What is the recommended management for a pregnant woman with obsessive-compulsive disorder (OCD)?

Management of OCD During Pregnancy

For pregnant women with OCD, cognitive behavioral therapy with exposure and response prevention (CBT with ERP) should be the first-line treatment for mild to moderate symptoms, while SSRIs—particularly sertraline—should be continued or initiated for moderate to severe OCD when the benefits of treatment outweigh the risks of untreated illness. 1, 2

Initial Assessment and Risk Stratification

When evaluating a pregnant woman with OCD, immediately assess:

• Severity of obsessions and compulsions and their impact on daily functioning, self-care, and prenatal care adherence 3
• Specific symptom content: Perinatal OCD commonly involves fears of harming the baby (aggressive obsessions), contamination fears, and associated cleaning/checking compulsions 1, 4
• Suicidal ideation or severe functional impairment requiring urgent psychiatric referral 3
• Co-occurring psychiatric conditions (depression, anxiety, ADHD) that may complicate treatment planning 5, 2

Treatment Algorithm by Severity

Mild to Moderate OCD

Start with non-pharmacological interventions:

• Cognitive Behavioral Therapy with Exposure and Response Prevention (CBT with ERP) is the gold-standard treatment with the strongest evidence base for perinatal OCD 1, 4, 2
• CBT with ERP has demonstrated efficacy in both observational studies and randomized controlled trials specifically for perinatal OCD 1
• Psychoeducation about OCD symptoms, particularly normalizing intrusive thoughts about infant harm (which are common and do not indicate intent), helps reduce distress and shame 5, 4
• Prevention programs incorporating CBT principles into prenatal care have shown significant reductions in postpartum OCS at 1,3, and 6 months compared to control conditions 6

Moderate to Severe OCD Requiring Medication

Do not reflexively discontinue SSRIs upon pregnancy confirmation—untreated OCD poses significant risks to both mother and fetus. 7, 3

Preferred pharmacological approach:

• Sertraline is the preferred SSRI due to its established safety profile and extensive use in pregnancy 8, 9
• Continue current SSRI if already well-controlled on medication, as switching introduces unnecessary risk 7, 3
• Use the lowest effective dose while maintaining symptom control 3
• SSRIs should be used "only if the potential benefit justifies the potential risk to the fetus," but for moderate-severe OCD, this threshold is typically met 8

Critical medication considerations:

• Neonates exposed to SSRIs late in the third trimester may develop transient complications (respiratory distress, jitteriness, feeding difficulties) requiring monitoring but not contraindication 8
• There is a small increased risk of persistent pulmonary hypertension of the newborn (PPHN), occurring in 1-2 per 1000 live births, though epidemiologic data are mixed 8
• Women who discontinue antidepressants during pregnancy show significantly increased relapse rates compared to those who continue medication 8

When to Refer to Psychiatry

Refer to a reproductive psychiatrist or general psychiatrist when: 3, 2

• OCD symptoms are moderate to severe and interfering with maternal functioning or self-care 3
• Medication management is being considered or needs optimization 3, 2
• Suicidal ideation or severe functional impairment is present (urgent referral) 3
• Co-occurring psychiatric conditions complicate management 2, 5

Supportive Measures Throughout Pregnancy

Address modifiable factors that worsen OCD symptoms: 5, 2

• Optimize sleep (sleep deprivation exacerbates symptoms) 5
• Ensure adequate nutrition with regular meals throughout the day 5
• Develop a support network involving family, obstetrics, psychiatry, and primary care 5, 2
• Monitor for deteriorating mental health with frequent visits assessing symptom severity and treatment adherence 2, 3

Breastfeeding Considerations

• Sertraline can be continued during breastfeeding with infant monitoring for appropriate weight gain and developmental milestones 7
• The decision to breastfeed while taking SSRIs should involve discussion of risks versus benefits, with close infant monitoring 5
• Sertraline is excreted in breast milk in unknown amounts, requiring caution but not absolute contraindication 8

Critical Pitfalls to Avoid

• Do not dismiss intrusive thoughts about harming the baby as "normal pregnancy anxiety"—these are hallmark OCD symptoms requiring specific treatment with ERP 4, 1
• Do not discontinue effective SSRI treatment reflexively upon pregnancy confirmation—the risks of untreated moderate-severe OCD (impaired prenatal care, maternal distress, functional impairment) often exceed medication risks 7, 8
• Do not use benzodiazepines for OCD anxiety in pregnancy due to addiction potential and lack of efficacy for core OCD symptoms 2
• Do not assume postpartum OCD will resolve spontaneously—without treatment, symptoms often persist and impair mother-infant interactions 4, 1