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Letters Paroxetine during pregnancy

Authors’ reply to Mangin and colleagues

BMJ 2011; 343 doi: (Published 10 August 2011) Cite this as: BMJ 2011;343:d5079
  1. Shaughn O’Brien, professor of academic obstetrics and gynaecology1,
  2. Andrea Rapkin, professor of obstetrics and gynaecology2,
  3. Lorraine Dennerstein, professorial fellow3,
  4. Tracy Nevatte, postdoctoral research associate4
  1. 1Keele University and University Hospital of North Staffordshire, Staffordshire, UK
  2. 2David Geffen School of Medicine at UCLA, Department of Obstetrics and Gynecology, Box 951740, Los Angeles, CA, USA
  3. 3National Aging Research Institute, Department of Psychiatry, University of Melbourne, Vic, Australia
  4. 4Keele University, Institute of Science and Technology in Medicine, Guy-Hilton Research Centre, Stoke on Trent, Staffordshire ST4 7QB, UK
  1. t.nevatte{at}

It has been called to our attention that our statement that selective serotonin reuptake inhibitors (SSRIs) have not been shown to be teratogenic is in error.1

Selective serotonin reuptake inhibitors cross the placenta and are found in breast milk.2 Although the risk of major malformations is very low, the severity of the potential structural and behavioural risks for the infant associated with taking SSRIs and selective noradrenaline reuptake inhibitors (SNRIs) in the first trimester of pregnancy is real and must be weighed against the risks associated with severe depression and anxiety in pregnancy.2 During late pregnancy the occurrence of postnatal SSRI related symptoms increases to 30% of exposed infants.2 Paroxetine has been associated with right ventricular outflow tract defects, cleft lip or palate, and digestive system defects; luoxetine has been associated with an increased risk of isolated ventricular septal defects.3 4 However, current data on the associated risks of SSRI use during the first trimester are limited and further well designed studies are required.5 6 Even so, the small risk associated with SSRIs should be taken into consideration when discussing treatment plans with a patient.

Women with core premenstrual disorder who do not have a coexistent psychiatric disorder should be warned of the small but potentially severe fetal risks, provided with effective contraceptive methods, and stop taking the SSRI/SNRI as soon as they have an obviously delayed menstrual period or a positive pregnancy test. The requirement for SSRI/SNRI treatment should disappear once a woman with core premenstrual disorder becomes pregnant as the premenstrual symptoms improve. Those with coexisting psychiatric disorders, such as depression, should be managed jointly with a psychiatrist, and whether to continue such drug treatment in the event of conception should be decided when the drugs are first prescribed and then reassessed at frequent intervals.


Cite this as: BMJ 2011;343:d5079


  • Competing interests: No support from any organisation for the submitted work [clinical review article]; SO’B and LD have been reimbursed by Bayer Schering (the manufacturer of Yaz) for attending several conferences, consulted to the company, been paid for running educational programmes and speaking at symposiums, and received research grants from the company; SO’B has received fees for participating in an expert advisory group for the National Institute for Health and Clinical Excellence (NICE) and is editor in chief of obstetrics and gynaecology for Map of Medicine; SO’B has also been paid by AstraZeneca for attending a symposium and speaking; the International Society for Premenstrual Disorders (ISPMD), which is chaired by SO’B, received an unrestricted educational grant from Bayer Schering for the consensus meeting; Both SO’B and TN have received research funding for Symptometrics, the Keele University/University Hospital of North Staffordshire spin-out company, and for which they also have a contract as inventors of the innovation, which may generate income in the future. AR has no competing interests.


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