SOFT 2004 Meeting Abstracts - Society of Forensic Toxicologists

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SERTRALINE WITHDRAWAL IN A NEWBORN - COULD THIS BE A FACTOR IN THE CAUSE OF
DEATH
Laureen J. Marinetti* and Russell L.Uptegrove.
Montgomery County Coroner's Office (MCCO), 361 West Third Street, Dayton, OH 45402
A 4·day-old infant was found not breathing by her mother at about 6am. The infant was wrapped in a blanket
and lying on her back on a large sectional couch near her sleeping father. The mother confirmed that the infant's
face and head were several inches from her husband and were not obstructed in any way. The infant was
transported to the emergency room where a heart rhythm was established and she was placed on a ventilator.
The infant was later found to be brain dead and was removed from the ventilator. She was pronounced dead
approximately 12 hours after the mother had first found her.
The mother received regular pre-natal care and was diagnosed with gestational diabetes. As a result she had bi­
weekly testing for the last several weeks of her pregnancy. In addition she also experienced sleeplessness and
had been prescribed sertraline, which she took as prescribed. The birth was induced and was an uneventful
delivery reSUlting in a 71b, 60z infant. The infant was fed formula (similac) and was not breast-fed at any time.
The infant was released from the hospital 2 days after she was born. Approximately 24 hours after birth the
infant became irritable, screaming and crying after every feeding. The last two nights prior to her death she was
awake all night in this highly irritable state.
Significant findings at the time of autopsy included epicardial hemorrhage on the anterior surface of the heart,
(consistent with cardiopulmonary resuscitative efforts), and pulmonary and liver congestion.
The toxicology laboratory at MCCO received the following specimens; hospital blood (3 mL), heart blood (16
mL), cerebral spinal fluid (CSF), gastric, liver, vitreous fluid, bile and head hair. Analysis of the heart blood
revealed the presence of 16 nglmL sertraline and 113 nglmL norsertraline, the hospital blood revealed 71 ng/mL
norsertraline and analysis of the liver revealed 230 nglg sertraline and 4000 ng/g norsertraline. Sertraline was
detected in the hospital blood but the small amount of specimen received precluded its accurate measurement.
Sertraline and norsertraline quantitation was accomplished using high performance liquid chromatography
(HPLC) with a CI8 column and ultra violet detection with confirmation by gas chromatography/mass
spectrometry (GC/MS).
A review of the literature reveals neonatal complications when selective serotonin re-uptake inhibitors (SSRl's)
are used by the mother near term. Paroxetine, sertraline, fluvoxamine and fluoxetine have been associated with
withdrawal symptoms in the neonate. The withdrawal symptoms are diverse but most commonly include;
respiratory distress, hypoglycemia, jaundice (Costei et al. 2003) and irritability, constant crying, shivering,
increased tonus, eating and sleeping difficulties and convulsions, (Nordeng et at. 2001). The symptoms usually
occur after 2 days and last for an average of 10 days to one month (Salvia-Roiges et aL 2003). While the SSRI's
have not been associated with teratogenic risks, it is clear that the potential for withdrawal exists - especially if
the mother does not breast-feed the infant. Hendrick et at. 2003 determined cord blood concentrations of
sertraline and norsertraline in II newborn babies whose mothers were prescribed the drug. The ranges were as
follows, sertraline; less than I up to 14 nglmL and norsertraline; less than I up to 72 nglmL. None of these babies
experienced withdrawal symptoms but it is unknown ifthey were breast-fed.
Based on the clinical history of the infant's feeding and sleeping difficulties, irritability and crying, and the fact
that the infant was being fed formula instead of being breast fed, it is possible that the infant was undergoing
withdrawal from sertraline which it was exposed to in utero. A search of the medical literature revealed no
reported cases of an infant's death due to exposure to or withdrawal from sertraline but some infants exposed to
SSRI's in utero required treatment for the withdrawal symptoms. The cause and manner of death was listed as
undetermined. In conclusion not enough information is known to conclude that SSRl's are safe to administer to
a pregnant woman, especially in the third trimester.
Key Words: Sertraline, Neonate, Withdrawal
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