Perinatal Anxiety

Perinatal anxiety is clinically significant anxiety arising or worsening during pregnancy or in the first 12 months after birth. It includes generalised anxiety disorder, panic disorder, obsessive compulsive disorder, social anxiety, specific phobias (including tokophobia, fear of childbirth) and post-traumatic stress disorder after traumatic birth.

• Affects about 15 to 20 percent of women in pregnancy and the postpartum year; it is as common as perinatal depression and often coexists with it.
• Risk factors: previous anxiety or depression, history of trauma or abuse, previous pregnancy loss or complicated birth, infertility, unplanned pregnancy, lack of partner and social support, intimate partner violence, financial stress, medical problems in the mother or infant, neonatal intensive care admission, and perfectionism.
• Untreated anxiety is linked to preterm birth, low birth weight, poor bonding, reduced breastfeeding, postnatal depression, and child emotional and behavioural problems.
• Intrusive thoughts of accidental or deliberate harm to the baby are common in new mothers and in obsessive compulsive disorder, and are distressing rather than a sign of intent to harm.

• Persistent excessive worry about the pregnancy, baby's health, birth, feeding, and ability to cope; restlessness, irritability, muscle tension, fatigue, poor concentration and sleep disturbance that is not due to the baby alone.
• Panic attacks: palpitations, breathlessness, chest tightness, dizziness, paraesthesia, fear of dying.
• Obsessions and compulsions: checking the baby's breathing, excessive cleaning, avoiding being alone with the baby, repeated reassurance seeking.
• Re-experiencing and avoidance after a traumatic birth.
• Physical symptoms that mimic anxiety need to be separated: tachycardia, palpitations and breathlessness occur in normal pregnancy.
• Ask about mood, suicidal thoughts, substance use (alcohol, cannabis, caffeine), bonding with the baby, intimate partner violence, and psychotic symptoms.
• Red flags: hallucinations, delusions, confusion, severe insomnia and elevated or labile mood in the first weeks after birth (postpartum psychosis, a psychiatric emergency), and suicidal or infanticidal thoughts with intent.

• Clinical interview with validated screening: GAD-7 (a score of 10 or more suggests significant anxiety), the Edinburgh Postnatal Depression Scale and its anxiety subscale (items 3, 4 and 5; 6 or more suggests anxiety), and the Perinatal Anxiety Screening Scale.
• Confirm diagnosis with diagnostic criteria for the specific disorder.
• Exclude physical causes: thyroid function (TSH; hyperthyroidism or postpartum thyroiditis), FBC and ferritin (anaemia), glucose, electrolytes, ECG for palpitations, echocardiogram if breathlessness is out of proportion (peripartum cardiomyopathy), D-dimer or imaging if pulmonary embolism is suspected, blood pressure and urine protein (pre-eclampsia), hyperemesis effects, caffeine and substance use.
• Assess risk to self and the baby, safeguarding, and functioning.
• Differentials: normal pregnancy worries, depression, bipolar disorder, postpartum psychosis, adjustment disorder, thyroid disease, anaemia, cardiac disease, medication or substance effects.

Psychoeducation and self-help (all women)

• Explain that perinatal anxiety is common and treatable; advise regular sleep (protect one stretch of sleep with partner help for night feeds), meals, daily physical activity (walking 30 minutes), limiting caffeine to under 200 mg daily, avoiding alcohol and cannabis, relaxation and breathing exercises, mindfulness, and peer support.
• Therapist supported self-help using cognitive behavioural principles is suitable for mild symptoms.

Psychological therapy (first line for moderate symptoms)

• Cognitive behavioural therapy, 8 to 16 sessions, individual or group; exposure and response prevention for obsessive compulsive disorder; trauma focused therapy for post-traumatic stress; counselling for fear of childbirth; interpersonal therapy; couples or family sessions.

Medicines (moderate to severe anxiety, or when therapy is unavailable or ineffective)

• Sertraline is preferred in pregnancy and breastfeeding: 25 mg orally once daily for 1 week, then 50 mg daily, increasing in steps of 25 to 50 mg every 1 to 2 weeks to 50 to 200 mg; response over 4 to 8 weeks; continue for at least 6 to 12 months after remission.
• Alternatives: escitalopram 5 mg daily increasing to 10 to 20 mg; citalopram 10 mg increasing to 20 mg (maximum 20 mg); fluoxetine 10 mg daily increasing to 20 to 40 mg (long half life; may accumulate in the infant during breastfeeding); venlafaxine modified release 37.5 mg increasing to 75 to 225 mg (monitor blood pressure).
• Avoid paroxetine in pregnancy (cardiac malformations in the first trimester).
• Neonatal adaptation: SSRI exposure in late pregnancy can cause transient irritability, jitteriness, feeding difficulty and respiratory distress in the newborn for days; inform the birth team, observe the baby for 48 hours, and do not stop treatment abruptly because relapse risk is high. Persistent pulmonary hypertension of the newborn is a rare risk.
• Short term relief of severe symptoms or panic: propranolol 10 to 20 mg orally up to three times daily (monitor fetal growth and neonatal heart rate and glucose if used late in pregnancy); a benzodiazepine (lorazepam 0.5 mg or diazepam 2 mg) at the lowest dose for no more than 2 to 4 weeks, with a plan to taper, because of neonatal sedation, floppy infant syndrome and withdrawal near delivery.
• Avoid hydroxyzine in early pregnancy; avoid valproate and carbamazepine as anxiolytics.
• Breastfeeding: sertraline and escitalopram pass minimally into milk and are compatible; observe the infant for sedation, poor feeding, and irritability; short term lorazepam 0.5 mg at night is acceptable.

Severe or high risk cases

• Urgent specialist perinatal mental health assessment for severe symptoms, suicidal thoughts, psychosis, or risk to the infant; admission to a mother and baby unit where available.
• Postpartum psychosis: emergency admission.

Follow up

• Review every 2 weeks at the start of treatment, then monthly through pregnancy and the first postnatal year; repeat GAD-7 and the Edinburgh scale; screen at postnatal visits, with a risk plan across birth and postpartum; involve the partner and the midwife or health visitor.