ery. he manufacturer recommends that if possible, the dosage should be decreased or drug discontinued 2 to 3 days prior to delivery to reduce this risk (West-Ward, 2016). Findings typically persist for 1 to 2 weeks and may include neonatal hypothyroidism, diabetes insipidus, cardiomegaly, bradycar dia, electrocardiogram abnormalities, cyanosis, and hypotonia (American College of Obstetricians and Gynecologists, 2016).
As a class, these medications are not considered major teratogens (American College of Obstetricians and Gynecologists, 2016). The one exception is paroxetine, which has been associated with a higher risk for cardiac anomalies, particularly atrial and ventricular septal defects. Three large databases-a Swedish national registry, a United States insurance claims database, and the Motherisk Program-each identified a 1.5-to twofold greater risk for cardiac malformations following first-trimester paroxetine exposure (Bar-Oz, 2007; Sebela, 2017). For these reasons, the American College of Obstetricians and Gynecologists (2016) recommends that paroxetine be avoided in women planning pregnancy. Fetal echocardiography should be considered for those with first-trimester paroxetine exposure.
Neonatal efects have been associated with prenatal exposure to selective serotonin-reuptake inhibitors (SSRIs) and selective norepinephrine-reuptake inhibitors (SNRIs). Approximately 25 percent of neonates exposed to SSRIs in late pregnancy manifest one or more nonspecific findings considered to represent poor neonatal adaptation (Chambers, 2006; Costei, 2002; Jordan, 2008). Collectively termed the neonatal behavioral syndrome, findings can include jitteriness, irritability, hyper-or hypotonia, feeding abnormalities, vomiting, hypoglycemia, thermoregulatory instability, and respiratory abnormalities. Fortunately, these neonatal behaviors are typically mild and self-limited and last approximately 2 days. Jordan and coworkers (2008) reported that afected newborns were not more likely to require a higher level of care, to experience respiratory abnormalities, or to have prolonged hospitalization. Rarely, neonates exposed to SSRIs in late pregnancy demonstrated more severe adaptation abnormalities (Ornoy, 2017).
Another concern with late-pregnancy exposure is the possible association of SSRI medications with persistent pulmonary hypertension of the newborn (PPH). he baseline incidence approximates 2 cases per 1000 term newborns. PPHN is characterized by elevated pulmonary vascular resistance with right-to-Ieft shunting and resultant hypoxemia. Two recent population-based cohort studies-together involving more than 5 million pregnancies-identiied an attributable risk of only 1 to 2 cases per 1000 births (Huybrechts, 2015; Kieler, 2012). Not only is the risk for this condition quite low, but cases associated with SSRI medication have not been severe (Ornoy,i2017).
No antipsychotic medications are considered teratogenic. Exposed neonates can manifest abnormal extrapyramidal muscle movements and withdrawal symptoms that include agitation, abnormally enhanced or diminished muscle tone, tremor, sleepiness, feeding diiculty, and respiratory abnormalities. These indings are nonspeciic and transient, similar to the neonatal behavioral syndrome that can follow SSRI exposure. An FDA (2011) alert cites all medications in this class. These include older drugs such as haloperidol and chlorpromazine, as well as newer medications such as aripiprazole, olanzapine, quetiapine, and risperidone.