Part 3: Planning for the Postpartum Period
This is a continuation of the case presented in a previous post.
Ms. D continued to be somewhat symptomatic but much more stable during the rest of her pregnancy while on the combination of fluoxetine and clonazepam. There was a discussion regarding the option of increasing her dose of fluoxetine to provide further benefit, but the patient decided that even though she was not feeling her best she wanted to remain on 20mg.
At her last appointment prior to delivery, she discussed her desire to change to venlafaxine ER after delivery, as fluoxetine had sexual side effects that she did not have on venlafaxine ER and because venlafaxine was more effective for her. The patient stated that she would like to formula feed after delivery.
Here are some key points to consider:
It is important to get as well as possible prior to delivery to give the patient the best chance of doing well during the postpartum period. This often would include optimizing the dose of medications.
She has a history of responding very well and very quickly to venlafaxine ER, but the immediate postpartum period is an especially vulnerable time. Typically it is recommended that patients stay on the medications taken during pregnancy across the postpartum period rather than switching to another medication and potentially increasing the risk of relapse during the postpartum period.
Betty Wang, MD
In an attempt to get full remission, and considering that the demands of motherhood on daytime fatigue, the consideration of low dose modafanil during the day would likely help improve her mood. It would depend on where she was still having the problem.
Thanks, Chevies Newman, M.D.
@Chevies Newman, Fatigue is obviously a common problem in new mothers, yet we typically do not use stimulants or agents like modafanil to treat fatigue. For most women, fatigue stems from sleep disruption. Thus the first step in managing fatigue would be to put into place interventions that may help to improve sleep quality.
Often treating the depression or anxiety helps at least to some degree to lessen fatigue.
To date, we have no data on the safety of modafanil in nursing infants, thus we tend not to use it in women who are breastfeeding.
Thanks for your comment.
Again, thanks so much for these profiles. It helps me to read them and stay focused on helping my clients. The world of pregnancy, medication and breastfeeding is quite complex, thanks, Kathy
I typically use Prozac during the pregnancy and then switch to Zoloft at delivery (because of its shorter half life) for breastfeeding women. You have said you recommend maintaining the woman on the same meds postpartum… Would you recommend staying on Prozac if the woman was doing well during the pregnancy?
Would you advise this mom to breast feed the baby since fluoxetine is excreted through breast milk?
Did she decide to breastfeed because of a personal choice or because the medication is not safe for breastfeeding? Aren’t there more risks for taking fluoxetine during the 3rd trimester than during breastfeeding? I’m asking because I am currently in my 3rd trimester NOT taking medication but considering to either not breastfeed so I can take medication or to go back on fluoxetine.
We generally do recommend that if a woman is doing well during pregnancy on Prozac, or any other antidepressant, that she continue that medication throughout the postpartum period. Switching medications at this point may increase the risk of relapse.
As a Behavior Medicine Specialist for CDAPP (California Diabetes and Pregnancy Program), I train health care providers who work with pregnant women with diabetes. This series is very helpful, as depression is one of the most common psychological issues we find with with the patients in our programs, and it is difficult to make these complicated decisions.
Your readers may be interested in the three algorithms found in the following article which can be found on-line:
“The Management of Depression During Pregnancy: a Report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists”
Yonkers,M.D, Wisner,M.D.,MS. et al.
from the Journal of Obstetrics and Gynecology
Vol 114,No.3, Sept 2009 pp.703-713