Postpartum Anxiety

Postpartum anxiety is excessive worry, fear and physical tension in the year after birth that is out of proportion to the situation and interferes with daily life. It affects 10 to 20 percent of women and often occurs together with depression. It matters because it impairs sleep, feeding and bonding, and untreated anxiety may persist for years.

• Risk factors: previous anxiety or depression, difficult birth, preterm or sick infant, poor social support, partner conflict, intimate partner violence, sleep deprivation, financial stress, previous pregnancy loss.
• Worries commonly centre on the infant's health, feeding and safety.
• Anxiety often coexists with postpartum depression.

Women have constant worry, restlessness, irritability, difficulty sleeping even when the baby sleeps, muscle tension, palpitations, shortness of breath, nausea, panic attacks, checking the baby repeatedly and avoiding situations. They may fear being alone with the baby.

• Tachycardia, tremor, sweating, normal examination otherwise.
• Repeated seeking of reassurance and checking.
• Differential diagnosis: normal new parent worry, postpartum depression, postpartum obsessive compulsive symptoms, panic disorder, thyrotoxicosis or postpartum thyroiditis, anaemia, peripartum cardiomyopathy, pulmonary embolism, caffeine excess, substance use, post traumatic stress after birth.
• Complications: depression, poor sleep and exhaustion, feeding difficulty, impaired bonding, avoidance of the infant, substance use, suicidal thoughts, chronic anxiety disorder.

The approach is a screening questionnaire followed by clinical interview and exclusion of physical causes.

• Generalised Anxiety Disorder 7 item score of 10 or more, and Edinburgh Postnatal Depression Scale of 13 or more to detect coexisting depression (a score of 5 or more on its three anxiety items, items 3 to 5, also suggests anxiety).
• Interview for panic, intrusive thoughts, birth trauma, safety of the woman and the infant; question on suicidal thoughts.
• Haemoglobin, thyroid stimulating hormone, glucose, ECG for palpitations.
• HIV test and malaria test where symptoms are new with fever or weight loss.

The principle is psychological therapy and support first, with a breastfeeding compatible antidepressant for moderate to severe or persistent symptoms.

• Supportive: reassurance and education; sleep protection with a partner or relative taking night feeds; cognitive behavioural therapy for 8 to 12 sessions; mindfulness and breathing exercises; regular light exercise; reduce caffeine; peer and community support groups; address abuse, poverty and partner conflict.
• Pharmacological: sertraline 25 mg oral once daily for 7 days then 50 mg once daily, increased by 25 to 50 mg every 2 weeks to a usual dose of 50 to 100 mg (maximum 200 mg), continued for at least 6 to 12 months after recovery; propranolol 10 to 20 mg oral 8-hourly for up to 4 weeks for physical symptoms; short term sleep aid: promethazine 10 to 25 mg oral at night for up to 7 days; lorazepam 0.5 mg oral once as needed (maximum 2 mg daily for no more than 7 days) only for severe panic.
• Procedures: none.
• Special groups: breastfeeding women prefer sertraline (low infant exposure); fluoxetine is avoided because of its long half life; avoid long acting benzodiazepines; women with bipolar features have specialist assessment before starting an antidepressant; women with thyroid disease need that treated first.
• Red flags: suicidal thoughts, thoughts of harming the baby, hallucinations or delusions, inability to eat, sleep or care for the infant, panic attacks with chest pain, substance misuse.
• Follow-up: review at 2 weeks after starting treatment and then every 4 weeks; repeat questionnaires at each visit; review at 6 weeks and 3 months; taper sertraline over 4 weeks when stopping; plan support in a later pregnancy.