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20 Posttraumatic Stress Disorder
429
negative impact on women and the baby (Koen etal. 2016; Partt etal. 2014), it is
of importance to identify and treat women with PTSD in the perinatal period.
20.3 Pharmacological Treatment
There is no distinctive guideline in the literature for the treatment of perinatal PTSD,
despite evidence that PTSD occurs in a signicant proportion of pregnant and in
pregnant or lactating women and it is associated with poor outcomes such as preterm birth (Shaw etal. 2014; Yonkers etal. 2014). Although insufcient data, it is
presumed that treatment methods known to be effective in the treatment of PTSD
may also be effective in the perinatal period. Unfortunately, there is also limited
data on therapeutic interventions for the PTSD non-perinatal population. The guidelines of PTSD treatment recommend that psychological treatments, especially
trauma-focused psychotherapies, should be preferentially used as a routine rst
treatment of PTSD (Australian Centre for Posttraumatic Mental Health 2013; World
Health Organization 2013). Numerous systematic reviews and meta-analyses demonstrated that the psychotherapeutic interventions, including trauma-focused cognitive behavioral therapy (CBT), exposure therapy and eye movement desensitization
and reprocessing (EMDR), and debrieng and counselling, are effective on the
symptoms of PTSD (Cusack etal. 2016; Chen et al. 2014; Gamble etal. 2002;
Buhmann etal. 2018; Ford and Courtois 2020; Forbes etal. 2020).
Although the effectiveness of pharmacological drugs in the treatment of posttraumatic stress disorder has been discussed, they are still widely used, especially
because psychological interventions cannot be found or unresponsive (Hoskins
etal. 2015). It is likely that pharmacotherapies may relieve from symptoms such as
sleep problems, depression, and anxiety, which are common in PTSD, rather than
complete remission (Bowers and Ressler 2015).
20.3.1 General Considerations
Determining the appropriate psychiatric medications to use in the treatment of
PTSD in the perinatal period is complicated by pregnancy and breastfeeding.
Principally, nonpharmacological methods should be preferred rstly in the pregnant
or lactating women for the treatment of PTSD.However, it is sometimes necessary
to use pharmacological treatment, in patients with severe anxiety and depressive
symptoms, malnutrition, or disturbance of sleep (Baldwin etal. 2014). On the other
hand, trauma-focused psychotherapies can often temporarily increase symptoms.
Therefore, medications that reduce PTSD symptoms can be a very useful secondline or adjunctive treatment during psychotherapy (Forbes etal. 2020; Ford and
Courtois 2020). A wide range of pharmacotherapy has been tested in the treatment
of PTSD, but it is unclear which pharmacological treatment should be selected
among all the compounds available for perinatal PTSD. The pharmacologic
430
M. Sahingoz and S. Sari
treatments reported to be efcacious in the literature for the treatment of PTSD may
be preferred according to their safety in pregnant or lactating women.
The primary concerns regarding the use of psychotropic medications during
pregnancy and lactation include physical or neurobehavioral teratogenesis in the
fetus, neonatal toxicity, and neonatal withdrawal. Before PTSD treatment is decided,
it should be evaluated conditions such as severity of depression and anxiety, risk of
suicide, nutrition deciency, and sleep disturbances due to PTSD. In addition, it
should be identied whether the PTSD itself or treatment of PTSD is independently
associated with possible negative effects on both mother and infant as well as potential benets of treatment. The risks and benets of medication use during pregnancy
or breastfeeding should be weighed individually. Finally, clinicians should inform
both mother and father about the possible risks of treated or untreated PTSD.Parents
and physicians must decide together for the regimen of treatment.
Psychotropic medicines should be selected with respect to evidence for both
efcacy and safety in the perinatal period. If possible, psychotropics should be used
at the lowest doses and shortly and avoided use of combination of medications. Due
to the pharmacokinetic changes in pregnancy, clinicians should closely monitor
patients, especially during the third trimester and the antepartum period, to maintain
a therapeutic blood level and to avoid toxicity.
20.3.2 First-Line Pharmacotherapy ofPTSD
Most guidelines agree that serotonin reuptake inhibitor antidepressants (SSRIs) are
the drugs of rst choice, being backed by a large body of evidence from randomized
controlled trials (RCTs) (Davidson 2016; Jeffreys etal. 2012; Watts etal. 2013).
SSRIs often produce modest results despite having currently the most evidence of
efcacy on PTSD treatment (Ipser and Stein 2012). The use of selective norepinephrine-serotonin reuptake inhibitors (SNRIs), particularly venlafaxine, is also
supported by clinical guidelines (National Academies Press 2014).
There are only two medications approved for the treatment of PTSD by the
U.S. Food and Drug Administration (FDA), sertraline and paroxetine. All other
medications for PTSD are considered off-label use. Paroxetine, sertraline, and
uoxetine were found to be superior to placebo in treating PTSD (Martenyi etal.
2002; Martenyi and Soldatenkova 2006; Davidson etal. 2005). Furthermore, there
is evidence that uoxetine, paroxetine, and venlafaxine are statistically signicantly
superior to placebo in the treatment of PTSD, while sertraline is ineffective or less
effective (Hoskins etal. 2015; Buhmann and Andersen 2017). A large multinational
RCT found venlafaxine was effective for PTSD re-experiencing and avoidance/
numbing clusters, but not for hyperarousal (Davidson etal. 2006). Although venlafaxine demonstrated a large initial effect, this decreased over time (Lee etal. 2016).
Other SSRIs, such as citalopram and uvoxamine, currently have far less evidence
for their effectiveness in PTSD (Shalev et al. 2012; Escalona et al. 2002).
Fluvoxamine showed improvement in subjective sleep quality and PTSD symptoms
in a few studies (Neylan etal. 2001).
20 Posttraumatic Stress Disorder
431
To date, SSRIs are the most studied medications in pregnancy and lactation
among available psychotropic drugs (McAllister-Williams etal. 2017). Paroxetine
has stronger support for the efcacy in the treatment of non-perinatal PTSD than
sertraline (Ipser and Stein 2012). However, paroxetine and uoxetine are not recommended during pregnancy due to evidence suggesting increased risk of fetal defects
(Jain and Lacy 2005; Womersley etal. 2017). The literature shows that paroxetine
and uoxetine have the strongest association with congenital malformations and
negative birth outcomes while the associations between sertraline and citalopram
with negative outcomes remain weaker. Citalopram may also be preferred in pregnant women, but it has lesser evidence than sertraline for their effectiveness in
PTSD.Fluvoxamine is not recommended during pregnancy because of limited data
on both its safety in the fetus and efcacy in PTSD treatment (Larsen etal. 2015).
Limited data on venlafaxine show that use of venlafaxine during pregnancy does not
increase the teratogenic risk (Einarson etal. 2001; Einarson etal. 2009). Considering
sertraline is supported by a large body of data for the treatment of PTSD and has the
largest safety data on its use in pregnancy, it is recommended to choose sertraline
from the class of SSRIs as the rst-line medicine for the treatment of PTSD in pregnant women. (Womersley et al. 2017; Thomson and Sharma 2021). However, in
cases where a patient has previously responded to an alternative rst-line drug, it
may be preferred to this medication during pregnancy also.
Several studies on antidepressants and breastfeeding indicated that paroxetine
and sertraline produce lower infant plasma levels than other antidepressants while
citalopram and especially uoxetine produce the highest plasma levels in infants.
Therefore, sertraline and paroxetine should be preferred as rst-line drugs during
the lactation period (Womersley etal. 2017; Ram and Gandotra 2015; Larsen etal.
2015). Among the antidepressants, sertraline seems to be the best option during the
perinatal period as it can also be continued in breastfeeding. Fluoxetine and citalopram/escitalopram are not appropriate for rst-line treatments of PTSD in lactation
due to the high infant exposure for these drugs. Venlafaxine and uvoxamine should
not be considered as rst-line therapies because of inadequate data on safety in
lactation. However, other antidepressants except sertraline and paroxetine can be
used in special cases such as a history of their effectivity, or if the mother has used
one of these drugs during pregnancy.
20.3.3 Second-Line Pharmacotherapy ofPTSD
Second-line recommended medications generally include less evidence of effectiveness on PTSD symptoms. Additionally, many of them have a greater side effect
prole than SSRI or SNRI medications, for example, tricyclic antidepressants
(TCAs) and monoamine oxidase inhibitors (MAOIs).
TCAs and MAOIs were the rst medications tested in RCTs for treating
PTSD.Despite promising results from some RCTs for TCA in PTSD, high dropout
rates due to common side effects complicated the interpretation of results in these
studies (Davidson etal. 1990; Reist etal. 1989; Sullivan and Neria 2009). TCAs are
432
M. Sahingoz and S. Sari
not generally recommended as rst-line medications in guidelines for the treatment
of PTSD.However, they may be considered useful as add-on therapy to another
drug or psychotherapy, to enhance sleep or to resolve specic symptoms, such as
dissociation, pain (Davidson 2015). A review of the literature on the safety of TCA
antidepressants in pregnancy suggests that although there is a slight increase in the
rates of congenital anomalies in some studies, most studies did not show any
increase (Ornoy etal. 2017). However, a meta-analysis has shown that exposure to
TCAs during late gestation was associated with poor neonatal adaptation (Gentile
2010). The use of TCAs (except doxepin) appears to be a relatively safe option dur-
ing breastfeeding (Eberhard-Gran etal. 2006), but there is a case of amitriptyline
presenting with severe sedation and poor nutrition in the breastfed baby (Uguz
2017). When the limited data on both efcacy in the treatment of PTSD and safety
for the maternal use of TCAs in gestation and lactation are considered, their use
during the perinatal period is restricted.
Phenelzine provided mixed evidence for its efcacy in the treatment of PTSD
(Shestatzky etal. 1988; Kosten et al. 1991); nevertheless, brofaromine failed to
produce efcacy on PTSD symptoms in two placebo-controlled trials (Katz etal.
1994; Baker etal. 1995). For MAOIs, the necessity of a low tyramine diet to avoid
hypertensive crisis and their contraindication in combination with other antidepressants and sympathomimetics means this class also has limited use (Sullivan and
Neria 2009). There is also a very limited amount of data on the safety of MAOIs
during both pregnancy and breastfeeding (Kennedy etal. 2017; Bauer etal. 2017).
It is recommended to avoid these medications due to dietary and medication restrictions, along with the potential to cause hypertensive crises in the perinatal period
(Lusskin etal. 2018).
Nefazodone has been shown to signicantly improve most PTSD symptoms,
including intrusive thoughts, avoidant behaviors, emotional numbing, nightmares,
sleep, depression, and anger, but unadvisable because of the risk of hepatotoxicity
in pregnant or lactating women (Lee etal. 2016; Detweiler etal. 2016). Trazodone
is one of the most prescribed medications in the treatment of PTSD patients with
insomnia or nightmares. There have been no RCTs to demonstrate its efcacy for
sleep disturbances related to PTSD despite it has benecial effects on sleep habits
(Warner etal. 2001; Detweiler etal. 2016). Limited available data of trazodone in
the perinatal period suggest that it is safe to use both during pregnancy due to the
low risk of malformation and during breastfeeding due to a low relative infant dose
(Smit etal. 2016; Kristensen etal. 2007; Klier etal. 2007). Mirtazapine was reported
to improve PTSD symptoms and associated anxiety as well as useful in reducing the
frequency and intensity of nightmares (Davidson etal. 2005; Detweiler etal. 2016).
However, it should be noted that the data on mirtazapine support its use as an augmenting agent in addition to another medication, most commonly sertraline, rather
than as a monotherapy in improving PTSD symptoms (Schneier et al. 2015;
Thomson and Sharma 2021). Most of the data show that mirtazapine does not
increase the risk of malformation in pregnancy and is also relatively reliable in lactation (Einarson etal. 2003; Smit etal. 2016). Therefore, mirtazapine and trazodone
20 Posttraumatic Stress Disorder
433
may be used in pregnant or breastfeeding women with PTSD for the treatment of
sleep disturbances.
Atypical antipsychotics have also been used for PTSD if the treatment use of
SSRIs does not show efcacy. The relatively large body of evidence of pharmacological treatment for PTSD indicates that atypical antipsychotics may be effective
in PTSD with promising initial ndings (Ipser and Stein 2012; Ahearn etal. 2011).
Although many studies were performed on the use of antipsychotics as augmentation agents, there is less evidence on these medications as monotherapy in PTSD
treatment (Carey etal. 2012; Berger etal. 2009). While there are some studies recommending antipsychotics to treat co-morbid psychotic symptoms/disorders or comorbid bipolar disorder in PTSD patients (Hamner et al. 1999; Hamner et al.
2003a), others reported that second-generation antipsychotics (SGAs) were used
primarily to target refractory insomnia/sleep disturbances in patients with PTSD
(Hermes etal. 2014). Many reviews and meta-analyses to date have found that risperidone and olanzapine generally have greater evidence of effectiveness than quetiapine or aripiprazole in the treatment of non-perinatal PTSD (Koek etal. 2016).
For risperidone, there are positive results in the reduction of several PTSD symptom clusters such as re-experiencing and hyperarousal subscale scores with adjunctive risperidone for antidepressant-resistant PTSD (Reich et al. 2004). Some
placebo-controlled studies of risperidone monotherapy indicated that it may be utilized as an effective in the management of PTSD (Padala etal. 2006); in contrast,
others did not (Rothbaum etal. 2008).
As both monotherapy and augmentation with SSRIs in PTSD patients, the use of
olanzapine is supported by evidence on symptom improvement in placebocontrolled trials (Stein etal. 2002; Carey etal. 2012). In addition, olanzapine has
also been shown to have positive effects in improving sleep problems (Carey etal.
2012). However, in a controlled study of olanzapine monotherapy in PTSD, the
clinical response to olanzapine (n=10) was inadequate (Buttereld etal. 2001).
There is limited data in the literature for the use of quetiapine in PTSD, but quetiapine is one of the most prescribed anti-nightmare medications in PTSD (Detweiler
etal. 2016). Especially, for the sleep disturbances related to PTSD, quetiapine was
found to be benecial in some but not all trials (Sokolski etal. 2003; Hamner etal.
2003b). A recent systematic review suggests that aripiprazole as monotherapy or
adjunct therapy for PTSD appears to improve symptoms associated with PTSD,
such as anxiety, avoidance, hyperarousal, re-experiencing symptoms, and quality
and length of sleep (Britnell etal. 2017). A small placebo-controlled study hypothesized signicantly lower PTSD and depressive symptoms in the ziprasidone versus
placebo group, but researchers terminated the study because intolerable adverse
effects occurred in a signicant proportion of patients receiving ziprasidone (Kellner
etal. 2010).
There are very little data for the second-generation antipsychotic drugs, with
respect to teratogenic or toxic effects on the fetus. A recent review reported that a
slight increase in the rate of congenital anomalies following prenatal risperidone
was observed in some smaller studies (Ornoy etal. 2017). A few studies have suggested that these agents may increase the risk of hyperglycemia in pregnant women
434
M. Sahingoz and S. Sari
as well as the rate of poor neonatal adaptation (Gentile 2004). However, most available studies on the safety of the second-generation antipsychotics in pregnancy and
lactation demonstrated that they did not increase the risk of overall deformity
(McKenna etal. 2005; Ornoy etal. 2017). Given the amount of clinical data on the
safety in the perinatal period and efcacy in PTSD treatment of the secondgeneration antipsychotics, it is recommended to use risperidone and olanzapine during pregnancy, and olanzapine and quetiapine during lactation. There are
controversial results on the efcacy of augmentation of antipsychotics with SSRIs
in non-perinatal PTSD (Stein etal. 2002; Hamner etal. 2003b; Britnell etal. 2017).
Moreover, antipsychotic augmentation may lead to higher adverse effects than
monotherapy on the fetus or breastfed infant. As such, these treatments should be
considered when women have failed to respond to monotherapies or have a comorbid condition such as bipolar disorder; and they should be used at as low doses as
possible.
There are various recommendations among the guidelines and treatment algorithms for antiadrenergic agents in PTSD treatment (Koek etal. 2016). Several
RCTs of prazosin observed that it had benecial effects on nightmares and insomnia
related to PTSD (Taylor etal. 2008), but results have been mixed regarding its efcacy for the full PTSD syndrome (Raskind etal. 2007). Some reports recommend
prazosin as the rst-line pharmacotherapy in PTSD patients with sleep disturbances
before SSRIs (Bajor etal. 2011), while Ipser and Stein (2012) recommended it for
sleep and nightmares unresponsive to SSRIs. In contrast with prazosin, there have
been inadequate evidence on sleep disturbances or PTSD symptoms for both guanfacine and clonidine (Neylan etal. 2006; Alao etal. 2012). Although available limited data on the use of prazosin in pregnancy do not support an association between
prazosin and congenital defects, the use of prazosin is not recommended during
pregnancy and breastfeeding due to insufcient data on prazosin safety (Lubbe and
Hodge 1981).
Most of the studies of propranolol have been examined in the prevention of posttraumatic symptoms and it has been found that benecial in reducing the development of PTSD after trauma by some investigators (Pitman etal. 2002) although not
others (Hoge etal. 2012). Additionally, Brunet etal. (2014) found that propranolol
administration during an exposure session reduced physiological hyperarousal during later re-exposure. Propranolol has been extensively used to treat a variety of
conditions such as hypertension and pheochromocytoma in the mother, and tachyarrhythmias in both the mother and fetus during pregnancy, and no teratogenicity
associated with this agent has been documented (Ferrero etal. 2004). However,
since adverse fetal effects have occasionally been noted, it is only recommended for
use in pregnant women with PTSD when the benet outweighs the risk (Meidahl
Petersen etal. 2012). Despite no adverse effects in the breastfed infant have been
reported and propranolol levels in breast milk are low, it is recommended that monitoring the signs of beta blockade of the infant and planning the feeding at least 3
hours after administration of maternal propranolol (Taylor and Turner 1981; Thorley
and McAinsh 1983).
20 Posttraumatic Stress Disorder
435
To date, there is little evidence to support the use of antiepileptics in the treatment of PTSD.Bajor etal. (2011) found evidence effectiveness of lamotrigine or
topiramate on re-experiencing symptoms, lamotrigine on avoidance/numbing
symptoms, and levetiracetam on global symptoms in patients with PTSD.Several
reports recommended topiramate for PTSD symptoms including nightmares (Watts
etal. 2013; Detweiler etal. 2016), while others did not (Hoskins etal. 2015). In
addition, numerous systematic reviews indicated that antiepileptics failed to achieve
signicance for treating PTSD symptoms (Lee etal. 2016).
Exposure to antiepileptics, including valproic acid and carbamazepine, during
pregnancy is known to be associated with an increased risk of major congenital
malformations (Ornoy etal. 2017). Similarly, current evidence suggests topiramate
may be teratogenic and may also lead to an increase in the rate of developmental
problems (Hernandez-Diaz etal. 2018; Alsaad etal. 2015). Infants who were breastfed by mothers treated with topiramate were found to have very low serum levels
and no side effects (Gentile 2009). Lamotrigine has a good safety prole compared
with other antiepileptics and most studies found no increase in the rate of major
congenital anomalies (Cunnington etal. 2011). On the other hand, it should not be
forgotten that data about neurodevelopmental outcomes are rather limited.
Lamotrigine is considered moderately safe during breastfeeding (Davanzo etal.
2013). Given both the inconclusive evidence on the efcacy of antiepileptics in the
treatment of PTSD and concerns about their effects on the infant, antiepileptics are
not recommended for use in pregnant or lactating women with PTSD.
Numerous systematic reviews indicated that benzodiazepines have no benet in
PTSD, despite they historically one of the medications most prescribed in patients
with PTSD (Katzman etal. 2014; Hoskins etal. 2015; Jeffreys etal. 2012). However,
eszopiclone, a hypnotic drug, was found useful in only one study (Pollack etal.
2011). According to several guidelines, benzodiazepines are contraindicated for
patients with disinhibition and addiction problems (Jeffreys et al. 2012; Foa
etal. 2008).
Recent reviews suggest that NMDA receptor modulators may have potential for
benet in treating PTSD by playing a role on the glutamatergic receptor subtype
NMDA in fear extinction and reconsolidation (Kerbage and Richa 2015; Bernardy
and Friedman 2015). However, there have been limited clinical data.
20.3.4 Prevention ofPTSD After Trauma
It is estimated that up to 80% of the whole people will experience at least one potentially traumatic event (de Vries and Olff 2009; Frans etal. 2005). Fortunately, PTSD
or other psychopathology does not develop in many people. Therefore, it is hypothesized that posttraumatic stress symptoms may be prevented in individuals exposed
to trauma (Birur etal. 2017; Horn et al. 2016; Qi etal. 2016). There are many
approaches to PTSD prevention, the most common of which is psychotherapy. The
ndings of systematic reviews and controlled trials suggest that trauma-focused
CBT is potentially benecial in preventing chronic posttraumatic symptoms, when
436
M. Sahingoz and S. Sari
provided within 6 months of the incident (Roberts etal. 2009). Also, few evidence
indicate that the use of pharmacological interventions immediately after exposure to
trauma may reduce the risk of developing of PTSD (Nash and Watson 2012). Several
medications such as propranolol, glucocorticoids, opioids, antidepressants, neuroleptics, and salbutamol have been tested in the early aftermath of trauma with an
attempt to prevent PTSD (Birur etal. 2017; Horn etal. 2016; Qi etal. 2016; Nash
and Watson 2012).
A placebo-controlled randomized study found that acute administration of propranolol (160mg/day) was superior to placebo in reducing subsequent posttraumatic symptoms and physiological hyper-activity to reminders of trauma, but did
not reduce the emergence of posttraumatic stress disorder at 1 month (Pitman etal.
2002). A naturalistic study shows that acute administration of propranolol (120mg/
day) prevented the emergence of PTSD at 2 months (Vaiva etal. 2003), but not all
evidence is consistent (Nugent etal. 2010; Stein et al. 2007). Based on scientic
evidence on effectivity of propranolol for preventing traumatic symptoms in nonperinatal patients, propranolol can be given in pregnant and lactating women at low
doses and for short periods after exposure to trauma.
Findings from controlled trials of glucocorticoids such as hydrocortisone
(Delahanty etal. 2013; Schelling etal. 2001) are promising and support suggestions
that cortisol administration after trauma may be a useful approach in preventing
PTSD (Schelling etal. 1999). But this strategy does not appropriate during pregnancy and lactation due to cortisol may disrupt the hypothalamic–pituitary–adrenal axis.
While benzodiazepines are widely used in acute trauma settings, the rationale for
their use in treating trauma has been undermined by the negative ndings of a nonrandomized controlled trial of clonazepam or alprazolam (Gelpin etal. 1996). Early
administration of temazepam following life-threatening incidents resulted in a
larger proportion of participants developing PTSD in a small randomized, placebocontrolled trial (Mellman etal. 2002). There is evidence for the efcacy for sertraline in preventing posttraumatic symptoms (Stoddard Jr etal. 2011), but not for
gabapentin (Stein etal. 2007) or escitalopram (Shalev etal. 2012). A small number
of randomized double-blind placebo-controlled relapse prevention studies nd evidence for the efcacy of longer-term treatment, for uoxetine (Martenyi etal. 2002)
and sertraline (Davidson etal. 2005).
20.4 Conclusion
Management of women with PTSD during perinatal period is important given that
they are not only at higher risk of pregnancy complications and adverse perinatal
outcomes (Ayers and Ford 2014) but also postpartum PTSD which may have negative impact on women and the baby (Koen et al. 2016; Partt et al. 2014).
Nevertheless, there are no published guidelines regarding the clinical approach to
women with PTSD during the perinatal period. Especially, pregnant women determined to be in risk groups should be monitored closely and necessary support
20 Posttraumatic Stress Disorder
437
Table 20.1
There are risks of untreated PTSD as well as the medications on the fetus or infants
Before PTSD treatment is decided, it should be evaluated conditions such as severity of
depression and anxiety, risk of suicide, nutrition deciency, and sleep disturbances due to
PTSD
Clinicians and patients are concerned about the possible risks associated with PTSD and the
medications
The treatment should be individualized
Both the patients and the exposed fetus or infant should be closely monitored
Monotherapy and lowest therapeutic doses are preferred
The rst-line medications recommended for treating PTSD are sertraline, paroxetine,
venlafaxine, and uoxetine
According to their safety, sertraline may be preferred during pregnancy and sertraline and
paroxetine may preferred during lactation
Trazodone, mirtazapine, followed by, and olanzapine are the most useful and reliable
medications for sleep disturbances such as nightmares and insomnia in perinatal PTSD
Risperidone, olanzapine lesser to quetiapine and ziprasidone are the most preferable
antipsychotic drugs for augmentation treatment in PTSD
In cases where the rst-line medications cannot be used such as in comorbid bipolar disorder
or ineffective, it is recommended to use risperidone and olanzapine during pregnancy, and
olanzapine and quetiapine during lactation
Propranolol can be given to pregnant and lactating women at low doses and for short periods
within 48hours after exposure to trauma
Benzodiazepines should be avoided in the treatment of PTSD
PTSD posttraumatic stress disorder
Expert recommendations based on scientic evidence and clinical experience
should be provided. Clinicians should carefully consider the anticipated benets
and risks of pharmacological treatment of PTSD in pregnant or lactating women,
including the potential risks of harm to a developing child; therefore, treatment
should be individualized (Table20.1).
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