Management of Anxiety During Pregnancy
Cognitive Behavioral Therapy (CBT) and mindfulness therapy are the first-line treatments for anxiety during pregnancy, with sertraline as the preferred medication when pharmacotherapy becomes necessary. 1
Non-Pharmacological Approaches: First-Line Treatment
Evidence-Based Psychotherapy
Mindfulness therapy: Most effective non-pharmacological intervention for anxiety during pregnancy with highest SUCRA score 2
- Increases self-compassion and significantly reduces anxiety symptoms
- Beneficial for both high-risk pregnancies and healthy pregnant women
Cognitive Behavioral Therapy (CBT):
Other Non-Pharmacological Options
- Mind-body exercises: Effective for reducing anxiety symptoms in healthy pregnant women 2
- Relaxation techniques: Can help manage anxiety symptoms 3
- Yoga: Shows positive effects on anxiety reduction during pregnancy 3
- Music therapy: Demonstrated effectiveness in reducing anxiety during pregnancy 3
Pharmacological Treatment: Second-Line Approach
When non-pharmacological interventions are insufficient for moderate to severe anxiety:
Preferred Medication
- Sertraline: First-choice SSRI for pregnant women 1
- Starting dose: 25-50mg daily
- Maximum dose: 200mg daily
- Should be used concurrently with psychotherapy
Important Medication Considerations
- Ensure folic acid supplementation (400 mcg daily) to reduce risk of neural tube defects 1
- Monitor for third-trimester complications with SSRIs 1
- Be aware that neonates exposed to SSRIs late in the third trimester may develop complications requiring prolonged hospitalization, respiratory support, and tube feeding 4
Treatment Algorithm
| Anxiety Severity | Recommended Approach |
|---|---|
| Mild to Moderate | 1. Begin with CBT/mindfulness therapy 2. Reassess at 4-8 weeks 3. If insufficient improvement, consider adding sertraline |
| Moderate to Severe | 1. Begin CBT/mindfulness therapy 2. Consider adding sertraline (starting at 25-50mg daily) 3. Reassess at 4-8 weeks 4. Adjust sertraline dose as needed (max 200mg daily) |
Monitoring and Follow-up
- Regular reassessment at 4 weeks and 8 weeks after each treatment change 1
- Use validated screening tools such as GAD-7 to assess severity and functional impairment 1
- In the third trimester, discuss potential tapering of medication to minimize neonatal effects 1
Important Considerations
- Untreated anxiety during pregnancy is associated with increased risks of spontaneous abortion, preterm birth, and negative impacts on maternal-infant bonding 1
- For moderate to severe anxiety, the benefits of appropriate treatment outweigh the risks of untreated anxiety during pregnancy 1
- If medication is discontinued during pregnancy, there is a significant increase in relapse risk 4
- The decision to use medication must carefully weigh both the potential risks of taking an SSRI against the established benefits of treating anxiety 4
Cautions and Pitfalls
- Avoid abrupt discontinuation of SSRIs; use gradual tapering when discontinuing 4
- Be aware of potential drug interactions, particularly with MAOIs 4
- For women with liver impairment, use lower or less frequent doses of sertraline 4
- Monitor closely for signs of serotonin syndrome if other serotonergic medications are used concurrently 4