Given the limited information on the reproductive safety of certain medications, it is common for women to discontinue anti-anxiety medications during pregnancy. However, many women experience worsening of their anxiety symptoms during pregnancy, and it seems that the first trimester may be particularly difficult. Cognitive-behavioral therapy and relaxation techniques may be very useful for treating anxiety symptoms during pregnancy and may reduce the need for medication.

Some women, however, may not be able to remain symptom-free during pregnancy without medication and may instead elect to continue treatment with anti-anxiety medications. When choosing a medication for use during pregnancy, it is important to choose an effective treatment with a good safety profile. We have the most information on the reproductive safety of Prozac (fluoxetine) and the tricyclic antidepressants. These medications are effective for the treatment of anxiety disorders, and research indicates that there is no increase in risk of major congenital malformation in infants exposed to these medications in utero. Nor is there any consistent evidence that these medications are associated with any serious complications during pregnancy. There is also one report on the safety of Celexa (citalopram), indicating no increased risk of major malformation in exposed children. We have less information available on the safety of other serotonin reuptake inhibitors (SSRIs), including paroxetine, sertraline, and fluvoxamine.

Data regarding the use of benzodiazepines (such as Klonopin, Valium, and Ativan) during pregnancy is somewhat controversial. Early reports suggested that there may be an increased risk of cleft lip and palate associated with first trimester exposure to these medications, estimating the risk to be about 0.7%; however, more recent studies have suggested that the risk may be even lower. Since this risk is restricted to the first trimester, benzodiazepines may be used without risk of teratogenesis during the second and third trimesters. Symptoms of toxicity have been reported in newborns, and these include sedation, decreased muscle tone (floppiness), and breathing problems. In general, these symptoms appear infrequently but probably occur more commonly in women taking higher dosages of medication. There are also some reports of benzodiazepine withdrawal occurring in newborns exposed to benzodiazepines in utero, including irritability, sleep disruption, and, less commonly, seizure.

How anxiety in the mother may affect the pregnancy has been a topic of recent research, and several studies indicate that women who experience clinically significant anxiety symptoms during pregnancy are more likely to have preterm labor and low birthweight infants, as well as other complications, including pre-eclampsia. Thus it is crucial that women with anxiety disorders be monitored carefully during pregnancy, such that appropriate treatment may be administered should anxiety symptoms emerge during pregnancy.

Ruta M. Nonacs, MD PhD

Glover V. O’Connor TG. Effects of antenatal stress and anxiety: Implications for development and psychiatry. British Journal of Psychiatry. 180:389-91, 2002.