Pregnant Woman and the blues

Depression is so common now-a-days, given the stress in fast-tracked life.  Nuclear families, pressure to work & earn for living, travel, stress of job appraisal, career growth and effects of maternity break on career have caused immense stress in a Woman’s mid-year life.

It is the support from Parents and Siblings which seems to be the protective factor to avoid the stress going overboard for many decades for the birthing woman. Not to mention, the in-laws in most (not all) Asian families where the support mostly is minimal to a woman during pregnancy and postpartum. Given the rituals during pregnancy and post-delivery in Asian families, the clash between the families could damage the morale of the woman, who loses the love and affection of husband and parents at the same time, caught between the sleeplessness and the duties of a new mom. However, the term depression does not go well with men partly, as they might feel guilty for having been a part of that diagnosis in their wives!

 On the other side of it, there needs to be more awareness amongst women that depression can occur during pregnancy and in post-partum period. The responsibility falls on the shoulders of the clinicians to make the families understand better about the support that needs to be provided to the pregnant woman. It is better to enquire how they feel within themselves during every antenatal check-up so that it remains a screening method. Probably, leaflet about depression and antidepressants could be placed in the clinics so that they could become aware of warning signs when they have to seek help. Women could open up to doctors particularly when husband or in-laws are not present during consultations. When found in low mood, we could probably start on low dose of antidepressants or give advice about CBT or counselling.

As doctors, we could face a patient on antidepressants trying to become pregnant or a pregnant woman presenting in low mood. I had a general discussion with colleagues about which antidepressant is safe in pregnancy and breastfeeding.

If a woman on antidepressant intends to become pregnant, the best thing is to provide the information about safety of the medications. If on paroxetine, it needs to be changed. However, if she is stable for a while on a safe SSRI or TCA, it is best to continue the same. The question arises, which is safe, if we were to start one in a woman who is depressed after becoming pregnant or in postpartum.

Pregnancy:

TCA s and some SSRIs are safe in pregnancy. Tricyclic antidepressants, such as amitriptyline and imipramine, have lower known risks in pregnancy than other antidepressants. The risk of adverse events during pregnancy, in case of overdose is higher than with SSRIs. Hence SSRIs are preferred during pregnancy in women who are at risk of overdose.

Fluoxetine is the best-documented selective serotonin re-uptake inhibitor (SSRI) used in pregnancy.

Information on the safety of other SSRIs in pregnancy is limited. The use of fluoxetine in the first trimester of pregnancy is not associated with teratogenicity effects. There is small risk of neonatal withdrawal syndrome characterised by convulsions, irritability and feeding problems when used in last trimester. We also need to inform patients that there is a small risk of cardiac defects in babies,

 born to mothers on other SSRIs. Use of SSRIs may be associated with Persistent Pulmonary hypertension in the new-born and hence, paediatric assessment after delivery is advised. However, this is not a common side-effect that needs to scare a woman to deny a worthy medication that could improve her quality of life. The benefits obviously should outweigh the risks during prescription.

Breast feeding:

The selective serotonin reuptake inhibitors (SSRIs) sertraline can safely be given to a woman who is

breastfeeding provided the infant is healthy and baby's progress is monitored. Citalopram and fluoxetine are less preferred as they are secreted more in breast milk than sertraline; but these could be considered if the woman has been successfully treated with one of these drugs during pregnancy. 

So, Summarising, Fluoxetine is preferred during pregnancy and sertraline during breastfeeding.

It is better to use the lowest possible (maintenance) dose and monitor effects (adverse) carefully.

 All the more, the clinical care does not end with prescribing medications. It is best to ensure that the family around helps the woman to combat the mood and stress.  It is the moral, psycho-social support network that really helps to overcome the stressful period of pregnancy and delivery.

Reference for MRCOG exams about Depression in Pregnancy and Breastfeeding: 

1.      Moses-Kolko EL et al. Neonatal signs after late in utero exposure to serotonin reuptake inhibitors: literature review and implications for clinical applications. JAMA 2005;293:2372-83.

2.     NICE (February 2007). Antenatal and postnatal mental health.  

3.      Chambers CD et al. Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med. 2006 Feb 9;354(6):579-87 

4.      http://depression-in-pregnancy.org/ 

5.      http://www.rcpsych.ac.uk/mentalhealthinfo/problems/mentalhealthinpregnancy.aspx