Risks of SSRIs During Pregnancy on Neonatal Transition

Neonatal Adaptation Syndrome

SSRIs used during pregnancy can cause neonatal adaptation syndrome in approximately one-third of exposed newborns, with symptoms including crying, irritability, jitteriness, tremors, poor feeding, hypertonia, tachypnea, sleep disturbance, hypoglycemia, and seizures that typically appear within hours to days after birth and usually resolve within 1-2 weeks 1, 2, 3
Symptoms of neonatal adaptation syndrome typically begin within hours to days after birth and most resolve spontaneously within 1-2 weeks 1, 2, 3
Common symptoms of neonatal adaptation syndrome include crying, irritability, jitteriness, restlessness, tremors, shivering, poor sucking, feeding difficulties, hypertonia, tachypnea, sleep disturbance, hypoglycemia, and seizures 1, 2, 3

There is debate whether symptoms of neonatal adaptation syndrome represent serotonin syndrome or SSRI withdrawal 3
Serotonin syndrome is characterized by changes in mental status, autonomic hyperactivity, and neuromuscular abnormalities 3
Serotonin withdrawal manifests with anxiety, headache, nausea, fatigue, and low mood 3

In severely affected infants, pharmacological intervention may be required 2, 3
There is a possible association between SSRI use during pregnancy and persistent pulmonary hypertension of the newborn (PPHN) 4
The number needed to harm for PPHN with late pregnancy SSRI exposure is approximately 286-351 4

Infants exposed to SSRIs in utero should be monitored for at least 48 hours after birth, and arrange for early follow-up after hospital discharge 5, 6
In severely affected infants, a short-term course of chlorpromazine has provided measurable relief of symptoms 2
The American Academy of Pediatrics recommends that SSRI treatment should be continued during pregnancy at the lowest effective dose when clinically indicated 5, 6

Untreated depression during pregnancy is associated with premature birth, decreased initiation of breastfeeding, and potential harmful effects on the mother-infant relationship 4, 6
Women who discontinue antidepressant medication during pregnancy show a significant increase in relapse of major depression

Paroxetine and sertraline are considered to have more favorable profiles during breastfeeding due to lower infant-to-maternal plasma concentration ratios 5, 4
Sertraline, paroxetine, and fluvoxamine are minimally excreted in human milk and provide the infant <10% of the maternal daily dose 5

Use the lowest effective dose of SSRI during pregnancy 4, 6
Monitor for symptoms of depression throughout pregnancy 4, 6
For women already taking SSRIs who become pregnant, continuation of treatment is generally recommended if clinically indicated 4

Sertraline crosses the placenta and can be found in amniotic fluid, according to the Journal of Child Psychology and Psychiatry and Allied Disciplines 7