The answer is D. Fluoxetine has solid data for safety in breastfeeding mothers. Although sertraline passes into breast milk at a slightly lower rate than fluoxetine, given the patient’s good response to fluoxetine previously which resulted in remission during pregnancy and the good safety data on fluoxetine, the most reasonable initial approach would be to increase the fluoxetine. Most SSRIs pass into breast milk at a dose that is less than 10% of the maternal dose. Augmentation with quetiapine is premature and may not be acceptable to the patient in light of sedation that could limit her ability to respond to her baby at night. Bupropion has been reported to induce infant seizures and would not be the first line antidepressant treatment in a breastfeeding patient. ECT should be reserved for more severe symptoms such as suicidality or desire to harm the infant or if first-line approaches fail.

Publication reference : Stewart DE, Vigod S. Postpartum depression. NEJM 2016; 375: 2177-2186
Reference URL: https://www.ncbi.nlm.nih.gov/pubmed/27959754