Revisão Sistemática Sobre Distúrbios de Ansiedade Durante a Gravidez

J Clin Psychiatry 67:0, Month 2006 1For R

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major depressive disorder during the perinatal period, i.e.,during pregnancy and the first year postpartum.13 Itis now commonly held that approximately 13% of womenwill exhibit symptoms of depression during pregnancyand/or the postpartum period.4,5 Although significantgaps in the research remain, both pharmacotherapy andpsychotherapy are effective treatments for perinataldepression.69

Anxiety disorders in the perinatal period have receivedless research attention. Recent findings indicate thatsymptoms of anxiety are common during pregnancyand the postpartum period10,11 and that maternal symp-toms of anxiety during pregnancy are associated withadverse fetal and developmental consequences.12 Over-activity of the maternal neuroendocrine system has beenimplicated in negative health outcomes seen in fetusesborn to stressed or anxious mothers. Fetal exposure to

Anxiety Disorders DuringPregnancy and the Postpartum Period:

A Systematic Review

Lori E. Ross, Ph.D.; and Linda M. McLean, Ph.D., C.Psych.

Objective: The postpartum period is rec-ognized as a time of vulnerability to affectivedisorders, particularly postpartum depression.In contrast, the prevalence and clinical presenta-tion of anxiety disorders during pregnancy andthe postpartum period have received little re-search attention. In this article, we review themedical literature as it relates to the prevalenceand clinical presentation of panic disorder,obsessive-compulsive disorder, posttraumaticstress disorder, and generalized anxiety disorderduring pregnancy and the postpartum period.

Data Sources: MEDLINE (1966 to July 2005week 1) and PsycInfo (1840 to July 2005 week 1)were searched using combinations of the follow-ing search terms: pregnancy, childbirth, postpar-tum, panic disorder, phobia, obsessive-compulsivedisorder, posttraumatic stress disorder, and gen-eralized anxiety disorder.

Study Selection: All relevant papers publishedin English and reporting original data related toperinatal anxiety disorders were included.

Data Extraction: Studies were examinedfor data related to the prevalence, presentation,predictors/risk factors, new onset, course, andtreatment of anxiety disorders during pregnancyand the postpartum period.

Data Synthesis: Anxiety disorders are com-mon during the perinatal period, with reportedrates of obsessive-compulsive disorder and gener-alized anxiety disorder being higher in postpar-tum women than in the general population. Theperinatal context of anxiety disorders presentsunique issues for detection and management.

Conclusions: Future research is needed toestimate the prevalence of perinatal anxiety disor-ders more precisely, to identify potential implica-tions of maternal anxiety disorders for maternalquality of life and child development, and to de-termine safe and effective treatment methods.

(J Clin Psychiatry 2006;67:000000)

A

Received Sept. 19, 2005; accepted January 30, 2006. From theWomens Mental Health and Addiction Research Section, Centre forAddiction and Mental Health, Department of Psychiatry, University ofToronto (Dr. Ross); and Princess Margaret HospitalUniversity HealthNetwork (Dr. McLean), Toronto, Ontario, Canada.

Dr. Ross is supported by a Career Scientist Award from the OntarioMinistry of Health and Long-Term Care and the Ontario Womens HealthCouncil, Ontario, Canada.

Portions of this manuscript were presented at the XIII World Congressof Psychiatry, September 1015, 2005, Cairo, Egypt.

In the spirit of full disclosure and in compliance with all ACCMEEssential Areas and Policies, the faculty for this CME article were askedto complete a statement regarding all relevant financial relationshipsbetween themselves or their spouse/partner and any commercial interest(i.e., any proprietary entity producing health care goods or servicesconsumed by, or used on, patients) occurring within at least 12 monthsprior to joining this activity. The CME Institute has resolved any conflictsof interest that were identified. The disclosures are as follows: Drs. Rossand McLean have no personal affiliations or financial relationships withany proprietary entity producing health care goods or services consumedby, or used on, patients to disclose relative to the article.

The authors thank Diane Meschino, M.D., andCindy-Lee Dennis, Ph.D., for their helpful comments on an earlier versionof this manuscript; Alicja Fishell, M.D., and Jasmine Gandhi, M.D., fortheir clinical expertise; and Raliza Stoyanova, B.Sc., and CorrieGoldfinger, B.A., for their assistance in the preparation of the manuscript.

The opinions, results, and conclusions are those of the authors, and noendorsement by the Ontario Ministry of Health and Long-Term Care isintended or should be inferred.

Corresponding author and reprints: Lori E. Ross, Ph.D., the WomensMental Health and Addiction Research Section, Centre for Addiction andMental Health, Department of Psychiatry, University of Toronto, 250College St., Toronto, Ontario M5T 1R8 (e-mail: [email protected]).

growing body of research has characterized theclinical presentation, prevalence, and treatment of

FOCUS ON WOMENS MENTAL HEALTH

2 J Clin Psychiatry 67:0, Month 2006

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elevated levels of hormones (particularly cortisol) maycontribute to premature labor and delivery.13,14 Maternalexposure to stress and anxiety may precipitate the releaseof catecholamines that can result in maternal vasocon-striction and ultimately a limitation of oxygen and vitalnutrients to the fetus.15 The exposure of the fetus to mater-nal stress and increased levels of adrenal hormones there-fore has possible consequences for fetal central nervoussystem development and specifically glucocorticoid brainreceptor development.14,16

The peak age at onset for anxiety disorders in womenoccurs in the mid- to late-20s,17 during the childbearingyears. Considering the high prevalence of mood and anxi-ety disorders in women, it follows that substantial num-bers of women will exhibit symptoms and may thereforebenefit from treatment for anxiety disorders during preg-nancy and the postpartum period. There is consequently apressing need to broaden the study of perinatal mentalhealth to include rigorous empirical study of perinatalanxiety disorders.18 This article reviews the published lit-erature as it relates to perinatal panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, andgeneralized anxiety disorder.

METHOD

Two electronic databases, MEDLINE (1966 to July2005 week 1) and PsycInfo (1840 to July 2005 week 1),were searched using combinations of the following searchterms: pregnancy, childbirth, postpartum, panic disorder,phobia, obsessive-compulsive disorder, posttraumaticstress disorder, and generalized anxiety disorder. Addi-tional publications were identified from reference lists ofretrieved articles. All relevant papers published in Englishand reporting original data related to perinatal anxiety dis-orders were included. Due to space restrictions, literaturereporting on anxiety symptoms or subsyndromal anxietyand papers reviewing theoretical perspectives on perinatalanxiety disorders were excluded from the review. Only 2studies could be identified that reported on phobia duringthe perinatal period,19,20 and as such perinatal agoraphobiaand social phobia were not included in this review. Al-though large case series have been included, small caseseries (N < 5) and individual case reports have been in-cluded only where illustrative.

RESULTS

Panic DisorderPanic disorder is characterized by sudden, recurrent,

and unpredictable panic attacks, associated with persis-tent worry about the possibility of having future panicattacks.21 Symptoms of panic attacks typically includeshortness of breath, heart palpitations, chest pain, dizzi-ness, and fear of losing control or dying. Approximately

50% of individuals with panic disorder also have comor-bid major depression.21

Prevalence of perinatal panic disorder. Despite vari-ability in assessment times and procedures, relativelyconsistent prevalence rates ranging from 1.3% to 2.0%have been reported for panic disorder during the perinatalperiod (Table 1).19,20,2224 In comparison, the DSM-IV re-ports lifetime prevalence rates of panic disorder rangingfrom 1.5% to 3.5% and 1-year prevalence rates of 1.0% to2.0%, with a typical age at onset at late adolescence to themid-30s.21

Presentation and predictors of perinatal panic dis-order. Although symptoms of panic during the perinatalperiod are typical of symptoms in the general population,they are often interpreted in the context of the perinatalstate. For example, women may interpret panic attacksduring pregnancy as an indication that something iswrong with the fetus.34 In a qualitative, phenomenolog-ical study of 6 postpartum women with panic disorder,women reported feeling unable to leave their homes totake their children to groups and activities and worriedabout the long-term impact of their panic disorder and theresulting isolation on their children.35

Although no literature has reported risk factors foror predictors of perinatal panic disorder, there is someevidence from retrospective studies of a relationship be-tween lactation/weaning and panic symptoms. In a reportincluding 43 breastfed babies, weaning of 12 (28%) wasassociated with exacerbation of panic in the mother.36 Inanother study of 22 women, 1 participant reported onsetof panic at weaning.37 A third study found that 9 of 16women who did not breast-feed their babies had panic at-tacks during the postpartum period, as compared to only2 of 17 women who breast-fed.38 Six of these women re-ported onset of panic attacks with weaning. Controlled,prospective studies are needed to determine whetherbreastfeeding reduces, and/or weaning increases, risk forpanic disorder.

New onset of panic disorder. Few studies have ex-amined incidence of perinatal panic disorder (Table 2). Aretrospective study of first panic in a sample of 64 child-bearing women treated at an academic research clinicfound that significantly more women reported onset dur-ing the first 12 weeks postpartum than would be expectedby chance (10.9% vs. 0.92%).39 The mean time of onsetwas 7.3 weeks postpartum (range, 112 weeks). How-ever, due to the retrospective nature of this study, it ispossible that women associated onset of symptoms withchildbirth due to its prominence in the memory as a majorlife event. Controlled research is needed to determine ifthe postpartum period is associated with increased riskfor new onset of panic disorder.

Course of preexisting panic disorder. Many womenexperience pregnancy following the onset of panic disor-der, and some limited research has described the perinatal



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Tabl

e 1.

Pre

vale

nce

of A

nxie

ty D

isor

ders

Dur

ing

the

Per

inat

al P

erio

dSt

udy

Out

com

eA

sses

smen

t Tim

eN

Prev

alen

ce (%

)N

otes

Pani

c di

sord

erSm

ith e

t al (

2004

)22PR

IME-

MD

Brie

f Pat

ient

Hea

lth Q

uesti

onna

ireA

ny p

oint

in p

regn

ancy

387

2.0

Zar e

t al (

2002

)23A

nxie

ty D

isor

ders

Inte

rvie

w S

ched

ule-

Revi

sed

32 w

eeks

ges

tatio

n45

31.

338

6 pa

rtici

pant

s int

ervi

ewed

; 67

assu

med

neg

ativ

efo

r anx

iety

diso

rder

s (did

not m

eet p

rescre

encr

iteria

)Su

tter-D

alla

y et

al (

2004

)20M

ini-I

nter

natio

nal N

euro

psyc

hiat

ric In

terv

iew

Third

trim

este

r of p

regn

ancy

497

1.4

Excl

uded

mul

tiple

pre

gnan

cies

, pre

mat

ure

birth

s,an

d ce

sare

an d

eliv

ery

Wen

zel e

t al (

2001

)24M

odifi

ed n

onpa

tient

SCI

DVa

riabl

e w

eeks

pos

tpar

tum

788

1.5

All

parti

cipa

nts h

ad a

t lea

st m

oder

ate

sym

ptom

so

f dep

ress

ion

Wen

zel e

t al (

2005

)19N

onpa

tient

SCI

D8

wee

ks p

ostp

artu

m14

71.

4O

bses

sive-

com

pulsi

ve d

isord

erZa

r et a

l (20

02)23

Anx

iety

Dis

orde

rs In

terv

iew

Sch

edul

e-Re

vise

d32

wee

ks g

esta

tion

453

0.2

386

parti

cipa

nts i

nter

view

ed; 6

7 as

sum

ed n

egat

ive

Sutte

r-Dal

lay

et a

l (20

04)20

Min

i-Int

erna

tiona

l Neu

rops

ychi

atric

Inte

rvie

wTh

ird tr

imes

ter o

f pre

gnan

cy49

71.

2Ex

clud

ed m

ultip

le p

regn

anci

es, p

rem

atur

e bi

rths,

and

cesa

rean

del

iver

yW

enze

l et a

l (20

05)19

Non

patie

nt S

CID

8 w

eeks

pos

tpar

tum

147

2.7

Wen

zel e

t al (

2001

)24M

odifi

ed n

onpa

tient

SCI

DVa

riabl

e w

eeks

pos

tpar

tum

588

3.9

All

parti

cipa

nts h

ad a

t lea

st m

oder

ate

sym

ptom

so

f dep

ress

ion

Post

traum

atic

stre

ss d

isord

erLo

vela

nd C

ook

et a

l (20

04)25

Dia

gnos

tic In

terv

iew

Sch

edul

eA

ny p

oint

in p

regn

ancy

744

7.7

Econ

omic

ally

disa

dvan

tage

d sa

mpl

e, 2

3% u

nder

19 y

ears

of a

geSo

derq

uist

et a

l (20

04)26

Trau

mat

ic E

vent

Sca

le32

wee

ks g

esta

tion

1224

2.3

Ayer

s and

Pic

kerin

g (20

01)27

MM

PI-2

PTS

D S

cale

36 w

eeks

ges

tatio

n22

28.

1Su

tter-D

alla

y et

al (

2004

)20M

ini-I

nter

natio

nal N

euro

psyc

hiat

ric In

terv

iew

Third

trim

este

r of p

regn

ancy

497

0Ex

clud

ed m

ultip

le p

regn

anci

es, p

rem

atur

e bi

rths,

and

cesa

rean

del

iver

ySo

et e

t al (

2003

)28Tr

aum

atic

Eve

nt S

cale

4 w

eeks

pos

tpar

tum

103

1.9

Child

birth

spec

ified

as t

raum

atic

eve

ntCr

eedy

et a

l (20

00)29

Post

partu

m S

tress

Sym

ptom

s Int

ervi

ew4

6 w

eeks

pos

tpar

tum

400

5.6

Child

birth

spec

ified

as t

raum

atic

eve

nt(v

ia tel

epho

ne)

Czar

nock

a an

d Sl

ade

(2000

)30PT

SD-Q

uesti

onna

ire de

rived

for t

his st

udy

6 w

eeks

pos

tpar

tum

264

3.0

Child

birth

spec

ified

as t

raum

atic

eve

ntfr

om th

e PT

SD In

terv

iew

Ayer

s and

Pic

kerin

g (20

01)27

PTSD

Sym

ptom

Sca

le6

wee

ks p

ostp

artu

m21

86.

9Ch

ildbi

rth sp

ecifi

ed a

s tra

umat

ic e

vent

Wen

zel e

t al (

2005

)19N

onpa

tient

SCI

D8

wee

ks p

ostp

artu

m14

70

Child

birth

spec

ified

as t

raum

atic

eve

ntAy

ers a

nd P

icke

ring

(2001

) 27

PTSD

Sym

ptom

Sca

le6

mon

ths p

ostp

artu

m20

13.

5Ch

ildbi

rth sp

ecifi

ed a

s tra

umat

ic e

vent

Wijm

a et a

l (199

7)31

Surv

ey d

evel

oped

for t

he st

udy

With

in 1

yea

r pos

tpar

tum

1640

1.7

Child

birth

spec

ified

as t

raum

atic

eve

nt

Gen

eral

ized

anx

iety

diso

rder

Sutte

r-Dal

lay

et a

l (20

04)20

Min

i-Int

erna

tiona

l Neu

rops

ychi

atric

Inte

rvie

wTh

ird tr

imes

ter o

f pre

gnan

cy49

78.

5Ex

clud

ed m

ultip

le p

regn

anci

es, p

rem

atur

e bi

rths,

and

cesa

rean

del

iver

yW

enze

l et a

l (20

03)32

Non

patie

nt S

CID

8 w

eeks

pos

tpar

tum

684.

4D

urat

ion

crite

rion

shor

tene

d to

8 w

eeks

(sinc

e birt

h of t

he ch

ild)

Wen

zel e

t al (

2005

)19N

onpa

tient

SCI

D8

wee

ks p

ostp

artu

m14

78.

2D

urat

ion

crite

rion

shor

tene

d to

8 w

eeks

(sinc

e birt

h of t

he ch

ild)

Bal

lard

et a

l (19

93)33

Psyc

hiat

ric A

sses

smen

t Sca

le (R

DC di

agno

sis)

6 m

onth

s pos

tpar

tum

148

6.1

Not

all

parti

cipa

nts w

ere

inte

rvie

wed

(iden

tified

as pr

obab

le ca

ses u

sing E

PDS)

Abb

revi

atio

ns: E

PDS

=Ed

inbu

rgh

Post

nata

l Dep

ress

ion

Scal

e, M

MPI

=M

inne

sota

Mul

tipha

sic

Pers

onal

ity In

vent

ory,

PR

IME-

MD

=Pr

imar

y Ca

re E

valu

atio

n of

Men

tal D

isord

ers,

RDC

=R

esea

rch

Dia

gnos

tic C

riter

ia, S

CID

=St

ruct

ured

Clin

ical

Inte

rvie

w fo

r DSM

-IV.



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course of illness in these women. Although there areconflicting findings, a general pattern of improvement inpanic symptoms during pregnancy, followed by worsen-ing during the postpartum period, has been reported inretrospective studies and case reports (Table 3).36,38,49,50However, other evidence (see, for example, references4548) suggests that the most common effect of perinatalstatus on panic disorder may be no change in symptomseverity. For example, one longitudinal study of 22women with panic disorder and comorbid mood disorderfollowed over 5 years found that the most common effectof pregnancy on panic symptoms was no change frombaseline during pregnancy (31 pregnancies, 69%).45 How-ever, when change did occur, it was likely to be a decreasein symptoms (12 pregnancies, 27%). Similarly, mostwomen did not experience a change in symptom intensityduring the postpartum period (31 pregnancies, 69%).However, when change did occur, it tended to be an in-crease in or onset of symptoms (14 pregnancies, 31%),while none of the women reported a decrease in symp-toms during the postpartum period. An interesting findingin this report was that the pattern of change (if any) in

panic symptoms was not consistent across gestationsfor the majority of women who experienced more than 1pregnancy (9 of 14 women, 64%).45 These results suggestthat pregravid symptom severity may be the best predictorof the perinatal course of panic disorder for most women.

Treatment of perinatal panic disorder. Research evi-dence to guide treatment of perinatal panic disorder is ex-tremely limited, as no controlled or uncontrolled studieshave been published. Case reports have described suc-cessful treatment with antipanic medications, particularlyimipramine,51,52 and cognitive-behavioral therapy.53 Otherself-care strategies, such as elimination of caffeine, reduc-tion of sleep deprivation, and relaxation techniques, havebeen recommended if avoidance of pharmacotherapy isdesired and possible.50

Appropriate differential diagnosis is important beforeinitiating treatment for an anxiety disorder during theperinatal period, although this issue has not been ad-dressed in the research literature. Thyroid dysfunctionand anemia are commonly seen in perinatal womenand may be associated with symptoms of panic or gener-alized anxiety. Preeclampsia can also be associated with

Table 2. New Onset of Anxiety Disorders During the Perinatal Perioda

Study Design N Incidence OnsetPanic disorderSholomskas et al (1993)39 Interviews regarding chronology of panic 64 10.9% (N = 7) 7.3 weeks postpartum

disorder with childbearing women treatedat a tertiary care center

Villeponteaux et al (1992)37 Questionnaire regarding changes in panic 22 9.1% (N = 2) Within 3 months postpartumsymptoms during pregnancy administeredto former panic disorder outpatients

Northcott and Stein (1994)36 Retrospective questionnaire regarding 97 3% (N = 3) During pregnancychanges in panic symptoms during 9% (N = 9) Within 6 months postpartumpregnancy administered to former panicdisorder outpatients

Obsessive-compulsive disorderMaina et al (1999)40 Retrospective interviews with consecutive 33 25% (N = 8) During postpartum period

OCD outpatients and healthy comparisonsample to establish stressful life eventspotentially associated with OCD onset

Neziroglu et al (1992)41 Questionnaire regarding chronology of OCD 59 39% (N = 23) During pregnancyrelative to childbearing completed byfemale OCD outpatients

Williams and Koran (1997)42 Standardized telephone interview regarding 38 13% (N = 5) During pregnancyclinical course of OCD during and after 0% (N = 0) During postpartum periodpregnancy with OCD outpatients

Buttolph and Holland (1990)43 Questionnaire regarding chronology of OCD 39 22% (N = 6) During pregnancyrelative to pregnancy and childbirth sent to 29.5% (N = 8) During postpartum period (triggeredOCD outpatients by birth and care of child)

Labad et al (2005)44 Retrospective semistructured interview 46 (17 at 6.0% (N = 1) During third trimester of pregnancyregarding relationship between least 18.0% (N = 3) Within 1 month postpartumreproductive cycle events and OCD with 1 livefemale outpatients birth)

Posttraumatic stress disorderAyers and Pickering (2001)27 Prospective study of women recruited from 218 3.2% (N = 7) 6 weeks postpartum

antenatal clinics between 1636 weeksgestation

aStudies reported in Table 1 assumed that generalized anxiety disorder (GAD) had onset following childbirth, but no studies to date have conductedbaseline assessments in order to assess incidence of perinatal GAD.

Abbreviation: OCD = obsessive-compulsive disorder.



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Tabl

e 3.

Cou

rse

of A

nxie

ty D

isor

ders

Dur

ing

the

Per

inat

al P

erio

da

Preg

nanc

ybPo

stpa

rtum

b

Sym

ptom

No

Sym

ptom

Sym

ptom

No

Sym

ptom

Stud

yN

Incl

usio

n Cr

iteria

and

Des

ign

Dec

reas

eCh

ange

Incr

ease

Dec

reas

eCh

ange

Incr

ease

Not

esPa

nic

diso

rder

Vill

epon

teau

x et

al

22 (4

4 preg

nanc

ies)

At l

east

1 p

regn

ancy

afte

r ons

et66

%(29

)18

%(8)

16%

(7)5

wom

en (2

3%) n

oted r

eturn

of(1

992)3

7o

f pan

ic d

isord

er, n

o u

se o

fpa

nic

atta

cks w

ithin

3 m

onth

sps

ycho

tropi

c m

edic

atio

nspo

stpa

rtum

; 1 w

oman

(4.5%

)n

ote

d re

turn

of p

anic

atta

cks

at w

eani

ngW

isne

r et a

l (19

96)45

22 (4

5 preg

nanc

ies)

Pani

c an

d co

mor

bid

moo

d di

sord

er27

%(12

)69

%(31

)4.

4%(2)

0%(0)

69%

(31)

31%

(14)

3 w

omen

(14%

) had

psyc

hotro

picdi

agno

sis; f

ollo

wed

ove

r 5 y

ears

med

icat

ion

expo

sure

. Pat

tern

of

chan

ge a

cros

s per

inat

al p

erio

dw

as in

cons

iste

nt fo

r 9 o

f 14

mu

ltipa

rous

wom

enN

orth

cott

and

Stei

n46

(67 p

regna

ncies

)R

etro

spec

tive

surv

ey o

f clin

ic43

%(29

)24

%(16

)33

%(22

)18

%(12

)19

%(13

)63

%(42

)Pa

ttern

of c

hang

e ac

ross

per

inat

al(1

994)3

6pa

tient

s with

at l

east

1 p

regn

ancy

perio

d w

as in

cons

isten

t for

afte

r ons

et o

f pan

ic d

isord

er9

of 2

0 m

ultip

arou

s wom

enCo

hen

et a

l (19

94)46

49R

etro

spec

tive

char

t rev

iew

of w

omen

20%

(10)

57%

(28)

20%

(10)

65%

(N=

32) t

ook a

ntipa

nicw

ith p

regr

avid

pan

ic d

isord

erm

edic

atio

n at

som

e po

int

acro

ss p

regn

ancy

durin

g pr

egna

ncy.

O

ne w

oman

expe

rienc

ed h

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paniclike symptoms, including racing pulse, difficultybreathing, and generalized anxiety.54 Medical evaluation,including assessment of thyroid function, hemoglobinlevels, and blood pressure, is necessary, particularly incases of new onset of anxiety during the perinatal period.Pheochromocytoma, a rare tumor of the adrenal gland, isalso associated with symptoms of panic and generalizedanxiety, as well as hypertension.55 Unrecognized perinatalpheochromocytoma can have fatal consequences, as nor-mal delivery can trigger hypertensive failure. Investiga-tion for pheochromocytoma is therefore warranted in anywoman with severe or symptomatic hypertension present-ing with unusual features such as headache, palpitations,or excessive sweating. Diagnosis can be made using24-hour urinary catecholamine assay for epinephrine,norepinephrine, and their metabolites. Scheduled cesar-ean delivery is usually necessary.56

A full review of safety issues related to medicationexposure in utero and through breast milk is beyond thescope of this article. However, the data reported to dateon potential effects of exposure of the developing fetus/breastfeeding infant to selective serotonin reuptake inhib-itors (SSRIs) are largely reassuring.57,58 It is important tonote that untreated panic disorder could have negativeeffects on fetal development.35,50 Findings from a studythat examined the effect of an acute maternal stress re-sponse and anxiety on fetal heart rate in 17 healthy, third-trimester pregnant women indicated an increase in fetalheart rate patterns that could alter the neurobehavioral de-velopment of the fetus.16 A careful risk-benefit assessmentis therefore required in making treatment decisions duringthe perinatal period.59

Obsessive-Compulsive DisorderObsessive-compulsive disorder (OCD) is character-

ized by intrusive thoughts or images, known as obses-sions, and/or repetitive or ritualistic behaviors or thoughtpatterns, known as compulsions. Typically, obsessions areanxiety provoking, whereas compulsions reduce anxiety,particularly when triggered by obsessions.21

OCD, more than other anxiety disorders, is thought tohave a strong neurobiological basis, having been associ-ated with cortico-striatal-thalamic-cortical circuits, and tobe closely related to other neurologic conditions such asTourettes syndrome. Perhaps as a result of this neurobio-logical basis, OCD is notable in that its symptoms varylittle across time, culture, and age.60 The sex difference inprevalence of OCD is small as compared to those forother mood and anxiety disorders. In at least one epi-demiologic study, the difference was no longer statisti-cally significant after controlling for sociodemographicdifferences between men and women (e.g., marital andemployment status).61

Prevalence of perinatal OCD. Four studies have as-sessed the prevalence of OCD during the perinatal period

(see Table 1).19,20,23,24 The results suggest that the preva-lence of OCD may be lower during pregnancy (0.2%1.2%) than during the postpartum period (2.7%3.9%).The DSM-IV reports an estimated lifetime prevalence ofOCD in the general population of 2.5% and 1-year preva-lence of 1.5% to 2.1%.21

Presentation and predictors of perinatal OCD. It hasbeen extensively reported that obsessions in perinatalwomen often include fears of intentionally or accidentallyharming the fetus or child.43,62,63 In one recent retrospec-tive study, over half (54%) of a sample of 17 women withOCD and at least 1 live birth reported obsessions orcompulsions related to the fetus/newborn during preg-nancy or the postpartum period.44 An exception comesfrom a cross-sectional study of 47 postpartum womenwith symptoms of both depression and OCD whosethought content did not include infant harm.24 Unlikeother investigations (e.g., Jennings et al.64), this study didnot include a structured tool specifically probing thoughtsof infant harm. As a result, participants may not have feltcomfortable reporting these thoughts to an unfamiliar in-terviewer when not directly queried.

Obsessional thoughts about harming the infant are notspecific to OCD: they have been reported by over 40% ofwomen with postpartum depression64,65 and from 34% to65% of new parents in volunteer community samples.66,67The prevalence of such intrusive thoughts across diag-noses and in healthy community samples suggests thatat subclinical levels, they may be a normal feature of newparenthood. Evolutionary theories propose that thesethoughts may be adaptive in that they may cause the par-ent to be vigilant in protecting the infant from potentialharm.68 These adaptive behaviors may trigger or increaseobsessional symptoms in women with preexisting OCDor a genetic, neurologic, or cognitive vulnerability toOCD.68

It is important that OCD-related obsessions of infantharm be carefully differentiated from infanticidal ideationcharacteristic of postpartum psychosis and severe post-partum depression. The primary difference in clinicalpresentation relates to insight: women with OCD aretypically aware that their symptoms are unreasonable,identify the thoughts as unwanted and separate fromthemselves (ego-dystonic), and go to great lengths toavoid acting on them.68 There are no documented cases inthe literature of women with pure OCD intentionallyharming their infants. In contrast, women with postpar-tum psychosis, which affects only 0.1% of childbearingwomen,69 typically lack insight, do not have fear or anxi-ety associated with the thoughts, and, if untreated, mayact upon hallucinations or delusions that prescribe harm-ing their children and/or themselves.70 Women presentingwith infanticidal ideation in the context of postpartumpsychosis or severe postpartum depression require emer-gency psychiatric care to prevent such behavior. Women



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with OCD in the absence of severe comorbid depressioncan be reassured that this condition has not been associ-ated with infanticide in previous research.71

In contrast to obsessions, compulsive behaviors werenot observed in perinatal women with OCD in early casereports or case series.72 However, a more recent cross-sectional study of 84 postpartum women with eitherobsessions or compulsions found that compulsive hand-washing or cleaning behavior was common and was oftenattributed to concerns that the infant would be exposedto contamination.24 Women who reported other types ofcompulsive behaviors (e.g., checking or counting) eitherdid not meet diagnostic criteria for OCD or reported thatthey had engaged in these behaviors prior to the birth ofthe child.24

Infant-focused symptoms of OCD could have impor-tant implications for development of the mother-infant re-lationship. Some women who fear harming their infantsare reported to modify their behavior with their children,in some cases resulting in an inability or refusal to carefor them.62,64,72 In one study of 7 women with postpartumOCD, 5 women (71%) reported dysfunctional maternalbehavior, including avoidance of or fear of separationfrom the infant/child.63 Disorders of the mother-infant re-lationship have been reported in 10% to 25% of womenreferred to psychiatrists following childbirth.73 Althoughthe concept of impaired mother-infant interaction is con-troversial and to date is not recognized as a disorder in theDSM-IV, risk for child neglect and psychiatric or learningdisorders has been reported among children whose moth-ers exhibit impaired maternal behavior.74

Case reports suggest that comorbid depression iscommon among perinatal OCD patients, evolvingapproximately 2 to 3 weeks following onset of OCDsymptoms.63,72 However, a cross-sectional study of acommunity sample of 147 women found that comorbiddepression was present in less than half of the participantswith syndromal or subsyndromal OCD.19 This wascontrasted with comorbidity rates of 50% or greateramong women with panic disorder or generalized anxietydisorder (GAD).19

Personal psychiatric history may also be associatedwith OCD. One retrospective study of 17 OCD patientswith at least 1 live birth found that those with postpartumonset or worsening of OCD were more likely than thosewithout postpartum onset or worsening to have a historyof major depressive disorder.44 Premenstrual depressivemood was also significantly associated with both postpar-tum onset and worsening of OCD, suggesting a commonvulnerability to psychiatric symptoms related to the pre-menstrual and perinatal periods.44

An early retrospective study of 16 women with chil-dren suggested an association between perinatal OCDand preterm delivery, postterm delivery, and deliveryby cesarean section without labor.40 A more recent

retrospective study of 17 women who had given birth toa live child found that none of the clinical or obstetricvariables examined, including being primiparous, type ofdelivery, and pregnancy, delivery, or postpartum compli-cations, were associated with onset or an increase in OCDsymptoms during the postpartum period.44

New onset of OCD. Several studies have investigatedthe extent to which women with OCD report the onset oftheir illness to be associated with pregnancy or childbirth(summarized in Table 2). Studies of new-onset perinatalOCD have been retrospective and uncontrolled and there-fore subject to remembering or reporting bias. However,results indicate that as many as 40% of childbearing OCDoutpatients have onset during pregnancy,4144 and up to30% have onset during the postpartum period.43,44 Thesefindings are supported by numerous case reports.62,63,72

Course of preexisting OCD. Only 2 studies haveassessed the course of OCD across the perinatal period(Table 3). In the larger study, 57 women outpatientswith OCD were interviewed retrospectively regarding thecourse of their illness in relation to reproductive events;38 of these women had been pregnant, and 31 had deliv-ered at least 1 child.42 Of the 29 women with preexistingOCD who became pregnant, the majority (N = 20, 69%)reported no change in their symptoms during pregnancy,whereas those who reported a change were approximatelyequally distributed between improvement and worsening.Seven (29%) of the 24 women with a full-term live birthreported postpartum exacerbation of symptoms.42 Thesame general pattern of findings was also observed in amore recent study including 12 OCD patients with at least1 live birth.44

Treatment of perinatal OCD. As with panic disorder,no controlled studies have been conducted to examine ef-fectiveness of treatment methods for perinatal OCD. Casereports provide preliminary evidence that SSRIs and be-havior therapy, either independently or in combination,are most likely effective.43,62,63,72,75 One open-label studyfound that quetiapine augmentation was an effective man-agement strategy for postpartum OCD among 11 of 14women who were nonresponders to SSRI or serotonin-norepinephrine reuptake inhibitor monotherapy.76

For OCD outside of the perinatal period, the SSRIshave been shown to be effective and well tolerated. Thereis also empirical support demonstrating that cognitive-behavioral approaches, administered either individuallyor in groups, can control OCD symptoms.60 Until furtherdata are available, perinatal OCD is best managed in thesame manner as OCD in the general population. However,potential effects of medications on the fetus/breastfeedinginfant are a consideration.71

Posttraumatic Stress DisorderPosttraumatic stress disorder (PTSD) is an anxiety

disorder characterized by exposure to a traumatic event



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appraised by the individual as one that could involveactual or threatened death or serious injury or a threat tothe physical integrity of self or others (criterion A1).21Moreover, the persons response to the stressor involvesintense fear, helplessness, or horror (criterion A2).21Symptoms of PTSD include reexperiencing of the trau-matic event, such as intrusive recollections or recurrentand distressing dreams of the event; avoidance of stimuliassociated with the trauma and numbing of emotional re-sponsiveness; and hyperarousal, such as difficulty sleep-ing and concentrating and irritability. PTSD is acute if theduration of symptoms is less than 3 months and is chronicif symptoms persist beyond 3 months.21 Although theDSM-IV does not specifically identify childbirth as anexample of an extreme stressor, reports suggest that child-birth can qualify as a traumatic event that results in PTSDin some women.77

Prevalence of perinatal PTSD. PTSD has been rec-ognized as occurring after stressful medical and surgicalprocedures that involve intense pain,78 invasive medicalprocedures,79 and obstetric and gynecologic procedures,80suggesting that it is also relevant to consider traumaticlabor and birth experiences as potential stressors forPTSD symptoms.81 For example, in a retrospective cross-sectional study, 500 volunteer participants were recruitedthrough advertisements, and of the total sample, 20% de-scribed having undergone at some point, at least 1 monthpreviously, an obstetric or gynecologic procedure thatthey considered very distressing or terrifying and out ofthe range of normal experience.80 The 20% who reporteddistressing procedures were then recontacted and asked tocomplete the measure for PTSD diagnosis (PTSD Inter-view82). Results indicated that 30 respondents (6%) metdiagnostic criteria for PTSD, suggesting that women whoexperience traumatic obstetric and/or gynecologic proce-dures may develop PTSD. Reliance on self-report of ret-rospective data is a limitation of this study, although theuse of a standardized measure helps to attenuate thisconcern. Furthermore, additional follow-up of the 6% ofparticipants who met acute PTSD criteria may have con-tributed information as to those who went on to meetchronic PTSD criteria.

Studies that have assessed the prevalence of PTSD as-sociated with the perinatal period are summarized inTable 1. A variety of assessment measures have been ap-plied to this population to diagnose prevalence of PTSDand PTSD symptoms in the postpartum period. The in-consistency in assessment measures, and in particular theabsence of differentiation between clinical PTSD andPTSD symptoms, may in part explain the wide rangeof prevalence values (0%6.9%) reported. Two studieshave investigated prevalence of PTSD among pregnantwomen, yielding rates of 2.3%26 and 7.7%.25 The DSM-IVreports prevalence rates for community-based popula-tions for PTSD ranging from 1% to 14%, with variability

related to methods of measurement and the populationsampled. Two studies have reported that approximately25% of their perinatal samples were partially symp-tomatic for PTSD.28,29 However, use of the term PTSDsymptoms in the literature is problematic and may misleadone to conclude this to be a diagnosis of PTSD. PTSDsymptoms, however, may resolve and be more like anacute stress response or disorder. A further limitation tothe studies reviewed is the single assessment time: thelack of longitudinal follow-up limits our knowledge ofthe trajectory and course over time of those who domeet criteria for acute PTSD, chronic PTSD, or PTSDsymptoms.19,20,77,78

Presentation and predictors of perinatal PTSD.Perinatal PTSD has been associated with some distinctclinical features, including avoidance of the baby/impaired mother-infant relationship, sexual dysfunction,and avoidance of future childbearing. Case reports de-scribe women who avoided sexual involvement with theirpartners because sexual activity resulted in reexperienc-ing of the pain and distress experienced during traumaticlabor.83 PTSD occurring after childbirth may lead to post-ponement or avoidance of future childbearing,83 or re-quests for planned cesarean sections in an attempt toavoid retraumatization by childbirth.84,85 Requests for ter-mination of an unplanned pregnancy86 and sterilization83have also been documented.

Case reports and qualitative studies have describedwomen with PTSD-type reactions who avoided contactwith their infants, sometimes for several years, as a resultof a childbirth experience perceived as traumatic.77,8789 Inthese cases, the child may be a stimulus for reexperienc-ing of the traumatic delivery. Similarly, qualitative re-search indicates that some women may avoid not onlytheir own infant, but also other mothers and babies fol-lowing a traumatic childbirth experience,77 resulting in in-creased maternal isolation.

Previous mental health history, and particularly a his-tory of major depression or generalized anxiety disorder,has been associated with risk for PTSD.25,30,31 AlthoughPTSD and depression may frequently be comorbid in theperinatal period,19 researchers have reported that postnatalPTSD and depression also occur in the absence of one an-other.30,90 In a cross-sectional study, 6 of the 8 womenidentified as meeting criteria for PTSD had elevatedscores indicative of depression on the Edinburgh Postna-tal Depression Scale. Both trait anxiety30 and anxiety sen-sitivity91 have also been associated with risk for PTSD.

Recent and childhood experiences of trauma have beenassociated with PTSD in the general population,92 but fewstudies have investigated these variables in relation toperinatal PTSD. Studies of perinatal women have foundan association between experiencing 2 or more previoustraumatic life events and risk for perinatal PTSD.25,93 In aconvenience sample of trauma-exposed pregnant women,



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very high rates (58%) of PTSD were identified.94 Finally,a cross-sectional study of 31 Cambodian mothers in Aus-tralia found that the number of pre-migration traumas ex-perienced or witnessed was significantly associated withPTSD symptoms.95 The types of trauma associated withperinatal PTSD in these studies have been variable. In onestudy, PTSD symptom scores were highest among womenwho reported partner-related traumatic events.94 Anotherstudy found that the most commonly reported traumasamong women with PTSD were the unexpected death ofa close friend or relative and having something terriblehappen to a close friend or relative.25

Childhood or adulthood sexual assault can also be as-sociated with perinatal PTSD. Loveland Cook et al.25 re-ported that 50.9% and 35.1% of subjects with PTSD intheir sample of economically disadvantaged pregnantwomen reported sexual assault by a nonrelative and rela-tive, respectively, and that 36.8% of the sample experi-enced the traumatic event that precipitated PTSD prior tothe age of 15 years. These results are consistent with re-search indicating high rates of childhood abuse amongwomen seeking treatment for perinatal depression.96,97Women with a history of sexual abuse may experiencetriggering of memories of abuse in response to childbirthprocedures. This may result in avoidance of necessarymedical procedures (e.g., internal examination).92,98

A potential relationship between type of delivery andpostpartum PTSD has received inconsistent support in theliterature. One prospective study measured PTSD symp-toms 6 weeks after delivery in 40 women who had givenbirth in one of 4 manners: spontaneous vaginal delivery,induced vaginal delivery, instrumental vaginal delivery(involving assisted delivery by forceps with an unex-pected episiotomy under local anesthetic), or emergencycesarean section. Women who underwent instrumentaldeliveries endorsed more PTSD symptoms than didwomen who underwent spontaneous vaginal delivery orcesarean section.99 A similar prospective study comparedthe incidence of PTSD in 326 women undergoing normalvaginal delivery, instrumental delivery, elective cesareansection, or emergency cesarean section. At 4 weeks post-partum, mothers who had undergone an emergency ce-sarean delivery and those who had instrumental vaginaldeliveries reported significantly more PTSD symptomsthan those who had had either elective cesarean sectionsor spontaneous vaginal deliveries.100

In contrast, a third study of 40 women found that thosewho delivered by elective cesarean section had higheranxiety and PTSD scores than those who had spontaneousvaginal deliveries or emergency cesarean sections.91 Fi-nally, the largest study of this question (N = 1550) foundthat women who underwent emergency cesarean sectionor instrumental deliveries were 6.3 times and 4.8 times,respectively, more likely than women who underwentspontaneous vaginal deliveries to meet criteria for PTSD

at 4 weeks postpartum.122 However, the authors note thatnumerically more women with normal vaginal deliveriesthan with emergency cesarean section or instrumental de-liveries met criteria for PTSD in their sample, suggestingthat characteristics of both the birth event and the indi-vidual are relevant in determining risk for postpartumPTSD. Appraisal of the childbirth experience as traumaticmay be a better predictor of PTSD than type of delivery.77

Other aspects of the birth experience besides typeof delivery may contribute to risk of PTSD, includingpain80,90,91,101 and powerlessness or lack of control30,31,80,101during labor and delivery. Perceived quality of the in-trapartum care provided by medical personnel has beenassociated with PTSD symptoms.80,91 In Becks phenom-enological study of birth trauma, perceived lack of com-munication by labor and delivery staff contributed to theappraisal of a traumatic birth.77 Perceptions of low levelsof social support from hospital staff have been related toPTSD symptoms in both qualitative and quantitative stud-ies,30,31,101 as has lack of support from the womans partnerduring the birth.30

Finally, maternal and infant complications have beenassociated with perinatal PTSD. For example, higher lev-els of PTSD symptoms have been reported among moth-ers of premature infants than among mothers of healthy,full-term infants.102 Preeclampsia has also been associatedwith risk for PTSD.103,104

New onset of PTSD. Only 1 study has prospectivelyassessed incidence of PTSD across the perinatal period.27This study included an assessment in late pregnancy andas such demonstrates the first evidence of new-onsetPTSD following childbirth. As summarized in Table 2,3.2% of the sample showed onset of PTSD by 6 weekspostpartum. Further, the authors identified a small butsignificant proportion of women (1.5%) who developedchronic PTSD (i.e., PTSD persisting for 3 months ormore).27

Course of preexisting PTSD. No studies have reportedon the course of PTSD in perinatal women with preexist-ing disorder.

Treatment of perinatal PTSD. No published studieshave evaluated treatment interventions for perinatalPTSD. However, some efforts have been made to preventPTSD among women assessed as having had a traumaticchildbirth using critical event debriefing. This preventionstrategy involves talking about the traumatic experiencewith a trained professional: both validation and accom-modation of the traumatic event may be facilitated. De-briefing interventions for perinatal PTSD are supportedby evidence from qualitative studies that women who per-ceive childbirth to have been traumatic express a desire todiscuss and analyze their experiences at length.77,101

Early studies of critical event debriefing with perinatalpopulations yielded conflicting results, both when de-briefing was used to attempt to prevent PTSD100,105 and



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when it was used to prevent postpartum depression.106,107In fact, in the well-designed study by Small and col-leagues,107 women who were randomly assigned to re-ceive a midwife-led debriefing session after an operativedelivery had increased rates of maternal depression at 6months postpartum. However, a more recent study foundthat a debriefing-modeled counseling intervention was ef-fective in reducing risk of trauma symptoms and depres-sion at 3 months postpartum.108 Several notable featuresin the design of this intervention may have contributed tothe positive results. First, women were selected for par-ticipation in the study by interviewing them within 72hours of birth to determine if they met criterion A of theDSM-IV criteria for diagnosis of PTSD. As such, partici-pants were only included in the study if they perceivedtheir childbirth experience to have been traumatic, ratherthan on the basis of having had an operative delivery, aswas typically done in previous debriefing studies. Further,the counseling intervention administered in this studyconsisted not only of face-to-face debriefing in the imme-diate postpartum period, but also telephone counseling at4 to 6 weeks postpartum.108 This design is consistent withfindings from the general PTSD literature that a singledebriefing session immediately following a traumaticevent may be ineffective in preventing PTSD and may infact cause harm.109 The recent promising results suggestthat further research is warranted to examine the potentialfor prevention of perinatal PTSD using debriefing-stylecounseling interventions.

Generalized Anxiety DisorderGeneralized anxiety disorder is a chronic condition

characterized by at least 6 months of frequent worry, to-gether with additional symptoms including poor concen-tration, muscle tension, fatigue, and restlessness.21 GADaffects approximately 5% of the general population.110

According to DSM-IV criteria, symptoms of GAD arerequired to be present for 6 months before a diagnosis canbe made,21 and therefore diagnostic criteria for new-onsetGAD are unlikely to be met during either the 9 monthsof pregnancy or the early postpartum period. Further, un-like the other anxiety disorders, onset of GAD in womentypically occurs past age 35110 and therefore may postdatechildbearing for many women. Adjustment disorder withanxiety is usually the appropriate differential diagnosisduring the perinatal period. Adjustment disorder withanxiety is characterized by the same symptoms as GAD,but the symptoms occur in the context of a stressful lifeevent (e.g., pregnancy or childbirth) and last no longerthan 6 months from the time of this event.21,111

Prevalence of perinatal GAD. Only 1 study hasestimated the prevalence of GAD during pregnancy,reporting a rate of 8.5% during the third trimester of preg-nancy.20 Three studies have estimated the prevalence ofGAD or adjustment disorder with anxiety during the

postpartum period, yielding rates of 4.4% to 8.2% (seeTable 1).19,32,33 The range in sample size (68148 partici-pants) may explain some of the variability in the esti-mates. The DSM-IV reports a 1-year prevalence rate forGAD of approximately 3% in a community sample and alifetime prevalence rate of 5%,21 suggesting that GAD/adjustment disorder with anxiety may be more commonin postpartum women than among the general population.

Presentation and predictors of perinatal GAD. Itcan be difficult to differentiate GAD from normal,nonpathologic anxiety, since worries about the healthof the fetus or anticipation of a painful delivery are com-mon among healthy perinatal women.112 In one study,a Pregnancy Experiences Scale was developed andadministered to a sample of nearly 200 women in the sec-ond and third trimesters of pregnancy.113 The most fre-quently endorsed hassles were discomforts of pregnancy,inability to do tasks/chores, and clothing/shoes not fitting.Thoughts about labor and delivery and whether the babywas normal were endorsed by 80% and 76% of thesample, respectively. It should be noted that uplifts (posi-tive experiences), including how much the baby is mov-ing and visits to the obstetrician/midwife, were endorsedmore often and with greater intensity than were hassles.Women who reported greater hassles also reported greateruplifts, indicating that personality variables may influ-ence how normal pregnancy-related events are inter-preted.113 Domains of worry have also been assessedamong postpartum women: in one study, a PostpartumWorry Scale was developed and administered to asample of 68 women at 8 weeks postpartum. Worriesabout finances, the participants appearance, householdduties, and the cleanliness of surroundings were mostfrequently endorsed.114

No studies to date have compared the content andnature of worry in women with GAD to that in healthyperinatal women. In the general population, GAD is dis-tinguished from normal worry on the basis of 3 character-istics: in GAD, worry is excessive and interferes withdaily functioning; worry is widespread, usually to mul-tiple domains of the persons life; and worry can occurwithout any identifiable trigger.21 These same characteris-tics may be helpful in differentiating perinatal GAD fromnormal anxiety as well. It has been recommended thatperinatal worry be further investigated when a woman isworrying more than other perinatal women, when shecannot be reassured or cannot control the worry, or whenexcessive and uncontrollable worry has persisted for 6months or more.34

No studies have reported on risk factors for orpredictors of GAD in the perinatal period. However, 1cross-sectional study has described correlates of anxietysymptoms in perinatal women. Wenzel et al.19 found thatpersonal psychiatric history, family psychiatric history,and socioeconomic status were significantly associated



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with anxiety symptoms assessed using the Beck AnxietyInventory. Additional research is needed to determinewhether these variables are predictive of clinically sig-nificant anxiety disorders.

New onset of GAD. As described above, new onsetof GAD is unlikely during the perinatal period, due tothe duration criterion for the diagnosis. None of the stud-ies of perinatal adjustment disorder with anxiety haveconducted baseline assessments to determine whethersymptoms began during the perinatal period or were pre-existing. In their cross-sectional study of postpartumanxiety disorders, Wenzel et al.32 reported that 2 of the 3women who met diagnostic criteria for GAD describedsubsyndromal worry prior to pregnancy or childbirth; thethird woman reported a history of clinically significantGAD symptoms prior to pregnancy. Research is thereforeneeded to establish whether the perinatal period is associ-ated with new-onset GAD and/or adjustment disorderwith anxiety.

Course of preexisting GAD. No studies have exam-ined the course of preexisting GAD across the perinatalperiod.

Treatment of perinatal GAD. No studies have in-vestigated treatment of perinatal GAD; however, there isevidence for the effectiveness of cognitive-behavioraltherapy, SSRIs, and benzodiazepines in the general popu-lation of GAD patients.115 As with panic disorder, carefulassessment is required to rule out potential medical causesof anxiety symptoms before treatment is initiated. If phar-macotherapy is used, antidepressant medications are pre-ferred over the benzodiazepines due to their better safetyprofile for the developing fetus and/or breastfeedinginfant.58,116

CONCLUSIONS ANDFUTURE RESEARCH DIRECTIONS

This review is limited by the quality of the availableresearch evidence. To date, few studies have examinedprevalence of perinatal anxiety disorders as defined bydiagnostic criteria,21 and no studies have included appro-priate non-perinatal control groups. The measures used toassess anxiety have varied considerably from study tostudy and do not always conform to DSM diagnostic cri-teria. For example, in the case of PTSD, it is necessary todistinguish among appraising a birth as being traumatic,experiencing an acute traumatic stress response (e.g.,symptoms of intrusion and/or avoidance), and clinicallymeeting the DSM-IV criteria for a diagnosis of PTSD.

The studies that have reported on prevalence of perina-tal anxiety disorders are typically based on small, selectedsamples (such as women participating in an interventiontrial or women reporting symptoms of depression). Inmost cases, only women who met certain screening crite-ria, and not the total sample, were interviewed with struc-

tured diagnostic interviews. This could have resulted inunderestimates of prevalence due to missed cases amongthe portion of the sample that was not interviewed. Inspite of these limitations, however, it is notable that theliterature reviewed suggests higher prevalence of OCDand GAD in women during the prenatal and/or postpar-tum period than in the general population.21 Further, ap-propriately controlled studies are needed to confirm thisfinding.

Available evidence suggests that unique clinicalfeatures of perinatal anxiety disorders could have impor-tant implications for the mother-infant relationship35,63,77;however, these data are largely derived from case reportsand qualitative studies. The prevalence and precisenature of these disruptions remain unclear and under-investigated. Further systematic investigation of the po-tential impact of perinatal anxiety disorders on infant de-velopment and mother-infant attachment is needed.

Very limited data are available to guide clinical inter-ventions for women with or at risk for perinatal anxietydisorders. It has been presumed that treatments for panicdisorder, OCD, and GAD will be as effective during theperinatal period as they are outside the perinatal period,but research is needed to confirm that this is so. Data areconflicting with respect to the effectiveness of criticaldebriefing strategies in the prevention of PTSD, and noempirically based clinical interventions are available asstandard of care. Further research to identify empiricallyvalidated intervention protocols is required to ensurequality and consistency of care for women with perinatalanxiety disorders.

Anxiety symptoms and disorders may also developin women with fertility problems and those who experi-ence a pregnancy loss.117 Similarly, there is some evi-dence that new and prospective fathers and partners maydevelop anxiety disorders.118,119 More research is neededto further elucidate the risk for anxiety disorders in thesepopulations.

The literature identified for this review includes fewprospective, longitudinal studies. As such, few studieshave examined whether the anxiety disorders predatechildbirth. Causal factors for anxiety disorders that pre-date pregnancy may be very different than those for anxi-ety disorders with perinatal onset.120 Future researchshould screen for both current and lifetime anxiety disor-ders. Longitudinal studies will also allow for better as-sessment of time of onset for perinatal anxiety disorders(i.e., to determine times within the perinatal period whenrisk of onset is highest).

In conclusion, the limited available research indicatesthat anxiety disorders are common during the perinatalperiod. The high prevalence of these disorders, and par-ticularly of OCD and GAD, indicates a potential role forscreening. As has been described in the literature on peri-natal depression, providers of obstetric care are most



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likely ideally placed to perform the necessary screeningand assessment due to their frequent contact with womenacross the perinatal period.121 Considering the lack of ad-equate psychometric data regarding the use of existinganxiety scales in perinatal populations, there may be aneed to develop accurate, acceptable, and feasible screen-ing tools for perinatal anxiety disorders. Finally, due tothe complexity of anxiety disorders in this population,and the potential for impact on the fetus/infant, the impor-tance of multidisciplinary team approaches in provisionof psychiatric care is evident.

Drug names: imipramine (Tofranil, Surmontil, and others), quetiapine(Seroquel).

Disclosure of off-label usage: The authors have determined that, to thebest of their knowledge, imipramine is not approved by the U.S. Foodand Drug Administration for the treatment of perinatal panic disorder,and quetiapine is not approved for perinatal obsessive-compulsivedisorder.

REFERENCES

1. Robertson E, Grace S, Wallington T, et al. Antenatal risk factors for post-partum depression: a synthesis of recent literature. Gen Hosp Psychiatry2004;26:289295

2. Dennis CL, Stewart DE. Treatment of postpartum depression, pt 1:a critical review of biological interventions. J Clin Psychiatry2004;65:12421251

3. Dennis CL. Treatment of postpartum depression, pt 2: a critical reviewof nonbiological interventions. J Clin Psychiatry 2004;65:12521265

4. OHara MW, Swain AM. Rates and risk of postpartum depression:a meta-analysis. Int Rev Psychiatry 1996;8:3754

5. Bennett HA, Einarson A, Taddio A, et al. Prevalence of depression duringpregnancy: systematic review. Obstet Gynecol 2004;103:698709

6. Appleby L, Warner R, Whitton A, et al. A controlled study of fluoxetineand cognitive-behavioural counselling in the treatment of postnataldepression. BMJ 1997;314:932936

7. Spinelli MG. Interpersonal psychotherapy for depressed antepartumwomen: a pilot study. Am J Psychiatry 1997;154:10281030

8. Cooper PJ, Murray L, Wilson A, et al. Controlled trial of the short- andlong-term effect of psychological treatment of post-partum depression,pt 1: impact on maternal mood. Br J Psychiatry 2003;182:412419

9. Sharma V. Pharmacotherapy of postpartum depression. Expert OpinPharmacother 2002;3:14211431

10. Stuart S, Couser G, Schilder K, et al. Postpartum anxiety and depression:onset and comorbidity in a community sample. J Nerv Ment Dis1998;186:420424

11. Heron J, OConnor TG, Evans J, et al. The course of anxiety and depres-sion through pregnancy and the postpartum in a community sample.J Affect Disord 2004;80:6573

12. OConnor TG, Heron J, Glover V, for the Alspac Study Team. Antenatalanxiety predicts child behavioral/emotional problems independently ofpostnatal depression. J Am Acad Child Adolesc Psychiatry2002;41:14701477

13. Sandman CA, Wadhwa PD, Dunkel-Schetter C, et al. Psychobiologicalinfluences of stress and HPA regulation on the human fetus and infantbirth outcomes. Ann N Y Acad Sci 1994;739:198210

14. Wadhwa PD, Sandman CA, Porto M, et al. The association betweenprenatal stress and infant birth weight and gestational age at birth:a prospective investigation. Am J Obstet Gynecol 1993;169:858865

15. Copper RL, Goldenberg RL, Das A, et al. The preterm prediction study:maternal stress is associated with spontaneous preterm birth at less thanthirty-five weeks gestation. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.Am J Obstet Gynecol 1996;175:12861292

16. Monk C, Fifer WP, Myers MM, et al. Maternal stress responsesand anxiety during pregnancy: effects on fetal heart rate. Dev

Psychobiol 2000;36:677717. Pigott TA. Anxiety disorders in women. Psychiatr Clin North Am

2003;26:62167218. Matthey S. Detection and treatment of postnatal depression (perinatal

depression or anxiety). Curr Opin Psychiatry 2004;17:212919. Wenzel A, Haugen EN, Jackson LC, et al. Anxiety symptoms and disor-

ders at 8 weeks postpartum. J Anxiety Disord 2005;19:29531120. Sutter-Dallay AL, Giaconne-Marcesche V, Glatigny-Dallay E, et al.

Women with anxiety disorders during pregnancy are at increased risk ofintense postnatal depressive symptoms: a prospective survey of theMATQUID cohort. Eur Psychiatry 2004;19:459463

21. American Psychiatric Association. Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition. Washington, DC: AmericanPsychiatric Association; 1994

22. Smith MV, Rosenheck RA, Cavaleri MA, et al. Screening for and detec-tion of depression, panic disorder, and PTSD in public-sector obstetricclinics. Psychiatr Serv 2004;55:407414

23. Zar M, Wijma K, Wijma B. Relations between anxiety disorders and fearof childbirth during late pregnancy. Clin Psychol Psychother 2002;9:122130

24. Wenzel A, Gorman L, OHara MW, et al. The occurrence of panic andobsessive compulsive symptoms in women with postpartum dysphoria:a prospective study. Arch Women Ment Health 2001;4:512

25. Loveland Cook CA, Flick LH, Homan SM, et al. Posttraumatic stressdisorder in pregnancy: prevalence, risk factors, and treatment. ObstetGynecol 2004;103:710717

26. Soderquist J, Wijma K, Wijma B. Traumatic stress in late pregnancy.J Anxiety Disord 2004;18:127142

27. Ayers S, Pickering AD. Do women get posttraumatic stress disorder asa result of childbirth? a prospective study of incidence. Birth 2001;28:111118

28. Soet JE, Brack GA, DiIorio C. Prevalence and predictors of womensexperience of psychological trauma during childbirth. Birth 2003;30:3646

29. Creedy DK, Shochet IM, Horsfall J. Childbirth and the developmentof acute trauma symptoms: incidence and contributing factors. Birth2000;27:104111

30. Czarnocka J, Slade P. Prevalence and predictors of post-traumatic stresssymptoms following childbirth, pt 1. Br J Clin Psychol 2000;39:3551

31. Wijma K, Soderquist J, Wijma B. Posttraumatic stress disorder afterchildbirth: a cross sectional study. J Anxiety Disord 1997;11:587597

32. Wenzel A, Haugen EN, Jackson LC, et al. Prevalence of generalizedanxiety at eight weeks postpartum. Arch Women Ment Health 2003;6:4349

33. Ballard C, Davis R, Handy S, et al. Postpartum anxiety in mothers andfathers. Eur J Psychiatry 1993;7:117121

34. Weisberg RB, Paquette JA. Screening and treatment of anxiety disordersin pregnant and lactating women. Womens Health Issues 2002;12:3236

35. Beck CT. Postpartum onset of panic disorder. Image J Nurs Sch 1998;30:131135

36. Northcott CJ, Stein MB. Panic disorder in pregnancy. J Clin Psychiatry1994;55:539542

37. Villeponteaux VA, Lydiard RB, Laraia MT, et al. The effects of preg-nancy on preexisting panic disorder. J Clin Psychiatry 1992;53:201203

38. Klein DF, Skrobala AM, Garfinkel RS. Preliminary look at the effects ofpregnancy on the course of panic disorder. Anxiety 1994;1:227232

39. Sholomskas DE, Wickamaratne PJ, Dogolo L, et al. Postpartum onset ofpanic disorder: a coincidental event? J Clin Psychiatry 1993;54:476480

40. Maina G, Albert U, Bogetto F, et al. Recent life events and obsessive-compulsive disorder (OCD): the role of pregnancy/delivery. PsychiatryRes 1999;89:4958

41. Neziroglu F, Anemone R, Yaryura-Tobias JA. Onset of obsessive-compulsive disorder in pregnancy. Am J Psychiatry 1992;149:947950

42. Williams KE, Koran LM. Obsessive-compulsive disorder in pregnancy,the puerperium, and the premenstruum. J Clin Psychiatry 1997;58:330334

43. Buttolph L, Holland A. Obsessive-compulsive disorder in pregnancy andchildbirth. In: Jenike M, Baer L, Minichiello WE, eds. Obsessive-Compulsive Disorder: Theory and Management. Chicago, Ill:Yearbook Medical Publishers; 1990:8995

44. Labad J, Menchon JM, Alonso P, et al. Female reproductive cycle andobsessive-compulsive disorder. J Clin Psychiatry 2005;66:428435

45. Wisner KL, Peindl KS, Hanusa BH. Effects of childbearing on the



evie

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nly

For R

evie

wO

nly

For R

evie

wO

nly

For R

evie

wO

nly

For R

evie

wO

nly

For R

evie

wO

nly

natural history of panic disorder with comorbid mood disorder. J AffectDisord 1996;41:173180

46. Cohen LS, Sichel DA, Dimmock JA, et al. Impact of pregnancy on panicdisorder: a case series. J Clin Psychiatry 1994;55:284288

47. Cohen LS, Sichel DA, Dimmock JA, et al. Postpartum course in womenwith preexisting panic disorder. J Clin Psychiatry 1994;55:289292

48. Cohen LS, Sichel DA, Faraone SV, et al. Course of panic disorder duringpregnancy and the puerperium: a preliminary study. Biol Psychiatry1996;39:950954

49. George DT, Ladenheim JA, Nutt DJ. Effect of pregnancy on panicattacks. Am J Psychiatry 1987;144:10781079

50. Cowley DS, Roy-Byrne PP. Panic disorder during pregnancy.J Psychosom Obstet Gynaecol 1989;10:193210

51. Metz A, Sichel DA, Goff DC. Postpartum panic disorder. J ClinPsychiatry 1988;49:278279

52. Ware MR, DeVane CL. Imipramine treatment of panic disorder duringpregnancy. J Clin Psychiatry 1990;51:482484

53. Robinson L, Walker JR, Anderson D. Cognitive-behavioural treatmentof panic disorder during pregnancy and lactation. Can J Psychiatry1992;37:623626

54. Wagner LK. Diagnosis and management of preeclampsia. Am FamPhysician 2004;70:23172324

55. Harper MA, Murnaghan GA, Kennedy L, et al. Phaeochromocytoma inpregnancy: five cases and a review of the literature. Br J Obstet Gynaecol1989;96:594606

56. Almog B, Kupferminc MJ, Many A, et al. Pheochromocytoma in preg-nancy: a case report and review of the literature. Acta Obstet GynecolScand 2000;79:709711

57. Weissman AM, Levy BT, Hartz AJ, et al. Pooled analysis of antidepres-sant levels in lactating mothers, breast milk, and nursing infants. Am JPsychiatry 2004;161:10661078

58. Ross L, Gunasekera S, Rowland M, et al. Pharmacotherapy for psychiat-ric disorders in pregnancy. In: Riecher-Rossler A, Steiner M, eds.Perinatal Stress, Mood and Anxiety Disorders. Basel, Switzerland:Karger; 2005:112136

59. March D, Yonkers KA. Panic disorder during pregnancy. Ment Fitness2004;3:4351

60. Stein DJ. Obsessive-compulsive disorder. Lancet 2002;360:39740561. Karno M, Golding JM, Sorenson SB, et al. The epidemiology of

obsessive-compulsive disorder in five US communities. Arch GenPsychiatry 1988;45:10941099

62. Sichel DA, Cohen LS, Rosenbaum JF, et al. Postpartum onset ofobsessive-compulsive disorder. Psychosomatics 1993;34:277279

63. Arnold LM. A case series of women with postpartum-onset obsessive-compulsive disorder. Primary Care Companion J Clin Psychiatry1999;1:103108

64. Jennings KD, Ross S, Popper S, et al. Thoughts of harming infants indepressed and nondepressed mothers. J Affect Disord 1999;54:2128

65. Wisner KL, Peindl KS, Gigliotti T, et al. Obsessions and compulsions inwomen with postpartum depression. J Clin Psychiatry 1999;60:176180

66. Abramowitz JS, Schwartz SA, Moore KM. Obsessional thoughts in post-partum females and their partners: content, severity, and relationship withdepression. J Clin Psychol Med Settings 2003;10:157164

67. Leckman JF, Mayes LC, Feldman R, et al. Early parental preoccupationsand behaviors and their possible relationship to the symptoms ofobsessive-compulsive disorder. Acta Psychiatr Scand Suppl 1999;396:126

68. Abramowitz JS, Schwartz SA, Moore KM, et al. Obsessive-compulsivesymptoms in pregnancy and the puerperium: a review of the literature.J Anxiety Disord 2003;17:461478

69. Terp IM, Mortensen PB. Post-partum psychoses: clinical diagnoses andrelative risk of admission after parturition. Br J Psychiatry1998;172:521526

70. Spinelli MG. Maternal infanticide associated with mental illness:prevention and the promise of saved lives. Am J Psychiatry 2004;161:15481557

71. Brandes M, Soares CN, Cohen LS. Postpartum onset obsessive-compulsive disorder: diagnosis and management. Arch Women MentHealth 2004;7:99110

72. Sichel DA, Cohen LS, Dimmock JA, et al. Postpartum obsessive com-pulsive disorder: a case series. J Clin Psychiatry 1993;54:156159

73. Brockington IF. Motherhood and Mental Health. London, England:Oxford University Press; 1996

74. Brockington I. Postpartum psychiatric disorders. Lancet 2004;363:303310

75. Chelmow D, Halfin VP. Pregnancy complicated by obsessive-compulsive disorder. J Matern Fetal Med 1997;6:3134

76. Misri S, Milis L. Obsessive-compulsive disorder in the postpartum:open-label trial of quetiapine augmentation. J Clin Psychopharmacol2004;24:624627

77. Beck CT. Post-traumatic stress disorder due to childbirth: the aftermath.Nurs Res 2004;53:216224

78. Fisch RZ, Tadmor O. Iatrogenic post-traumatic stress disorder [letter].Lancet 1989;2:1397

79. Shalev AY, Schreiber S, Galai T, et al. Post-traumatic stress disorderfollowing medical events, pt 2. Br J Clin Psychol 1993;32:247253

80. Menage J. Post-traumatic stress disorders in women who have under-gone obstetric and/or gynecological procedures. J Reprod InfantPsychol 1993;11:221228

81. Mayou RA, Smith KA. Post traumatic symptoms following medicalillness and treatment. J Psychosom Res 1997;43:121123

82. Watson CG, Juba MP, Manifold V, et al. The PTSD Interview: ratio-nale, description, reliability, and concurrent validity of a DSM-III-basedtechnique. J Clin Psychol 1991;47:179188

83. Fones C. Posttraumatic stress disorder occurring after painful child-birth. J Nerv Ment Dis 1996;184:195196

84. Ryding EL. Investigation of 33 women who demanded a cesarean sec-tion for personal reasons. Acta Obstet Gynecol Scand 1993;72:280285

85. Ryding EL, Wijma B, Wijma K. Posttraumatic stress reactions afteremergency cesarean section. Acta Obstet Gynecol Scand 1997;76:856861

86. Goldbeck-Wood S. Post-traumatic stress disorder may follow child-birth. BMJ 1996;313:774

87. Reynolds J. Posttraumatic stress disorder after childbirth: the phenom-enon of traumatic birth. CMAJ 1997;156:831835

88. Ballard CG, Stanley AK, Brockington IF. Post-traumatic stress disorder(PTSD) after childbirth. Br J Psychiatry 1995;166:525528

89. Weaver J. Childbirth: preventing posttraumatic stress disorder.Professional Care Mother Child 1997;7:23

90. Lyons S. A prospective study of post-traumatic stress symptoms1 month following childbirth in a group of 42 first-time mothers.J Reprod Infant Psychol 1998;16:91105

91. Keogh E, Ayers S, Francis H. Does anxiety sensitivity predict post-traumatic stress symptoms following childbirth? Cogn Behav Ther2002;31:145155

92. van der Kolk BA, Pelcovitz D, Roth S, et al. Dissociation, somatiza-tion, and affect dysregulation: the complexity of adaptation of trauma.Am J Psychiatry 1996;153:8393

93. Cohen MM, Ansara D, Schei B, et al. Posttraumatic stress disorder afterpregnancy, labor, and delivery. J Womens Health (Larchmt)2004;13:315324

94. Harris-Britt A, Martin SL, Li Y, et al. Posttraumatic stress disorder andassociated functional impairments during pregnancy: some conse-quences of violence against women. J Clin Psychol Med Settings2004;11:253264

95. Matthey S, Silove D, Barnett B, et al. Correlates of depression andPTSD in Cambodian women with young children: a pilot study. StressMed 1999;15:103107

96. Buist A. Childhood abuse, parenting and postpartum depression.Aust N Z J Psychiatry 1998;32:479487

97. Benedict MI, Paine LL, Paine LA, et al. The association of childhoodsexual abuse with depressive symptoms during pregnancy, and selectedpregnancy outcomes. Child Abuse Negl 1999;23:659670

98. Cromptom J. Post-traumatic stress disorder and childbirth.Br J Midwifery 1996;4:714

99. MaClean L, McDermott M, May C. Method of delivery and subjectivedistress: womens emotional responses to childbirth practices. J ReprodInfant Psychol 2000;18:153162

100. Ryding EL, Wijma K, Wijma B. Predisposing psychological factors forposttraumatic stress reactions after emergency cesarean section. ActaObstet Gynecol Scand 1998;77:351352

101. Allen S. A qualitative analysis of the process, mediating variables andimpact of traumatic childbirth. J Reprod Infant Psychol 1998;16:107137

102. Holditch-Davis D, Bartlett TR, Blickman AL, et al. Posttraumatic stresssymptoms in mothers of premature infants. J Obstet Gynecol Neonatal



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Nurs 2003;32:161171103. Engelhard IM, van Rij M, Boullart I, et al. Posttraumatic stress disorder

after pre-eclampsia: an exploratory study. Gen Hospital Psychiatry2002;24:260264

104. van Pampus MG, Wolf H, Schultz WCW, et al. Posttraumatic stressdisorder following preeclampsia and HELLP syndrome. J PsychosomObstet Gynaecol 2004;25:183187

105. Priest SR, Henderson J, Evans SF, et al. Stress debriefing after child-birth: a randomised controlled trial. Med J Aust 2003;178:542545

106. Lavender T, Walkinshaw SA. Can midwives reduce postpartumpsychological morbidity? a randomized trial. Birth 1998;25:215219

107. Small R, Lumley J, Donohue L, et al. Randomised controlled trial ofmidwife led debriefing to reduce maternal depression after operativechildbirth. BMJ 2000;321:10431047

108. Gamble J, Creedy D, Moyle W, et al. Effectiveness of a counselingintervention after a traumatic childbirth: a randomized controlled trial.Birth 2005;32:1119

109. Rose S, Bisson J, Churchill R, et al. Psychological debriefing for pre-venting post traumatic stress disorder (PTSD). Cochrane Database SystRev 2002;CD000560

110. Carter AS, Gar

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