Antidepressants use during Pregnancy/이재라 전임의


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Antidepressants use during Pregnancy/이재라 전임의

  1. 1.  Depression is an illness thatinvolves the body, mood andthoughts It impacts the way a personfunctions socially, at work,and in relationships. It is a medical condition thatrequires diagnosis andtreatment
  2. 2.  Depression can be caused by one or more Imbalance of certain chemicals in the brain. Triggered bystress, medication ,other medical problems. Certain personality factors or genetic traits.
  3. 3.  Over the last 2 weeks, most of the day nearly every day, five ofthe following (one symptom must be mood or interest), whichmust cause marked distress or impairment in important areas offunctioning① Depressed mood② Markedly diminished interest or pleasure③ Significant weight loss or gain unrelated to dieting④ Insomnia or hypersomnia⑤ Psychomotor agitation/retardation⑥ Fatigue or loss of energy⑦ Feelings of worthlessness/guilt⑧ Diminished ability to concentrate⑨ Recurrent thoughts of death
  4. 4.  6 to 12% - Gavin and co-workers (2005) 10.7% - Dennis and associates (2007) 13% of pregnant women -Cooper and associates (2007) Incidence to be as high as 30%(Lee and colleagues, Westdahl and associates, 2007) 3.2 % of more than 25,000 prenatal patients at the MayoClinic took SSRIs during pregnancy Conversely(Wichmanand colleagues (2009))
  5. 5.  Postpartum depression—major or minor—develops in10 to 20 % of parturients Associated with Young maternal age Unmarried status Smoking or drinking Substance abuse Hyperemesis gravidarum Preterm birth High utilization of sick leave during pregnancy
  6. 6.  Approximately 80% of people who receivetreatment for Depression improve. Three types of treatment: Psychotherapy Medication Electroconvulsive Therapy (ECT)
  7. 7. 1. Selective Serotonin Reuptake Inhibitor (SSRI) Sertraline (Zoloft) Fluoxetine (Prozac) Paroxetine (Paxil) Citalopram (Celexa) Escitalopram (Lexapro)2. Tricyclic Antidepressant (TCA) Amitriptyline (Elavil) Nortriptyline (Pamelor) Imipramine (Tofranil) Desipramine (Norpramin) Doxepine (Sinequan) Trimipramine (Surmontil)
  8. 8. 3. Serotonin-Norepinephrine Reuptake Inhibitors (SNRI)• Venlafexine (Effexor)• Desvenlafaxin (Pristiq)• Duloxetine (Cymbalta)4. MAO Inhibitors• Phenelzine (Nardil)• Tranylcypromine (Parnate)5. Atypical Antidepressants• Bupropion (Wellbutrin)• Trazodone (Desyrel)• Mirtazepine (Remeron)
  9. 9. 1. Risk of pregnancy loss or miscarriage.2. Risk of organ malformation or teratogenesis.3. Risk of neonatal toxicity or withdrawal syndromes during the acuteneonatal period.4. Risk of long-term neurobehavioral sequelae. FDA classification (A, B, C, D, X) this system of classification is often ambiguous and may leadsome to make conclusions that are not warranted. TCAs have been labeled as category D agents :available datado not support this assertion, suggest that these drugs aresafe for use during pregnancy.
  10. 10.  TCAs The lowest known risk in pregnancy and breast feeding Dangerous if overdosed SSRIs Paroxetine (Paxil): 1st trimester : ASD, VSD, Right ventricular outflowdefects Sertraline (Zoloft): ASD, VSD,omphalocele Citalopram (Celexa) + Esitalopram (Lexapro): anencephaly, omphalocele, craniosynostosis
  11. 11.  SSRIs and TCAsLate pregnancy  persistent pulmonary hypertension Miscarriage/stillbirth/low birth weightData is conflicting and inconclusive
  12. 12.  SSRI –m/c used antidepressants in pregnancy citalopram, escitalopram, fluoxetine, fluvoxamine,paroxetine, sertraline Congenital cardiac malformations was increased 1.5to 2 fold following 1st trimester paroxetine exposure.
  13. 13.  The overall rate of infants with cardiovascular malformationsamong women who took paroxetine was increasedapproximately 0.5 to 1.0 percentage points above the rate forinfants with other antidepressant exposure in utero. Most of these defects were atrial and ventricular septaldefects• Recommended that paroxetine use be avoided in womenwho are either pregnant or planning pregnancy and that fetalechocardiography should be considered for women withearly pregnancy paroxetine exposure.• the American College of Obstetricians and Gynecologists (2007)
  14. 14.  There are two types of neonatal effects that have beendescribed following maternal SSRI use in pregnancy.1. Neonatal behavioral syndrome Up to a fourth of fetuses exposed in the lasttrimester Most SSRI-related neonatal case reportsspecifically involved paroxetine and fluoxetineexposures
  15. 15.  Symptoms include: Jitteriness Tachypnea Tremulousness Hypertonia Restlessness Signs include CNS, motor, respiratory, and GI signs Usually mild, transient with resolution by 2 weeks Severe syndrome Seizures, dehydration, excessive weight loss,hyperpyrexia, intubation Rare in full-term infants
  16. 16.  Tapering and discontinuation of the antidepressantover 10 to 14 days before the EDC Reintroduction of the drug immediately after birth. However, if a woman has a history of rapiddecompensation during antidepressant taper ordiscontinuation, this strategy is likely to carry more riskthan continued treatment.
  17. 17. 2. The second neonatal syndrome Rare Persistent pulmonary hypertension in the newborn(PPHN). High pulmonary vascular resistance, right-to-leftshunting, and profound hypoxemia Mortality rates are as high as 20 percent, and manysurvivors have long-term morbidityTreatment with these medications during pregnancyshould be individualized
  18. 18.  In patients with less severe depression, it may beappropriate to consider discontinuation ofpharmacological therapy during pregnancy Women with recurrent or refractory depressive illnessmay decide in collaboration with their clinician that thesafest option is to continue pharmacological treatment during pregnancy Paroxetine -> fluoxetine or citalopram.
  19. 19.  Fluoxetine and citalopram - first-line choices The TCAs and bupropion have also been relatively wellcharacterized and can be considered reasonabletreatment options during pregnancy. Several investigators have described a reduction inserum levels of TCAs during pregnancy. Increase in daily TCA or SSRI dosage may be requiredto obtain remission.
  20. 20.  The American College of Obstetricians andGynecologists (2007) concluded that the absolute risk ofany birth defect is very small and that SSRIs are notmajor teratogens. May be enough data to not pick as first line drug inpregnancy (or planning pregnancy): Fluoxetine (Prozac) – if will be breastfeeding Larger prospective studies with better controls forconfounding variables are required