depression in pregnancy and post-partum
TRANSCRIPT
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Depression in PregnancyDepression in Pregnancyand the Post-Partumand the Post-Partum
Ali Al-IbrahimAli Al-Ibrahim
MFM FellowMFM Fellow
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Myth BustersMyth Busters
Pregnancy is a time ofPregnancy is a time ofemotional well-beingemotional well-being
Category B is a safe category in pregnancyCategory B is a safe category in pregnancy
There is a specific algorithm for the treatmentThere is a specific algorithm for the treatmentof pregnant patientsof pregnant patients
It is best to stop psychotropic medicationsIt is best to stop psychotropic medications
priorpriorto conceptionto conception It is best to taper psychotropic medicationsIt is best to taper psychotropic medications
prior to deliveryprior to delivery
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MDD in pregnancyMDD in pregnancy
10-16% of women have major depression during10-16% of women have major depression during
pregnancypregnancy
Associated with problems for both mother and fetusAssociated with problems for both mother and fetus
When emerges in pregnancy, is frequently overlookedWhen emerges in pregnancy, is frequently overlooked
Pregnancy is neither protective, nor exacerbating forPregnancy is neither protective, nor exacerbating for
depressive disordersdepressive disorders
Under-recognized and under-treated in primary careUnder-recognized and under-treated in primary caresettingssettings
Cohen L, Nonacs R (editors):Mood and Anxiety Disorders During Pregnancy and Postpartum (Review of Psychiatry Series, Vol 24,
umber 4 . ashin ton DC APPI 005
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PERCENTAGE OF MOTHERSPERCENTAGE OF MOTHERS
WITH SEVERE DEPRESSIONWITH SEVERE DEPRESSION
WHO DID NOT TALK TO DOCTOR OR COUNSELORWHO DID NOT TALK TO DOCTOR OR COUNSELOR
57.5
72.2
79.9 78.3
100
73.1
0
10
2030
40
50
60
70
80
90
100
White African
American
Hispanics Asian Pacific
Islander
Native
American
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Antidepressant Use inAntidepressant Use inPregnancyPregnancy
Recent studies estimate up to 9% ofRecent studies estimate up to 9% of
pregnant women may take an SSRIpregnant women may take an SSRI
during pregnancyduring pregnancy
Several studies have also shown anSeveral studies have also shown an
increaseincrease in antidepressant usein antidepressant use
SSRIs accounted for the largestSSRIs accounted for the largest
increaseincrease
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A Multisite Retrospective Study
118,935 deliveries2001-2005, 6.6% women
took antidepressants
Antidepressant useincreased from 2%
deliveries in 1996 to 7.6%
deliveries in 2005
SSRI use increased
from 1.5% in 1996 to
6.4% in 2004
Andrade S et al. Use of antidepressant medications during pregnancy: a multisite study. American Journal of Obstetrics and Gynecology.
Feb. 2008
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Why is this important?Why is this important?
All women of childbearing years areAll women of childbearing years are
potentiallypotentiallypregnant until provenpregnant until proven
otherwiseotherwise
Approximately 50% pregnancies areApproximately 50% pregnancies are
unplannedunplanned
10-16% women have major depression during10-16% women have major depression during
pregnancypregnancy
Risk benefit analysis ideally prior toRisk benefit analysis ideally prior to
conception, every medication change!conception, every medication change!
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Weighing the Risks and BenefitsWeighing the Risks and Benefits
Risk of untreated mental illnessRisk of untreated mental illness Risk of relapse of psychiatric illnessRisk of relapse of psychiatric illness
Effects of psychiatric illness on the fetusEffects of psychiatric illness on the fetus
Teratogenicity of psychotropic medicationsTeratogenicity of psychotropic medications
Long term behavioral effectsLong term behavioral effects
Incomplete reproductive safety data forIncomplete reproductive safety data for
medicationsmedications
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Risk of Untreated PsychiatricRisk of Untreated PsychiatricIllness in PregnancyIllness in Pregnancy
Maternal Depression may cause:Maternal Depression may cause: Preterm birth, low birth-weight, smaller headPreterm birth, low birth-weight, smaller head
circumference, and lower Apgar scorescircumference, and lower Apgar scores Contribute to poor self-care, inattention toContribute to poor self-care, inattention to
prenatal careprenatal care Women are more likely to smoke, useWomen are more likely to smoke, use
alcohol or illicit drugsalcohol or illicit drugs Children of depressed mothers are moreChildren of depressed mothers are more
likely to have behavioral problems, delayslikely to have behavioral problems, delaysin cognitive, motor and emotionalin cognitive, motor and emotionaldevelopmentdevelopment
Risk for suicideRisk for suicide
Nonacs R, Viguera A, Cohen L.Psychiatric Aspects of Pregnancy. Womens Mental Health, a Comprehensive Textbook. Ed. SusanKornstein and Anita Clayton. New York, NY, 2002.
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Anxiety and Stress in PregnancyAnxiety and Stress in Pregnancy
Lead to poor outcomesLead to poor outcomes
Increase cortisol and adrenocorticotropicIncrease cortisol and adrenocorticotropic
hormone levelshormone levels
May be associated with preeclampsiaMay be associated with preeclampsia
May reduce uteroplacental blood-flowMay reduce uteroplacental blood-flow
Antenatal anxiety predicts postpartum anxietyAntenatal anxiety predicts postpartum anxietyand depressionand depression
Cohen L, Nonacs R (editors):Mood and Anxiety Disorders During Pregnancy and Postpartum (Review of Psychiatry Series, Vol. 24,
Number 4). Washington, DC, APPI, 2005
Heron J, O;Connor T et al. The course of anxiety and depression through pregnancy and the postpartum in a community sample. J. Affect.
Disord 80:65-73,2004.
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Depression Relapse in Pregnancy:Depression Relapse in Pregnancy:Cohen et al. 2006:Cohen et al. 2006:
43% of the women
experienced relapse
during pregnancy
26% who maintained
medication relapsed
68% who discontinued
medication relapsed
Cohen L, Altshuler L, Harlow B et al.Relapse of Major Depression During Pregnancy in Women Who Maintain or Discontinue
Antidepressant Treatment. JAMA Vol 295 (5),: 499-507, 2006.
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Risks Associated withRisks Associated withMedications in PregnancyMedications in Pregnancy
Pregnancy loss or miscarriagePregnancy loss or miscarriage
Organ malformation or teratogenesisOrgan malformation or teratogenesis
Neonatal toxicity or withdrawal syndromesNeonatal toxicity or withdrawal syndromes Long-term neurobehavioral sequelaeLong-term neurobehavioral sequelae
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OrganogenesisOrganogenesis
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SSRIs in PregnancySSRIs in Pregnancy
No major teratogenic risk associated withNo major teratogenic risk associated with
SSRI useSSRI use
Possible increase in cardiac defects with firstPossible increase in cardiac defects with first
trimester exposure totrimester exposure toparoxetineparoxetine
Adverse perinatal outcomes: conflicting dataAdverse perinatal outcomes: conflicting data
Persistent pulmonary hypertensionPersistent pulmonary hypertension Possible increase in spontaneous abortionPossible increase in spontaneous abortion
No significant developmental delay in childrenNo significant developmental delay in children
Cohen L. Treatment of Bipolar Disorder During Pregnancy.J. Clinical Psychiatry 68 (9), 2007: 4-9.
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Late 3Late 3rdrd trimester exposuretrimester exposure
Neonatal Behavioral SyndromeNeonatal Behavioral Syndrome Symptoms include:Symptoms include:
JitterinessJitteriness
TachypneaTachypnea TremulousnessTremulousness HypertoniaHypertonia RestlessnessRestlessness
Difficult to differentiate reported adverseDifficult to differentiate reported adverseoutcomes related to:outcomes related to: Antidepressant exposureAntidepressant exposure
Antidepressant withdrawalAntidepressant withdrawal
Maternal depression and anxietyMaternal depression and anxiety
R d P
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SSRIs and PersistentSSRIs and PersistentPulmonary HypertensionPulmonary Hypertension
Cohort Study: SSRIs in late pregnancy may beCohort Study: SSRIs in late pregnancy may bea risk factor for PPHNa risk factor for PPHN (Chambers et al 1996)(Chambers et al 1996)
Case-Control Study:Case-Control Study: (Chambers et al 2006)(Chambers et al 2006)
14 infants were exposed to an SSRI after the 2014 infants were exposed to an SSRI after the 20ththweek of gestationweek of gestation
Retrospective designRetrospective design
Absolute risk: 7/1000 womenAbsolute risk: 7/1000 women
Based on this study, in April 2006 the FDABased on this study, in April 2006 the FDArequired a label change to include SSRIsrequired a label change to include SSRIsincreasing the risk for PPHNincreasing the risk for PPHN
Chambers C, Hernandez-Diaz S, Van-Marter L et al. Selective Serotonin-Reuptake Inhibitors and Risk of Persistent Pulmonary Hypertension
of the Newborn. N Engl J Med. Vol 354:6 579-587, February 9, 2006.
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Paxil and Cardiac DefectsPaxil and Cardiac Defects
Multiple studies show no increased risk ofMultiple studies show no increased risk ofcardiac defects with Paxil or othercardiac defects with Paxil or otherantidepressantsantidepressants
Meta-analysis (Koren et al. 2007)Meta-analysis (Koren et al. 2007) Increased risk for cardiac malformationIncreased risk for cardiac malformation Women using antidepressants had higherWomen using antidepressants had higher
numbers of echocardiograms, amniocentesisnumbers of echocardiograms, amniocentesisand ultrasoundsand ultrasounds
Women on paroxetine used the drug for anxietyWomen on paroxetine used the drug for anxietyand panicand panic
Epidemiologic Study (Koren et al. 2008)Epidemiologic Study (Koren et al. 2008) 1,174 unpublished cases and 2,061 cases from1,174 unpublished cases and 2,061 cases from
published database studiespublished database studies
The rate of cardiovascular defect falls within theThe rate of cardiovascular defect falls within thenormal rate in the general populationnormal rate in the general populationBar-Oz, Einarson T, Koren G et al. Clinical Therapeutics. 2007: 29: 918-926.
Einarson A, Pistelli A, Koren G.AJP. 1008: 1-4. April, 2008
FDA C iFDA C t i
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FDA CategoriesFDA CategoriesCATEGORY INTERPRETATION
A Adequate, well-controlled studies in pregnant women have not shown an increased risk offetal abnormalities to the fetus in any trimester of pregnancy.
B Animal studies have revealed no evidence of harm to the fetus, however, there are noadequate and well-controlled studies in pregnant women.OR
Animal studies have shown an adverse effect, but adequate and well-controlled studies inpregnant women have failed to demonstrate a risk to the fetus in any trimester.
CAnimal studies have shown an adverse effect and there are no adequate and well-controlled studies in pregnant women.OR
No animal studies have been conducted and there are no adequate and well-controlledstudies in pregnant women.
D Adequate well-controlled or observational studies in pregnant women have demonstrateda risk to the fetus.However, the benefits of therapy may outweigh the potential risk. For example, the drug
may be acceptable if needed in a life-threatening situation or serious disease for whichsafer drugs cannot be used or are ineffective.
X Adequate well-controlled or observational studies in animals or pregnant women havedemonstrated positive evidence of fetal abnormalities or risks.
The use of the product is contraindicated in women who are or may become pregnant.
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Other AntidepressantsOther Antidepressants
VenlafaxineVenlafaxine
TrazodoneTrazodone
MirtazapineMirtazapine DuloxetineDuloxetine
BupropionBupropion
MAOI inhibitors are avoided inMAOI inhibitors are avoided inpregnancypregnancy
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Tricyclic AntidepressantsTricyclic Antidepressants
No major risk for malformationsNo major risk for malformations
Desipramine and nortriptylineDesipramine and nortriptyline
preferred - less anticholinergicpreferred - less anticholinergic
activityactivity
Perinatal syndromes described inPerinatal syndromes described in
infantsinfants Anticholinergic effects are transientAnticholinergic effects are transient
(bowel obstruction, urinary retention)(bowel obstruction, urinary retention)
Withdrawal SyndromeWithdrawal Syndrome
No lon -term neurobehavioral effectsNo lon -term neurobehavioral effects
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Medication Reduction orMedication Reduction orDiscontinuation Prior To DeliveryDiscontinuation Prior To Delivery
Adverse effects on the fetus:Adverse effects on the fetus: HypotoniaHypotonia
Neonatal withdrawal syndromesNeonatal withdrawal syndromes
Neonatal apneaNeonatal apnea
Temperature dysregulationTemperature dysregulation
But rare, temporary, treatable, andBut rare, temporary, treatable, and
reversiblereversible
Higher risk of relapse in pregnancyHigher risk of relapse in pregnancy
and post-partumand post-partum
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Other Treatment OptionsOther Treatment Options
Cognitive Behavioral TherapyCognitive Behavioral Therapy
Interpersonal TherapyInterpersonal Therapy
Group TherapyGroup Therapy Light TherapyLight Therapy
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Electroconvulsive TherapyElectroconvulsive Therapy
Safety well documented over 50years
Organ Dysgenesis
Occasional reports of malformations but noOccasional reports of malformations but nodirect causal link to ECTdirect causal link to ECT
Intrauterine Growth Defects/NeonatalToxicity NoneNone
Neurobehavioral Teratogenicity Few case reports - developmental delays or MRFew case reports - developmental delays or MR
No direct causal link to ECTNo direct causal link to ECT
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Recommendations continuedRecommendations continued
ECT for psychotic depressionECT for psychotic depression
Review all risks and benefits ofReview all risks and benefits of
treatmenttreatment
Moms should be monitored carefullyMoms should be monitored carefully
for increased depression, mania orfor increased depression, mania or
psychosispsychosis
Dosages may need to be adjustedDosages may need to be adjusted
GoalGoal is monotherapy and minimalis monotherapy and minimal
effective dosageeffective dosageAltshuler L, Cohen, L, Moline M et al. Treatment of Depression in Women: A Summary of the ExpertConsensus Guidelines.Journal of Psychiatric Press: 185-208, May, 2001
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Postpartum Depression versusPostpartum Depression versusPostpartum BluesPostpartum Blues
DisorderDisorder IncidencIncidencee
(%)(%)
TimeTimeCourseCourse
ClinicalClinicalFeaturesFeatures
PostpartumPostpartum
BluesBlues
75-8575-85 11stst PPPPweek- 2week- 2
weeksweeks
Mood instability,Mood instability,
tearfulness,tearfulness,
anxiety, insomniaanxiety, insomnia
PostpartumPostpartumDepressionDepression
1010 11stst
ppppmonthmonth
Depressed mood, guilt,Depressed mood, guilt,
fear of harm coming tofear of harm coming to
baby, obsessionalbaby, obsessional
featuresfeatures
PostpartumPostpartum
Ps chosisPs chosis
0.1-0.20.1-0.2 11stst pppp
monthmonth
Disorientation,Disorientation,
confusion, delusions,confusion, delusions,hallucinations, ra idhallucinations, rapid
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Risk Factors for PostpartumRisk Factors for PostpartumDepressionDepression
Previous history of MDD- 24% riskPrevious history of MDD- 24% risk Depression during pregnancy- 35%Depression during pregnancy- 35% Previous postpartum depression-50%Previous postpartum depression-50% Stressful life eventsStressful life events Marital dissatisfactionMarital dissatisfaction Demographic variables may be weakDemographic variables may be weak
contributorscontributors Hormonal fluctuationsHormonal fluctuations
Burt, V. Hendrick, V. Clinical manual of Womens Mental Health. Arlington, VA 2005.
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Recommendations for ScreeningRecommendations for Screening
Edinburgh Postnatal DepressionEdinburgh Postnatal Depression
ScaleScale
PP Depression ScalePP Depression Scale
Responsiveness of mom and babyResponsiveness of mom and baby
Sleep patternsSleep patterns
Weight loss or gainWeight loss or gain Assess for fears of infant harmAssess for fears of infant harm
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Individualized Risk BenefitIndividualized Risk BenefitAnalysis PlanAnalysis Plan
Risk ofUntreated
PPD
Benefits ofTreatment
Previous TxOf Depression
Risk ofAntidepressant
Treatment
Risk ofBreastfeeding
Infant SerumLevels
TargetSymptoms
Maternal
Wishes
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SSRIs and LactationSSRIs and Lactation
ParoxetineParoxetine andand Sertraline-Sertraline- 11stst lineline Less than 10% maternal levelLess than 10% maternal level
FluoxetineFluoxetine Exceeded 10% maternal level (22%Exceeded 10% maternal level (22%
cases)cases)
CitalopramCitalopram Exceeded 10% maternal level (17%Exceeded 10% maternal level (17%
cases)cases)
EscitalopramEscitalopram andand FluvoxamineFluvoxamine Few case reportsFew case reportsAcademy of Breastfeeding Medicine Protocol Committee Clinical Protocol #18: Use of Antidepressants in NursingMothers.Breast eedin Medicine. VOl 3. 1 2008.
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Tricyclics, Heterocyclics, andTricyclics, Heterocyclics, andLactationLactation
NortriptylineNortriptyline- undetectable in infant serum- undetectable in infant serum Growing evidence that other tricyclics appear to be safeGrowing evidence that other tricyclics appear to be safe
DoxepinDoxepin-- cautionedcautioneddue to hypotonia, poor feedingdue to hypotonia, poor feeding
MirtazapineMirtazapine- no adverse effects reported- no adverse effects reported BupropionBupropion
SNRIsSNRIs
Trazodone-Trazodone- infant levels less than 10%infant levels less than 10% MAOI inhibitors-MAOI inhibitors- discontinuediscontinue
Menon, S. Psychotropic Medication during Pregnancy and Lactation. Arch. Gynecol. Obstet. 277: 1-13, 2008.
Complementary and AlternativeComplementary and Alternative
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Complementary and AlternativeComplementary and AlternativeMedications for PerinatalMedications for Perinatal
DepressionDepression
Omega-3-fatty acidsOmega-3-fatty acids:: general datageneral data
support use in pregnancy andsupport use in pregnancy and
postpartumpostpartum
S-adenosyl-methionine:S-adenosyl-methionine: SomeSome
efficacy in reducing depressionefficacy in reducing depression
Folate:Folate: some evidence to supportsome evidence to support
augmentation for depressionaugmentation for depression
St. Johns Wort-St. Johns Wort- some evidence ofsome evidence of
efficacy- possible drug interactionsefficacy- possible drug interactionsFreeman, M. Complementary and Alternative Medicine for Perinatal Depression. Journal of Affective Disorders, 2008.
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CAM continuedCAM continued
Bright light therapy:Bright light therapy: evidenceevidence
supports potential use in perinatalsupports potential use in perinatal
and postpartumand postpartum
Acupuncture:Acupuncture: caution advised incaution advised in
pregnant womenpregnant women
Massage:Massage: some efficacy insome efficacy in
pregnancypregnancy
Exercise:Exercise: appears to haveappears to have
antidepressant effectsantidepressant effects
Recommendations forRecommendations for
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Recommendations forRecommendations forAntidepressant Treatment inAntidepressant Treatment in
Lactating WomenLactating Women Individualized risk-benefit analysisIndividualized risk-benefit analysis PsychotherapyPsychotherapy
Mild to moderate depressionMild to moderate depression
PsychotherapyPsychotherapy ++ antidepressantantidepressant Moderate to severe depressionModerate to severe depression
NoNo prior antidepressant:prior antidepressant: ParoxetineParoxetine oror SertralineSertraline
Prior successfulsuccessfulantidepressantantidepressanttreatmenttreatment
Discuss data with mom; consider as firstDiscuss data with mom; consider as firstAcademy of Breastfeeding Medicine Protocol Committee Clinical Protocol #18: Use of Antidepressants in Nursing Mothers. BreastfeedingMedicine. VOl 3. (1), 2008.
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ConclusionsConclusions
Every female patient ofEvery female patient ofchildbearing years ischildbearing years ispotentially pregnant!potentially pregnant!
Ideally, decisions aboutIdeally, decisions aboutpsychotropic medications shouldpsychotropic medications should
be made prior to conceptionbe made prior to conception
Consider non-pharmacologicConsider non-pharmacologic
lC l i
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ConclusionsConclusions
Risk-benefit analysisRisk-benefit analysis Minimize medication number andMinimize medication number and
dosedose
Document, document, document!Document, document, document!
In all cases, optimizing theIn all cases, optimizing themothers health and ability tomothers health and ability toparent should be consideredparent should be considered
crucial for the developing childcrucial for the developing child
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Thanks for coming!!Thanks for coming!!
Questions?Questions?
R fReferences
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ReferencesReferences
Bupropion Pregnancy Registry Interim Report September 1997 through 31 August 2007 Issued: December 2007 Glaxo Smith Kline
CDC: Births: Preliminary Data 2006; National Vital Statistics Report. Volume 57, Number 7, December 2007.
Cohen L, Nonacs R (editors):Mood and Anxiety Disorders During Pregnancy and Postpartum (Review of Psychiatry Series, Vol 24, Number 4).
Washington, DC, APPI, 2005
Cohen L. Treatment of Bipolar Disorder During Pregnancy.J. Clinical Psychiatry 68 (9), 2007: 4-9.
Altshuler et al. Pharmacological Management of psychiatric illness in pregnancy: dilemmas and guidelines. Am J. Psychiatry 1996;
153: 592-606.
Chambers C, Hernandez-Diaz S, Van-Marter L et al. Selective Serotonin-Reuptake Inhibitors and Risk of Persistent Pulmonary Hypertension of
the Newborn. N Engl J Med. Vol 354:6 579-587, February 9, 2006.
Finer, L and Henshaw K. Disparities in Rates of Unintended Pregnancy in the United States, 1994 and 2001.Perspectives on Sexual andReproductive Health. Vol 38 (2), 90-96, 2006.
Cohen L, Altshuler L, Harlow B et al.Relapse of Major Depression During Pregnancy in Women Who Maintain or Discontinue
Antidepressant Treatment. JAMA Vol 295 (5),: 499-507, 2006.
Chambers C, Johnson K, Dick, L et al.Birth Outcomes in Pregnant Women Taking Fluoxetine.N Engl J Med 335:1010-1015, 1996.
Bar-Oz B. Einarson T, Einarson A. et al.Paroxetine and Congenital Malformations: Meta-Analysis and Considerations of
Potential Confounding Factors. Clinical Therapeutics, Vol 29(5)918-926, 2007.
Einarson A, Pistelli A, DeSantis M. et al.Evaluation of the Risk of Congenital cardiovascular Defects Associated with Use of Paroxetine
During Pregnancy. Am J Psychiatry in advance- April 1, 2008.
ABM Clinical Protocol #18: Use of Antidepressants in Nursing Mothers. Breastfeeding Medicine.VOl 3. (1), 2008.
Burt, V. Hendrick, V. Clinical manual of Womens Mental Health. Arlington, VA 2005.
Andrade S et al. Use of antidepressant medications during pregnancy: a multisite study. American Journal of Obstetrics and Gynecology.
Feb. 2008
F M A t t l D i N i ti th T t t Dil A J P hi t V l 164(8)1162 1165 2007
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U.S. Food and Drug Administration. FDA Public Health Advisory,Paroxetine. Available at:
http://www.fda.gov/cer/drug/advisory/paroxetine200512.htm. Accessed April 7, 2008
Newport D, Viguera A, Nemeroff C et al.Atypical Antipsychotic Administration During Late Pregnancy: Placental Passage and
Obstetrical Outcome. Am J Psychiatry, 164:8, 1214-1220 August 2007.
Yaeger D., Smith H., Altshuler L.Atypical Antipsychotics in the Treatment of Schizophrenia During Pregnancy and the Postpartum. Am J
Psychiatry 163:12, 2064-2070, 2006.
Nonacs R, Viguera A, Cohen L.Psychiatric Aspects of Pregnancy. Womens Mental Health, a Comprehensive Textbook. Ed. Susan Kornstein
and Anita Clayton. New York, NY, 2002.
Koren, G.Medication Safety in Pregnancy and Breastfeeding. 2007
Heron J, O;Connor T et al. The course of anxiety and depression through pregnancy and the postpartum in a community sample. J.
Affect. Disord 80:65-73,2004.
Gentile S.Prophylactic Treatment of Bipolar Disorder in Pregnancy and Breastfeeding: Focus on Emerging Mood
Stabilizers. Bipolar Disorders. 8:207-220, 2006.
Newport D, Stowe Z et al.Psychiatric Disorders in Pregnancy.Neurologic Clinics Vol 22: 863-893, 2004.
Viguera A, Stowe Z, Cohen C et al. Risk of Recurrence in Women with Bipolar Disorder During Pregnancy: Prospective Study of Mood
Stabilizer Discontinuation. Am J Psychiatry. 164:12 December 2007, 1817-1824.
Freeman M.Antenatal Depression: Navigating the Treatment Dilemmas. Am J Psychiatry Vol 164(8)1162-1165, 2007.
Menon, S. Psychotropic Medication during Pregnancy and Lactation. Arch. Gynecol. Obstet. 277: 1-13, 2008.
http://www.fda.gov/cer/drug/advisory/paroxetine200512.htm.%20Accessed%20April%207http://www.fda.gov/cer/drug/advisory/paroxetine200512.htm.%20Accessed%20April%207