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

3. 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

4. 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!”

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

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

7. 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

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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.

16. Next Presentation Considering Risks of Medication in Pregnancy