Although it would be ideal to discontinue all drugs during pregnancy, the patient and physician are faced with a dilemma. The risk of relapse is a serious concern in patients with recurrent depression because the risk may be increased during pregnancy or the postpartum period. This risk is particularly high for patients with a prior history of depression during or following pregnancy. The long history of tricyclic use without observation of birth defects argues for the safety of these agents. Of course, the patient must be informed of the possible risks and benefits of taking the drug and of discontinuing treatment before making a decision.
If tricyclics are continued during pregnancy, dosage adjustment may be required because of metabolic changes related to the pregnancy (Altshuler and Hendrick 1996). Drug withdrawal following delivery can occur in the infant and is characterized by tachypnea, cyanosis, irritability, and poor sucking reflex. The drugs in this class should be discontinued 1 week prior to delivery if possible. The tricyclics are excreted in breast milk at concentrations similar to those in plasma. The actual quantity delivered, however, is very small, so that drug levels in the infant are usually undetectable (Rudorfer and Potter 1997).
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