1. ANGELS Update Antidepressants in Pregnancy Linda L.M. Worley, MD, Associate Professor UAMS, Departments of Psychiatry & OB/GYN

2. REVIEW: Untreated Depression in PG linked to increased risks for: Miscarriage Growth restriction (Teixeira et al 1999; British Medical Journal) Poor prenatal care compliance & nutritional intake Use of other drugs/smoking Prematurity Pre-eclampsia (Kurki et al 2000; Obstetrics and Gynecology) Low APGAR scores

3. REVIEW: Untreated Depression in PG linked to increased risks for: Suicidal ideation & attempts (Einarson et al 2001; J Psychiatry Neurosci) Postpartum depression (Post 1992; Am J Psychiatry) Decreased success @ breastfeeding Increased CRH & decreased fetal responses to a novel stimulus (Sandman et al 1999; Ann NY Acad Sciences) Irritable & difficult to console infants

4. Risks of exposure to antidepressants Neonatal discontinuation syndrome (see next slide)

5. Jitteriness Hypo- thermia “Poor Perinatal adaptation” (Chambers et al 1996) “Serotonin overstimulation” (Laine et al 2003) Tachypnea/ respiratory distress/ desaturation on feeding Hypoglycemia Poor tone Weak/absent cry Myoclonus Restlessness Tremor Shivering Hyperreflexia Nausea Involuntary movements Rigidity

6. Cautious approach Informed consent: Risks & benefits of treatment versus not Monitor neonate for withdrawal &/or toxicity from antidepressants for at least 48 hours after birth (Koren 2004; Arch Pediatr Adolesc Medicine)

7. Potential Strategies to Manage Neonate To Decrease Risk for Toxicity: Taper/stop maternal drug prior to due date if risk of maternal illness doesn’t outweigh risk of complications To Decrease Risk for Withdrawal: Lactation may provide minimal additional dose to reduce rapid drug concentration drop