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B. D. Daniel et al.
2. Prioritize monotherapy: It is generally preferred to achieve symptom remission
with a single pharmacological agent.
3. Minimize medication switching: A thorough assessment of the efcacy of prior
medications is critical. If side effects are manageable, it is advisable to optimize
the current dosage before considering a transition to another medication.
4. Consider untreated or inadequately treated mental health disorders as an expo-
sure: While the risks associated with any psychopharmacological agent should
be considered in the clinical decision-making process, healthcare professionals
must also acknowledge the risks associated with inadequate treatment of mental
health conditions.
Table 19.1 summarizes these recommendations. Similar recommendations are
outlined in the Maudsley guidelines (Maudsley 2021).
In terms of pharmacological options, current guidelines advocate for the use of
selective serotonin reuptake inhibitors (SSRIs) as a rst-line treatment for perinatal
ADs, when appropriate. This recommendation is supported by a substantial body of
evidence detailing their safety for use during pregnancy and breastfeeding
(McAllister-Williams etal. 2017). Alternatively, serotonin-norepinephrine reuptake
Table 19.1 Expert recommendations based on scientic evidence and clinical experience
There are risks associated with both untreated anxiety disorders and the medications used to
treat them in terms of fetal or infant exposure (ACOG 2023; NICE 2020)
Treatment decisions should be based on a careful psychiatric assessment (NICE 2020)
The treatment should be individualized (ACOG 2023; NICE 2020)
Both the patients and the exposed fetus or infant should be closely monitored (NICE 2020)
Choose an antidepressant that has worked before. For patients who are antidepressant-naive,
medication selection should be based on the recommendations below, with careful
consideration of patient preference, as antidepressants generally exhibit similar efcacy and
side effect proles (ACOG 2023; NICE 2020)
If a patient with pre-existing anxiety disorders is well-managed on an antidepressant, do not
switch it during pregnancy or lactation (ACOG 2023)
Minimize exposure to both illness and medication (ACOG 2023; NICE 2020):
Untreated/inadequately treated illness is an exposure
Use lowest effective doses
Minimize switching of medications
Monotherapy is preferred, when possible
The rst-line agents recommended for treating anxiety disorders during pregnancy are
sertraline and escitalopram (ACOG 2023)
The rst-line agents recommended for treating anxiety disorders during lactation are sertraline
and paroxetine (Uguz 2021)
Benzodiazepines should be avoided or prescribed sparingly as a treatment for perinatal anxiety
(ACOG 2023; Maudsley 2021; NICE 2020)
Mirtazapine at 7.5 to 15mg/day may be added to SSRIs for pregnant patients with severe
insomnia, decreased appetite and nausea/vomiting (Uguz 2013)
Tricyclics, such as imipramine, and SNRI, such as Venlafaxina, are similarly efcacious but
exhibit a comparatively lower safety prole, thus limiting their use to the second line or in
cases of non-response to SSRIs (Uguz 2021; Uguz etal. 2014, 2016)
19 Anxiety Disorders
409
inhibitors (SNRIs) are also considered viable options. ACOG discourages the use of
benzodiazepines, recommending their sparing use or, where possible, their complete avoidance during the perinatal period.
The most signicant factors inuencing the selection of a specic SSRI or SNRI
for patients with perinatal ADs include the available scientic evidence regarding
the safety of each.
The selection of a specic SSRI or SNRI is primarily guided by the available
evidence on its safety prole during pregnancy and breastfeeding, alongside the
mother’s previous history of response and tolerability to treatment. For women who
have previously experienced effective management of symptoms with an antidepressant of any class (e.g., SSRI or SNRI), the same medication should typically be
considered as the rst-line pharmacotherapy. Most experts recommend starting
treatment with SSRIs or SNRIs at approximately half the lowest recommended dose
to minimize the likelihood of early side effects such as anxiety, agitation, or insomnia (Thorsness etal. 2018). Additionally, the treatment of anxiety and related conditions often requires up-titration to doses higher than those commonly prescribed for
depression. Finally, individuals receiving treatment for anxiety or anxiety-related
conditions are generally advised to remain in remission for an extended period
before any consideration is given to tapering or discontinuing pharmacotherapy.
19.6.2 General Considerations forPharmacological Treatment
inPregnancy
In terms of pharmacological management, the ACOG (2023) recommends that
treatment for ADs during pregnancy be individualized, taking into account any prior
response to therapy when applicable. In cases where there is no history of pharmacotherapy, sertraline or escitalopram are considered appropriate rst-line options
due to their efcacy and tolerability proles (ACOG 2023; Cipriani etal. 2009)
(Table19.1). Citalopram is also deemed a favorable choice, supported by its established fetal safety prole (Womersley etal. 2017; Larsen etal. 2015; Uguz 2015;
Myles et al. 2013). Fluoxetine has a prolonged half-life and active metabolites
(Weissman et al. 2004); while this does not imply uoxetine should be excluded
from treatment, especially for patients with a history of successful outcomes on the
medication, its use during pregnancy requires a careful assessment of the potential
benets to the mother versus the risks to the fetus. Paroxetine is associated with an
increased risk of congenital malformations, particularly septal heart defects
(Grigoriadis etal. 2013; Myles etal. 2013). In light of these characteristics, neither
uoxetine nor paroxetine is recommended as rst-line treatments for ADs in pregnant women (Womersley etal. 2017; Larsen etal. 2015; Uguz 2015). Nevertheless,
both antidepressants present a low absolute risk of birth defects and remain viable
options for patients with AD in pregnancy who cannot tolerate or do not respond to
sertraline, citalopram, or escitalopram (Uguz 2015; Grigoriadis etal. 2013; Myles
etal. 2013).
410
B. D. Daniel et al.
TCAs, particularly imipramine and clomipramine, may also be considered an
additional pharmacological option, although the available data on their safety during pregnancy are more limited compared to SSRIs. As such, TCAs are generally
regarded as second-line options for psychopharmacological therapy (Uguz etal.
2014, 2016) (Table19.1).
Mirtazapine, another potential pharmacological choice, appears to have a favorable safety prole during pregnancy, as noted in a systematic review (Smit etal.
2016); one case report (Uguz 2013) presented the successful use of low-dose mir-
tazapine, also highlighting its effectiveness in reducing severe symptoms of nausea
and vomiting during the rst gestational weeks in two cases. Another case report
presented the benecial effect of low-dose mirtazapine added to SSRIs in treating
symptoms of severe nausea, insomnia, and loss of appetite that accompany ADs
during pregnancy (Uguz 2013) (Table19.1).
If benzodiazepines are prescribed, they should be used transiently as a bridge
until SSRIs or SNRIs achieve the expected response (ACOG 2023); their routine
use is not recommended unless “severe anxiety and/or agitation” occurs (NICE)
(Table19.1). However, benzodiazepines may have a clinical role in the pharmacological management of ADs in specic clinical settings. As ACOG suggests, they
are often used to manage acute symptoms until the benets of SSRIs or SNRIs take
effect. They may also be considered when rst-line treatment options have proven
ineffective. Although their use as primary treatment of anxiety is not recommended
due to side effects and risk for dependence, benzodiazepines have a limited but
overall relatively acceptable perinatal safety prole (Wikner etal. 2007).
19.6.3 General Considerations forPharmacological Treatment
During Breastfeeding
For women with ADs, it is crucial not to discourage them from breastfeeding if it is
their preferred method of feeding the baby. Furthermore, if the woman has maintained a stable drug regimen throughout pregnancy, psychopharmacotherapy should
not be altered in the postpartum period unless signicant contraindications arise. As
in pregnancy, drugs with more extensive safety data are preferred, though the individual’s history must also be taken into account in clinical decision-making (ACOG
2023; Gentile 2008; Eberhard-Gran etal. 2006). Measures such as the relative infant
dose (RID) should be evaluated to assess the infant’s exposure to a medication
through breast milk relative to the maternal dose. Factors inuencing the RID
include lipid solubility, half-life, oral bioavailability, molecular weight, drug ionization, and protein binding. Generally, an RID of less than 10% is considered compatible with breastfeeding; however, medication-specic data should also be considered.
Additionally, the infant’s age and preterm birth should be accounted for, as immature metabolic pathways can reduce drug clearance. A consensus has emerged from
existing research regarding the use of certain SSRIs during breastfeeding, particularly sertraline and paroxetine, which are supported by extensive scientic data on
their safety in breastfed infants (Uguz 2021; Pogliani etal. 2019; Schoretsanitis
19 Anxiety Disorders
411
etal. 2019; Molenaar et al. 2018; McAllister-Williams et al. 2017) (Table19.1).
Due to their low levels in breast milk, the amounts of sertraline and paroxetine
ingested by infants are minimal and typically undetectable in serum. However, the
weakly active metabolite norsertraline (desmethylsertraline) may occasionally be
detected at low levels in the infant’s serum. Most authors consider sertraline and
paroxetine among the preferred antidepressants during breastfeeding, thus constituting rst-line therapy (Uguz 2021; Grzeskowiak etal. 2018; Molenaar etal. 2018;
McAllister-Williams etal. 2017; Weissman etal. 2004).
Citalopram, escitalopram, and particularly uoxetine are less recommended during breastfeeding. Fluoxetine tends to have a higher average concentration in breast
milk compared to other SSRIs (Pogliani etal. 2019). Furthermore, the long-acting
active metabolite noruoxetine has been detected in the serum of most breastfed
infants during the rst 2 months postpartum and, in some cases, beyond. Adverse
effects, including colic, agitation, and drowsiness, have been observed in some
breastfed infants. Nonetheless, if uoxetine is necessary for the mother, especially
if it was taken during pregnancy or if other antidepressants are ineffective, its use,
while not rst-line, is considered compatible with breastfeeding (Uguz 2021; Amir
etal. 2011; Berle and Spigset 2011; Lanza di Scalea and Wisner 2009).
Citalopram and escitalopram, although not rst-line SSRIs during lactation, are
less prone to accumulation and may be more favorable than uoxetine (Uguz 2021;
Pogliani et al. 2019; Uguz et al. 2018; Gentile and Fusco 2017; Orsolini and
Bellantuono 2015). As with pregnancy, the use of mirtazapine during breastfeeding
is also considered compatible, with evidence indicating low levels in milk and minimal risk of adverse effects in breastfed infants, particularly those older than 2
months (Uguz 2021).
With regard to TCAs, both imipramine and clomipramine are generally compatible with breastfeeding (Uguz 2021; Schafer and Genna 2015; Davanzo etal. 2011;
Lanza di Scalea and Wisner 2009), although there are some differences. Imipramine
and its metabolite exhibit low levels in breast milk and have not been detected in the
serum of breastfed infants, making its use unlikely to cause adverse effects, especially if the infant is older than 2 months (Uguz 2016; Birnbaum etal. 1999; Misri
and Sivertz 1991). In fact, according to a safety scoring system, imipramine is considered appropriate for use during breastfeeding (Uguz 2021). However, other
agents may be preferred when large doses are required or when breastfeeding a
preterm infant (Davanzo etal. 2011).
Clomipramine, while acceptable during lactation, requires caution according to
a safety scoring system (Uguz 2021; Yoshida etal. 1997; Misri and Sivertz 1991).
Safer alternatives may be preferable, especially during the neonatal period and in
cases of prematurity. Therefore, TCAs should generally not be considered rst-line
treatments during breastfeeding.
Regarding the use of benzodiazepines during breastfeeding, the main guidelines
(ACOG 2023; Maudsley 2021; NICE 2020) recommend caution, as these drugs can
be transferred to the infant through breast milk, posing a risk of adverse effects
(Table19.1). If benzodiazepine use is considered necessary, it is advisable to select
those with a short half-life, such as lorazepam, with the lowest effective dose being
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B. D. Daniel et al.
administered (Rowe etal. 2013), particularly during the neonatal period and in
cases of prematurity (Sachs 2013). Conversely, benzodiazepines with a long halflife, such as diazepam, should be avoided to minimize the risk of drug accumulation
in the infant (Borgatta etal. 1997; Dusci et al. 1990; Wesson etal. 1985; Brandt
1976; Cole and Hailey 1975; Patrick etal. 1972). With these precautions in mind,
the occasional, low-dose use of benzodiazepines is generally considered compatible
with breastfeeding (Kelly etal. 2012; Iqbal etal. 2002; Hägg and Spigset 2000;
McElhatton 1994; Kanto 1982). In particular, expert authors regard the use of some
benzodiazepines, including lorazepam, brotizolam, midazolam, and oxazepam, as
safe or very likely safe during breastfeeding (Nishimura etal. 2021; Saito et al.
2021; Uguz 2021; Kelly etal. 2012; Wretlind 1987).
19.7 Treatment ofPanic Disorder (PD)
PD is a relatively common psychiatric condition characterized by recurrent, spontaneous panic attacks. This disorder is observed twice as frequently in women compared to men, with the average age of onset typically coinciding with the childbearing
years in women. Consequently, it is expected that a proportion of women in the
perinatal period may experience PD.According to a recent review, the estimated
prevalence of PD during pregnancy varies across studies, ranging from 0.2% to
7.0% (Al-Awabdeh etal. 2024). Moreover, pregnancy can affect the severity of preexisting PD symptoms, with up to 33% of patients experiencing exacerbation during pregnancy (Uguz 2016; Bandelow etal. 2006).
When deciding on pharmacological treatment of perinatal PD, it is important to
consider the potential neonatal outcomes if the disorder is left untreated. A study
(Uguz etal. 2018) found that infants born to untreated pregnant patients had signicantly lower birth weight and gestational age at delivery, compared to infants of
healthy pregnant women or pregnant women pharmacologically treated.
Additionally, the infants of untreated patients had a higher rate of hospitalization in
the neonatal care unit. These ndings suggest that pharmacological treatment of PD
during pregnancy should not be overlooked, as it may have benecial effects in
reducing the risk of negative neonatal outcomes related to maternal PD.
Even though there is no unanimous consensus on the clinical indications for
using anti-panic medications during the perinatal period, specic clinical features
outlined by Uguz (2016) may serve as potential criteria for initiating pharmacological treatment for PD during this time. These include:
• Severe PD leading to signicant impairment in work, social, or family functioning.
• Comorbidity with severe major depressive disorder or other ADs.
• Severe maternal weight loss and/or metabolic disturbances attributable to PD.
• High maternal suicide risk.
• Uncontrolled medical conditions exacerbated by elevated anxiety levels.
• A temporal relationship between the onset of intrauterine growth restriction in
the fetus and maternal PD symptoms.
19 Anxiety Disorders
• A history of ineffective psychotherapy or poor adherence to treatment.
413
19.7.1 General Consideration onPerinatal PD
Pharmacological Treatment
Currently, no evidence-based guidelines or placebo-controlled studies specically
address the pharmacological treatment of PD during the perinatal period.
However, pharmacological agents demonstrated to be effective in the general
population are generally considered equally efcacious during pregnancy and lactation. SSRIs, imipramine, clomipramine, venlafaxine, and benzodiazepines are
established as effective treatments for PD.Additionally, mirtazapine may also be a
viable treatment option (Uguz etal. 2016; Serretti etal. 2011; Batelaan etal. 2012;
Marchesi 2008; Bandelow and Rüther 2004).
When selecting pharmacological agents during pregnancy, considerations should
include the patient’s history of response to specic medications and any previous
adverse drug reactions, thus ensuring the most appropriate therapeutic choice.
19.7.2 Clinical Practice Suggestions forthePharmacological
Treatment ofPD inPregnancy
SSRIs should be the preferred pharmacological option for PDs during pregnancy.
Specically, sertraline, citalopram, and escitalopram are recommended as rst-line
medications due to their favorable fetal safety prole (Womersley et al. 2017;
Marchesi etal. 2016; Larsen etal. 2015; Uguz 2015; Myles etal. 2013). A recent
retrospective study (Uguz 2020) assessing the efcacy of citalopram in 22 pregnant
women diagnosed with PD found that a dosage of 20mg/day of citalopram was
effective in treating PD during pregnancy. Regarding other SSRIs, paroxetine is
associated with an increased risk of congenital malformations, particularly those
affecting the heart (septal defects) (Grigoriadis etal. 2013; Myles et al. 2013).
Fluoxetine is also associated with birth defects, albeit to a lesser extent than paroxetine (Weissman etal. 2004); however, due to the long half-life of its active metabolites, it carries a reduced risk of neonatal withdrawal syndrome. As a result, neither
of these two SSRIs is recommended as a rst-line treatment (Myles etal. 2013).
However, they may be considered for pregnant women with PD who have not
responded to other antidepressant treatments.
TCAs represent an alternative pharmacological option, though safety data on
their use during pregnancy remain more limited compared to SSRIs. Pregnant
patients with PD treated with imipramine (Uguz et al. 2014; Ware and DeVane
1990) have beneted from pharmacotherapy, reporting remission of panic symp-
toms. Specically, a study involving 16 pregnant women with panic attacks found
low-dose imipramine (10–40 mg/day) to be effective, with 75% of participants
experiencing a statistically signicant reduction in the mean number of weekly
panic attacks (Uguz etal. 2014).
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B. D. Daniel et al.
Venlafaxine, an established treatment for PD, is widely used as a rst-line agent
in non-pregnant women (Batelaan etal. 2012). However, during pregnancy, it is
generally regarded as a second-line option due to the relatively limited safety data
compared to SSRIs. A 2019 observational study involving 281 pregnancies exposed
to venlafaxine found no conclusive evidence linking its use to risks of adverse pregnancy or fetal outcomes (Richardson etal. 2019).
In cases of partial response to rst-line therapy, the combination of SSRIs and
mirtazapine may be a viable alternative. Case reports have supported the adjunctive
use of low-dose mirtazapine (7.5–15mg/day) with SSRIs in pregnant women experiencing severe nausea, insomnia, and reduced appetite associated with PD (Uguz
2013) (Table19.1).
Benzodiazepines remain an effective and widely used treatment for PD
(Marchesi 2008). Despite their rapid onset of action, these medications present
several disadvantages, including the potential for physical dependence, abuse,
withdrawal symptoms, and the possibility of cognitive impairment in patients
(Marchesi 2008). Moreover, some authors have indicated that the concomitant use
of benzodiazepines and antidepressants is associated with an elevated risk of birth
defects. Consequently, benzodiazepines should be reserved for short-term use at
the lowest possible dosage, either as a bridge until antidepressants achieve the
expected response or in cases of “severe anxiety and/or agitation” (ACOG 2023;
Marchesi 2008). When their use is necessary, short half-life agents, such as lorazepam, are preferred (Rowe etal. 2013).
19.7.3 Clinical Practice Suggestions forthePharmacological
Treatment ofPD During Breastfeeding
Most authors consider sertraline and paroxetine among the preferred antidepressants for use during breastfeeding (Uguz 2021; Grzeskowiak etal. 2018; Molenaar
etal. 2018; McAllister-Williams etal. 2017; Weissman etal. 2004), as both exhibit
undetectable or low infant plasma concentrations and a RID of 0.5–2.8% (paroxetine) and 0.5–3% (sertraline) (NICE 2020; Pogliani etal. 2019; Uguz etal. 2016;
Berle and Spigset 2011; Weissman etal. 2004; Begg etal. 1999).
Among other SSRIs, escitalopram presents undetectable or low infant plasma
concentrations, with a RID ranging from 3% to 8.3% (NICE 2020; Neuman etal.
2014; Bellantuono etal. 2012; Berle and Spigset 2011). Citalopram, while excreted
into breast milk in small amounts, has occasionally been reported to reach an RID
exceeding 10% (NICE 2020; Pogliani etal. 2019; Heikkinen etal. 2002). Fluoxetine
is excreted into human milk in small to moderate amounts, yet its relative dose
(>10%) may be higher than that of other antidepressants in the same SSRI group
(NICE 2020; Pogliani et al. 2019; Epperson etal. 2003; Hendrick et al. 2001b).
Therefore, while these SSRIs may be considered compatible with breastfeeding
under certain circumstances, they should not be regarded as rst-line treatments. In
particular, uoxetine use requires careful consideration due to its higher RID.
19 Anxiety Disorders
With regard to TCAs, a study (Uguz etal. 2016) presented the results of 6 patients
with PD treated with low doses of imipramine (dosages ranging from 25 to 35mg/
day) during breastfeeding. The level of anxiety symptoms signicantly decreased
after treatment; in fact, the response rate was 66.7%, with all participants reporting
a reduction in symptoms to varying degrees. These ndings suggest that low doses
of imipramine may serve as a pharmacological alternative to paroxetine and sertraline for breastfeeding women with PD.
415
19.8 Treatment ofGeneralized Anxiety Disorder (GAD)
Perinatal GAD has a high prevalence, ranging from 8.5% to 10.5% during pregnancy and 4.4% to 10.8% in the postpartum period (Buist and Gotman 2011; SutterDallay etal. 2004). Despite its signicant impact on the patient’s functioning, this
potentially debilitating mental health condition is often underdiagnosed. A key
challenge in perinatal GAD diagnosis lies in differentiating between normal and
pathological worry. Given its potential to negatively inuence neonatal outcomes,
early detection and timely intervention are essential.
19.8.1 General Consideration onPerinatal GAD
Pharmacological Treatment
Treatment approaches for perinatal GAD vary depending on the severity of the condition. CBT is considered the rst-line treatment for mild to moderate perinatal
GAD.However, for moderate to severe cases, pharmacotherapy should be considered (Misri etal. 2015). SSRIs and SNRIs are the primary pharmacological options
for managing GAD.The use of SSRIs/SNRIs in the management of perinatal GAD
should be determined on an individual basis. Patients with a prior history of SSRI/
SNRI use should continue their prescribed medication to minimize the risk of
relapse, with the possible exception of paroxetine due to its potential cardiac risks
to the fetus. For women initiating pharmacological treatment for the rst time, an
SSRI/SNRI with established efcacy for GAD should be selected. Furthermore,
preference may be given to those agents with low accumulation in breast milk, a
proven safety prole during pregnancy, and a low drug concentration ratio in the
umbilical cord and serum (Misri etal. 2015).
19.8.2 Clinical Practice Suggestions forthePharmacological
Treatment ofGAD inPregnancy
According to guidelines, pharmacotherapy may be indicated for pregnant women
with moderate to severe, treatment-resistant GAD.Over the past decade, the use of
SSRIs during pregnancy has become increasingly common in clinical practice.
Recent studies indicate that the safety prole of SSRIs, including their use during
416
the rst trimester, is generally reassuring (Huybrechts etal. 2014; Jimenez-Solem
etal. 2013; Reis and Källén 2010). However, we recommend prescribing sertraline
and citalopram as rst-line options due to their extensive study and established
safety prole in pregnancy.
Regarding SNRIs, venlafaxine may be considered as a potential treatment option
during early pregnancy for women with severe GAD who have previously demonstrated a favorable response to this medication (Bellantuono etal. 2015). More specically, venlafaxine may be considered for use early in pregnancy in the following
clinical situations: (1) women with a documented history of recurrent, severe GAD
who are currently receiving venlafaxine for long-term maintenance; and (2) women
experiencing a severe new episode of GAD who have previously responded successfully to venlafaxine treatment (Bellantuono etal. 2015).
BDZs remain effective for the rapid treatment of short-term anxiety, particularly
for alleviating somatic symptoms. Given that antidepressants typically require several weeks to show therapeutic effects, BDZs may be used for brief treatment to
provide an immediate anxiolytic response. As noted, lorazepam may be preferred
over other BDZs due to its lower accumulation in fetal tissue (Misri etal. 2015).
B. D. Daniel et al.
19.8.3 Clinical Practice Suggestions forthePharmacological
Treatment ofGAD During Breastfeeding
The available data regarding the effects of SSRIs on breastfeeding infants are on the
whole reassuring, and breastfeeding should generally not be discouraged in women
using these medications. A review (Rowe etal. 2015) showed that the transfer of
sertraline, uvoxamine, and paroxetine into human milk is low, with even lower
levels of uptake by the infant. To date, minimal or no adverse effects have been
reported following the use of these three SSRIs in breastfeeding mothers. Regarding
SNRIs, few but encouraging data have emerged from limited studies on the neonatal
safety of venlafaxine and duloxetine during breastfeeding (Bellantuono etal. 2015;
Boyce etal. 2011; Briggs etal. 2009; Newport etal. 2009; Berle etal. 2004; Ilett
etal. 2002; Hendrick etal. 2001a). Adverse events in infants breastfed by mothers
using these medications have been reported only occasionally (Orsolini and
Bellantuono 2015). When benzodiazepines are considered, a short-acting formulation should be selected, and the lowest effective dose should be administered for the
shortest duration to minimize infant exposure.
19.9 Treatment ofSpecific andSocial Phobias
The existing literature on the treatment of both specic and social phobias during
the perinatal period is notably limited, with a lack of studies specically addressing
the postpartum phase (Nath etal. 2020). The available data on the prevalence of
these disorders during the perinatal period are as follows:
19 Anxiety Disorders
417
• Prevalence rates for specic phobia range from 3.2% to 19.9% (Nath etal. 2020;
Fairbrother etal. 2016; Goodman etal. 2014).
• For social phobia, prevalence rates across ve studies vary from 0.2% to 5.1%
(Wisner etal. 2013; Navarro etal. 2008; Wenzel etal. 2005).
• For agoraphobia, the prevalence rates reported in two studies were 0% and 0.6%
(Navarro etal. 2008; Wenzel etal. 2005).
Specic phobias, such as emetophobia (fear of vomiting) and blood-injection
phobia (including needle phobia), are particularly relevant in the context of pregnancy (Patel and Hollins 2015). These disorders can have signicant consequences;
emetophobia has been associated with pregnancy avoidance, termination of pregnancy, and the avoidance of surgical procedures or general anesthesia due to a fear
of vomiting (Veale and Lambrou 2006). Additionally, in cases of severe needle phobia, women may delay seeking antenatal care and avoid necessary blood tests and
injections (McAllister etal. 2012). A study has shown that pregnant women with
needle phobia are at higher risk for adverse obstetric and neonatal outcomes, including prematurity, low birth weight, and neonatal morbidity (Lilliecreutz etal. 2010).
In recent years, there has been growing interest in the phenomenon of birth phobia,
also known as tocophobia. The intensity of this phobia can lead to avoidance of
pregnancy or a preference for cesarean section (Demšar etal. 2018).
To date, research focused on the treatment of phobias in the perinatal period has
largely concentrated on non-pharmacological interventions, which fall outside the
scope of this chapter.
19.10 Conclusion
As elucidated throughout this chapter, ADs during the perinatal period are prevalent
yet often underestimated. The ramications of these disorders, when left unrecognized or inadequately addressed, are signicant and multifaceted. They pose considerable risks not only to the pregnant woman or new mother—heightening the
likelihood of postpartum depression, suicidal ideation, pre-eclampsia, fear of childbirth, diminished breastfeeding, maladaptive coping mechanisms, and substance
misuse (e.g., alcohol)—but also to neonatal health outcomes. Such adverse effects
may encompass preterm birth, low Apgar scores, fetal hyperactivity, irregular fetal
heart rates, polyhydramnios, small size for gestational age, and low birth weight.
The implications of untreated perinatal anxiety are not conned to the immediate
perinatal period; they extend into the long term, potentially contributing to a range
of challenges in offspring, such as sleep disturbances, feeding difculties, activity
issues during infancy, and an increased risk of attention decits, hyperactivity, and
emotional or behavioral disorders throughout childhood.
To date, no placebo-controlled studies have directly compared the outcomes of
women with perinatal anxiety disorders receiving pharmacological treatment to
those remaining untreated. As such, deriving denitive conclusions about the most
effective treatment strategies during this critical period remains a challenge.