“I’m worried. I can’t sleep. It’s anxiety.” The message came from Natalie a few minutes after I logged into our live chat service at MotherToBaby.org. “I’m 14 weeks pregnant and worried about taking SSRIs.” As a Teratogen Information Specialist, I answer questions about exposures against during pregnancy and breastfeeding and I was happy to chat with Natalie about it.
Natalie had just returned from a visit to her OB/GYN office where she was diagnosed with anxiety. She had shared with her doctor that she was having trouble eating and sleeping, and experiencing overwhelming thoughts and constant worry about the future. Natalie’s OB/GYN was concerned that what she was describing was more than the typical pregnancy concerns that many women have. She recommended that Natalie be started on an SSRI to help manage her symptoms.
Natalie knew she had to do something to deal with her anxiety, but she was reluctant to take any medication. “I read online that SSRIs can cause withdrawal symptoms in the baby and I would never want to do anything to harm my baby!” type quickly. “Instead of taking this drug, would it be better for me to suffer for the next 26 weeks so that my baby can be born well?”
Natalie’s question was not unusual. Here in the United States, anxiety affects about 6.8 million adults, and women are twice as likely as men to have this mood disorder. Additionally, approximately 6% of women will develop anxiety at some point during their pregnancy. Non-pharmacological approaches can be an effective first-line treatment for some people. Some women benefit from daily meditation or exercise. For others, opening up with a friend or attending speaking sessions can help. Natalie had tried all of these options in her first trimester and unfortunately her anxiety was getting worse.
I knew Natalie wanted a quick answer to her question about withdrawal, but I told her that first it was important for us to consider how necessary it was for her to deal with her mood disorder. I applaud Natalie for recognizing the symptoms of anxiety and having an honest conversation with her doctor about how she was feeling. I then informed her that many women feel that suffering these feelings during pregnancy may be the best option. However, we know that stress can actually cause problems of its own when left untreated. Studies have identified an increased risk for preterm birth (baby born before 37 weeks) and low birth weight when women do not properly manage their stress during pregnancy. Women with untreated anxiety may also have more trouble bonding with their baby both during pregnancy and after birth. Finally, a personal history of stress before or during pregnancy is a known risk factor for developing a severe postpartum mood disorder.
Natalie fully understood the importance of weighing the risks against the benefits. Her niece had been born prematurely and has seen firsthand how terrifying this experience was for her sister. She agreed that dealing with her stress was important.
Natalie’s doctor had recommended that she start sertraline (Zoloft), which belongs to a class of drugs known as selective serotonin reuptake inhibitors, or SSRIs. Other drugs in this class include citalopram (Celexa), fluoxetine (Prozac), and paroxetine (Paxil), to name a few. SSRIs are well studied, which means we have a good idea of what the effects might be when a woman takes one of these drugs during pregnancy. Withdrawal (also known as Neonatal Adjustment Syndrome) is one such known effect.
Babies of women taking SSRIs at the time of delivery may have some difficulties in the first few days of life. Reported symptoms include nervousness, increased muscle tone, irritability, constant crying, sleep changes, tremors, difficulty eating, and breathing problems. Not every baby will experience these symptoms. For SSRI drugs, it is estimated that 10-30% of babies will be affected.
Some babies with withdrawal symptoms may need to spend time in the neonatal intensive care unit (NICU) to receive additional care. However, in most cases the symptoms are mild and resolve within two weeks. Reassuringly, there does not appear to be a dose-response relationship, meaning that women who need more medication to manage their anxiety are not expected to have babies at higher risk of withdrawal.
“I feel so much better after talking to you and I really feel like this withdrawal issue can be dealt with if I plan ahead,” Natalie said. “I believe it will be in my baby’s best interest to start taking this medicine as soon as possible to get my anxiety under control.” I was delighted that Natalie had contacted us to chat with us about this matter. It may be a complicated subject, but certainly not uncommon. Now armed with the latest information available, Natalie can make the best choice for her and her baby
Bibliographical references:
• US Stress Statistics: https://www.womenshealth.gov/mental-health/illnesses/generalized-anxiety-disorder.html
• Pregnancy stress statistics: http://www.postpartum.net/learn-more/anxiety-during-pregnancy-postpartum/
• Postpartum anxiety: https://www.anxiety.org/postpartum-anxiety-risk-factors
• Medicines used to treat anxiety:
