Safety Considerations

Medication can be effective in treating depression in pregnant women and in women who are breastfeeding. However, some medications may also have negative side effects on some patients who are pregnant or breastfeeding. Potential side effects can include low birth weight, pre-term birth, pulmonary hypertension in newborns, and irritability or agitation in newborns, among other effects.

The chart below is updated as of 2011 and describes the advantages, disadvantages, and potential effects of various antidepressants during pregnancy and breastfeeding [v][vi][vii]

Antidepressant Medication

Advantages During Pregnancy

Disadvantages During Pregnancy

Estimated % of Maternal Dose to Breastfeeding Baby**

Reported Side Effects to Breastfeeding Babies***

Teratogenicity

(causing fetal malformations)

Bupropion (Wellbutrin)

Fewer sexual side effects

Less excess weight gain

Helps with smoking cessation

Limited data available

Lowers seizure threshold

Can cause insomnia

May increase risk of miscarriage

2%

Seizures

Morphologic – limited evidence of cardiac malformations, increased risk for pulmonary hypertension
Behavioral – limited evidence of increased risk of ADHD

Citalopram (Celexa)

Few interactions with other medications

Limited data available

 

0.7% - 9.0%

Uneasy sleep, drowsiness, irritability, weight loss

Morphologic – risk of neural tube defect
Behavioral – none found

Desipramine (Norpramin)

More studies in human pregnancy, including neurodevelopmental follow-up

Maternal side effects additive to pregnancy effects

Orthostatic hypotension, risking decreased placental perfusion

Fetal and neonatal side effects: tachycardia, urinary retention

1%

Agitation of newborn, potential triggering of seizure activity if there is a history of seizures

None found

Desvenlafaxine

None specific, but may be optimal for some individual patients

No systematic studies in human pregnancy

Unknown

Unknown

Unknown

Duloxetine (Cymbalta)

Also treats diabetic peripheral neuropathic pain

 

No systemic studies in human pregnancy

0.1%

Unknown

Unknown

Escitalopram (Lexapro)

Few interactions with other medications

No systemic studies in human pregnancy

3.9% - 7.9%

Enterocolitis

Unknown

Fluoxetine (Prozac)

More studies in human pregnancy, including meta-analysis and neurodevelopmental follow up

More reports of neonatal side effects than some other antidepressants

1.2% - 12%

Excessive crying, irritability, vomiting, watery stools, difficulty sleeping, tremor, somnolence, hypotonia, decreased weight gain, hyperglycemia

Morphologic: increased risk of cardiovascular malformations

Behavioral – none found

Mirtazapine (Remeron)

Fewer sexual side effects

Helps restore appetite in women who are not gaining weight

Less likely to exacerbate nausea and vomiting

Limited data available

Can cause excessive weight gain

Tends to be sedating

May increase risk of preterm birth

0.6% - 2.8%

None

Morphologic – none found
Behavioral - unknown

Nortriptyline (Pamelor)

More studies in human pregnancy, including neurodevelopmental follow-up

Balanced antidepressant; may be effective when selective agents are not

Maternal side effects additive to pregnancy effects

Orthostatic hypotension, risking decreased placental perfusion

Fetal and neonatal side effects: tachycardia, urinary retention

1.3%

None

None found

Paroexetine (Paxil)

Minimal association with cardiovascular malformations but may be optimal for some individual patients

 

More reports of neonatal side effects than most other antidepressants

ACOG recommends fetal echo for all exposed fetuses

0.1% - 4.3%

Irritability, sleepiness, constipation, SIADH

Morphologic – possible increased risk of cardiovascular malformation

Behavioral - unknown

Sertraline (Zoloft)

Relatively well-studied in human pregnancy

Fewer reports of neonatal side effects than other antidepressants

Minimal association with omphalocele and septal defects*

0.4% - 2.3%

Drug of choice by OBs and pediatricians

Morphologic – unlikely increased risk of omphalocele and septic defects

Behavioral – none found

Venlafaxine (Effexor)

None specific, but may be optimal for some individual patients

Limited data available

 

5.2% - 7.6%

Decreased weight gain

Morphologic – none found
Behavioral - unknown

*Absolute risk is small

** These are weight-adjusted estimates that include the agent and its active metabolites.

*** These are based on case reports; this does not mean that it is confirmed to be due to the medication.

References:

  1. American College of Obstetricians and Gynecologists. (2008). Perinatal Depression Screening: Tools for Obstetrician-Gynecologists. Available at: http://mail.ny.acog.org/website/DepressionToolKit.pdf.
  2. Information for Providers on Antidepressants during pregnancy and breast feeding – September 2011. http://www2.illinois.gov/hfs/SiteCollectionDocuments/mch_medchart.pdf
  3. Physicians Desk Reference