Depression in Pregnancy

 

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

  • 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.

Symptoms of Depression

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

 

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

 

Postpartum Depression

 

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:

  • Level A evidence (from good and consistent scientific evidence):
    • Lithium exposure in pregnancy may be associated with a small increase in congenital cardiac malformations, with a risk ratio of 1.2 to 7.7.
    • Valproate exposure in pregnancy is associated with an increased risk for fetal abnormalities and should be avoided if possible, especially during the first trimester.
    • Carbamazepine exposure during pregnancy is associated with fetal carbamazepine syndrome and should be avoided if possible, especially during the first trimester.
    • Maternal benzodiazepine use shortly before delivery is associated with floppy infant syndrome.
  • Level B evidence (from limited or inconsistent scientific evidence):
    • Paroxetine use in pregnant women and women who are planning to become pregnant should be avoided, if possible, and fetal echocardiography should be considered when fetuses are exposed to paroxetine in early pregnancy.
    • Prenatal benzodiazepine exposure increased the risk for oral cleft (absolute risk increased by 0.01%).
    • Lamotrigine is a potential maintenance therapy option for pregnant women with bipolar disorder and has a growing reproductive safety profile relative to alternative mood stabilizers.
    • Untreated or inadequately treated maternal psychiatric illness may have various negative consequences.
  • Level C evidence (primarily from consensus and expert opinion):
    • Multidisciplinary care management involving the patient's obstetrician, mental health clinician, primary health care provider, and pediatrician is recommended whenever possible.
    • Use of a single medication at a higher dose is favored vs the use of multiple medications to treat psychiatric illness during pregnancy.
    • Close monitoring of lithium during pregnancy and postpartum is recommended.
    • Measuring serum drug levels in breast-fed neonates is not recommended.
    • Treatment with selective serotonin-reuptake inhibitors, selective norepinephrine reuptake inhibitors, or both during pregnancy should be individualized.
    • A fetal echocardiogram examination should be considered when the fetus is exposed to lithium during the first trimester of pregnancy.

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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