A Deeper Shade of Blue

Earlier this year a study published in the New England Journal of Medicine linked SSRI use during late pregnancy to an increased risk of persistent pulmonary hypertension in the newborn. Persistent pulmonary hypertension of the newborn (PPHN) is a cardiovascular syndrome typically occurring in full-term or near-term infants. Typically within 12 hours of delivery, infants present with respiratory distress and, in the worst cases, require assisted ventilation.

A recent study published in the New England Journal of Medicine has linked SSRI use during late pregnancy to an increased risk of persistent pulmonary hypertension in the newborn. Persistent pulmonary hypertension of the newborn (PPHN) is a cardiovascular syndrome typically occurring in full-term or near-term infants. Typically within 12 hours of delivery, infants present with respiratory distress and, in the worst cases, require assisted ventilation.

In this study, the authors identified 637 infants with possible PPHN and a control group of 836 women and their infants with no drug exposure. Infants exposed to an SSRI antidepressant after the 20th week of gestation were about six times as likely to develop PPHN than unexposed infants. Neither the use of SSRIs before the 20th week of gestation nor the use of non-SSRI antidepressants at any time during the pregnancy were associated with an increased risk of PPHN.

It is difficult to reconcile these findings with other studies investigating neonatal outcomes in infants exposed to antidepressants in utero. There have been reports of adverse events in exposed infants, most commonly symptoms of jitteriness, sleep disturbance, feeding problems, and excessive crying. There have also been reports of respiratory distress (usually tachypnea or rapid breathing); however, the observed symptoms were relatively mild, transient, and did not require specific medical intervention, suggesting that these cases were not PPHN, a more serious complication.

These findings are likely to generate significant anxiety among child-bearing women who suffer from depression. To avoid or withhold antidepressants during pregnancy places these women - and their children - at risk. Depression in the mother is not a benign event and, when left untreated during pregnancy, has been associated with poor neonatal outcomes, including preterm birth, low birth weight, and lower Apgar scores. If we assume that these findings are correct, the risk of PPHN is still relatively small; the authors estimate PPHN occurs in less than 1% of infants exposed to SSRIs in late pregnancy. Thus many women with more severe or recurrent illness may elect to continue treatment with SSRIs during pregnancy, acknowledging that the risks associated with untreated depression are greater than the risks of SSRI use.

Chambers CD, Hernandez-Diaz S, Van Marter LJ, Werler MM, et al. Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. New England Journal of Medicine 2006; 354(6):579-87.

For more information on this topic, go to:

SSRIs and Persistent Pulmonary Hypertension: New Findings 

The MGH Center for Women’s Mental Heath

Medscape

Canadian Medical Association Journal