11/8/2023
Management of Depression in Pregnancy
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Depression in pregnancy and the postpartum period is common and affects up to 1 in 7 women. The risk for a major depressive episode is about 12% during pregnancy and about 7% in the 3 months following delivery. Risk factors include history of trauma or traumatic birth, a personal or family history of depression, lack of partner support, life stress, lack of social support, and difficulty breastfeeding. Biologic factors such as serotonin-related dysregulation of the hypothalamic-pituitary-adrenal axis, elevated cortisol concentrations, and enhanced neurotropic factors may also have a role.
Screening for depression is recommended at least once perinatally and at the postpartum visit. The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used tool and may be most specific for perinatal depression. Screening itself may have a positive effect on symptoms. Ideally, patients who screen positive should be connected to treatment and/or referral for mental health care.
Untreated symptomatic depression is associated with risks. Women with mood disorders during pregnancy are more likely to use illicit substances and tobacco, more likely to have concurrent medical conditions and poor weight gain, and less likely to have adequate prenatal care. Risk for spontaneous abortion may be increased. Obstetric risks related to depression symptoms in pregnancy include preterm delivery and low birth weight. These associations are stronger when symptoms occur later in pregnancy. Children of depressed mothers are more likely to require psychiatric care and exhibit suicidal behavior later in life.
Risks of untreated disease should be weighed against risk for treatment. The approach to treatment of depression in pregnancy includes initiation of therapy, medication, or both. Selective serotonin reuptake inhibitors (SSRIs) are the most studied category of antidepressant therapy in pregnancy. In general, evidence for teratogenicity of SSRI use in the first trimester is limited, although paroxetine should be avoided if possible given its possible connection to congenital cardiac malformations. SSRI use in later pregnancy may be associated with transient neonatal withdrawal effects after birth such as mild respiratory distress, jitteriness, and need for neonatal intensive care unit admission. There is a modest association with persistent neonatal pulmonary hypertension, but the risk is most likely outweighed by the potential benefits of treatment. In general, optimization of symptoms with a single SSRI is best because polytherapy only increases any potential exposure. Dosage adjustments (increases) may be necessary to achieve effectiveness with advancing gestation.
For a woman taking an SSRI, risks of treatment cessation during pregnancy or when she becomes pregnant should be discussed. One study demonstrated a 68% chance of symptom relapse when antidepressant treatment was discontinued during pregnancy. Shared decision-making and an individualized approach are important in navigating treatment options in each case. Potential fetal exposures exist in the setting of either untreated symptomatic depression or SSRI treatment.
Postpartum treatment options have expanded to include intravenous allopregnanolone, a GABA modulator, which has been shown to quickly improve symptoms in patients with severe postpartum depression. Its use requires hospitalization and cessation of breastfeeding. SSRI use is considered compatible with breastfeeding.
Postpartum depression symptoms should be distinguished from those of postpartum psychosis, which is encountered much less frequently and usually requires hospitalization and evaluation. Postpartum psychosis tends to occur more commonly in patients with a history of bipolar disorder or may represent an initial episode of bipolar disorder or schizophrenia.
Further Reading:
ACOG Committee on Practice Bulletins--Obstetrics. ACOG Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists number 92, April 2008 (replaces practice bulletin number 87, November 2007). Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol. 2008 Apr;111(4):1001-20. doi: 10.1097/AOG.0b013e31816fd910. PMID: 18378767.
Yonkers, KA. Management of depression and psychoses in pregnancy and in the puerperium. (2019). In Creasy RK, Resnik R, et al., Maternal Fetal Medicine Principles and Practice 8th Edition (pp 1232-42).
ACOG Committee Opinion No. 757: Screening for Perinatal Depression. Obstet Gynecol. 2018 Nov;132(5):e208-e212. doi: 10.1097/AOG.0000000000002927. PMID: 30629567.
Masarwa R, Bar-Oz B, Gorelik E, et al. Prenatal exposure to selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors and risk for persistent pulmonary hypertension of the newborn: a systematic review, meta-analysis, and network meta-analysis. Am J Obstet Gynecol. 2019 Jan;220(1):57.e1-57.e13. doi: 10.1016/j.ajog.2018.08.030. Epub 2018 Aug 28. PMID: 30170040.
Kanes S, Colquhoun H, Gunduz-Bruce H, et al. Brexanolone (SAGE-547 injection) in post-partum depression: a randomised controlled trial. Lancet. 2017 Jul 29;390(10093):480-489. doi: 10.1016/S0140-6736(17)31264-3. Epub 2017 Jun 12. PMID: 28619476.
Initial Publication November 2023
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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.
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