Part 2: Pregnancy
This is a continuation of the case presented in a previous post.
After discussing the risk of relapse, as well as the risks and benefits of using various antidepressants during pregnancy, Ms. D decided that she would like to come off venlafaxine and try to remain off psychiatric medications during her pregnancy. She planned to continue psychotherapy in an effort to reduce her risk of relapse while off of medication.
She slowly tapered off her venlafaxine ER 150mg, and she conceived quickly after the taper. She reported that she did well during the first half of the pregnancy with some noticeable but tolerable anxiety and stated that she did not have any significant depressive symptoms during the pregnancy.
As she entered the third trimester, however, her anxiety symptoms worsened and she also began to have significant depressive symptoms. Seemingly small issues were causing excessive anxiety, and she began having frequent crying episodes. Given the escalating symptoms, she and her husband decided that it would be best to restart an antidepressant before delivery.
Some issues to consider:
In this case, the patient was able to remain off psychiatric medications for the majority of her pregnancy. Many patients and clinicians are particularly concerned about first trimester exposure to medications, as organ formation occurs in the first 12 weeks of pregnancy. While this is a very key issue, it is vital to remember that the risks and benefits of every decision must be considered, as there are also risks associated with untreated depression and anxiety during pregnancy.
At this point the patient is in her third trimester and is significantly depressed. One of the biggest risk factors for postpartum depression is depression during pregnancy. Thus one important goal is to get the patient as well as possible prior to delivery to improve her chances of staying well in the postpartum period.
SSRIs and venlafaxine ER taken late in pregnancy have been associated with transient neonatal symptoms such as jitteriness, irritability, restlessness and poor feeding. Luckily these symptoms appear to be temporary and often resolve without treatment.
Persistent pulmonary hypertension of the newborn (PPHN) has been associated with SSRI use after 20 weeks gestation, however more recent studies have shown a much lower risk or no association. Venlafaxine has not been included in published studies examining the risk of PPHN.
As discussed in Part One of this series, the patient only had a partial response to fluoxetine during her last trial of this medication and did not feel that sertraline and escitalopram were effective. Given her significant symptoms of depression and the fact that she was already in her third trimester, we generally advise patients to resume what has worked the best – in this case, venlafaxine.
The patient chose to go on fluoxetine, because there is more information regarding its use during pregnancy than venlafaxine. She also decided to try clonazepam, which she took sparingly for the treatment of her anxiety symptoms. Going back on an antidepressant was a difficult decision for her, and she waited a few weeks between receiving the prescription of fluoxetine and actually taking the medication. Her symptoms improved on 20mg of fluoxetine, but she was still not feeling as well as she did on venlafaxine.
Betty Wang, MD
I think this scenario is pretty common due to patient concerns about the effects of medication on the developing fetus. It sounds like Ms. D got through the most concerning time of the pregnancy without medication which is a success. As a therapist, I advocate for patient’s engaging in therapy to develop coping strategies in the presence or absence of medication. You describe therapy the patient as engaging in therapy as a preventive measure (“to reduce the risk of relapse”. I am wondering if the patient continued with the therapy once she restarted the medication?
@Lisa Kelly, She did continue the therapy throughout pregnancy and into the postpartum period. While very helpful to her, it did not eliminate her more severe symptoms of depression and anxiety.
Thanks for your comment.
I am most concerned about patient being on klonopin as it is pregnancy category D.