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PREGNANCY
Depression in Pregnancy
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Although pregnancy is often a time of great happiness, that's not the
reality for all women. At least one in ten pregnant women suffers from bouts
of
depression.
Hormonal changes can make you feel more anxious than usual. Anxiety is
a condition that can require careful management during pregnancy.
Depression and anxiety may go unnoticed as women often dismiss their
feelings, that often accompanies pregnancy. So don't be shy about
letting your doctor or midwife know if you feel low. Your emotional health
is every bit as important as your physical health.
Research has shown, for instance, that depression and anxiety can increase
your risk for
preterm labor.2000-01 These conditions can
reduce your
ability to care for yourself and your developing baby.
Risk Factors For Depression
In Pregnancy
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- Personal or family history of depression or anxiety. If you've
struggled in the past withdepression or
extreme anxiety (or, to a lesser extent, if depression runs in your
family), you're more likely to become depressed now that you're
expecting.
- Relationship difficulties. If you're in a troubled
relationship and talking things out as a couple isn't working, you
should request counselling. Don't make the
mistake of assuming that your baby's arrival will make everything rosy. A
newborn will only add to the strain on your relationship — so don't put off
seeking professional advice on repairing your relationship now, particularly
if you're the victim of abuse.
- Fertility treatments. If you had trouble getting pregnant,
you've been under a lot of stress. And if you've gone through multiple
fertility procedures, you may still be dealing with the emotional side
effects of months or even years of treatments and anxiety-laden waiting. On
top of that, now that you're pregnant, it's not uncommon to be terrified of
losing the baby you worked so hard to conceive. All of these make you more
prone to depression.
- Previous pregnancy loss. If you've miscarried or lost a baby in the
past, it's not surprising that you are worrying about the safety of this pregnancy. And
if the loss was recent or if you've miscarried several times in the last
year, you may not have had time to fully recover emotionally or physically.
And as with fertility treatments, if you're dealing with health restrictions
you're more vulnerable to depression and anxiety.
- Problems with your pregnancy. A complicated or
high-risk pregnancy can take an
emotional toll. (Women who are pregnant withtwins or more often fall into this category.) The strain of
having to endure difficult procedures combined with fear about your baby's
well-being is often difficult to cope with. Likewise, not being able to work
or do other things you're used to doing makes it tougher to maintain your
emotional balance. Taking proper steps now will also reduce your risk for problems
after giving birth — and help you to better enjoy the baby you've worked so
hard to bring into the world.
- Stressful life events including financial worries,
moving house, changing jobs jobs and any major
concerns or life changes such as these — as well as a breakup, the
death of a close friend or family member, or a job loss can take their
toll.
- Past history of abuse. Women who've survived emotional,
sexual, physical, or verbal abuse may have low self-esteem, a sense of
helplessness, or feelings of isolation — all of which contribute to a
higher risk for depression. Pregnancy can trigger painful memories of
your past abuse as you prepare for parenthood.
- Other risk factors. If you are young, single, or have an unplanned
pregnancy, your risk of depression is higher.
Some fatigue and difficulty sleeping, are common among
healthy women during pregnancy. But when they're combined with a sense of
sadness or hopelessness or they interfere with your ability to function,
depression may be a factor.
If you feel unable to handle your daily responsibilities or are having
thoughts of harming yourself, call your doctor or midwife immediately for a
referral to a counsellor. Seeing a therapist or psychiatrist isn't an
indication of weakness. On the contrary, it shows that you're willing to
take the steps necessary to keep your baby and yourself safe and healthy.
If you've experienced three or more of the following symptoms for more than
two weeks, talk to your healthcare provider about whether you should see a
therapist:
- A sense that nothing feels enjoyable or fun
- Feeling blue, sad, or "empty" for most of the
day, every day
- Difficulty concentrating
- Extreme irritability or agitation or
excessive crying
- Trouble sleeping or sleeping all the time
- Extreme or never-ending fatigue
- A desire to eat all the time or not wanting
to eat at all
- Inappropriate guilt or feelings of
worthlessness or hopelessness
- Finally, mood swings with cycles of depression alternating with periods of
an abnormally high spirits — including increased activity, little need to
sleep or eat, racing thoughts, inappropriate social behavior, or poor
judgment — are signs of a serious condition called bipolar disorder, which
requires immediate attention. Call your caregiver if you have those
symptoms.
Treatment of Depression in
Pregnancy
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Psychotherapy and antidepressant medication can be used during
pregnancy. Don't try to treat yourself by taking St. John's wort or
other remedies. The safety of these remedies during pregnancy is
unknown, and they're not an effective substitute for professional help.
Take it easy. Resist the urge to pack in as many chores as you can
before the baby comes. You may feel the need to set up the nursery,
clean the house, or work as much as you can before going on
maternity leave but there is no reason to do more than you feel capable of. You
won't have as much time for yourself once the baby's around. Read a book, have
breakfast in bed, or go for a nice long walk. Choose something that makes you
feel good. Taking care of yourself is an essential part of taking care
of your baby.
Bond with your partner. Make sure you're spending plenty of time
with your partner and nurturing your relationship. Take a vacation now
if you can. Do what you can to strengthen your connection so that once
the baby comes, you'll have that bond to rely on.
Talk it out. Air out your fears and worries about the future with
your partner, friends, and family.
Manage your stress. Don't let frustration build up in your life.
Find ways to take care of yourself emotionally. Take breaks, get plenty
of sleep, get some exercise, and eat well. If you find anxiety creeping
in, try taking a pregnancy yoga class or practicing meditation.
There is some reassurance that drug treatement of depression in pregnancy has
no adverse effect on the baby.0802
About half of women who suffer from
depression during pregnancy go on to develop
postpartum
depression, but getting treated during pregnancy can reduce your
chances significantly. Here are a few other things you can do:
- Get into the habit of taking care of yourself now so it becomes part
of your routine.
- Plan ways to take breaks and get time off to rest once
the baby comes.
- Talk with your partner about how you're going to divide the
household responsibilities and care for each other as well as for your
baby.
- Build a support network now (made up of friends, family members,
your partner, healthcare practitioner, or therapist) so that your
helpers will already be in place when the baby arrives.
- Start lining up help with cooking, cleaning, or baby care so
you'll be able to grab some much-needed time to shower, nap, or take a
walk after the baby arrives.
Guidelines for the treatment of psychiatric illness during pregnancy.
The American College of Obstetricians and Gynecologists (ACOG)
has issued updated guidelines for the treatment of certain
psychiatric illnesses during pregnancy and breast-feeding. The April
2008 Practice Bulletin updates the previous November 2007 bulletin
and is based on current evidence of risks and benefits of treatment
of psychiatric illnesses during pregnancy. The guidelines are
designed to aid clinicians in providing appropriate care.
"The bulletin acknowledges that there's good evidence that untreated
or inadequately treated mental illness is unhealthy, which is probably
one of the first times it's ever been pointed out so definitively,"
Zachary N. Stowe, MD, from Emory University in Atlanta, Georgia, who
contributed to the development of these guidelines, toldMedscape
Psychiatry.
The committee that developed the practice bulletin sought to evaluate
all available information and provide a critical appraisal of whether
particular studies should influence treatment paths, he added.
The study is published in the April issue ofObstetrics and
Gynecology.
Risks of Fetal Exposure vs Untreated Maternal Illness
It is estimated that each year in the United States, more than
500,000 women have psychiatric illnesses before or during pregnancy, and
one third of all pregnant women are exposed to psychiatric medication
during their pregnancy, the bulletin authors write.
"Advising a pregnant or breastfeeding woman to discontinue medication
exchanges the fetal or neonatal risks of medication exposure for the
risk of untreated mental illness," they note. Untreated or inadequately
treated maternal mental illness "may result in poor compliance with
prenatal care, inadequate nutrition, exposure to additional medications
or herbal medicines, increased alcohol and tobacco use, deficits in
mother-infant bonding, and disruptions within the family environment,"
they add.
"All psychotropic medications studied to date cross the placenta, are
present in amniotic fluid and can also enter human breast milk," the
authors write.
They summarized their findings in the following 15 recommendations
and conclusions stratified according to the strength of the evidence
supporting them:
The Practice Bulletin was developed by the ACOG committee on
Practice Bulletins with the assistance of Dr. Stowe and Kimberly Ragan,
MSW, at the Life Enrichment Counseling Center, in Gainesville, Virginia.
Obstet Gynecol. 2008;111:1001-1020.
Clinical Context
Psychiatric illness can promote multiple negative effects on
pregnancy outcomes. Anxiety disorders are associated with an increased
risk for forceps deliveries, prolonged labor, fetal distress, and
preterm delivery. Maternal depression increases the risk for low birth
weight delivery, as does schizophrenia. Schizophrenia is also associated
with placental abnormalities and antenatal hemorrhage.
Despite these negative effects of psychiatric illnesses on pregnancy,
there are also significant concerns with the safety of psychotropic
medications during gestation. All psychotropic medications cross the
placenta and are present in amniotic fluid. The current review examines
the safety of these medications.
Study Highlights
- Psychiatric illness during pregnancy is best managed with a
multidisciplinary approach involving the obstetrician, mental health
clinician, and primary care provider.
- A single medication at a higher dose is preferred vs multidrug
therapy for psychiatric illness during pregnancy.
- Of women receiving medications for depression at conception,
more than 60% will have symptoms of depression during pregnancy. The
risks for negative pregnancy outcomes are higher when depression
occurs in the late second to early third trimester.
- Women with depression may be considered for medical therapy
during pregnancy on an individual basis, depending primarily on the
severity of the illness. However, paroxetine should be avoided
because of evidence of congenital cardiac malformations,
anencephaly, and omphalocele with the use of this medication during
pregnancy.
- Other selective serotonin-reuptake inhibitors are not considered
major teratogens. Limited data from studies of antidepressants other
than selective serotonin-reuptake inhibitors have failed to
demonstrate any significant fetal anomalies associated with their
use.
- Prenatal use of benzodiazepines increases the risk for oral
cleft by 0.01%, and maternal benzodiazepine use immediately before
delivery can result in floppy infant syndrome. It remains unclear
whether there are any long-term neurobehavioral consequences of
maternal benzodiazepine use on children.
- Lithium can increase the risk for cardiac malformations by a
factor of 1.2 to 7.7 and the risk for overall congenital
malformations by a factor of 1.5 to 3. Neonatal lithium toxicity can
result in flaccidity, lethargy, and poor suck reflexes.
- Echocardiogram examination of the fetus should be considered for
women exposed to lithium during the first trimester.
- Women using lithium for mild bipolar disorder should be
considered for tapering of the medication before conception, whereas
women at moderate risk for relapse of bipolar disorder may stop
lithium until organogenesis is complete. Women at a high risk for
relapse of bipolar disorder may continue lithium throughout
gestation.
- Valproate and carbamazepine should be avoided in pregnancy, if
possible, because each is associated with a higher risk for fetal
anomalies. Lamotrigine appears to be a safer choice as a treatment
of bipolar disorder.
- Typical antipsychotic drugs have a more extensive reproductive
safety profile vs second-generation antipsychotic medications. No
significant teratogenic effects have been documented with the use of
chlorpromazine, haloperidol, and perphenazine. Nonetheless,
second-generation antipsychotic drugs have not been associated with
a significant risk for neonatal toxicity or somatic teratogenesis.
- Exposure to selective serotonin-reuptake inhibitors in breast
milk is lower than during fetal growth, and tricyclic
antidepressants (except doxepin) are also generally safe during
breast-feeding. The use of lithium during breast-feeding is
discouraged, but valproate and carbamazepine are most likely safe.
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DISCLAIMER
The aim of this web site is to provide a general guide and it is
not intended as a substitute for a consultation with an appropriate specialist
in respect of individual care and treatment.
Thank you for your visiting us at 2womenshealth.com.
This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist at Whipps Cross University Hospital, London.
I do hope that you find the answers to your questions in the patient information and medical advice provided.
If you still have unanswered questions, please consider entering them into one of our forums and I will try to assist you.
 
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