Fetal tachyarrhythmia and maternal antidepressant treatment

Placental and fetal effects of antenatal exposure to antidepressants or untreated maternal depression

OBJECTIVE

To assess systematically the effects of antidepressants and untreated maternal depression on human placenta and the developing fetus.

METHODS

Pertinent medical literature information was identified using MEDLINE/PubMed, SCOPUS and EMBASE. Electronic searches, limited to human studies published in English, provided 21 studies reporting primary data on placental and fetal effects of antidepressant exposure or untreated gestational depression.

RESULTS

The impact of antidepressants and non-medicated maternal depression on placental functioning and fetal biochemical architecture seems to be demonstrated, although its clinical significance remains unclear. More robust data seem to indicate that exposure to either antidepressants or untreated maternal depression may induce epigenetic changes and interfere with the physiological fetal behavior. Two cases of iatrogenic fetal tachyarrhythmia have also been reported.

CONCLUSIONS

Future research should clarify the clinical relevance of the impact of antidepressant and untreated maternal depression exposure on placental functioning. Moreover, ultrasound studies investigating fetal responses to antidepressants or maternal depressive symptoms are mandatory. This assessment should be performed during the whole duration of gestational period, when different fetal behavioral patterns become progressively detectable. Analyses of biochemical and epigenetic modifications associated with maternal mood symptoms and antidepressant treatment should also be implemented.

Tricyclic antidepressants in pregnancy and puerperium

INTRODUCTION

Several concerns have been raised regarding the reproductive safety of the antidepressants most frequently used in clinical practice, such as selective serotonin reuptake inhibitors (SSRIs).

AREAS COVERED

This article aims to assess the risk/benefit ratio of the use of alternative pharmacological options, specifically tricyclic antidepressants (TCAs) in pregnancy and puerperium.

EXPERT OPINION

Although TCAs have been prescribed for several decades, their own teratogenic potential to cause structural defects remains undetermined. However, some signals seem to exist suggesting that prenatal clomipramine exposure may increase the risk of cardiac defects. Moreover, TCAs have been associated with the risk of prenatal antidepressant exposure syndrome. Among TCAs, clomipramine seems to be associated with more severe and prolonged neonatal symptoms. However, some findings of this syndrome reported with SSRI use, such as persistent pulmonary hypertension of the newborn, necrotizing enterocolitis and QT prolongation, have not been described after TCA exposure. Hence, current evidence suggests that, as a group, a preference of TCAs over SSRIs in early pregnancy is not justified. In contrast, there appears to be a small gain in safety if TCAs (with the exception of clomipramine) are used in late pregnancy. Among this class of antidepressants, nortriptyline seems to be safest medication for use during breastfeeding.

The use of antidepressant medication in pregnancy

The use of antidepressant medications during pregnancy has stimulated much professional and public debate. As a consequence, considerable data on the reproductive safety of antidepressants has been generated that exceeds the available information for most, if not all, other classes of medications that may be used in the perinatal period. Despite progress to date, definitive conclusions are limited by the methodological issues inherent to clinical research involving illness versus treatment effects in pregnancy. A notable shortcoming is the limited discussion of statistically significant (a mathematical determination) versus clinically significant (incorporation of incidence and effect sizes into practical relevance). Research emphasises completing an individualised 'risk-benefit' assessment, which is a laudable goal but falls short in providing succinct practical guidelines that includes the key educational points for patients. In this chapter, we focus on areas in which the preponderance of data are consistent, and there is concordance with the preclinical literature to generate a practical approach for antidepressant use in pregnancy.

Psychotropics

The risks during pregnancy from commonly prescribed psychopharmacological agents are summarized in this article. Psychotropic agents included in this discussion are antidepressants, antianxiety agents, and antipsychotic agents. The focus of this review is to describe the association between these medications and the incidence of congenital malformations. Epidemiological studies, cohort studies, case reports, and animal studies are discussed.

The outcome of pregnancy in 689 women exposed to therapeutic doses of antidepressants. A collaborative study of the European Network of Teratology Information Services (ENTIS)

The European Network of the Teratology Information Services (ENTIS) has collected and evaluated data on 689 pregnancies in which exposure to tricyclic and nontricyclic antidepressants occurred. Data were collected prospectively from the time of in utero exposure and all the cases were followed up to the first few weeks of postnatal life using standardized procedures. In most cases, no longer term follow-up data were available. Approximately two-thirds of the mothers were on multidrug therapy, and of those, half took a benzodiazepine. About 95% of the patients were exposed during the first trimester. The most striking feature of the pregnancy outcomes is that 97% of live-born babies were morphologically normal. The incidence of spontaneous abortion and late fetal/neonatal deaths were within the normal range. Fourteen live-born babies and one fetus had either major or minor malformations, and six had minor anomalies. However, there was no increase in either a particular type of malformation or a specific pattern of defects. Another 31 infants without malformations had neonatal problems; these were usually associated with chronic multidrug therapy, especially near term. Elective termination of pregnancy occurred more frequently in the multidrug groups (86 out of 488) than in the monotherapy groups (20 out of 201), but data concerning the condition of the fetus are not available in the majority of the cases. Overall, no causal relationship could be established between in utero exposure to antidepressants and adverse pregnancy outcome.