The use of antidepressants during pregnancy has no long term neurodevelopmental or behavioural effects on the child, however they may be associated with an increased risk of postpartum haemorrhage, suggests the findings from three studies published today in BJOG: An International Journal of Obstetrics and Gynaecology (BJOG).
Depression and anxiety are the most common mental health problems during pregnancy, with around 12% of women in the UK experiencing depression at some point during pregnancy and the postnatal period. The use of antidepressants such as selective serotonin reuptake inhibitors (SSRIs) to treat depression during pregnancy has become increasingly common, however, it is unclear whether any increased risk to the fetus, and health problems for the woman or baby, can be attributed directly to these drugs or may be caused by other factors. The research published today examines the effects SSRI use on the health of both the mother and the long term development of the child.
A study from the Norwegian Institute of Public Health looked at the effects of prenatal exposure to SSRIs on motor skill development at 3 years old in 51,404 children from the Norwegian Mother and Child Cohort Study. In this cohort 159 mothers reported a prolonged use of SSRIs during pregnancy. Their children had a slight delay in the development of fine and gross motor skills compared to children unexposed during pregnancy. However, the authors of this paper acknowledge that the numbers are so small, no change in clinical practice is warranted.
Marte Handal, lead author of the study from the Norwegian Institute of Public Health said:
“Our results show that treatment with SSRIs during longer time periods in pregnancy was weakly associated with a delayed motor development at age three. However, only a very small number of children had a severe delay. Even though we did take into account maternal symptoms of depression we still did not have complete information on the severity of the maternal depression in the different groups. Effective treatment of depression during pregnancy is essential and these results should not discourage healthcare professionals from prescribing or continuing antidepressant treatment to those who need it.”
In another study, an Australian team analysed data from 49,000 women registered on the Danish National Birth Cohort, to examine the impact of prenatal exposure to SSRIs on behavioural problems at aged 7. Results found that untreated prenatal depression (231 children) was associated with an increased risk of problem behaviour in the children, hyperactivity, inattention, and peer problems. This increased risk was not seen in the children (210 children) whose mothers took antidepressants, including SSRIs.
In a separate study, the same team examined the risk of postpartum haemorrhage (the loss of between 500 to 1,000ml of blood within the first 24 hours after giving birth) in mothers taking antidepressants in the final three months of their pregnancy, at the Women's and Children's Hospital in Adelaide, Australia. For women without psychiatric illness (28,000 women) or who were not taking antidepressants (1,292) the risk of postpartum haemorrhage was 11%. This increased to 16% for women taking antidepressants (558). Risk of severe postpartum haemorrhage and of postpartum anaemia were almost doubled by SSRI use.
Dr Luke Grzeskowiak, lead author of the studies from The University of Adelaide, Australia, said:
“It is reassuring to find that prenatal exposure to antidepressants did not affect a child’s behaviour at age 7, however as with any medication, the benefits and risks but always be considered.
"Regarding our other study, overall the risks for postpartum haemorrhage are largely unknown. We found separate increases in risk with placenta praevia, prolonged labour, hypertension and assisted vaginal delivery, as well as the increased risk seen with antidepressant use. However we did not have data on known risks such as use of oxytocin during delivery, nor did we have any data on the severity of the underlying maternal psychiatric illness. Consequently, it is possible that the women who took antidepressants late in pregnancy were those with the most severe illness and it is this which is responsible for the increased risk of postpartum haemorrhage and not the antidepressant. Based on this study alone we do not recommend that women stop taking medication for depression during pregnancy, but are closely monitored in order to reduce the risk of any potential increased risk of bleeding as much as possible.”
John Thorp, BJOG Deputy Editor-in-chief said:
"These studies add to a growing body of evidence about the safety of taking antidepressants during pregnancy. While there are some increased risks, the evidence so far seems to be that the risks of untreated depression outweigh the risks of taking them. But the more we understand the better prepared the medical profession will be to help women through their pregnancy and birth."
RCOG response to BJOG studies on SSRI use in pregnancy
Dr Patrick O’Brien, a maternal mental health expert and spokesperson for the Royal College of Obstetricians and Gynaecologists (RCOG), said:
"The decision whether or not to use SSRIs during pregnancy must be considered on an individual basis as untreated maternal depression can itself be harmful. Pregnant women and mothers can be reassured from these studies which suggest there are no clinically important long term neurodevelopmental or behavioural problems associated with taking SSRIs.
“While it is useful for women to be aware that SSRI use may increase the risk of postpartum haemorrhage, more research needs to be done to understand what is behind this increased risk. Women should not stop taking their medication without first discussing their options with their doctor and if necessary extra precautions can be taken to prevent postpartum haemorrhage at the time of birth."
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The Royal College of Obstetricians and Gynaecologists is a medical charity that champions the provision of high quality women’s healthcare in the UK and beyond. It is dedicated to encouraging the study and advancing the science and practice of obstetrics and gynaecology. It does this through postgraduate medical education and training and the publication of clinical guidelines and reports on aspects of the specialty and service provision.
M Handal, S Skurtveit, K Furu, S Hernandez-Diaz, E Skovlund, W Nystad, R Selmer. Motor development in children prenatally exposed to selective serotonin reuptake inhibitors: a large population-based pregnancy cohort study. BJOG 2015; DOI: 10.1111/1471-0528.13582
LE Grzeskowiak, JL Morrison,TB Henriksen, BH Bech, C Obel, J Olsen, LH Pedersen. Prenatal Antidepressant Exposure and Child Behavioural Outcomes at 7-Years of Age: A study within the Danish National Birth Cohort. BJOG 2015; DOI: 10.1111/1471-0528.13611
LE Grzeskowiak, R McBain, GA Dekker, VL Cliftona. Antidepressant use in late gestation and risk of postpartum haemorrhage: a retrospective cohort study. BJOG 2015; DOI: 10.1111/1471-0528.13612
L Siminerio, R Venkataramanan, S Caritis. Selective serotonin reuptake inhibitors and childhood motor skill impairment - what can be concluded? BJOG DOI: 10.1111/1471-0528.13581
Postpartum Haemorrhage, Prevention and Management (Green-top Guideline No. 52)
Management of Women with Mental Health Issues during Pregnancy and the Postnatal Period (Good Practice No.14)
Antenatal and postnatal mental health: clinical management and service guidance
NICE guidelines (CG192)