Minimising risks of first trimester exposure: Assessing low mood during pregnancy
This excellent review will be widely read and used by practising clinicians . Prescribing antidepressants in pregnancy is a familiar dilemma, but, at ~5%, the prevalence of antidepressant prescribing in trimester 1 is high enough to make this a public health concern. We identified a dose-response association between selective serotonin reuptake inhibitor (SSRI) exposure and major congenital anomalies or stillbirth and, most specifically, severe congenital heart defects . Without SSRIs, 6 infants in 200 were born with a major anomaly or stillborn: SSRI exposure raised this to 7 in 200. A posteriori subgroup analysis highlighted increased risks to those exposed to substance misuse or heavy alcohol use.
Balancing the number needed to harm from first trimester prescribing, 192, with the severity of potential adverse effects (stillbirth or major anomaly) might entail taking records of SSRI prescriptions as indicating need for additional preconception care. Suggestions include:
o Using electronic health records to identify women of childbearing age prescribed antidepressants.
o Contacting all women prescribed antidepressants, not just those identifying themselves as planning pregnancy, since ~43% UK pregnancies are unplanned.
o Regarding substance misuse or heavy drinking as possible indicators of high risk from SSRI prescribing (6.3%).
o Expanding pre-conception care to include: reviewing therapeutic regimens, particularly high doses of SSRIs; reflecting that ~40% women discontinuing SSRIs after conception do not restart within a year of childbirth , and cognitive behavioural therapy may be equally effective .
o Prescribing folic acid, which may reduce the prevalence of CHD .
o Consider offering women prescribed SSRIs in pregnancy 24-26 week and third trimester scans or alternative continuous monitoring technology to:
• take advantage of advances in monitoring and surgery in utero
• ensure appropriate levels of neonatal care are available at birth.
o Consider offering a modified care pathway to include detailed ultrasound scans with views of the 4 cardiac chambers, outflow tracts and aortic arch plus Doppler investigation of blood flow.
Many of these suggestions, which are offered to supplement the current review , could be embraced by nurse or midwives and the wider multidisciplinary team.
1. Kirby Natalie, Kilsby Anna, Walker Ruth. Assessing low mood during pregnancy BMJ 2019; 366 :l4584
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Competing interests: No competing interests