depression and anxiety in peripartum

Table of Contents

1. Depression1

1.1. Diagnosis

  • during pregnancy and in the first year postpartum
    • perinatal depression
  • DSM: peripartum - during pregnancy and 4 weeks after
  • among most common morbidities of pregnancy and postnatal period

1.2. Epidemiology

  • 7.5% unipolar MDE during pregnancy
  • 6.5% in first 3 months postpartum

1.3. Sequelae

  • can affect infant development
  • future depression risk
  • family and vocational functioning
  • poorer nutrition and prenatal care
  • higher risk of smoking and drug use
  • increased risk of poor obstetrical outcomes
    • small neonates for gestational age
    • NICU admission and complications
    • impairments in mother-infant bonding
    • infant sleep difficulties
    • mild developmental delays
    • emotional problems in offspring

1.4. Management

  • pregnancy conversation should be part of assessment for all depressed women of childbearing age. 50% unplanned.
  • limited evidence

1.4.1. SSRI risks

  • motherisk.org for SSRI risk
  • paroxetine: increased risk of CV malformation in first trimester
  • most resolve spontaneously
  • fluoxetine: some increase in malformation
  • MAOIs: avoid due to interaction with analgesic and anesthetics
  • Doxepin: avoid as too much secretion in breast milk
  • modest link between SSRI use and spontaneous abortion
  • SSRI use linked to 4-day shortened gestational duration and reduced birth weight of ~74g
  • third trimester use: at delivery, syndrome of poor neonatal adaptation marked by jitteriness, irritability, tremor, resp distress, and excessive crying
    • supportive care, 2-14 days
    • risk is higher with paroxetine, venlafaxine, fluoxetine
  • late SSRI use (but not early): linked with persistent pulmonary hypertension of newborn (PPHN): risk of ~3/1000 vs general ~2/1000
  • limited data report no lasting cognitive, language, emotional, or behavioural problems in offspring
  • link to ASD: significant methodological limitations, need replication
  • during breastfeeding: 5-10x lower risk than in-utero exposure
    • relative infant dose of <10% are generally safe and all SSRI and SNRIs tested to date meet this criteria

1.4.2. During pregnancy

  • mild to moderate
    • First line: CBT, OPT
    • Second line: Citalopram, escitalopram, sertraline
      • other SSRIs have limited reproductive data
    • Third line:
      • exercise, acupuncture, bright light therapy
      • ECT for severe, psychotic, treatment resistant
      • bupropion, des/venlafaxine, duloxetine, fluoxetine, mirtazapine, TCA
  • severe
    • for severe, pharmacotherapies move up one level: second line to first line
    • combination pharm should be considered with caution - not enough data

1.4.3. Postpartum

  • breastfeeding is not contraindicated
    • concerns include short term adverse reactions and longer-term neurodev effects
  • if not breastfeeding: general CANMAT applies
  • mild to moderate
    • First line: CBT, IPT
    • Second line: Citalopram, escitalopram, sertraline, combination SSRI+CBT/IPT
      • sertraline has the lowest relative infant dose, citalopram is higher but no severe reaction (restlessness, insomnia, irritability)
    • Third line:
      • exercise, acupuncture, behavioural activation
      • fluoxetine, fluvoxamine, paroxetine, TCAs (except doxepin)
      • ECT, TMS
      • bupropion, des/venlafaxine, duloxetine, mirtazapine: limited evidence
  • severe
    • pharmacotherapies move up one level: second line to first line

2. Anxiety2

2.1. Epidemiology

  • unchanged during pregnancy
  • some increase in risk of GAD

2.2. Risks

  • No relationship between anxiety and adverse perinatal outcomes
  • Anxiety symptoms have been associated with depression, substance use, anemia, and decreased use of prenatal vitamins
  • parenting:
    • less promoting of psychological autonomy
    • predictive of child cognitive development
    • subsequent development of anxiety disorders in children

2.3. Treatment

  • CBT is beneficial
  • pharmacotherapy
    • motherisk.org
    • antidepressants: see above
    • benzodiazepines
      • risk of oral cleft, absolute risk is small <1%
      • neonatal withdrawal and toxicity
      • long-term neurobehavioural effects remain uncertain
      • breastfeeding: low levels, support breastfeeding
    • atypical antipsychotics
      • no malformation risk so far: data is inconsistent/inconclusive
      • some association with increased/decreased birth weight, increased risk for preterm birth
      • second-gen: risk of diabetes in the mother
      • health canada: potential risk for abnormal muscle movements and withdrawal symptoms in infants exposed during 3rd trimester
      • low levels in breastmilk

Footnotes:

1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994788/

2

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4120194/

Author: Armin

Created: 2022-07-30 Sat 01:12

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