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Selective serotonin reuptake inhibitors during pregnancy and risk of persistent pulmonary hypertension in the newborn: population based cohort study from the five Nordic countries

BMJ 2012; 344 doi: (Published 12 January 2012) Cite this as: BMJ 2012;344:d8012

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Re: Selective serotonin reuptake inhibitors during pregnancy and risk of persistent pulmonary hypertension in the newborn: population based cohort study from the five Nordic countries

This new Nordic series makes a useful and important contribution to the catalogue of safety data relating to the use of psychotropic drugs in pregnancy. In interpreting such data in a clinical context however; it
is crucial for medical practitioners to temper their perception of neonatal risks from maternal medication, with a broad consideration of the neonatal implications of sub-optimally treated maternal depression.

In addition to the well-publicised phenomenon of impaired maternal-infant bonding; maternal depression can have a number of other decisive implications for the offspring. The effects of maternal depression can begin to exert themselves in-utero and continue throughout the life course of the individual. For example maternal depression and anxiety are significant risk factors for pre term birth and low birth-weight respectively. Some studies have found that sub-optimally treated maternal depression, can as much as double the risk of pre-term labour. Both pre-term labour and being of low birth weight have serious implications in terms of morbidity and mortality; in a number of countries such as the UK for example, prematurity related conditions are the pre-eminent cause of infant death. Maternal depression and the associated chronic stress have also been demonstrated to produce sustained effects on the offspring’s gene expression. This can manifest as a lifelong impairment in the offspring’s physiological response to the external environment, conferring an increased risk of mental health disorders and chronic metabolic conditions such as cardiovascular disease and diabetes.

A common scenario in the ante-natal setting is one in which women present to hospital services with a history of depression, having had their anti-depressant medication stopped in the first trimester. After considering the safety data from a number of sources, medical practitioners in the community will often err on the side of caution and stop psychotropic medications completely - believing this to be in the best interests of the developing embryo / fetus. In many cases this is no doubt the correct decision and many women cope well during and after pregnancy even without medication. In women with more than a mild depression however, is not unusual to have to restart antidepressant medication as their coping mechanisms are gradually overwhelmed by the additional stresses that can be associated with pregnancy. If we extrapolate possible neonatal risks in these women, which exert themselves effects via insidious neuro-endocrine mechanisms throughout the antenatal period; we are compelled to consider whether it may have been better to keep them on their antidepressants in the first place. The process of restarting medications in women, who may have had them stopped under the premise of reducing fetal / neonatal risk; can pose a problem in itself. Underlying feelings of guilt and the perception that they may be unduly harming their unborn baby – can lead to significant problems with compliance.

Predicting the risk to a neonate / infant whose mother suffers with depression is therefore very complex. In light of this, risk stratification should not be limited to purely considering the potential side effects of psychotropic medications. The effects of reducing maternal depression through the use of psychotropic medications may have potential benefits that outweigh the neonatal risks conferred by the use of the drugs. Medical practitioners must take this into account when advising women about pharmacological treatment of depression during pregnancy if they wish to achieve the best possible outcome for mother and baby.

Competing interests: No competing interests

05 February 2012
Dileepa A` Wijeratne
Obstetrics & Gynaecology SpR
Yorkshire deanery
Pinderfields Hospital, Wakefield, WF1 4DG