Medication in Pregnancy and Breastfeeding

One of the biggest concerns for pregnant and nursing women and their doctors is what effect, if any, a medication might have on their baby.

Where possible, doctors will try to discontinue a needed medication prior to a woman becoming pregnant, and then if it is necessary, will often reintroduce the medication later on in the pregnancy. Sometimes the mood disorder is so severe that the risk of not treating it is worse than the risk a medication may pose to the baby. Little information is available on the effects that some of the medications used to treat depression and anxiety disorder have on the developing and nursing infant.

Where available, here's a summary of what the experts are telling pregnant and nursing mothers.

Tricyclic antidepressants (TCAs): includes Tofranil (imipramine), Elavil (amitriptyline), Pertofrane (desipramine), Sinequan (doxepin), Aventyl (nortriptyline), Triptil (protriptyline), Anafranil (clomipramine). No connection between the use of TCAs and physical malformations of the infant have been found. However, there may be some withdrawal effects in the baby including irritability, breathlessness and a poor sucking reflex, and the newborn should be monitored. As is true for all medications, the use of a TCA during the first trimester should be avoided if possible. Small amounts of these medications are also excreted in breast milk. Nevertheless, TCA concentrations in breast milk are felt to be minimal and experts feel that breastfeeding is compatible with the need to take a TCA provided women discuss it first with their doctor.

Selective serotonin reuptake inhibitors (SSRIs): includes Prozac (fluoxetine), Zoloft (sertraline), Luvox (fluvoxamine), and Paxil (paroxetine). Although widely used for the treatment of both depression and anxiety, it's still difficult to say with absolute certainty that these medications have no ill effects on infant development. Based on one large study of pregnant women who took fluoxetine during pregnancy, it would appear Prozac is generally safe during pregnancy, and it's likely that the other SSRIs are safe as well - although not that much information is available on the other SSRIs and pregnancy.

Withdrawal effects including jitteriness, restlessness and irritability have been reported in infants born to mothers taking an SSRI during pregnancy and if possible, SSRIs should be avoided during the first trimester. As for breastfeeding, both paroxetine and fluoxetine are excreted in breast milk in levels that could affect the infant, and cautious use of these two agents in nursing mothers is advised. Sertraline, in contrast, seems not to cross into breast milk in any appreciable amount and would appear to be a safer choice for nursing mothers.

Monoamine oxidase inhibitors (MAOIs): includes Parnate (tranylcypromine) and Nardil (phenelzine). In animals, these antidepressants have been linked to certain birth defects and they should not be considered as first-choice antidepressants for pregnant women requiring treatment. If used at all, they should be avoided in the first trimester. Women who must take an MAOI may be advised to bottle-feed as well, since these medications cross into breast milk and may affect the nursing infant.

Reversible inhibitors of monoamine oxidase (RIMAs): includes Manerix (moclobemide). At present, there is no good information on the safe use of Manerix during pregnancy or nursing. It would appear that the medication is not secreted to any significant extent in breast milk and provided women discuss it with their doctor, Manerix may be compatible with breastfeeding.

Newer antidepressants: includes Serzone (nefazodone), Effexor (venlafaxine), and Wellbutrin (bupropion). Currently, there is little information about the effects of the newer antidepressants on the developing and nursing infant. No evidence of ill effects have been seen in animal studies where high doses of Wellbutrin have been used. The use of these medications during pregnancy may be appropriate, but mother and infant should be appropriately monitored. Because of its potential to affect nursing infants in mothers taking Wellbutrin, women should discuss their desire to breastfeed versus their need to take the medication with their doctor.

Mood stabilizers: includes Depakene (valproic acid), Carbolith (lithium) Tegretol (carbamazepine). Infants born to mothers who have taken lithium during their first trimester of pregnancy can develop heart abnormalities related to lithium use - although the likelihood of this happening is low. Use closer to delivery has also been associated with toxicity in the newborn and in general, lithium should be avoided during pregnancy unless mother and infant are closely supervised. If a woman requires lithium, drug levels must be more closely monitored during and after pregnancy to ensure safe blood levels. Lithium is excreted in significant amounts in breast milk and it is not recommended that women breastfeed while taking lithium. Neural tube and related defects have similarly been reported in a small number of infants born to mothers who were treated with both carbamazepine and valproic acid and they, too, should be avoided, unless mother and infant are closely supervised. Carbamazepi ne and valproic acid would appear to be safer for nursing infants. If women require one of the other mood stabilizers during pregnancy, high levels of folic acid can help offset any additional risk of neural tube defect caused by the required medication.

L-Tryptophan: Strongly not recommended for use during pregnancy. Its effects on breast milk are unknown.

Benzodiazepines: Used during the first trimester, some studies suggest that infants born to women treated with a benzodiazepine may be prone to cleft lip or cleft palate, although these studies have recently been refuted. Later on in pregnancy, some types of benzodiazepines may be safely used for a short time to treat severe symptoms of anxiety. However, longer-term use is not recommended because of known withdrawal effects in the newborn. Some of these medications are excreted in breast milk and the use of benzodiazepines during breastfeeding can cause sedation in the infant.

Buspar (buspirone). An anti-anxiety medication used primarily in generalized anxiety disorder, the safety of this medication during pregnancy and breast-feeding has not been established. The possible benefits of the medication may outweigh potential risks to the infant and a pregnant woman should discuss her need for the medication with her physician if symptoms require medical therapy.

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