Pregnancy and antidepressants
The safety of taking antidepressants during pregnancy is still a topic of debate and new research. The main thing in the context of this issue is to determine which risks are more dangerous: using antidepressants or the consequences of depression without treatment. Since pregnancy provokes a variety of hormonal changes, in some cases anxiety and depression may increase. This often requires the prescription of psychotropic drugs, especially when non-pharmacological methods are ineffective. Left untreated, these conditions can affect fetal outcomes, leading to prematurity and low birth weight, potentially persisting and compromising maternal well-being in the postpartum period.
In recent years common practice is to prescribe selective serotonin reuptake inhibitors (SSRIs) to treat depression or anxiety during pregnancy. However, such therapy requires a personalized approach and should be based on assessing risks for the child and the mother. Reports containing information about abnormal pregnancy outcomes associated with the drug are classified as serious and must be expetidly reported to regulatory authorities.
Сlinical case description
With the DrugCard platform, we found an article in the Journal of Bahrain Medical Society about drug use by a woman before conception and in the first trimester of pregnancy, which led to severe consequences for the child – developmental defects. This article discusses a case where maternal use of Escitalopram during two consecutive pregnancies resulted in pulmonary valve stenosis in two children.
A full-term baby girl was born at 39 weeks of pregnancy. The baby cried immediately after birth and did not require any resuscitation measures. Before conception, the mother took Escitalopram regularly to treat an anxiety disorder. The drug was discontinued by the patient after confirmation of pregnancy at 6 weeks. Due to the disease relapse and anxiety symptoms recovery, sertraline was prescribed and used intermittently until the end of the pregnancy. On the first day of life, echocardiography revealed significant stenosis of the pulmonary valve, a small persistent foramen ovale, and a patent ductus arteriosus (PDA) of 2.5 mm with left-to-right shunting. On the 10th day, the child was transferred to the cardiology department, where transcatheter balloon dilatation of the pulmonary valve was performed.
It is important to note that her previous child, who was born 9 years ago, was also diagnosed with severe stenosis of the pulmonary valve in the neonatal period and underwent balloon dilatation and valvuloplasty. All abnormality studies performed during pregnancy were normal. The woman did not have diabetes and did not suffer from other known diseases, but she had anxiety symptoms. She reported taking the same drug, Escitalopram, for an anxiety disorder. Similar to the current pregnancy, she stopped taking the medication at 6 weeks of pregnancy.
Searching for the cause of the malformation
The exact mechanism by which SSRIs cause heart defects remains unclear. Several studies have been conducted to determine whether SSRI use during pregnancy increases the risk of congenital heart defects. However, they did not give definitive results. It is known that serotonin molecules are necessary for the development of myocardial cells and the septum of the heart chambers. Abnormal serotonin levels caused by SSRIs during this crucial period of early pregnancy can lead to developmental disorders.
Analysis of other SSRI adverse events showed that paroxetine and fluoxetine use during pregnancy was associated with an increased risk of several subtypes of congenital heart defects, including atrial septal defects, ventricular septal defects, and right ventricular outflow tract obstruction. Sertraline use is known to cause cardiovascular malformations, but our current case was identified because of the presence of an associated cardiac malformation in two consecutive pregnancies with concomitant use of escitalopram.
No similar data were found before, so we were interested in such a case and it once again confirms that the automated DrugCard platform is an indisputable assistant in detecting severe cases of adverse drug reactions.
Depression and anxiety are common manifestations during pregnancy that require early detection and intervention to prevent adverse fetal and maternal outcomes. A woman’s safety is paramount when initiating antidepressants, and deciding which medication to prescribe remains a major challenge for many physicians. In turn, marketing authorisation holders, during medical literature monitoring, must be vigilant to the special patient populations (children, the elderly, and pregnant women).