Issues in Treating Anxiety Disorders in Pregnancy

Understanding the Causes to Make Better Treatment Decisions

By Orit Avni-Barron, MD and Pamela S. Wiegartz, PhD | September 6, 2011

Dr Avni-Barron is a psychiatrist and the Founding Director of the women’s mental health service at The Fish Center for Women’s Health of the Brigham and Women’s Hospital, Boston. She is an Instructor of Psychiatry at Harvard Medical School, Boston. Dr Wiegartz is the Director of CBT Services and Training in the department of psychiatry at Brigham and Women’s Hospital and a Lecturer in Psychiatry at Harvard Medical School. She is a psychologist specializing in the cognitive-behavioral treatment of anxiety disorders and the author of The Pregnancy and Postpartum Anxiety Workbook. The authors report no conflicts of interest concerning the subject matter of this article.

Self-limited adverse effects as a consequence of medication withdrawal or hepatic immaturity develop in up to 30% of neonates.⁵¹ The risk of these adverse effects may be related to the length of antenatal antidepressant exposure rather than to the timing (early versus late pregnancy). A small yet significant increase in the risk of primary pulmonary hypertension in the newborn has been associated with SSRI exposure in late pregnancy.^52,53 However, a recent case-control study found this rare condition (0.17% incidence) to be associated with early cesarean birth—before the onset of labor—not with SSRI use.⁵⁴

Special considerations for antidepressant use in pregnancy include:

• Typical adverse effects of antidepressants may be particularly challenging during pregnancy (Table 1)

• Some women may need dose increases as pregnancy progresses because of pharmacokinetic and pharmacodynamic changes⁵⁵

• A partial dose taper may be considered toward the end of pregnancy in women with relatively low relapse risk

• The best-studied antidepressants in pregnancy are fluoxetine(Drug information on fluoxetine) and sertraline(Drug information on sertraline)⁵⁶

• If breast-feeding is planned, sertraline is the treatment of choice because the average breast milk sertraline level is low (an estimated 0.5% of the maternal weight-adjusted dose)⁵⁷

• Paroxetine(Drug information on paroxetine) should be avoided in the first trimester

Benzodiazepines. All benzodiazepines cross the placenta, but data on their adverse effects in pregnancy are largely based on methodologically flawed studies.⁵⁸ Risks that have been implicated by these studies are, therefore, controversial and include oral cleft, which was not borne out; preterm birth; and low birth weight.^59,60 Neonatal withdrawal has been associated with maternal use of benzodiazepines in late pregnancy and neonatal toxicity, with predelivery exposure.^61,62

Special considerations for benzodiazepine use in pregnancy are as follows:

• Caution is warranted in the first trimester, because data about teratogenicity are lacking and controversial

• A gradual taper may be considered toward the end of pregnancy

• Lorazepam(Drug information on lorazepam) does not accumulate in fetal tissue and may therefore decrease the risks associated with antenatal benzodiazepine use

Nutritional and herbal supplements. Use of vitamins, minerals, amino acids, and herbs are often perceived as safe, and patients may continue to use them during pregnancy. Although some agents have shown promise in the treatment of anxiety, they are not regulated by the FDA nor are they well studied, which raises concern about their purity, strength, and safety in pregnancy and their concomitant use with prescription medication. Caution is warranted in the use of such remedies in women who are pregnant or plan to become pregnant.

Summary

Anxiety disorders are common in pregnancy and have been associated with short- and long-term risks to both mother and fetus. As such, they should be identified and treated. Evidence-based, effective treatments for anxiety include CBT and pharmacological interventions. The risks of antenatal antidepressant treatment are minimal; data about risks associated with benzodiazepine use in the first trimester are lacking. Other potential risks can be minimized by following a few simple guidelines (Table 2). A multidisciplinary team approach that includes obstetricians, primary care physicians, and mental health professionals (as well as neonatologists and pediatricians when postnatal risks are anticipated) is recommended.

Pages: 1 2 3

Also in this Special Report

The Anxious Bipolar Patient

Exposure Therapy for Anxiety Disorders

Substance Use Disorders in Patients With Anxiety Disorders

Anxiety Disorders With Comorbid Substance Abuse

Issues in Treating Anxiety Disorders in Pregnancy

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Issues in Treating Anxiety Disorders in Pregnancy

Understanding the Causes to Make Better Treatment Decisions

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