants are commonly used in pregnancy and what are major cautions?

• A. Selective serotonin reuptake inhibitors are contraindicated in pregnancy.
• B. Tricyclic antidepressants are the preferred choice.
• C. Monoamine oxidase inhibitors are preferred in pregnancy.
• D. SSRIs such as sertraline are commonly used; caution with potential neonatal adaptation syndrome.

Answer: (D)

Treating depression during pregnancy focuses on helping the mother stay well while minimizing risk to the fetus and newborn. The antidepressant class most commonly used during pregnancy is the selective serotonin reuptake inhibitors, with sertraline frequently chosen because of its relatively favorable safety data and well-understood pharmacology in pregnancy.

A key caution with these medications is the potential for neonatal adaptation syndrome in babies exposed late in pregnancy. Newborns can show irritability, jitteriness, feeding difficulties, tremors, sleep disturbances, respiratory distress, and temperature instability after birth. These symptoms are generally self-limited and reversible with supportive care, but they require observation and can be distressing for both infant and family. There is also some discussion in the literature about risks such as persistent pulmonary hypertension of the newborn with late-pregnancy SSRI exposure and, for certain agents, a higher risk of specific congenital malformations if exposure occurs in the first trimester (notably with paroxetine, which is why it is less favored).

In practice, if ongoing antidepressant therapy is needed during pregnancy, a clinician often opts for an SSRI like sertraline at the lowest effective dose, with close coordination between obstetrics and pediatrics and careful monitoring at delivery for signs of neonatal adaptation. Abrupt discontinuation is generally avoided to prevent a relapse of maternal depression, which itself poses risks to both mother and baby.