After therapy, Laurie thought that her childhood sexual abuse was behind her. She was initially overjoyed at the prospect of becoming a parent, but as the pregnancy progressed, her growing baby led to physical discomfort that triggered memories of her previous abuse. Laurie had nightmares about her abuser and became hypervigilant of her surroundings, fearing for the safety of herself and her baby. After a flashback during a prenatal examination, she stopped going to her obstetrician and avoided all discussion of the baby.
Cognitive-behavioral therapy (CBT) has been found to be effective in the treatment of anxiety disorders. However, few data are available on the treatment of anxiety during pregnancy.30,31 Strategies such as stress reduction, exercise, sleep, and social support may improve well-being and reduce anxiety during pregnancy.
Short-term CBT is focused on concrete strategies to manage symptoms. During pregnancy, the aim is to correct distorted or catastrophic thinking, misinterpretations of physical symptoms, and maladaptive behavioral patterns that may maintain or escalate anxiety (eg, avoidance or ritualizing).32
Psychoeducation to assist in correctly identifying benign physical symptoms serves to counter fearful misappraisals. This, coupled with anxiety management strategies that include diaphragmatic breathing modified for use in pregnancy, can de-escalate panic symptoms and allow women to return to avoided situations.32
Identifying and challenging distorted beliefs about the protective function of worry and learning to better tolerate uncertainty are primary goals in treatment. The gradual reduction of reassurance or safety behaviors (such as excessive information-gathering or phone calls to the obstetrician) and focusing on the present moment using mindfulness techniques may also be effective in reducing anxiety.33
Recognizing obsessions as thoughts that are universal and do not require analysis or action is vital to reducing anxiety. The nature of feared consequences makes a gradual approach to testing out beliefs and approaching avoided thoughts or situations particularly important for antenatal OCD.
Correcting negative appraisals and addressing fears of childbirth early in the pregnancy may minimize vulnerability to postnatal PTSD symptoms.34 In addition to psychotherapy, women who have childbirth-related phobias and PTSD may benefit from preventive strategies. Developing a birth plan with the patient’s active involvement in decision making whenever feasible may increase perceptions of control and improve the experience of pregnancy and childbirth.35
Pregnant women with moderate to severe prenatal anxiety may require psychopharmacological treatment. However, information of mixed quality in lay media, stigma, and fear may lead women to decline effective pharmacological treatment; take less than the recommended dose; or stop treatment prematurely, which may lead to discontinuation symptoms, relapse of underlying anxiety, and even suicidal ideation.36,37
Clinicians may also be ambivalent about prescribing antidepressants and benzodiazepines for pregnant women because of personal attitudes and stigma and confusing information about the efficacy and safety of these agents in pregnancy.
Antidepressants. All antidepressants cross the placenta, and their transfer averages 70% to 86% of the maternal dose.38 Data on their effects in pregnancy are largely limited to case-control or retrospective studies because randomized, double-blind, placebo-controlled trials in pregnant women are not available.39
In prospective controlled studies or meta-analyses, no association has been found between antidepressant exposure and congenital anomalies as a result of antidepressant treatment in the first trimester.40-42 Retrospective studies show mixed results. However, in animal studies, paroxetine(Drug information on paroxetine) has been clearly identified as teratogenic, and it has been associated with cardiac malformations in several clinical studies.43-45 A statistically significant risk of miscarriage has been demonstrated in SSRI users; 3 of 10 prospective controlled studies support this finding.46
Preterm labor has been associated not only with venlafaxine, mirtazapine(Drug information on mirtazapine), and continuous exposure to SSRIs in the last trimester but also, to a lesser extent, with untreated anxiety.17,47-49 Other risks of preterm labor include gestational hypertension and smaller birth weight.50