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General Principles in Use of Medication for Perinatal Anxiety and Depression

Medication should be avoided where possible, especially during the first trimester; however alternative, nondrug treatments need to be considered where available and untreated anxiety and depression also pose risks.

•All the risks from exposure to eithermedication orillness are not yet known.

•All medication crosses the placenta and also appears in breast milk — to varying degrees

•Following consultation among health professionals and consultation with the woman and her partner, agreed, written, care plans should be drawn up and available to all concerned.

•If conception occurs unexpectedly, medication should notbe withdrawn abruptly and medical guidance is indicated.

•If medication is used, an effective dose should be prescribed:

•most antidepressants are also effective for anxiety

•polypharmacy should be avoided, also bearing in mind that patients may be self-medicating

•medication that has previously been effective in that patient should usually be first choice

•Careful monitoring is essential:

•mood stabilising drugs require close obstetric monitoring and adequate folate supplementation

•pharmacokinetics can change over the pregnancy and doses may need to be changed

•similar principles apply when using atypical antipsychotic drugs

•With a history of previous severe postnatal anxiety disorder, depression or psychosis, plan for prophylaxis in late pregnancy or immediately postpartum:

•exposure is generally higher through placental passage than through breast milk so medication used during pregnancy should be the one continued postpartum

•the infant should be clinically monitored subsequently

•Neonatal adaptation problems are common, though rarely severe, in healthy infants of women on antidepressant medication:

•since reduction or withdrawal of medication prior to delivery is not always possible or advisable, the infants should be closely monitored for 3 to 7 days postpartum

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