Bien que mal connue et sous diagnostiquée, la prévalence de la dépression chez la femme enceinte varie de 10 à 20 %. Le risque de la dépression non traitée est une augmentation des avortements spontanés, d’hypertension gravidique avec éclampsie, mais aussi un risque augmenté de pathologies néonatales. L’arrêt du traitement antidépresseur chez une femme dépressive constitue un risque accru de rechute et de tentative de suicide. Un traitement pharmacologique est indispensable si les traitements non médicamenteux sont insuffisants. Les données concernant l’utilisation au cours de la grossesse des inhibiteurs sélectifs de la recapture de la sérotonine (ISRS) font l’objet d’un débat depuis la publication en 2005 d’un risque malformatif majeur en particulier cardiaque avec la paroxétine. De nombreuses études depuis 2005 n’ont pas montré de risque malformatif global et spécifique associé à la prise d’ISRS, mais certaines ayant montré une association en particulier avec la paroxétine font que l’utilisation des ISRS doit être pesée pour chaque femme enceinte dépressive en tenant compte du rapport bénéfice risque. Une augmentation des avortements spontanés, de la prématurité et du faible poids de naissance ont été décrits. Les troubles néonataux fréquents nécessitent une prise en charge adaptée dans un service de néonatalogie. L’effet à long terme sur le neurodéveloppement est encore à explorer.

This article is a review of literature data concerning the use of selective serotonin reuptake inhibitors (SSRIs) by depressed pregnant women.

The adverse effects for the foetus, the newborn and the child were evaluated. The prevalence of depression during pregnancy is of around 10 to 20% of the population of childbearing women. Depression is often misdiagnosed and underestimated in pregnant women. Starting a pharmacological treatment for depression in these women is not easy because data concerning the safety of antidepressants during pregnancy are still unclear. The non-treated pathology is associated with higher risk of maternal morbidity, including arterial hypertension, which could lead to preeclampsia or eclampsia, ideation and suicide attempts, and postpartum depression. Foetal development is also affected and adverse outcomes such as prematurity, low birth weight, irritability, and sleep disorders are frequent. Pharmacological therapy is necessary when non-pharmacological treatment is insufficient. Suicide attempts and relapse of depression have been described when depressive women stopped their pharmacological treatment during pregnancy. Pregnant women diagnosed with depression must be treated. Selective SSRIs are now largely used in this pathology and have replaced tricyclic antidepressants because of fewer side effects. In general, drugs have a low teratogenic potential, only 4 to 5% of malformations are iatrogenic. Teratogenic risk is high between conception until the end of the second month of gestation. Safety of SSRIs treatment during pregnancy and potential risk for the foetus and newborn were unquestioned before publication, in the late 2005, of some alarming data concerning a possible teratogenic effect. Studies showed an increased risk for all congenital malformations with SSRIs and particularly with paroxetin. A few studies after 2005 have also found an association between prenatal exposure to SSRIs (especially paroxetin) and congenital malformations. However, other studies failed to demonstrate this association and the risk for cardiovascular malformations also does not seem to be significantly increased. Numerous studies in pregnant women have shown that SSRI treatments are associated with a significant increase of spontaneous abortion, preterm birth, and low birth weight. Exposure to SSRIs in late pregnancy has been associated with a three-fold increased risk of neonatal behavioural syndrome, including signs of withdrawal or serotonin impregnation. Restlessness, poor tone, respiratory distress, hypoglycaemia were the most frequent signs. These symptoms occur during the first days of life and are usually brief and not serious. Recent studies have also documented an increased risk of persistent pulmonary hypertension and cases of cerebral haemorrhage have been described. Data concerning a possible effect on motor and cognitive development at school age in children prenatally exposed to SSRIs are limited.

Although a number of studies revealed that SSRIs are not teratogenic, some of them showed congenital malformations associated with use of these antidepressants; in particular an increased risk of cardiac defects with paroxetin. In practice, the potential risk implies that the decision to treat a pregnant woman with SSRIs (notably paroxetin) should be taken carefully; this means double-checking the diagnosis, the potential benefits, adverse effects and possible alternatives. Neonatal toxicity seems to be relatively frequent when SSRIs are prescribed during late pregnancy. For all depressed pregnant women, the severity of the depression must be taken into consideration before introducing a pharmacological treatment. When depressive women are already treated, studies have shown that antidepressants must be maintained during pregnancy to prevent relapse and suicide attempts.