A 28-year-old primigravida at 16 weeks gestation comes to the office for a routine prenatal visit. The patient has had muscle aches for the past 3 months. She did not think much of her soreness early in the pregnancy, but her symptoms have become more bothersome. The patient reports feeling fatigued and sleeping restlessly even before becoming pregnant and takes short naps most days. Throughout the past year, she has spent much of her time thinking about whether she can tolerate the pain of labor and if her marriage and health will be affected by having a baby. The patient usually feels comforted after talking to her mother but becomes overwhelmed again soon after. She has no chronic medical conditions and takes a prenatal vitamin. Vital signs are within normal limits. Physical examination shows no abnormalities, and fetal heart tones are normal. Complete blood count, comprehensive metabolic panel, and TSH are normal. Which of the following is the most appropriate statement in response to this patient's condition?

Question

A 28-year-old primigravida at 16 weeks gestation comes to the office for a routine prenatal visit.  The patient has had muscle aches for the past 3 months.  She did not think much of her soreness early in the pregnancy, but her symptoms have become more bothersome.  The patient reports feeling fatigued and sleeping restlessly even before becoming pregnant and takes short naps most days.  Throughout the past year, she has spent much of her time thinking about whether she can tolerate the pain of labor and if her marriage and health will be affected by having a baby.  The patient usually feels comforted after talking to her mother but becomes overwhelmed again soon after.  She has no chronic medical conditions and takes a prenatal vitamin.  Vital signs are within normal limits.  Physical examination shows no abnormalities, and fetal heart tones are normal.  Complete blood count, comprehensive metabolic panel, and TSH are normal.  Which of the following is the most appropriate statement in response to this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d781_60c0_bc81_7dddefb78baa_MD0003_00 This patient's history of feeling easily overwhelmed by anxiety and multiple worries (eg, pain of labor, impact of baby on marriage and health), accompanied by nonspecific physical symptoms (eg, muscle aches, fatigue, and sleep disturbance that began before the pregnancy), is consistent with generalized anxiety disorder (GAD). GAD, a common anxiety disorder prevalent in the perinatal population, can negatively impact maternal and fetal health and mother-infant bonding. Treatment should be recommended when symptoms are distressing and interfering with functioning, as in this patient. First-line treatment of GAD consists of psychotherapy (eg, cognitive-behavioral therapy [CBT]) and/or psychopharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). Although some SSRIs and SNRIs can be used in pregnancy (eg, in stable patients at high risk of psychiatric decompensation without pharmacotherapy, in patients with distressing symptoms), psychotherapy can often be considered first. CBT techniques include cognitive restructuring to reduce catastrophic thinking and relaxation training (eg, breathing, progressive muscle relaxation) to address physical symptoms such as muscle tension, restlessness, and poor sleep. Applying these techniques during anxiety-provoking situations is effective in reducing psychological and physiological anxiety symptoms. (Choice A) Normal pregnancy-related anxiety can be managed with reassurance and family support. It is differentiated from GAD by the absence of significant distress or functional impairment. This patient's anxiety symptoms were present before she became pregnant and are worsening, distressing, and impairing; treatment is warranted. (Choice B) Acetaminophen and relaxation training can target some pregnancy-related physical and emotional changes. They would also target physical symptoms of GAD. However, they would not address the psychological aspects of anxiety. Psychotherapy that also targets the emotional and cognitive aspects of anxiety is more likely to improve overall functioning. (Choice C) Restless legs syndrome is common during pregnancy and can contribute to poor sleep and fatigue. However, it is characterized by an uncomfortable feeling at rest that is relieved by movement rather than by muscle aches. It would not explain this patient's excessive and overwhelming anxiety. Educational objective: Perinatal generalized anxiety disorder is common and requires treatment when symptoms are distressing and impairing. Psychotherapy is a first-line treatment. References: Generalized anxiety disorder. (http://www.ncbi.nlm.nih.gov/pubmed/30934083) Perinatal generalized anxiety disorder: assessment and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/26125602)

A 28-Year-Old Primigravida at 16 Weeks Gestation Comes to the Office