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Rapid response to:


Selective serotonin reuptake inhibitors in pregnancy and congenital malformations: population based cohort study

BMJ 2009; 339 doi: (Published 23 September 2009) Cite this as: BMJ 2009;339:b3569

Rapid Response:

Septal defects and SSRIs

Dear Dr Pedersen,

I read your article in the BMJ with great interest, and would like to
ask you for some added information. I assume that by septal defects you
refer to atrial and also to ventricular septal defects. My question is how
and when these were diagnosed. Small atrial septal defects are very
common. Those under 3 mm in size all close within the first year, and many
< 6mm diameter do the same. Therefore it makes a difference how they
were diagnosed. If there were routine or very frequent neonatal
echocardiograms, then a huge number of small and perhaps transient ASDs
will be diagnosed. If they were diagnosed clinically and perhaps after 1
year of age, then probably most would be at least moderately large and
clinically significant. The same problem applies to the VSDs, which have
an even higher incidence of spontaneous closure. It is quite possible that
mothers who had taken SSRIs during pregnancy were more intent on seeking
investigation of their infants, with resultant increase in detection of
minimal lesions.

The issue of the size of the defects is crucial for two reasons. If
they are small, they are usually trivial clinically and do not argue
against the use of SSRIs. Furthermore, developmentally the small ASDs and
VSDs may represent delayed closure of a normal septum rather than
teratological interference with a developmental mechanism.

I would appreciate your comments on these views, and also wonder of
you had data about the size and clinical significance of these defects.

Kindest regards, Julien Hoffman,
Professor of Pediatric Cardiology (Emeritus)

Competing interests:
None declared

Competing interests: No competing interests

19 October 2009
Julien I.E. Hoffman
Pediatric cardiologist
University of California, San Francisco, 94143, USA