In evaluating the safety of any medication during pregnancy, several concerns must be addressed. Will the medication have a negative impact on the developing fetus? Does the use of medication predispose women to premature delivery and/or undersized babies? Does taking medication throughout the pregnancy result in withdrawal symptoms in the newborn? Might there be other long-term problems associated with exposure before birth? The answers to these questions are not always clear. Human studies present ethical limitations and results from animal studies are not always applicable to humans. The doses of antidepressants given to laboratory animals usually far exceed those used in pregnant women, which does not allow for generalizations. Indeed, the FDA classification of medications into A, B, C, and D categories is relatively meaningless when it comes to pregnancy. For example, a category B medication is often prescribed routinely by physicians for women who are pregnant. However, a category B medication means that it has never been proven to be safe in humans, but that it has not shown to have birth defects in laboratory animals, usually rats. Recently, the American Psychiatric Association along with the American College of Gynecologists made several recommendations regarding antidepressants during pregnancy. They divided the recommendations into three categories.
1. Women thinking about getting pregnant:
Women on medication with mild or no symptoms for less than six months, may be appropriate to taper and discontinue medication before becoming pregnant. However, medication discontinuation may not be appropriate in women with a history of severe recurrent depression or who have had psychosis, bipolar disorder, a history of suicide attempts, or other psychiatric symptoms requiring medication.
2. Pregnant women currently taking antidepressants:
Women who would like to discontinue medication may attempt to do this if they are not experiencing symptoms, depending on their psychiatric history. Women with a history of recurrent depression are at a high risk of relapse if medication is discontinued. Women with recurrent depression or who continue to have symptoms despite their medication, may benefit from psychotherapy to replace and/or augment medication. Women with severe depression (with suicide attempts, functional impairment, or severe weight loss) should remain on medication. If the patient refuses medication, alternative treatment and monitoring should be in place, preferably prior to their antidepressants being discontinued.
3. Pregnant women who are not currently NOT taking antidepressants:
Psychotherapy, acupuncture, meditation and yoga may be beneficial in women to avoid antidepressant medication. For those women who do end up requiring antidepressants, the risks and benefits of treatment choices need to be evaluated and discussed at length. Factors that should be included are stage of gestation, the women’s symptom history, and other conditions and circumstances (smoking, weight issues, and alcohol abuse).
When considering the use of medication during pregnancy, benefits and risks exist for the mother and baby during four phases: 1) pregnancy, 2) delivery, 3) breast-feeding, and 4) infancy/toddlerhood. The traditional and prudent medical recommendation has been to avoid all medications during pregnancy. Certainly, this approach eliminates any risk to the fetus. What this traditional approach does not consider is the risk to the mother of eliminating unnecessary medications during pregnancy. One such risk may be a relapse of medical or psychiatric illnesses. A growing body of medical research has demonstrated that many medications can be taken safely during pregnancy. What is less known, is that in the absence of medication, congenital abnormalities occur in 3 to 4% of births of the general population. All of these above issues need to be addressed before a medication is started.
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Dr. Nicola Gray