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Real-World Challenges: Rosa Vivien Burt, MD, PhD The Women’s Life Center Resnick Neuropsychiatric Hospital at UCLA

Sertraline was effective Demographics 36 years old Married Mother of a toddler (2.5 years old) Sertraline was effective College Birth of son 1 year ago 10-week miscarriage Cognitive therapy was tried, but she was nonadherent  Anxious since childhood

2.5-year-old toddler is developmentally delayed “I’ve been told that antidepressants in pregnancy cause congenital defects and autism and other problems. But without this medication, my depression and anxiety come back, and I’ve such a hard time functioning. I am so confused. What I read is scary!”

Rosa’s Basic Treatment Program Team approach Husband Perinatal psychiatrist Primary physician Patient Obstetrician Referring psychiatrist

Rosa’s Basic Treatment Program Recommendation: continue sertraline at 100 mg/day during pregnancy and postpartum Psychotherapy encouraged Close psychiatric follow-up

Further Basic Treatment Recommendations Postpartum Breastfeeding Gestational week 18 High-resolution ultrasound Surveillance for neonatal adaptive difficulties OK with SSRIs Consider Sleep deprivation Patient and baby hospitalized for 48 hours Availability of child care Supplemental formula feeding

Listened to patient and her partner Rosa and husband decide to continue sertraline Addressed Personal Obstetric Psychiatric history Rosa’s illness and history Data on sertraline in pregnancy Satisficing approach

Dysphoric and irritable 2nd Trimester 3 months later Dysphoric and irritable Pregnant Sertraline 100 mg/day  125 mg/day  150 mg/day  CBT Increase in extracellular fluid volume Fetal movements Dilutional effect Psychiatrically stable

Psychiatric status stable 3rd Trimester Sertraline 150 mg/day Weekly CBT Gestational diabetes Psychiatric status stable Insulin Fetal parameters stable Pediatrician follows closely

Postpartum: Baby 12 hours 36 hours 1 week 37 weeks Boy Normal, vaginal, spontaneous delivery Postpartum: Baby 3500 grams Apgar: One minute: 7 Five minutes: 8 12 hours 36 hours 1 week Neonatal adaptive difficulties Gestational DM resolved Special care unit for observation Returned to mother Fully normalized Occasional jerking Minor lag in sucking Transient increased breathing rate Stabilized rapidly

The Postpartum Baby and older child meeting developmental milestones Delivery 3 months 6 months Sertraline 150 mg/day Overnight baby nurse Baby and older child meeting developmental milestones Mother-in-law and mother provided additional daytime assistance Breastfeeding with supplemental feedings Weaning CBT IUD placed

Take-Home Messages Encouraged and educated her to understand the value of psychotherapy Addressed the changing need for medication in pregnancy Carefully considered the patient’s history Anticipated possible complications and addressed them openly and calmly Addressed and understood development delay in the first child and its implication in subsequent pregnancy Addressed the miscarriage and how it affected her psychologically

Gestational diabetes addressed in CBT and treated with insulin Talked about neonatal adaptive difficulties with the patient Address the need for child care help: privately and affordable Breastfeeding issues were discussed

Key Points It is important to plan ahead of pregnancy and explain the possible risks of medication in pregnancy.  Real life issues need to be discussed before, during, and after pregnancy. Patients with depression and anxiety ought to be followed carefully by a perinatal psychiatrist prior to pregnancy, during pregnancy, and throughout the first postpartum year.

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