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Practice Practice Pointer

Assessing low mood during pregnancy

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4584 (Published 29 July 2019) Cite this as: BMJ 2019;366:l4584

Rapid Response:

Minimising risks of first trimester exposure: Assessing low mood during pregnancy

This excellent review will be widely read and used by practising clinicians [1]. 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 [2]. 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 [3], and cognitive behavioural therapy may be equally effective [4].
o Prescribing folic acid, which may reduce the prevalence of CHD [5].
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[6].

Many of these suggestions, which are offered to supplement the current review [1], could be embraced by nurse or midwives and the wider multidisciplinary team.

References
1. Kirby Natalie, Kilsby Anna, Walker Ruth. Assessing low mood during pregnancy BMJ 2019; 366 :l4584
2. Jordan S , Morris JK , Davies GI, Tucker D, Thayer DS, Luteijn JM, Morgan M, Garne E, Hansen AV, Klungsøyr K, Engeland A, Boyle B, Dolk H (2016) Article Source: Selective Serotonin Reuptake Inhibitor (SSRI) Antidepressants in Pregnancy and Congenital Anomalies: Analysis of Linked Databases in Wales, Norway and Funen, Denmark Plos One 11(12): e0165122. doi: 10.1371/journal.pone.0165122
3. Charlton RA, Jordan S, Pierini A, Garne E, Neville AJ, Hansen AV, et al. Selective serotonin reuptake inhibitor prescribing before, during and after pregnancy: a population-based study in six European regions. BJOG. 2015;122(7):1010-20. doi: 10.1111/1471-0528.13143.
4. Amick HR, Gartlehner G, Gaynes BN, Forneris C, Asher GN, Morgan LC, et al. Comparative benefits and harms of second generation antidepressants and cognitive behavioral therapies in initial treatment of major depressive disorder: systematic review and meta-analysis. BMJ. 2015;351:h6019. PubMed PMID: 26645251; PubMed Central PMCID: PMCPMC4673103.
5. Ionescu-Ittu R, Marelli AJ, Mackie AS, Pilote L. Prevalence of severe congenital heart disease after folic acid fortification of grain products: time trend analysis in Quebec, Canada. BMJ. 2009;338:b1673. PubMed PMID: 19436079; PubMed Central PMCID: PMCPMC2682153.
6. Li Y, Hua Y, Fang J, Wang C, Qiao L, Wan C, et al. Performance of different scan protocols of fetal echocardiography in the diagnosis of fetal congenital heart disease: a systematic review and meta-analysis. PLoS One. 2013;8(6):e65484. doi: 10.1371/journal.pone.0065484. PubMed PMID: 23750263; PubMed Central PMCID: PMCPMC3672155.

Competing interests: No competing interests

23 August 2019
Sue E. Jordan
Professor of health services research
Swansea University
Department of Nursing, Swansea University, Swansea SA2 8PP, UK