Anxiety occurs when the brain is stressed.
It is common to worry about your pregnancy or your baby’s health.
However, Anxiety requires medical interventions when worrying interferes with your usual activities.
Anxiety can cause difficulty sleeping, feeling tired or irritated.
People with anxiety may feel like their heart is pounding or beating fast, they may also start to sweat, tremble or shake, or feel short of breath, diarrhea, and constipation.
During anxiety attacks (also known as panic attacks), people may have fears of passing out, dying, or of losing control or “going crazy.”
Worry becomes an anxiety disorder when the thoughts are frequent, time-consuming, intrusive and irrational.
Intrusive thoughts are unwelcome thoughts or images that are upsetting. Irrational worry means worrying about things that are unlikely to happen.
Research has found that 8-10% of women have anxiety at some time during pregnancy. It is unlikely that anxiety alone is able to increase the chance of birth defects.
However, untreated anxiety has been related to preterm birth, low birth weight, and difficulty feeling connected (bonded) with the baby both during pregnancy and after delivery.
Having frequent negative thoughts can cause you to be less involved with your baby.
It is important to talk with your healthcare providers so that they can determine if you have an anxiety disorder and suggest ways to treat it.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4589308/
Information and education to pregnant women facilitates a successful intervention to treat anxiety.
For mild anxiety is indicated cognitive behavior therapy (CBT), relaxation, and mindfulness therapy.
Moderate/severe anxiety requires pharmacotherapy and CBT, individually or in combination.
No psychotropic medications are approved by the FDA or Health Canada in pregnancy; off-label pharmacological treatment is considered only if the benefit outweighs its risk.
First-line treatment for anxiety disorders:
Selective Serotonin Reuptake Inhibitors(SSRIs) and Serotonin Norepinephrine Reuptake Inhibitors (SNRIs).
Approved SSRIs (https://www.mayoclinic.org/diseases-conditions/depression/in-depth/ssris/art-20044825)
- Citalopram (Celexa)
- Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Paroxetine (Paxil, Pexeva)
- Sertraline (Zoloft)
- Vilazodone (Viibryd)
- Fluvoxamine
Approved SNRIs (https://www.mayoclinic.org/diseases-conditions/depression/in-depth/antidepressants/art-20044970):
- Desvenlafaxine (Pristiq, Khedezla)
- Duloxetine (Cymbalta)
- Levomilnacipran (Fetzima)
- Venlafaxine (Effexor XR)
Research suggests that SSRIs and SNRIs cross the placenta, with 70%–86% of the maternal dosage being transferred to the infant. Several studies have not found compelling evidence that SSRI/SNRIs as a class are generally associated with birth defects.
The exception is first-trimester exposure to paroxetine, which has been correlated with cardiac malformations. In light of conflicting data, our recommendation is to avoid paroxetine.
Small but significant associations between the use of SSRI/SNRIs:
– spontaneous abortions
– shorter gestational age
– preterm delivery
– lower APGAR scores in newborns
– risk of persistent pulmonary hypertension (use during third trimester)
– neonatal withdrawal symptoms: jitteriness, irritability, tremulousness, difficulty feeding, difficulty sleeping,
hypertonia, and other adverse symptoms such as seizures. (common, appearing in 30% of infants exposed to
SSRIs) but they are generally mild, transient, and self-limiting.
Benzodiazepines are an option for short-term treatment.
They are among the most commonly used prescription drug among pregnant women.
Because SSRIs/SNRIs require several weeks before the onset of their action, benzodiazepines can be used for brief interval in order to produce an immediate anxiolytic response.
There is serious concern about cognitive impairment with long-term use of benzodiazepines. Extended use of
benzodiazepines is associated with a substantial risk of dependence, withdrawal, and abuse.
Use in pregnancy can elevate the risk of neonatal withdrawal symptoms such as hypertonia, hyperreflexia, tremors, bradycardia, and sleep disturbance.
Although Benzodiazepines are not recommended in third trimestrer, lorazepam may be favored over other’s due to
its low accumulation in newborn.
Atypical antipsychotics can be considered for severe manifestations of anxiety, when other medications have been insufficient.
Newer atypicals such as quetiapine and aripiprazole seem to show promise in treatment of severe anxiety during pregnancy.
Olanzapine, risperidone, and ziprasidone are not recommended.
Side effects related to atypical antipsychotics include extrapyramidal symptoms, weight gain, diabetes, hyperlipidemia, and a prolonged QTc interval.
Atypical antipsychotics have been associated with an increased probability of therapeutic abortions as well as low
neonatal birth weight.
Doses of all medications used in anxiety should begin as low as possible and should be increased gradually as necessary. The use of a single medication is preferred if possible. Sudden discontinuation should be avoided.
Tricyclic antidepressants and monoamine oxidase inhibitors are not generally prescribed, primarily because of their less favorable side-effect profile.
Nonpharmacological Treatment Options
Psychotherapy is vital in recovering from an Anxiety Disorder.
The goal is to provide support in reducing mother-to-be’s worries to a more reasonable level.
Psychoeducation provides information about anxiety and treatment rationale. This is often the most important initial intervention and frequently improves adherence to treatment.
In general, pregnant women tend to prefer treatment with psychotherapy over medications, as pharmacological agents usually add another layer of worry for the mother.
Cognitive behavioral therapy is a form of psychotherapy focused on changing dysfunctional patterns of thinking and behavior. CBT’s overall effects are still clinically modest; patients receiving CBT could still require further treatment in order to reach remission.
Based on meditation techniques, mindfulness training is the practice of awareness and attention exercises focused on accepting one’s present state of emotions, thoughts, and physical sensations. Mindfulness has been shown to significantly reduce negative affect, state anxiety, pregnancy-specific anxiety, and stress during pregnancy.
Relaxation techniques
Activites such as progressive muscle relaxation and diaphragmatic breathing are an integral part of many CBT- oriented treatments for ANxiety.
https://www.nice.org.uk/guidance/cg192/chapter/1-recommendations
Pregnant woman should be aware of: benefits and harms of psychological and drug-related interventions, and the consequences of no treatment.
Prescriber will take into consideration: the woman’s previous response to these drugs, the stage of pregnancy, safety of these drugs and the risk of discontinuation symptoms in the woman and neonatal adaptation syndrome.
Benzodiazepines can only be considered for the short-term treatment of severe anxiety and agitation.
There are other medications used for treating mental health problems like antipsychotics, anticonvulsants and lithium:There is limited data on safety of these drugs during pregnancy and after birth. .
If a pregnant woman is stable on an antipsychotic/anticonvulsant/lithium and likely to relapse without medication, advise her to continue on it. Otherwise, it is advisable to reduce dose, and if possible, to stop taking the medication.
If a woman is taking lamotrigine[8] during pregnancy, check lamotrigine levels frequently during pregnancy and into the postnatal period because they vary substantially at these times.
https://adaa.org/living-with-anxiety/women/pregnancy-and-medication
https://mothertobaby.org/fact-sheets/stress-pregnancy/
What are ways to reduce stress?
- Talk about your feelings with friends, family, your boss, and/or healthcare professionals.
- Don’t be afraid to ask for help.
- Follow good health habits: avoid smoking, drinking alcohol or taking illegal drugs; eat a healthy diet; drink plenty of water; get the rest you need; if you have been prescribed medicine, take it as directed; and follow an exercise plan approved by your health care provider.
- Try to have fun. Find something you enjoy and do it. Feeling positive can be helpful.
https://mothertobaby.org/fact-sheets/benzodiazepines-pregnancy/
What is a benzodiazepine?
Benzodiazepines are medications that have been used to treat anxiety… sleeplessness, seizures, muscle spasms, and alcohol withdrawal. Diazepam (Valium®), alprazolam, (Xanax®), clonazepam (Klonopin®), temazepam (Restoril®), and lorazepam (Ativan®) are some examples of benzodiazepines, but there are others.
If you are taking a benzodiazepine near the time of delivery, your baby may have withdrawal symptoms. These include difficulty breathing, muscle weakness, irritability, crying, sleep disturbances, tremors, and jitteriness. It is important that your healthcare providers and your baby’s pediatrician know you are taking a benzodiazepine. If
symptoms develop, they usually resolve over a few weeks as the drug leaves the baby’s system. This is not expected to have any long-term effects.
It is unclear. Very few studies have looked at the long-term effects on children exposed during pregnancy. One human study suggested that children might be more likely to show certain behaviors, such as fearfulness and social withdrawal. However, more long-term studies are needed to understand if there are any concerns.
One human report and some animal data have suggested that the combination of temazepam and diphenhydramine (Benadryl®) may increase the chance for stillbirth or death shortly after birth. It is not known if this interaction will occur with all benzodiazepines. To be safe, it is best not to take diphenhydramine while you are taking a
benzodiazepine.
https://mothertobaby.org/baby-blog/is-it-normal-to-be-anxious-during-pregnancy/
anxiety disorders are diagnosed when fear and anxiety can be excessive and/or persistent over time and can interfere with a person’s ability to function in their daily life.
Anxiety disorders include generalized anxiety disorder, panic disorder, post-traumatic stress disorder, social phobia,
and other phobias. These conditions can cause individuals to experience a great deal of worry or fearfulness. Anxiety disorders can cause physical symptoms such as difficulty sleeping, fatigue, headaches, muscle aches, irritability, lightheadedness, dizziness, trembling, hot flashes, feeling out of breath, and nausea among other symptoms.6
https://www.mayoclinic.org/diseases-conditions/anxiety/diagnosis-treatment/drc-20350967
The two main treatments for anxiety disorders are psychotherapy and medications. You may benefit most from a combination of the two. It may take some trial and error to discover which treatments work best for you. Lifestyle changes can reduce your anxiety.
- Stay physically active most days of the week. Exercise is a powerful stress reducer.
- Avoid or reduce consumption of alcohol, recreational drugs, nicotine and coffee. They can cause or worsen anxiety.
- Use Visualization techniques, meditation and yoga to ease anxiety.
- Make sure you’re getting enough sleep to feel rested.
- Focus your eating on vegetables, fruits, whole grains and fish.
It is advisable to learn about anxiety, so you stick to your treatment. You could learn what triggers your anxiety/ stress, and avoid them. Whenever you feel anxious, take a walk or refocus your mind. Socializing and keeping a journal can reduce your anxiety as well
http://www.motherisk.org/women/updatesDetail.jsp?content_id=326
https://mothertobaby.org/fact-sheets/anxiety/
https://fhop.ucsf.edu/sites/fhop.ucsf.edu/files/custom_download/ Effects%20of%20maternal%20depression%2C%20anxiety%2C%20and%20perceived%20stress%20during%20pre g%20on%20preterm%20birth%20-%20systematic%20review.pdf
Anxiety is known to be more prevalent than depression at all stages of pregnancy although there is a high level of comorbidity of about 60% between the two.