Do Antidepressants Increase Risk of Miscarriage?

Dr. Sharon Orrange
Dr. Orrange is an Associate Professor of Clinical Medicine in the Division of Geriatric, Hospitalist and General Internal Medicine at the Keck School of Medicine of USC.
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With depression so common, many women of reproductive age will be on antidepressant meds while attempting to conceive. Do I have to stop taking my antidepressant once I’m pregnant? That’s a question we face in primary care all the time.

It’s a complicated thing to study because comparing folks with depression taking antidepressants with folks not suffering from depression isn’t a fair study—because depression itself may be (and likely is) a risk factor for miscarriage.

What risks may antidepressants present?

The risk to the fetus from antidepressant meds has received much attention, with reports of congenital malformations, persistent pulmonary hypertension of the newborn (PPHN), preterm birth and miscarriage.

The current evidence suggests that selective serotonin reuptake inhibitor (SSRI) exposure during pregnancy is associated with an increased risk of miscarriage compared to those not taking them, but the increases have been relatively modest.

What’s new?

We now have results of a huge study that provide reassurance about the use of antidepressants, suggesting they may not add additional risk of miscarriage in someone who is depressed. Here are the details, and remember this is crucial because it compared women with depression taking meds vs. women with depression not taking meds. Of about 1,005,000 pregnancies, the rate of miscarriage (before 22 weeks’ gestation) was 11%. The risk of miscarriage among pregnancies in women with depression treated with an antidepressant in early pregnancy was compared with the risk among pregnancies in women with depression who did not report use of antidepressants AND in women with no diagnosis of depression and no antidepressant use.

Which medications did they study?

The antidepressants included SSRIs (sertraline, paroxetine, fluvoxamine, and escitalopram as examples), serotonin-norepinephrine reuptake inhibitors (SNRIsvenlafaxine, Cymbalta, Effexor XR), and tricyclics (nortriptyline, amitriptyline).

What do we know from this large study?

The risk of miscarriage (spontaneous abortion) in women taking antidepressants was slightly higher compared with no antidepressant use. However, when they compared women with depression taking meds compared to women with depression (not on meds) the risk associated with antidepressant use dropped to 1.0.

This means after adjustment for the depression diagnosis, the risk is zero, and miscarriage rates are the same in unexposed (no antidepressants) and exposed (antidepressants) pregnancies.

Where does this leave us, can we recommend pregnant patients stay on antidepressants?

We should all be somewhat reassured by the findings of this study. There is no one size fits all decision with respect to whether you should continue antidepressants during pregnancy but safety does appear to be on your side.

Dr O.

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