I. Some figures on perinatal depression 70% of women have depressive symptoms during pregnancy, and 10-16% meet the diagnostic criteria for major depression (MDD). Approximately 40% of women with depression experience their first depressive episode in life during pregnancy and approximately 33% experience their first depressive episode after delivery. Postpartum depression occurs in 10-15% of women; suicide accounts for 20% of postpartum deaths. The significance of depression during pregnancy The diagnosis and treatment of postpartum depression is significantly underrepresented, in part because women are reluctant to report symptoms and seek help and/or take medication during this period. In fact, however, pregnancy and the postpartum period provide a valuable window of time for intervention: for women with limited financial resources, they have better access to medical care and observation during this particular time of life than during other periods of their lives. In addition, there is less stigma attached to preventive measures implemented during pregnancy. The United States Preventive Medicine Task Force (USPSTF) and the American College of Obstetricians and Gynecologists recommend at least one prenatal and postnatal screening for depression. Validated screening tools include the Edinburgh Postpartum Depression Scale, the Beck Depression Self-Rating Scale, and the Patient Health Questionnaire-9 (PHQ-9). For mild to moderate depression, psychotherapy should be the first step. However, for moderate to severe depression, or for those who have previously responded to depression treatment, antidepressant therapy should be the first line of treatment. The goal of treatment during pregnancy should be to achieve and maintain a normal state of mind. III. Psychotropic medications and pregnancy Approximately one-third of women during pregnancy have used psychotropic medications. However, it is difficult to distinguish the adverse effects of depression itself from the side effects of antidepressants in current studies, so it is rather difficult to obtain an exact cause-and-effect relationship. Each patient needs an individualized pros and cons analysis, both for the mother herself and for the child. In mild to moderate depression, psychotherapy always needs to be considered and some patients may prefer not to take medication; in more severe cases, psychotherapy can be combined with medication. When medication is needed, the lowest effective dose should be used; if the dose is insufficient, the mother and child will be exposed to the risks of depression itself and antidepressants, respectively. Whenever possible, a single medication should be used, titrated to an effective dose; side effects are greater with multiple medication combinations. The benefits and risks of medication do not rest with the psychiatrist alone, but also with the collaborating obstetrician; if feasible, the patient’s family should be involved. [The ABCDX system has been abandoned] Patient education is far more difficult than physicians figuring it out on their own. For patients and physicians, the ABCDX classification system previously used by the FDA provided little information and minimal help in decision making. For example, the system did not take into account the necessity of a patient’s medication, and the risks varied from drug to drug, even within the same class. In May 2015, the FDA has replaced the ABCDX system with a new system. The new system provides a new classification, including a summary of fetal risk, clinical considerations, and reporting of study data to improve physicians’ ability to assess the pros and cons of specific drugs. 1. Teratogenic risk Overall, SSRIs are safe; even though some studies have shown that SSRIs are associated with an increased risk of umbilical bulge, anencephaly, premature closure of cranial sutures, and cardiac malformations, the absolute risk is small. There have been several reports of a 1.5-2 times greater risk of cardiac malformations in infants exposed to paroxetine in the first trimester of pregnancy than in controls, but there are also studies that deny this association. Since then, paroxetine has been adjusted from Class C to Class D in the original ABCDX system. Despite conflicting data, most studies, including two recent large-scale case-control studies, have shown that none of the SSRIs, except paroxetine, resulted in a significantly increased risk of congenital heart defects. 2. Preterm birth Antidepressant use in mid- and late pregnancy was associated with preterm birth (delivery before 37 weeks of gestation), and this effect remained statistically significant compared with depressed pregnant women who were not exposed to antidepressants. However, the actual difference between the exposed and non-exposed groups was small, with the former delivering only about 3 days earlier than the latter, and was not clinically significant. 3. Birth weight Antidepressants are associated with low birth weight. Meta-analysis showed that the low birth weight in the group treated with antidepressants was not statistically significant compared to the depressed untreated group; a recent study showed that the birth weight of offspring in the depressed untreated group was significantly lower than in the antidepressant treated group. 4, autism spectrum disorder (ASD) Research findings are inconsistent. Several studies have found that SSRIs are associated with ASD, but ASD itself is associated with maternal depression, so causality is difficult to establish. For example, a large Danish study showed no correlation between antidepressant exposure and ASD after controlling for confounding factors, including the disease for which the antidepressant was prescribed and genetic factors. 5. persistent pulmonary hypertension of the newborn (PPHN) Several studies have shown that SSRIs are associated with PPHN, but most of them show that this association holds only when the drug is administered in the second trimester of pregnancy. symptoms of PPHN include mild respiratory distress, which may lead to hypoxia in the newborn and, in severe cases, to respiratory failure. This effect may be related to the direct effect of SSRIs causing vasoconstriction in the lungs. In 2006, the FDA issued a health recommendation addressing this issue; in December 2011, the FDA revised this based on evidence from the literature, suggesting that the previous correlation was weak or inconclusive. The absolute values of risk in studies suggesting a definite association were also low: 2.9C3.5/1000 in exposed individuals and 1.9/1000 in the general population. other confounding factors, such as obesity, cesarean delivery and preterm birth, are risk factors for PHN on the one hand and depression on the other; and in most studies, these factors were not adjusted for. 6. Neonatal behavioral syndrome or postpartum adaptation syndrome Antidepressants are associated with transient neonatal complications. Thirty percent of infants exposed to SSRIs and SNRIs in late pregnancy develop a range of symptoms, including irritability, respiratory distress, anxiety, shortness of breath, hypoglycemia, temperature instability, weak cry, poor muscle tone, poor feeding, and depression. These symptoms are transient and disappear after a few days or weeks of supportive treatment. It is unclear whether these symptoms are part of a withdrawal syndrome or are related to drug toxicity. Other antidepressants SNRIs: The risk of cardiac malformations is not elevated and the regression is similar to that of SSRIs, including respiratory problems, preterm delivery and postpartum adjustment syndrome (PNAS). Trazodone: The evidence is sparse. Published studies have shown that trazodone and nafazodone do not elevate the risk of major malformations compared to baseline levels. Mirtazapine: No association with congenital malformations was found. Studies have shown similar regression to SSRIs, including preterm birth. Bupropion: Several studies have shown that bupropion use in early pregnancy is associated with congenital heart defects, but the absolute risk is low, about 2.1/1000. however, most studies suggest that this drug does not elevate the risk of malformations. IV. Antidepressants and breastfeeding All psychotropic drugs can pass into breast milk; therefore, physicians may discourage breastfeeding in women who use psychotropic drugs. However, individualized assessment remains important: infant exposure to a mother whose illness is not effectively treated, exposure to antidepressants, and the mother’s personal wishes need to be considered in their entirety. Antidepressants are the most commonly used medications by breastfeeding mothers. Quantitatively, drug exposure in offspring from breastfeeding is significantly lower than exposure by the placental route, being only 1/10-1/5 of the latter. exposure levels are relatively high in infants 3-4 months of age, with most adverse reactions seen in infants younger than 2 months of age and very rare in those older than 6 months. Overall it is very safe, with few reports of adverse reactions. For most SSRIs, the amount of drug entering breast milk is small to undetectable. Fluoxetine and citalopram are present in relatively high levels in breast milk. Most relevant studies have shown that SSRIs exposure does not cause significant adverse reactions, with only isolated cases of necrotizing small bowel colitis reported. The most common adverse effects, which tend to be mild in degree and nonspecific, include irritability, decreased feeding, and sleep disturbances. Other drugs Venlafaxine: There is limited evidence that venlafaxine and its metabolite desmethylvenlafaxine are detectable in the blood of infants, but no adverse reactions have been reported. Duloxetine: Exposure through breastfeeding is minimal. Again, the evidence is limited and no evidence of adverse transitions has been reported. Desvenlafaxine: A small study showed no adverse effects in infants and a very low dose of drug in vivo. Bupropion: Two infants exposed via breastfeeding had no adverse effects and had undetectable blood drug concentrations. One 6-month-old infant had convulsions after exposure. Mirtazapine: In both cases, the infants had low to undetectable blood drug concentrations. In the other case, high levels of mirtazapine were reported in the infant, suggesting potential differences in individual elimination of mirtazapine. Trazodone: can be secreted through breast milk, but in extremely low amounts. Tricyclic antidepressants: The evidence is mainly from nortriptyline and promethazine. In most cases, infant blood levels are difficult to detect and there are no clinical adverse effects. Doxepin has been associated with sedation and respiratory depression in two case reports, so its use during breastfeeding should be generally avoided. Considering that antidepressants are generally safe, if a drug has been effective in previous or current therapy, then that drug should be preferred. The postpartum period is a critical period of increased susceptibility, and unknown medications should not be tried at this time, as both mother and child may suffer. For patients with no previous history of psychiatric treatment, many experts recommend sertraline or paroxetine as first-line therapy. Drug doses should be low enough to achieve symptom relief: underdosing may likewise cause double harm. Conclusions Depression during pregnancy and the postpartum period may lead to a range of adverse transitions for both mother and child. The teratogenic risk of most antidepressants is low, but physicians should still be mindful and provide patient education on this topic. Physicians should obtain a complete psychiatric history of the patient and individually assess the risk/benefit of the patient’s medication. Use the lowest effective dose to achieve a normal state of mind for the patient and avoid unnecessary harm from underdosing.