Pregnancy and the postpartum period are high risk periods for (recurrence of ) depressive episodes (incidence 10-12%), in particular in patients with pre-existing depressive disorders [1].Use of selective serotonin re-uptake inhibitors (SSRIs) and serotonin and norepinephrine re-uptake inhibitors (SNRIs) is increasing among women of childbearing age with known depression [2,3]. Of the women who discontinue their antidepressant treatment prior to conception, 68% experience a relapse during their pregnancy [4]. Continuing this medication during pregnancy can be essential for the wellbeing of both mother and child [5][6][7][8]. However, foetal exposure to potentially harmful medication should be minimized.Venlafaxine and its active metabolite Odesmethylvenlafaxine (ODV) are potent SNRIs. Exposure to venlafaxine during the third trimester of pregnancy carries a risk of approximately 30% for neonatal abstinence syndrome [9,10] We present the first case of neonatal seizures after intra-uterine exposure to venlafaxine, in which epileptiform activity was documented with electroencephalography (EEG).
Case reportA male infant was born in good condition after 41 weeks of gestation by normal vaginal delivery. Apgar scores (a classification of the condition of the newborn infant, with a range from 0 to 10, 10 is optimal [11]) were 9 at 1 min and 10 at 5 min. His birth weight was 4304 g (+1 SD). No congenital malformations were observed. The mother was a 28-year-old multigravida and was treated with venlafaxine 75 mg daily during pregnancy. She smoked 8 to 10 cigarettes daily. Family history was unremarkable. Substance abuse was ruled out during interview.At 18 h of age our patient was admitted to the neonatal high care unit because of tachypnoea and feeding difficulties. Further investigations showed: CRP 36 mg l -1 , Hb 14.6 mmol l -1 , capillary Ht 0.65 l l -1 . The serum concentrations of venlafaxine and its active metabolite ODV were below the sensitivity of the assay (5 m l -1 ). Glucose concentrations as well as a chest X-ray were unremarkable. The Finnegan score (a well evaluated 31 items observation scale to quantify and monitor neonatal abstinence symptoms in exposed neonates) [12] was 6 (with a point scale ranging per item from 0 to 1, 2 or 3) indicating mild withdrawal. A score Ն8 is indicative for severe neonatal abstinence.Neonatal infection could not be excluded (elevated CRP) and treatment with antibiotics was started. Fluid was given intravenously because of slight hyperviscosity.At 74 h of age episodes of extensor limb posturing that lasted for circa 3 min and severe agitation were seen. Furthermore the patient suffered from restlessness and tachypnoea and was perspiring profusely.The Finnegan scores were highly elevated (between 12 and 16). Neurological examination showed no further abnormalities. Differential diagnoses included hyperviscosity, hypoglycaemia, infection, cerebral vascular incidents, electrolyte imbalance and withdrawal. Hyperviscosity was only minimal and glucose and electrolytes were within...
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