After two years of trying, Tricia Stream was overjoyed to find herself pregnant with twins. But her mind quickly turned to the drug she'd been taking to treat her depression.
"I didn't know what to do," said Stream, 31, who had been taking the selective serotonin reuptake inhibitor Zoloft for seven years. "I was so worried about having a depressive episode, and I was really worried about postpartum depression. But I didn't want to expose my babies to the drug."
Left untreated, depression during pregnancy can increase the risk of pre-eclampsia, low birth weight and maternal suicide. But treating prenatal depression with certain antidepressants carries risks, too. A new study suggests SSRIs may increase the risk of preterm birth and delay fetal head growth.
"Our findings further raise the question whether maternal SSRI treatment during pregnancy is better or worse for the fetus than untreated maternal depression," wrote study author Hanan El Marroun of Erasmus Medical Center in Rotterdam, the Netherlands. "Clinicians must carefully weigh the known risks of untreated depression during pregnancy and the possible adverse effects of SSRIs."
The study followed 7,696 pregnant women, 570 of whom had untreated depressive symptoms and 99 of whom took SSRIs for depression.
"Untreated depressive symptoms were associated with a reduction in total body growth, including the fetal head, during pregnancy," the authors wrote. "In contrast, prenatal SSRI use was related to a reduced growth of the fetal head, whereas prenatal SSRI use did not affect growth of the fetal body."
While delayed fetal head growth may be linked behavioral problems and psychiatric disorders, the authors caution "we must be careful not to infer an association of SSRI use in pregnancy with future developmental problems."
Babies born to women taking SSRIs were also more likely to be born preterm, according to the study, which was published today in Archives of General Psychiatry.
But for some women, the benefits of taking SSRIs during pregnancy far exceed the risks.
"If we are talking about a woman who can't take care of her health as a result of battling with moderate to severe depression, she faces risks to herself as well as the baby that are associated with untreated depression during pregnancy," said Dr. Sudeepta Varma, clinical assistant professor of psychiatry at NYU Langone School of Medicine. "All doctors want to ensure healthy mom and baby. But if you don't take care of the mom, there may be no baby to speak of."
After weighing the benefits and the risks with her obstetrician and psychiatrist, Stream decided to keep taking Zoloft during her pregnancy.
"For me, there was more concern about the effects of depression than the effects of taking antidepressants," she said, describing the "I don't care" attitude typical of her depressive episodes.
Aside from miserable morning sickness, Stream's pregnancy was progressing fine until week 22, when she was admitted to the hospital with a weakened cervix. And despite drugs to prevent preterm birth, she went into labor at 27 weeks.
"I definitely felt the guilt, overwhelmingly," said Stream, describing how she felt "unable to protect them, unable to keep them healthy. They were Memorial Day babies when they were supposed to be Labor Day babies."
Logan and Caden Stream came out crying at 2 pounds, a good sign given their early arrival. And for three months, the tiny pink "Muppets" were hooked up to machines in the neonatal intensive care unit. Stream said she can't imagine how she would have fared off Zoloft.
"It probably would have made me feel like I was going to lose my children, as opposed to having a fighting spirit," she said. "I needed that strength."
After three months, the boys were strong enough to go home. And last week, a letter from a high-risk neonatologist said the 21-month-old twins had "no lasting effects of prematurity."
"That's the best news I ever could have gotten," said Stream. "I'm going to frame that."