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B. D. Daniel et al.
However, it is paramount to recognize that existing evidence suggests that pregnant
women and new mothers, along with their healthcare providers, should prioritize
the potential consequences of untreated ADs over the risks associated with appropriately managed and monitored pharmacotherapy.
Current literature indicates that sertraline, escitalopram, and citalopram are
among the most favorable antidepressants for the management of perinatal ADs,
offering a favorable balance of efcacy and safety. In contrast, TCAs, SNRIs, and
mirtazapine have not been studied as extensively as SSRIs. Should a short-term
regimen of benzodiazepines be deemed necessary, it should be prescribed with careful consideration. In the context of breastfeeding, there is a growing consensus
endorsing sertraline and paroxetine as rst-line pharmacotherapies. In conclusion,
the determination of the optimal pharmacological strategy for women facing perinatal ADs remains a complex endeavor. Nevertheless, the available safety data regarding specic medications, particularly SSRIs, provide reassurance. Therefore, when
pharmacological treatment is indicated—especially in cases of severe ADs or when
less invasive interventions have failed—it should be strongly considered. Such therapeutic decisions must be individualized, weighting the patient’s history of ADs,
current clinical status, severity, and overall functional impairment to ensure both
maternal and fetal well-being.
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Posttraumatic Stress Disorder
20
MineSahingoz andSerapSari
20.1 Introduction
Posttraumatic stress disorder (PTSD) is one of the signicant mental health concerns for women in the perinatal period, with prevalence estimates ranging from 0%
to 35% in pregnancy (Horsch etal. 2013; Mahenge etal. 2013) and from 0% to 21%
in postpartum (Schwab etal. 2012; Verreault etal. 2012). According to previous
studies, the likelihood of PTSD increases during pregnancy and reaches its peak just
before childbirth (Onoye etal. 2013). About one-third of women in the general
population have experienced a traumatic birth, and the risk of PTSD in postpartum
women is also increasing (Yildiz etal. 2017; Slade etal. 2022). It is possible that
PTSD can be re-triggered by events during pregnancy and childbirth for women
with a history of trauma or prior PTSD (Halvorsen etal. 2013). Several studies have
identied numerous risk factors that increase the likelihood of PTSD in the perinatal
period, including age, income level, history of trauma and psychological disturbances, trait anxiety, obstetric factors and complicated deliveries, and low social
support (van Son etal. 2005; Cerulli etal. 2011; Grekin and O’Hara 2014; CanetVélez etal. 2024). Additionally, PTSD symptoms may be more severe during the
peripartum period than at other life stages because the childbearing years have more
potential triggers. There is strong evidence that PTSD during pregnancy is associated with poor birth outcomes, such as preterm birth (Shaw etal. 2014; Yonkers
etal. 2014), and mothers with PTSD have been reported to have bonding difculties
with their babies and have more intrusive behaviors toward their babies (Davies
etal. 2008; Ionio and Di 2014). Treating PTSD in the perinatal period is critical
M. Sahingoz (*)
Meram Faculty of Medicine, Department of Psychiatry, Necmettin Erbakan University,
Konya, Turkey
S. Sari
Faculty of Medicine, Department of Psychiatry, Atatürk University, Erzurum, Turkey
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
F. Uguz, L. Orsolini (eds.), Perinatal Psychopharmacology,
https://doi.org/10.1007/978-3-031-99720-4_20
427
428
M. Sahingoz and S. Sari
because untreated PTSD may increase the risk of pregnancy complications and
adverse outcomes, affect the infant’s emotion regulation and development, and
treatment of pregnant and lactating women with psychotropic medications also has
potential risks (Bosquet Enlow etal. 2011; Garthus-Niegel etal. 2017). Unfortunately,
there are currently very limited data on the treatment of PTSD in the perinatal period.
20.2 Risks ofUntreated PTSD
PTSD is known to be a potentially disabling condition that can persist for decades
(Kessler etal. 1995; Marmar et al. 2015). This disorder is associated with high
comorbidity of psychiatric illnesses involving depression, anxiety, psychosis, personality, and substance use disorders (Galatzer-Levy et al. 2013; Gallagher and
Brown 2015). It has been suggested that both PTSD and co-occurring psychological
disorders increase the emergence of high-risk behaviors such as suicidal thoughts
and behaviors and alcohol/substance use in general trauma literature (Yarvis and
Schiess 2008). Although there is not adequate evidence, it should be considered that
women with perinatal PTSD may have similar risks. Traumatic stress and PTSD
during pregnancy may negatively affect birth outcomes or fetal development indirectly through risky health behaviors and poor self-care (e.g., attendance to medical
care, nutrition, and sleep). Furthermore, anxiety and depression may also increase
risks for preterm delivery, low birth weight, and reduced fetal growth (Morland
etal. 2007). On the other hand, PTSD during pregnancy may directly predispose
women to birth complications by neuroendocrine alterations, such as the dysregulation of cortisol, vasopressin, and oxytocin (Alder etal. 2007; Dunkel Schetter and
Tanner 2012; Shaw etal. 2014). There are reports suggesting that posttraumatic
stress is associated with preterm delivery (Shaw etal. 2014; Cook etal. 2018), decrement in infant head circumference at birth (Engel etal. 2005).
Several studies reported that maternal distress may associate with an adverse
impact on maternal and child health (Alder etal. 2007; Dunkel Schetter and Tanner
2012; Ding etal. 2014; Glover 2015) and may affect child developmental outcomes
and family functioning in the perinatal period (Ayers et al. 2006; Anderson and
Cacola 2017). A large prospective study found that women with higher postpartum
PTSD scores were signicantly less likely to have breastfed their infant (Beck
etal. 2011).
There is suggestive evidence that additional long-term impacts on families and
infants include breastfeeding difculties, as well as feelings of detachment with
infant and mother, infant behavior, and cognitive development (Ayers etal. 2006;
Creedy etal. 2000; Beck and Watson 2008). In addition, it has been suggested that
untreated PTSD is associated with sexual avoidance, secondary tokophobia (fear of
childbirth), disordered maternal-child bonding or overanxious/protective parenting
and maternal long-term physical and emotional health issues (Nicholls and Ayers
2007; Fenech and Thomson 2014; Ionio and Di 2014; Davies etal. 2008). Given
that perinatal PTSD related to high risk of pregnancy complications and adverse
birth outcomes (Ayers and Ford 2014) as well as postpartum PTSD may have