Management of Worsening Anxiety in a Pregnant Patient on Sertraline
Increase the sertraline dose to 50 mg daily, as this is the established optimal therapeutic dose for anxiety and depression, and continuing SSRIs at effective doses during pregnancy is recommended over discontinuation, which poses greater risks to both mother and fetus. 1, 2
Rationale for Dose Increase
Sertraline 25 mg is subtherapeutic. The starting and usually effective therapeutic dose is 50 mg/day, which represents the optimal dose when considering both efficacy and tolerability. 3
Pregnancy increases sertraline clearance. Pharmacokinetic studies show a tendency toward increased dose-adjusted concentrations being needed during pregnancy, meaning the current 25 mg dose is likely even less effective than it would be outside of pregnancy. 4
Untreated anxiety poses significant maternal-fetal risks. Untreated psychiatric illness during pregnancy is associated with premature birth, decreased breastfeeding initiation, and deterioration of maternal mental health that negatively impacts fetal development. 1
Safety Profile in Pregnancy
Sertraline is the preferred first-line SSRI in pregnancy. The American Academy of Pediatrics recommends sertraline due to its minimal excretion in breast milk and low infant-to-maternal plasma concentration ratios. 1
No adverse neurodevelopmental outcomes have been identified in recent reviews of infants with prenatal SSRI exposure. 1
The risks of untreated illness outweigh medication risks. Most psychotropic drugs are relatively safe in pregnancy, and not using them when indicated poses greater risk to both mother and child. 1
Dosing Strategy
Increase to 50 mg daily immediately. This is the standard therapeutic dose and should be well-tolerated given she has already been on 25 mg. 3
Monitor response over 2-4 weeks. If inadequate response persists, further increases in 50 mg increments can be made at weekly intervals up to a maximum of 200 mg/day. 3
Use systematic assessment. Consider standardized symptom rating scales to objectively track treatment response. 5
Critical Safety Monitoring
Watch for neonatal adaptation syndrome in the third trimester. Third-trimester SSRI exposure can cause transient neonatal symptoms that typically resolve within 1-2 weeks. 1
Avoid combining with other serotonergic agents. Do not add tramadol, dextromethorphan, St. John's wort, or other serotonergic medications due to risk of serotonin syndrome. 5, 6
Monitor for suicidality closely in the first months after dose adjustments, as recommended by the FDA. 6
Common Pitfalls to Avoid
Do not discontinue or maintain subtherapeutic dosing out of excessive caution. Withdrawal or inadequate treatment has harmful effects on the mother-infant dyad that exceed medication risks. 1, 2
Do not switch to paroxetine. While older FDA pregnancy category D classification raised concerns, paroxetine has been associated with increased risk of suicidal thinking compared to other SSRIs and should be avoided. 5, 7
Do not delay treatment while pursuing psychotherapy alone. While CBT is valuable and can be offered concurrently, this patient is already on medication and requesting escalation due to worsening symptoms—immediate pharmacological optimization is appropriate. 5
Additional Considerations
Confirm medication adherence before assuming treatment failure at the current dose. 5
Reassess at delivery and postpartum. Pharmacokinetic changes reverse after birth, potentially requiring dose adjustment in the nonpregnant, breastfeeding state. 2
Sertraline is compatible with breastfeeding and should be continued postpartum at the effective dose. 1