The use of antidepressant medication in pregnancy

Social determinants in prenatal antidepressant use and continuation: Systematic review and meta-analysis

INTRODUCTION

Depression is one of the most common co-morbidities during pregnancy; with severe symptoms, antidepressants are sometimes recommended. Social determinants are often linked with antidepressant use in the general population, and it is not known if this is the case for pregnant populations. Our objective was to determine if social determinants are associated with prenatal antidepressant intake via a systematic review and meta-analysis.

METHODS

A systematic search of five databases was conducted to identify publications from inception to October 2022 that reported associations with prenatal antidepressant intake (use/continuation) and one or more social determinants: education, race, immigration status, relationship, income, or employment. Eligible studies were included in random effects meta-analyses.

RESULTS

A total of 23 articles describing 22 studies were included. Education was significantly and positively associated with prenatal antidepressant continuation and heterogeneity was moderate. (Odds ratio = 0.83; 95% CI, 0.78 to 0.89; p < 0.00001; I2  = 53%). Meta-analyses of antidepressant use and education, race, and relationship status, and antidepressant continuation and income were not significant with high levels of heterogeneity.

DISCUSSION

While most social determinants in this review were not linked with prenatal antidepressant intake, lower maternal education level does seem to be associated with lower rates of prenatal antidepressant continuation.

CONCLUSIONS

Education appears to be linked with prenatal antidepressant intake. The low number of included studies precludes conclusive evidence for other social determinants.

The silent burden: a landscape analysis of common perinatal mental disorders in low- and middle-income countries

Background

Mental health has long fallen behind physical health in attention, funding, and action—especially in low- and middle-income countries (LMICs). It has been conspicuously absent from global reproductive, maternal, newborn, child, and adolescent health (MNCAH) programming, despite increasing awareness of the intergenerational impact of common perinatal mental disorders (CPMDs). However, the universal health coverage (UHC) movement and COVID-19 have brought mental health to the forefront, and the MNCAH community is looking to understand how to provide women effective, sustainable care at scale. To address this, MOMENTUM Country and Global Leadership (MCGL) commissioned a landscape analysis in December 2020 to assess the state of CPMDs and identify what is being done to address the burden in LMICs.

Methods

The landscape analysis (LA) used a multitiered approach. First, reviewers chose a scoping review methodology to search literature in PubMed, Google Scholar, PsychInfo, and Scopus. Titles and abstracts were reviewed before a multidisciplinary team conducted data extraction and analysis on relevant articles. Second, 44 key informant interviews and two focus group discussions were conducted with mental health, MNCAH, humanitarian, nutrition, gender-based violence (GBV), advocacy, and implementation research experts. Finally, reviewers completed a document analysis of relevant mental health policies from 19 countries.

Results

The LA identified risk factors for CPMDs, maternal mental health interventions and implementation strategies, and remaining knowledge gaps. Risk factors included social determinants, such as economic or gender inequality, and individual experiences, such as stillbirth. Core components identified in successful perinatal mental health (PMH) interventions at community level included stepped care, detailed context assessments, task-sharing models, and talk therapy; at health facility level, they included pre-service training on mental health, trained and supervised providers, referral and assessment processes, mental health support for providers, provision of respectful care, and linkages with GBV services. Yet, significant gaps remain in understanding how to address CPMDs.

Conclusion

These findings illuminate an urgent need to provide CPMD prevention and care to women in LMICs. The time is long overdue to take perinatal mental health seriously. Efforts should strive to generate better evidence while implementing successful approaches to help millions of women “suffering in silence.”

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04589-z.

Gestational exposure to antidepressants and risk of seizure in offspring: A systematic review and meta-analysis

In spite of the preliminary evidence suggesting a link between gestational use of antidepressant and neurodevelopmental disorders in their offspring, the association between maternal use of antidepressants during pregnancy and the risk of neurologically-related adverse outcomes such as neonatal seizure is still unclear. This study summarises the available evidence on the association between gestational exposure to any antidepressants and the risk of seizure in neonates and children. We found that gestational antidepressant exposure is associated with a 2.3-fold higher incidence of seizure in offspring. Although a causal relationship cannot be confirmed in view of other potential confounders, our findings warrant future research on related clinical aspects, and possibly more careful monitoring of foetal neurodevelopment in pregnant women taking antidepressants during pregnancy. However, this does not suggest the abrupt withdrawal of antidepressants during pregnancy for all cases at risk of seizure in offspring as this must be balanced with the risk of negative consequences caused by untreated maternal depression, and decision-making should be individualised for each patient.

LC-MS-MS Method for the Determination of Antidepressants and Benzodiazepines in Meconium

An LC-MS-MS method for the determination of 14 benzodiazepines (BZDs) (alprazolam, α-hydroxyalprazolam, clonazepam, bromazepam, diazepam, nordiazepam, lorazepam, lormetazepam, oxazepam, flunitrazepam, 7-aminoflunitrazepam, triazolam, midazolam and zolpidem) and 15 antidepressants (ADs) (amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, norclomipramine, fluoxetine, norfluoxetine, sertraline, norsertraline, paroxetine, venlafaxine, desmethylvenlafaxine, citalopram and desmethylcitalopram) in meconium was developed and validated. Meconium samples (0.25 ± 0.02 g) were homogenized in methanol and subjected to mixed-mode cation exchange solid-phase extraction. Chromatographic separation was performed in reversed phase, with a gradient of 0.1% formic acid in 2 mM ammonium formate and acetonitrile. Two different chromatographic gradient methods were employed, one for the separation of ADs and another for BZDs. Analytes were monitored by tandem mass spectrometry employing electrospray positive mode in MRM mode (2 transitions per compound). Method validation included: linearity [n = 5, limit of quantification (LOQ) to 400 ng/g], limits of detection (n = 6, 1-20 ng/g), LOQ (n = 9, 5-20 ng/g), selectivity (no endogenous or exogenous interferences), accuracy (n = 15, 90.6-111.5%), imprecision (n = 15, 0-14.6%), matrix effect (n = 10, -73 to 194.9%), extraction efficiency (n = 6, 35.9-91.2%), process efficiency (n = 6, 20.1-188.2%), stability 72 h in the autosampler (n = 3, -8.5 to 9%) and freeze/thaw stability (n = 3, -1.2 to -47%). The method was applied to four meconium specimens, which were analyzed with and without hydrolysis (enzymatic and alkaline). The authentic meconium samples tested positive for alprazolam, α-hydroxyalprazolam, clonazepam, diazepam, nordiazepam, fluoxetine, norfluoxetine, clomipramine and norclomipramine. Therefore, the present LC-MS-MS method allows a high throughput determination of the most common BZDs and ADs in meconium, which could be useful in clinical and forensic settings.

Prenatal Antidepressant Use and Risk of Adverse Neonatal Outcomes

OBJECTIVES

To estimate the risk of neonatal outcomes from patterns of prenatal antidepressant use.

METHODS

From the OptumLabs Data Warehouse, 226 932 singleton deliveries were identified. Antidepressant claims with coverage between the last menstrual period and 35 weeks' gestation were converted to fluoxetine equivalents, and a longitudinal cluster analysis was performed. Outcomes included major cardiac malformations (11.7 of 1000 births), preterm birth (75.7 of 1000 births), and newborn respiratory distress (54.2 of 1000 births). The lowest trajectory was the primary reference group, and depression and anxiety with no antidepressant claims served as secondary reference groups.

RESULTS

From 15 041 (6.6%) pregnancies exposed to an antidepressant, use patterns were best described as (1) low use (∼10 mg/day) with first-trimester reduction, (2) low sustained use (∼20 mg/day), (3) moderate use (∼40 mg/day) with first-trimester reduction, (4) moderate sustained use (∼40 mg/day), and (5) high sustained use (∼75 mg/day). Moderate sustained use increased the risk of major cardiac malformations, although results included the null when compared with depression or anxiety reference groups. Moderate sustained (adjusted risk ratio [RR] 1.31; 95% confidence interval [CI] 1.16-1.49) and high sustained (adjusted RR 1.78; 95% CI 1.48-2.14) trajectories were associated with an increased risk of preterm birth. All 4 trajectories increased the risk of neonatal respiratory distress in a dose-response fashion (adjusted RRs 1.36 [95% CI 1.20-1.50] to 2.23 [95% CI 1.83-2.77]).

CONCLUSIONS

Although findings support continuation of the lowest effective dose to treat depression or anxiety, which benefits the mother, they also highlight an increased risk for newborn respiratory distress in all groups and preterm birth at moderate to high sustained doses.

Antidepressant prescriptions, discontinuation, depression and perinatal outcomes, including breastfeeding: A population cohort analysis

Objectives

To explore associations between exposure to antidepressants, their discontinuation, depression [medicated or unmediated] and preterm birth [<37 and <32 weeks], small for gestational age (SGA) [<10th and <3rd centiles], breastfeeding [any] at 6–8 weeks.

Methods

Design: A population-based cohort study.

Setting: The Secure Anonymised Information Linkage [SAIL] databank in Wales, linking maternal primary care data with infant outcomes.

Participants: 107,573, 105,331, and 38,725 infants born 2000–2010 with information on prematurity, SGA and breastfeeding respectively, after exclusions.

Exposures: Maternal antidepressant prescriptions in trimesters 2 or 3, discontinuation after trimester 1, recorded diagnosis of depression [medicated or unmediated] in pregnancy.

Methods: Odds ratios for adverse pregnancy outcomes were calculated, adjusted for smoking, parity, socio-economic status, and depression.

Results

Exclusive formula feeding at 6–8 weeks was associated with prescriptions in trimesters 2 or 3 for any antidepressants (adjusted odds ratio [aOR] 0.81, 95% confidence intervals 0.67–0.98), SSRIs [aOR 0.77, 0.62–0.95], particularly higher doses [aOR 0.45, 0.23–0.86], discontinuation of antidepressants or SSRIs after trimester 1 (aOR 0.70, 0.57–0.83 and 0.66, 0.51–0.87), diagnosis of depression aOR 0.76 [0.70–0.82), particularly if medicated (aOR 0.70, 0.58–0.85), rather than unmedicated (aOR 0.87, 0.82–0.92). Preterm birth at <37 and <32 weeks’ gestation was associated with diagnosis of depression (aOR 1.27, 1.17–1.38, and 1.33, 1.09–1.62), particularly if medicated (aOR 1.56, 1.23–1.96, and 1.63, 0.94–2.84); birth at <37 weeks was associated with antidepressants, (aOR 1.24, 1.04–1.49]. SGA <3rd centile was associated with antidepressants (aOR 1.43, 1.07–1.90), and SSRIs (aOR 1.46, 1.06–2.00], particularly higher doses [aOR 2.10, 1.32–3.34]. All adverse outcomes were associated with socio-economic status and smoking.

Implications

Exposure to antidepressants or depression increased risks of exclusive formula feeding at 6–8 weeks, and prescription of antidepressants was associated with SGA <3^rd centile. Prescription of antidepressants offers a useful marker to target additional support and additional care before and during pregnancy and lactation.

Postpartum Bleeding in Pregnant Women Receiving SSRIs/SNRIs: New Insights From a Descriptive Observational Study and an Analysis of Data from the FAERS Database

PURPOSE

To date, the available data on the relationship between the use of selective serotonin reuptake inhibitors (SSRIs) or the serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine and postpartum hemorrhage (PPH) are conflicting and have not been extensively investigated, especially in terms of plasma drug concentrations. We performed data mining of antidepressant-induced PPH reported to the US Food and Drug Administration's Adverse Event Reporting System database, to assess the strength of the potential association between antidepressant pharmacotherapy and PPH in pregnant women. Concurrently, we carried out a descriptive observational population (pregnant women) analysis of the correlation between the plasma concentrations of SSRIs/SNRIs used during pregnancy and the extent of bleeding at delivery.

METHODS

A disproportionality analysis of individual case study reports of PPH associated with SSRIs or venlafaxine in pregnant women was performed. Reporting odds ratio was used as a measure of disproportionality analysis. Pregnant women treated with an SSRI or SNRI (venlafaxine) for depressive or anxiety disorder and who consented to plasma drug concentration monitoring at the time of delivery were recruited. Plasma drug concentration assay was performed according to validated LC-MS/MS. Based on plasma drug concentrations, patients were classified into 1 of 2 groups, in therapeutic range or below therapeutic range for the drug administered, in accordance with the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie guideline, and correlations with blood loss were identified, with PPH defined as a blood loss of >500 mL.

FINDINGS

Only 43 Individual Case Safety Reports (ICSRs) reported at least one SSRIs or venlafaxine as suspect drug in 14 years (database analyses). Forty-three women were enrolled in the study population (observational study). In 24 patients (55.8%) the plasma drug concentration was below the therapeutic threshold. Unexpectedly, the mean blood loss in the below-range group was significantly higher than that in the in-range group. PPH occurred in 30% of women: in 9.3% and in 20.7% of patients in the in-range and below-range groups, respectively.

IMPLICATIONS

Although preliminary, these data indicate a rather good tolerability profile of SSRIs/SNRIs regarding postpartum bleeding. Moreover, they suggest that keeping the plasma levels of SSRIs/SNRIs low as a precautionary measure does not reduce postpartum bleeding, which was higher in the below-range group. The findings from this study suggest that the use of therapeutic drug monitoring in pregnancy, a period in which multiple variables affect drug metabolism, may allow for better treatment customization, with subsequent advantages in terms of tolerability and efficacy of treatment.

Trick or treat? Evaluating contributing factors and sex-differences for developmental effects of maternal depression and its treatment

Maternal depression and treatment with selective serotonin reuptake inhibitors (SSRIs), the most common form of pharmaceutical intervention, can both have an impact on infant development. As such, it is difficult for healthcare providers to recommend a course of treatment to expectant mothers suffering from depression, or to women on antidepressant medication prior to pregnancy. This review will discuss the existing research on the developmental impacts of maternal depression and its treatment with SSRIs, with a particular focus on contributing factors that complicate our attempt to disentangle the consequences of maternal depression and its treatment such as the timing or severity of the depression. We will explore avenues for translational animal models to help address the question of "Trick or Treat", i.e.: which is worse for offspring development: exposure to maternal depression, or the SSRI treatment? Further, we will explore sex-dependent outcomes for the offspring in human and animal studies as male and female offspring may react differently to the presence of maternal depression or antidepressant treatment. Without more clinical and preclinical data, it remains difficult for women to make an informed decision regarding their depression treatment before, during, and after their pregnancy.

Maternal SSRIs experience and risk of ASD in offspring: a review

Antidepressants are extensively used during pregnancy and associated with severe outcomes, including innate malformations, prematurity, and low birth weight, etc. A recent study suggested that prenatal exposure to antidepressants may impair child neurodevelopment process. Thus, the aim of this review is to investigate the potential association between prenatal use of selective 5-HT reuptake inhibitors (SSRIs) and the risk of autism spectrum disorders (ASDs). Twelve studies related to the linkage between SSRI exposure during pregnancy and ASD in children were explored and compiled. However, there is a knowledge gap concerning the potential link between gestational exposure to antidepressants and the risk of ASDs. Despite such limitations, the available data show that some signal exists and signifies that antenatal exposure to SSRIs may increase the risk of ASDs. Thus, there is a vital need for further, large and well-designed research to definitively evaluate the existence and the magnitude of this severe risk.

Clubfoot Etiology: A Meta-Analysis and Systematic Review of Observational and Randomized Trials

BACKGROUND

Clubfoot is a common congenital anomaly with multiple potential risk factors. Identification of modifiable risk factors may minimize future incidence of clubfoot. The aim of this meta-analysis was to systematically review and analyze the best clinical evidence regarding risk factors associated with clubfoot.

METHODS

Medline, Embase, and Cochrane databases were systematically searched from 1967 to May 11, 2016 for studies reporting risk factors for clubfoot. Randomized trials and observational studies were eligible for inclusion, and assessed in duplicate. Study quality was assessed with the Newcastle-Ottawa Scale or Cochrane risk of bias tool; low quality studies were excluded, all randomized trials were included. Two reviewers extracted data independently. This meta-analysis was conducted in accordance with PRISMA guidelines. Pooled effect estimates for the odds of clubfoot were calculated using random or fixed-effects models based on heterogeneity.

RESULTS

Forty-two studies (28 case-control, 10 cohort, 4 randomized trials) comprising 31,844 clubfoot cases and 6,604,013 controls were included. Risk factors associated with increased odds of clubfoot included maternal smoking [odds ratio (OR)=1.65; 95% confidence interval (CI), 1.54-1.78], paternal smoking (OR=1.72; 95% CI, 1.05-2.84), maternal body mass index >30 (OR=1.46; 95% CI, 1.29-1.65), family history (OR=7.80; 95% CI, 4.04-15.04), amniocentesis (OR=2.08; 95% CI, 1.34-3.21), selective serotonin reuptake inhibitor exposure (OR=1.78; 95% CI, 1.34-2.37) maternal single status (OR=1.17; 95% CI, 1.11-1.23), gestational diabetes (OR=1.40; 95% CI, 1.13-1.72), nulliparity (OR=1.32; 95% CI, 1.19-1.45), male sex (OR=1.68; 95% CI, 1.48-1.94), and aboriginal Australian race (OR=2.35; 95% CI, 1.63-3.38).

CONCLUSIONS

Smoking, maternal obesity, family history, amniocentesis, and some selective serotonin reuptake inhibitor exposures are the most clinically relevant exposures associated with increased odds of clubfoot, with family history representing the greatest risk. Recognition of modifiable risk factors may help in counseling patients, and minimizing clubfoot incidence.

LEVEL OF EVIDENCE

Level II.

Longitudinal trajectories of antidepressant use in pregnancy and the postnatal period

Studies of antidepressant safety in pregnancy typically do not address complex patterns of use throughout pregnancy. We performed longitudinal trajectory modeling to describe patterns of antidepressant use in the first 32 weeks of pregnancy, and test whether these trajectories are associated with a reduction in birth weight or gestational age at delivery. Our study included 166 pregnant women with deliveries between 2011 and 2015 who were prescribed an antidepressant between 91 days prior to last menstrual period and 32 weeks of gestation. From electronic medical records, we estimated average daily dose and cumulative dose per week for the first 32 weeks of gestation and for the first 13 weeks postnatal. We clustered women with similar utilization patterns using k-means longitudinal modeling and assessed the associations between trajectory group and birth weight and gestational age at delivery. We identified four cumulative dose trajectory groups and three average daily dose trajectory groups in each period. Relative to the lowest trajectory group, the highest trajectory group during pregnancy was associated with reduced birth weight in multivariable analysis (average daily highest trajectory vs. lowest trajectory β - 314.1 g, 95% CI - 613.7, - 15.5) adjusted for depression severity score, maternal age, race, and pregnancy smoking. Trajectory groups were not associated with gestational age at delivery. The highest trajectory group of antidepressant use in pregnancy was associated with a modest reduction in birth weight but not with gestational age at delivery. Longitudinal trajectories allow for a dynamic visualization and quantification of medication use among pregnant women.

Newborn Brain Function Is Affected by Fetal Exposure to Maternal Serotonin Reuptake Inhibitors

Recent experimental animal studies have shown that fetal exposure to serotonin reuptake inhibitors (SRIs) affects brain development. Modern recording methods and advanced computational analyses of scalp electroencephalography (EEG) have opened a possibility to study if comparable changes are also observed in the human neonatal brain. We recruited mothers using SRI during pregnancy (n = 22) and controls (n = 62). Mood and anxiety of mothers, newborn neurology, and newborn cortical function (EEG) were assessed. The EEG parameters were compared between newborns exposed to drugs versus controls, followed by comparisons of newborn EEG features with maternal psychiatric assessments. Neurological assessment showed subtle abnormalities in the SRI-exposed newborns. The computational EEG analyses disclosed a reduced interhemispheric connectivity, lower cross-frequency integration, as well as reduced frontal activity at low-frequency oscillations. These effects were not related to maternal depression or anxiety. Our results suggest that antenatal serotonergic treatment might change newborn brain function in a manner compatible with the recent experimental studies. The present EEG findings suggest links at the level of neuronal activity between human studies and animal experiments. These links will also enable bidirectional translation in future studies on the neuronal mechanisms and long-term neurodevelopmental effects of early SRI exposure.

Predicting Factors of Depression, Antidepressant Use and Positive Response to Antidepressants in Perinatal and Postpartum Women

Background:

In the United States, there is a disparity in knowledge of nationwide depression prevalence, the antidepressant use and the antidepressant responses during perinatal/postpartum periods.

Objective:

This study investigated the predicting factors of depression, antidepressant use and positive antidepressant response during the perinatal/postpartum periods.

Method:

The 2007-2012 National Health and Nutrition Examination Surveys (NHANES) were combined to identify adult pregnant women, those within the 18-month postpartum period (n=492) and their depression statuses via demographics, health care accessibility, antidepressant use and illicit drug use information. The characteristics of different study groups were compared (depression versus no-depression groups, antidepressant users versus non-antidepressant users, and antidepressant responders versus antidepressant non-responders). Multivariable logistic regression analysis was used to predict factors of perinatal depression (PND)/ postpartum depression (PPD), antidepressant use and antidepressant positive response in PND/PPD.

Results:

PND/PPD individuals had higher rates of mental health visits. No predicting factor for developing PND/PPD was shown. Antidepressant users were significantly older with insurance and recent health checkups/ mental visits. Being below the poverty level and having some health care accessibility are predictors for being on antidepressants. Recent non-illicit drug use is a predictor for PND/PPD symptom improvement while on antidepressants.

Conclusion:

The group of those with social-economic disadvantages was more likely to be on antidepressants for PND/PPD. Illicit drug users were less likely to show improvement with antidepressants. The safety and efficacy of antidepressant use during this period is controversial. More studies need to focus on the barriers involving antidepressant treatments, the safety and outcomes of antidepressants for PND/PPD management.

Serotonin and poor neonatal adaptation after antidepressant exposure in utero

OBJECTIVE

Infants exposed to selective antidepressants (SADs) in utero are at risk to develop poor neonatal adaptation (PNA) postpartum. As symptoms are non-specific and the aetiology of PNA is unknown, the diagnostic process is hampered. We hypothesised that the serotonin metabolism plays a role in the aetiology of PNA.

METHODS

In this controlled study, infants admitted postpartum from February 2012 to August 2013 were included and followed for 3 days. Infants exposed to SADs during at least the last 2 weeks of fetal life were included in the patient group (n=63). Infants not exposed to psychotropic medication and admitted postpartum for another reason were included in the control group (n=126). The neonatal urinary 5-hydroxyindoleacetid acid (5-HIAA) levels of SAD-exposed infants who developed PNA, SAD-exposed infants who did not develop PNA and control infants were compared.

RESULTS

The course of the 5-HIAA levels over the first 3 days postpartum differed between infants with and without PNA (p≤0.001) with higher 5-HIAA levels in infants with PNA on day 1 (2.42 mmol/mol, p=0.001). Presence of maternal psychological distress modified this relationship.

CONCLUSIONS

A transient disturbance of the neonatal serotonergic system may play a role in the aetiology of PNA. Other factors, including the presence of maternal psychological distress, also seem to play a role.

Use of antidepressants during pregnancy in the Netherlands: observational study into postpartum interventions

Background

Psychiatric disorders and use of selective antidepressants during pregnancy can have negative effects on mother and infant postpartum. This study aimed to provide evidence-based recommendations on observation of antidepressant-exposed mother-infant dyads.

Methods

In this observational study, mother-infant dyads were observed for possible consequences of either the maternal psychiatric disorder or fetal exposure to selective antidepressants during pregnancy. These possible complications can lead to medical interventions, including 1. adjustment of antidepressants 2. admission to the psychiatric department 3. additional investigations due to indistinctness about the origin of neonatal symptoms 4. treatment of poor neonatal adaptation and 5. consultation of an external organization for additional care. The type, number and time to medical interventions were analyzed.

Results

In 61% of the 324 included mother-infant dyads one or more intrventions were performed. Adjustment of antidepressants and treatment of poor neonatal adaptation were most prevalent. In 75% of dyads the final intervention was performed within 48 h.

Conclusions

The high prevalence and type of medical interventions requires professional observation of all mother-infant dyads exposed to selective antidepressants. In the absence of specialized home care, hospital admission is indicated whereby an observational period of 48 h seems sufficient for most dyads.

Selective Serotonin Reuptake Inhibitor (SSRI) Antidepressants in Pregnancy and Congenital Anomalies: Analysis of Linked Databases in Wales, Norway and Funen, Denmark

Background

Hypothesised associations between in utero exposure to selective serotonin reuptake inhibitors (SSRIs) and congenital anomalies, particularly congenital heart defects (CHD), remain controversial. We investigated the putative teratogenicity of SSRI prescription in the 91 days either side of first day of last menstrual period (LMP).

Methods and Findings

Three population-based EUROCAT congenital anomaly registries- Norway (2004–2010), Wales (2000–2010) and Funen, Denmark (2000–2010)—were linked to the electronic healthcare databases holding prospectively collected prescription information for all pregnancies in the timeframes available. We included 519,117 deliveries, including foetuses terminated for congenital anomalies, with data covering pregnancy and the preceding quarter, including 462,641 with data covering pregnancy and one year either side. For SSRI exposures 91 days either side of LMP, separately and together, odds ratios with 95% confidence intervals (ORs, 95%CI) for all major anomalies were estimated. We also explored: pausing or discontinuing SSRIs preconception, confounding, high dose regimens, and, in Wales, diagnosis of depression. Results were combined in meta-analyses. SSRI prescription 91 days either side of LMP was associated with increased prevalence of severe congenital heart defects (CHD) (as defined by EUROCAT guide 1.3, 2005) (34/12,962 [0.26%] vs. 865/506,155 [0.17%] OR 1.50, 1.06–2.11), and the composite adverse outcome of 'anomaly or stillbirth' (473/12962, 3.65% vs. 15829/506,155, 3.13%, OR 1.13, 1.03–1.24). The increased prevalence of all major anomalies combined did not reach statistical significance (3.09% [400/12,962] vs. 2.67% [13,536/506,155] OR 1.09, 0.99–1.21). Adjusting for socio-economic status left ORs largely unchanged. The prevalence of anomalies and severe CHD was reduced when SSRI prescriptions were stopped or paused preconception, and increased when >1 prescription was recorded, but differences were not statistically significant. The dose-response relationship between severe CHD and SSRI dose (meta-regression OR 1.49, 1.12–1.97) was consistent with SSRI-exposure related risk. Analyses in Wales suggested no associations between anomalies and diagnosed depression.

Conclusion

The additional absolute risk of teratogenesis associated with SSRIs, if causal, is small. However, the high prevalence of SSRI use augments its public health importance, justifying modifications to preconception care.

Neonatal and childhood neurodevelopmental, health and educational outcomes of children exposed to antidepressants and maternal depression during pregnancy: protocol for a retrospective population-based cohort study using linked administrative data

INTRODUCTION

Antidepressants are commonly prescribed during pregnancy; however, there are inconsistent data on the safety of these medications during the prenatal period. To address this gap, this study will investigate short-term and long-term neurodevelopmental, physical and mental health, and educational outcomes of children who have been exposed to selective serotonin reuptake inhibitors (SSRIs) or selective serotonin norepinephrine reuptake inhibitors (SNRIs) and/or maternal depression during pregnancy.

METHODS AND ANALYSIS

Administrative data will be linked to generate 4 population-based exposed groups from all children born in Manitoba between 1996 and 2014 whose mother had at least 2 prescriptions for either an SSRI or SNRI: (1) throughout the prenatal period (beginning of pregnancy until birth); (2) in the first trimester (≤14 weeks gestation); (3) in the second trimester (15-26 weeks gestation); (4) in the third trimester (≥27 weeks gestation) and 1 population-based unexposed group consisting of children whose mothers had a diagnosis of mood or anxiety disorder during pregnancy but did not use antidepressants. Propensity scores and inverse probability treatment weights will be used to adjust for confounding. Multivariate regression modelling will determine whether, compared with untreated mood/anxiety disorder, prenatal exposure to antidepressant medications is associated with: (1) adverse birth and neonatal outcomes, including: preterm birth, low birth weight, low Apgar scores, respiratory distress, congenital malformations and persistent pulmonary hypertension; (2) adverse early childhood outcomes, including: early childhood education challenges, diagnosis of neurodevelopmental disorders and diagnosis of mental disorders. We will determine if exposure effects differ between SSRIs and SRNIs, and determine if exposure effects differ between gestation timing of exposure to antidepressants.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Manitoba Health Research Ethics Board. Dissemination of results will include engagement of stakeholders and patients, writing of reports for policymakers and patients, and publication of scientific papers.

Is poor neonatal adaptation after exposure to antidepressant medication related to fetal cortisol levels? An explorative study

BACKGROUND

As a marker for poor neonatal adaptation (PNA) is lacking, the diagnostic process is difficult and includes invasive additional testing.

AIMS

In order to develop a marker, it is essential to gain insight into the etiology of PNA. We hypothesized that the fetal cortisol level may play a role in this etiology.

STUDY DESIGN

Non-randomized, prospective controlled study.

OUTCOME MEASURES

We examined hair cortisol levels of infants exposed and not exposed to selective antidepressants (SADs) during pregnancy. These cortisol levels represent the mean cortisol level during the last trimester of pregnancy. Infants exposed to SADs who developed PNA according to the pediatrician (PNA+, n=25), infants exposed to SADs who did not develop PNA (PNA-, n=40) and infants not exposed to SADs (controls, n=105) were compared.

RESULTS

In infants with PNA, hair cortisol levels were higher compared to infants without PNA. However this difference was only statistically significant in female infants (girls B0.33, p=0.04, boys B0.05, p=0.82). There was no correlation between nonspecific distress, measured by the Finnegan score and fetal hair cortisol levels (B-0.15, p=0.30). All analyses were adjusted for type of delivery and gestational age.

CONCLUSIONS

Our results suggest that the hypothalamic pituitary adrenal (HPA) axis activity may play a sex-specific role in the development of PNA. As PNA is most likely of a multifactorial origin, it would be interesting to examine other factors possibly involved in the etiology of PNA in future studies, such as (epi) genetics.

Pregnancy and Electroconvulsive Therapy: A Multidisciplinary Approach

OBJECTIVE

To scrutinize a series of pregnant women treated with electroconvulsive therapy (ECT) at a tertiary treatment center and combine these data with a literature review to refine the treatment guidelines for ECT during pregnancy.

METHODS

A retrospective chart review of mentally ill pregnant patients treated with ECT since the establishment of a formal women's mental health program.

RESULTS

A total of 8 pregnant women treated with ECT were identified from January 2012 to August 2014. Information was extracted from the medical records of a total of 30 ECT treatments across this group. Subjects received an average of 3.75 ECT treatments (range, 1-7). All women were diagnosed as having a mood disorder (either unipolar or bipolar), and 5 of the 8 women had suicidal ideation. The treatment team for ECT was consistent across all treatments. Two women experienced significant complications after the initial treatment: 1) an acute episode of complete heart block; and 2) acute onset of mania after ECT. Obstetrical complications included 2 women with preterm delivery-one secondary to premature rupture of membranes. No other complications or adverse outcomes were recorded. The 5 women with suicidal ideation had symptom resolution, and significant symptom improvement was noted in 6 of the 8 women.

CONCLUSIONS

Electroconvulsive therapy is a safe and effective treatment during pregnancy and of particular benefit in the acute treatment of suicidal ideation.

Maternal exposure to carbamazepine at environmental concentrations can cross intestinal and placental barriers

Psychoactive pharmaceuticals have been found as teratogens at clinical dosage during pregnancy. These pharmaceuticals have also been detected in minute (ppb) concentrations in drinking water in the US, and are environmental contaminants that may be complicit in triggering neurological disorders in genetically susceptible individuals. Previous studies have determined that psychoactive pharmaceuticals (fluoxetine, venlafaxine and carbamazepine) at environmentally relevant concentrations enriched sets of genes regulating development and function of the nervous system in fathead minnows. Altered gene sets were also associated with potential neurological disorders, including autism spectrum disorders (ASD). Subsequent in vitro studies indicated that psychoactive pharmaceuticals altered ASD-associated synaptic protein expression and gene expression in human neuronal cells. However, it is unknown if environmentally relevant concentrations of these pharmaceuticals are able to cross biological barriers from mother to fetus, thus potentially posing risks to nervous system development. The main objective of this study was to test whether psychoactive pharmaceuticals (fluoxetine, venlafaxine, and carbamazepine) administered through the drinking water at environmental concentrations to pregnant mice could reach the brain of the developing embryo by crossing intestinal and placental barriers. We addressed this question by adding (2)H-isotope labeled pharmaceuticals to the drinking water of female mice for 20 days (10 pre-and 10 post-conception days), and quantifying (2)H-isotope enrichment signals in the dam liver and brain of developing embryos using isotope ratio mass spectrometry. Significant levels of (2)H enrichment was detected in the brain of embryos and livers of carbamazepine-treated mice but not in those of control dams, or for fluoxetine or venlafaxine application. These results provide the first evidence that carbamazepine in drinking water and at typical environmental concentrations is transmitted from mother to embryo. Our results, combined with previous evidence that carbamazepine may be associated with ASD in infants, warrant the closer examination of psychoactive pharmaceuticals in drinking water and their potential association with neurodevelopmental disorders.

Mirtazapine in pregnancy and lactation - A systematic review

Depression is common in pregnancy and associated with increased risk of adverse effects for the neonate. Treatment and prevention options include antidepressant therapy. The aim of this paper was to review the literature on safety of mirtazapine during pregnancy and lactation. In 31 papers a total of 390 cases of neonates exposed to mirtazapine during pregnancy or lactation have been described. There might be an association between mirtazapine and spontaneous abortion, however, this might be attributable to underlying psychiatric disease. An increased risk of major neonatal malformations associated with mirtazapine in pregnancy has not been reported. Although one study showed a nearly significant increase in occurrence of respiratory problems and hypoglycaemia, no indication of causality could be given. No other significant adverse effects on neonates were reported. Limited available data, four papers on 11 exposed neonates, suggest that use of mirtazapine during breastfeeding is safe due to a low relative infant dose. High plasma levels might be associated with increased body weight and sleep. However, the reported data are too scarce to come to a clear assessment of the risk of mirtazapine in lactation. No information is available on the use of mirtazapine in pregnancy and Poor Neonatal Adaptation Syndrome (PNAS) or neurobehavioral development at an age over one year. In conclusion, mirtazapine seems to be safe in pregnancy, especially regarding incidence of congenital malformations. There are not enough data available to come to a conclusion on the safety of mirtazapine during lactation.

Placental transfer of antidepressant medications: implications for postnatal adaptation syndrome

Seven to thirteen percent of women are either prescribed or taking (depending on the study) an antidepressant during pregnancy. Because antidepressants freely cross into the intrauterine environment, we aim to summarize the current findings on placental transfer of antidepressants. Although generally low risk, antidepressants have been associated with postnatal adaptation syndrome (PNAS). Specifically, we explore whether the antidepressants most closely associated with PNAS (paroxetine, fluoxetine, venlafaxine) cross the placenta to a greater extent than other antidepressants. We review research on antidepressants in the context of placental anatomy, placental transport mechanisms, placental metabolism, pharmacokinetics, as well as non-placental maternal and fetal factors. This provides insight into the complexity involved in understanding how placental transfer of antidepressants may relate to adverse perinatal outcomes. Ultimately, from this data there is no pattern in which PNAS is related to placental transfer of antidepressant medications. In general, there is large interindividual variability for each type of antidepressant. To make the most clinically informed decisions about the use of antidepressants in pregnancy, studies that link maternal, placental and fetal genetic polymorphisms, placental transfer rates and infant outcomes are needed.

Exploring the views and experiences of callers to the PANDA Post and Antenatal Depression Association Australian National Perinatal Depression Helpline: a cross-sectional survey

BACKGROUND

Anxiety and depression are common in the perinatal period. Telephone interventions, including telephone peer support and counselling, have been developed to support those experiencing perinatal mental illness. PANDA Post and Antenatal Depression Association provides support to women and men experiencing perinatal mental illness via the Australian National Perinatal Depression Helpline, encompassing both volunteer peer support and professional counselling. This study aimed to explore the experiences of callers to the Helpline.

METHODS

A cross-sectional survey design was used. All new callers from 1(st) May to 30(th) September 2013 were invited to participate. The survey, adapted from a previous survey of PANDA callers, included 23 questions using Likert-type scales, demographic and open-ended questions. Thematic network analysis was undertaken for responses to open-ended questions.

RESULTS

124 responses were received (124/405; 30% response). The majority of callers had called the Helpline regarding themselves (90%), with over one third (33%) of all callers seeking crisis support and help. Ninety-nine per cent of respondents 'agreed' or 'strongly agreed' that staff and/or volunteers understood their concerns, and 97% 'agreed' or 'strongly agreed' that overall PANDA had helped them. Callers described the PANDA service as uniquely tailored to the perinatal period, providing accessible, non-judgemental understanding and support, with a global theme from open-ended comments describing PANDA as 'a safe space to be heard and receive support without judgement'. Recommendations for service changes included increased hours of availability.

CONCLUSIONS

Callers reported positive experiences of accessing support from the PANDA National Perinatal Depression Helpline. The Helpline was described as an accessible and acceptable telephone support for individuals experiencing perinatal mental illness. Recommendations for changes to the service included an increase in hours of operation to enable greater responsiveness at times of need, reduced waiting times, and access to continuity with the same volunteer and/or telephone counsellor. The findings of the study will be useful in informing future service provision, review, and implementation.

Promise and peril: Dissemination of findings from studies of drugs used in pregnancy and their association with birth defects

BACKGROUND

When and how to publish birth defects research can be complex, especially in the context of drugs used in pregnancy. Such research frequently involves multiple stakeholders, including regulatory agencies. Researchers must balance the potential peril of an unnecessarily panicked populace versus the benefit of protecting the public's health.

METHODS

We use a case presentation and contemporary literature to highlight the potential tradeoffs that researchers must consider. We highlight important considerations including the public health impact, examining the likelihood of causality, understanding common considerations when using large data sources, the role of peer review and working in partnership with regulatory agencies.

RESULTS

We suggest that plans for analyses, dissemination and risk communication are done best a priori and not post hoc.

CONCLUSION

Rigorous research evaluating the impact of drugs used in pregnancy, coupled with effective dissemination strategies, has the potential improve outcomes for mothers and their infants for generations.

A Multidisciplinary Approach to the Treatment of Co-occurring Opioid Use Disorder and Posttraumatic Stress Disorder in Pregnancy: A Case Report

Perinatal opioid use disorders negatively impact maternal and neonatal outcomes and are a public health problem of increasing severity. More than half of women with a substance use disorder have a history of posttraumatic stress disorder that, if not adequately addressed, can impede substance use disorder treatment. This case report describes complexities in the treatment of a pregnant woman with opioid use disorder and posttraumatic stress disorder and reviews the psychotherapeutic and pharmacologic approaches available to treat these co-occurring disorders in pregnancy. This case demonstrates the importance of early screening and intervention for co-occurring posttraumatic stress disorder in pregnant women who use substances in a closely coordinated, multidisciplinary approach to improve outcomes for women and their infants.

Follow-up study of children whose mothers were treated with transcranial magnetic stimulation during pregnancy: preliminary results

OBJECTIVES

The purpose of this study is to determine the impact of repetitive transcranial stimulation (rTMS) treatment during pregnancy on neurodevelopment of children.

MATERIALS AND METHODS

Women who were treated with rTMS during pregnancy and delivered liveborn children between 2008 and 2013 were selected. A control group consisted of children whose mothers had a history of untreated depression during their pregnancy (N = 26). Early developmental characteristics of all the children in the study were evaluated, and their developmental levels were determined using the Ankara Developmental Screening Inventory.

RESULTS

The mean age of the children in the rTMS treatment group was 32.4 months (range 16-64 months), and that of the untreated group was 29.04 (range 14-63 months). Jaundice (N = 2) and febrile convulsion (N = 1) were the reported medical conditions in the children of the rTMS-treated group; jaundice (N = 3) and low birth weight (N = 1) were reported in the untreated group. In the rTMS group, mothers' perception of delay in language development was observed, but there were not any statistically significant differences in the prevalence rate compared with the untreated group (OR = 0.38; 95% CI 0.0860-1.6580).

CONCLUSIONS

Our results suggest that rTMS exposure during pregnancy is not associated with poorer cognitive or motor development outcomes in children aged 18-62 months. Although language development as reported by the mothers was found to be poorer than expected in the rTMS-treated group, the delay was found to be similar to the language delay observed in offspring of untreated mothers, as reported in previous studies of prenatal depression treated with selective serotonin reuptake inhibitors.