Anxiety in pregnancy:

1
Anxiety in pregnancy

• When do worries become pathological?

2
Anxiety Disorders in Pregnancy

• Pregnancy is generally a period of heightened
  anxiety
• Pregnancy does not protect against anxiety
  disorders
• Increased rate of anxiety disorders in pregnancy
• (6.6 vs. 2-4 nonpregnant women)
• Strong comorbidity with depression
• Rule out medical cause (hyperthyroidism)

3
Anxiety Disorders in Pregnancy

• Panic Disorder
• PTSD
• Past history of abuse
• Traumatic previous delivery
• OCD
• Obsessive worries about harming the fetus
• /- compulsions
• Ruminative worrying syndrome
• Good insight (vs. psychosis)

4
Case Presentation

• the worrying
• mom-to-be

5
Case Presentation

• . Mrs. O Age 30 Gravida 1 Para O, married and
  employed as an magazine editor.
• No major medical problems
• No history of abuse, trauma
• Past history of depression and anxiety treated
  with an antidepressant- off all meds prior to
  conception
• Mat. GM- bipolar d/o, Mom- worrier

6
Case Presentation

• -Referred to the Perinatal Mental Health Program
  at her husbands insistence when she was 6 wks
  preg
• -Extreme obsessions, ruminations, poor sleep,
  anhedonia
• -Antidepressant was recommended
• Presented to Motherisk at 12 weeks GA
• She had called numerous times asking the same
  questions repeatedly, despite each time receiving
  reassuring information that this medication was
  not teratogenic

7
Case Presentation

• Daily calls to family physician, obstetrician,
  psychiatrist and psychologist
• Constant checking on internet
• Information she received failed to alleviate her
  anxiety for more than a few hours
• She generalized her worries to new exposures that
  she thought may potentially harm her baby

8
Management

• a biopsychosocial/
• behavioural approach

9
Management

• Carefully evaluate the patient, addressing her
  current symptoms, past psychiatric history,
  especially during prior pregnancies or postpartum
  periods (if applicable).
• Assess patients past baseline temperament
  tendency to chronic anxiety/worrying/
  catastrophic thinking, dysthymia, dependency
  issues, etc.

10
Management

• Assess current social supports, especially
  husband and close family members.
• When possible, attempt to evaluate patient with
  her husband/partner in order to allow him
  opportunity to add information and ask questions

11
Management

• Meds Weigh risks of untreated illness against
  that of psychotropic treatment (risk/benefits) to
  both the expectant mother and her fetus
• Discuss with the patient how her concerns will be
  managed in pregnancy, which must be very specific
  and include the following

12
Management

• One individual on the health care team will be
  assigned to handle her questions concerning
  exposures that she worries about that could harm
  her baby. The other members of the team should
  refer her to that member if she asks these types
  of questions

13
Management

• She will refrain from accessing the internet,
  read books, magazines etc. as this may exacerbate
  her fears, due to the mostly non evidenced-based
  and often frightening information found in these
  resources

14
Management

• A time limit should be set for each contact with
  her primary care person, for example 5 minutes to
  discuss a concern. A specific concern will be
  discussed once only
• A similar time limit should be set with her
  partner at home

15
Conclusions

• Pregnancy is not protective for anxiety disorders
• Ruminative worrying may be a subtype of OCD that
  occurs specifically in pregnancy and postpartum
• Management involves a biopsychosocial/
  behavioural approach, including strict
  limit-setting and structure
• Treatment involves a collaborative,
  multidisciplinary team effort