Depression and anxiety in early pregnancy and risk for preeclampsia

Perinatal Mental Health in Women with Polycystic Ovary Syndrome: A Cross-Sectional Analysis of an Australian Population-Based Cohort

Women with polycystic ovary syndrome (PCOS) have many risk factors associated with perinatal mental disorders, but research in this area is scarce. This study aims to compare the prevalence of common perinatal mental disorders in women with and without PCOS, and examine the relationship between PCOS and common perinatal mental disorders. We performed a cross-sectional study on self-reported data of 5239 women born between 1973 to 1978 in the Australian Longitudinal Study on Women’s Health. Compared with women not reporting PCOS, women reporting PCOS had higher prevalence of antenatal depression (8.9% vs. 4.4%, p < 0.001), antenatal anxiety (11.7% vs. 5.6%, p < 0.001), postnatal depression (26.8% vs. 18.6%, p < 0.001) and postnatal anxiety (18.4% vs. 12.0%, p < 0.001). PCOS was positively associated with antenatal depression and/or anxiety (adjusted odds ratio 1.8, 95% confidence interval 1.2–2.6) but not postnatal depression and/or anxiety after controlling for sociodemographic and lifestyle factors, reproductive history, obstetric complications and pre-existing depression and anxiety. General perinatal guidelines currently do not recognize PCOS as a risk factor and the international evidence based PCOS guideline noted inadequate evidence in this area. This paper addresses the gap in literature and highlights the need to screen for common perinatal mental disorders in women with PCOS.

Maternal anxiety, depression and asthma and adverse pregnancy outcomes - a population based study

To evaluate associations between maternal anxiety or depression and adverse pregnancy outcomes, taking possible familial confounding and interaction with asthma into account, we conducted a cohort study of all singleton births in Sweden 2001–2013. We retrieved information about pregnancy, diagnoses of anxiety/depression, asthma, and prescribed medication from the Swedish Medical Birth, National Patient, and Prescribed Drug Registers. We estimated associations with regression models, performed cousin and sibling comparisons, and calculated interactions. In 950 301 identified pregnancies; 5.9% had anxiety/depression and 4.0% had asthma. Anxiety/depression was associated with adverse pregnancy outcomes (e.g. preeclampsia, adjusted Odds Ratio 1.17 (95% Confidence Interval 1.12, 1.22), instrumental delivery (1.14 (1.10, 1.18)), elective (1.62 (1.57, 1.68)) and emergency (1.32 (1.28, 1.35)) caesarean section (CS)). Their children had lower birth weight (−54 g (−59, −49)) and shorter gestational age (−0.29 weeks (−0.31, −0.28)). Associations were not confounded by familial factors and asthma did not modify the effect of anxiety/depression for outcomes other than elective CS, p < 0.001. In women with anxiety/depression diagnosis, untreated women had higher odds of elective CS compared to women on medication (1.30 (1.17, 1.43)). In conclusion, anxiety/depression should be considered when evaluating pregnant women’s risk of complications such as preeclampsia and non-vaginal deliveries.

Unraveling the Serum Metabolomic Profile of Post-partum Depression

Post-partum depression (PPD) is a severe psychiatric disorder affecting ∼15% of young mothers. Early life stressful conditions in periconceptual, fetal and early infant periods or exposure to maternal psychiatric disorders, have been linked to adverse childhood outcomes interfering with physiological, cognitive and emotional development. The molecular mechanisms of PPD are not yet fully understood. Unraveling the molecular underpinnings of PPD will allow timely detection and establishment of effective therapeutic approaches. To investigate the underlying molecular correlates of PPD in peripheral material, we compared the serum metabolomes of an in detail characterized group of mothers suffering from PPD and a control group of mothers, all from Heraklion, Crete in Greece. Serum samples were analyzed by a mass spectrometry platform for targeted metabolomics, based on selected reaction monitoring (SRM), which measures the levels of up to 300 metabolites. In the PPD group, we observed increased levels of glutathione-disulfide, adenylosuccinate, and ATP, which associate with oxidative stress, nucleotide biosynthesis and energy production pathways. We also followed up the metabolomic findings in a validation cohort of PPD mothers and controls. To the very best of our knowledge, this is the first metabolomic serum analysis in PPD. Our data show that molecular changes related to PPD are detectable in peripheral material, thus paving the way for additional studies in order to shed light on the molecular correlates of PPD.

Anxiety, depression and social support in pregnant women with a history of recurrent miscarriage: a cross-sectional study

Objective: This study aims to investigate the prevalence of anxiety and depressive symptoms and the associations between social support and anxiety/depressive symptoms amongst Chinese pregnant women with a history of recurrent miscarriage. Methods: A cross-sectional study was conducted in Guangzhou, China, between September 2016 and May 2017 with 278 Chinese pregnant women with a history of recurrent miscarriage. Measures included the Self-rating Anxiety Scale (SAS), the Edinburgh Postnatal Depression Scale (EPDS) and the Perceived Social Support Scale (PSSS). Results: The occurrence of anxiety (SAS ≥ 50) and depressive symptoms (EPDS ≥ 13) were 45.0% and 37.0%, respectively. The women reported moderate level of social support. The low and moderate level of social support and education of high school or below were the predictors for anxiety and depressive symptoms. The other predictors for anxiety symptoms were having been married for ≥5 years and no child. Another predictor for depressive symptoms was aged ≥35 years. Anxiety predicted depressive symptoms. Conclusion: The results suggest early routine screening for anxiety and depressive symptoms amongst the Chinese pregnant women with a history of recurrent miscarriage. Health-care professionals should give more effort to enhance these women's social support to decrease their anxiety and depressive symptoms.

The Prevalence of Anxiety Disorders During Pregnancy and the Postpartum Period: A Multivariate Bayesian Meta-Analysis

OBJECTIVE

To estimate the prevalence of anxiety disorders in pregnant and postpartum women and identify predictors accounting for variability across estimates.

DATA SOURCES

An electronic search of PsycINFO and PubMed was conducted from inception until July 2016, without date or language restrictions, and supplemented by articles referenced in the obtained sources. A Boolean search phrase utilized a combination of keywords related to pregnancy, postpartum, prevalence, and specific anxiety disorders.

STUDY SELECTION

Articles reporting the prevalence of 1 or more of 8 common anxiety disorders in pregnant or postpartum women were included. A total of 2,613 records were retrieved, with 26 studies ultimately included.

DATA EXTRACTION

Anxiety disorder prevalence and potential predictor variables (eg, parity) were extracted from each study. A Bayesian multivariate modeling approach estimated the prevalence and between-study heterogeneity of each disorder and the prevalence of having 1 or more anxiety disorder.

RESULTS

Individual disorder prevalence estimates ranged from 1.1% for posttraumatic stress disorder to 4.8% for specific phobia, with the prevalence of having at least 1 or more anxiety disorder estimated to be 20.7% (95% highest density interval [16.7% to 25.4%]). Substantial between-study heterogeneity was observed, suggesting that "true" prevalence varies broadly across samples. There was evidence of a small (3.1%) tendency for pregnant women to be more susceptible to anxiety disorders than postpartum women.

CONCLUSIONS

Peripartum anxiety disorders are more prevalent than previously thought, with 1 in 5 women in a typical sample meeting diagnostic criteria for at least 1 disorder. These findings highlight the need for anxiety screening, education, and referral in obstetrics and gynecology settings.

Neonatal intensive care unit admission and maternal postpartum depression

Objective: This study aimed to examine the impact of newborns' Neonatal Intensive Care Unit (NICU) admittance on maternal postpartum depression. Background: Prior research on the parental psychological impacts of a NICU admittance typically includes a hospital sample of parents following birth, so the causality of NICU admittance and maternal depressive symptomatology is unclear. Methods: 127 women across 38 counties in a South Central US state participated in online surveys in their third trimester and approximately six weeks post-birth in 2016. Pre- and post-birth assessments of depression were measured with the Center for Epidemiologic Studies Depression Scale (CES-D). NICU admittance was asked in the post-birth survey. t-Tests and multivariable regression analyses were used to determine predictors of NICU admittance and postnatal depressive symptomatology. Results: Findings indicate that prenatal depression does not differ significantly between mothers by NICU admission status, but NICU admission is a significant predictor of postpartum depressive symptomatology. Conclusions: Having a newborn admitted to the NICU is a risk factor for maternal postpartum depression. These findings have implications for practice; screening mothers in the NICU for depression as a target for intervention has the potential to improve maternal well-being, which in turn should enhance subsequent infant developmental outcomes.

Help Seeking in the Perinatal Period: A Review of Barriers and Facilitators

Perinatal depression affects approximately 10 to 20 percent of women during pregnancy or the first 12 months postpartum. Increased attention has been given to the prevalence of and screening for perinatal depression, yet little research addresses help seeking for this issue. The overall barriers and facilitators of help seeking among these women have yet to be addressed in a systematic way. A systematic literature review was conducted to identify studies that focused on help seeking among women with perinatal depression. Nineteen articles met the inclusion criteria discussed below and were included in this review. Barriers to help seeking for women with perinatal depression include social (e.g. stigma), structural (e.g. provider unavailable) and instrumental factors (e.g. cost). Facilitators of help seeking for women with perinatal depression were limited in scope. Recommendations for policy and the role of social workers are discussed.

Pregnancy complications, sick leave and service needs of women who experience perinatal distress, weak social support and dissatisfaction in their partner relationships

INTRODUCTION

Although perinatal distress is acknowledged as a burdening condition for pregnant women, its effects on pregnancy are not well known. This study was conducted to increase knowledge regarding the effects of distress on pregnancy-related problems. The study also assessed women's need for sick leave and increased prenatal care due to distress, and the effects of weak social support and dissatisfaction with their partner relationships.

METHODS

In total, 2523 women were screened for perinatal distress three times during pregnancy in this quantitative cohort study. Structured psychiatric interviews were conducted following the screening, with 562 of the participants. Data from participants' pregnancy records were also analysed. The study was conducted in primary healthcare centres in Iceland after receiving approval from the Icelandic National Bioethical Committee. The main outcome measures were pregnancy problems, sick leave issued and prenatal service needs.

RESULTS

Data from 503 women were analysed. The perinatal distress group (PDG) was significantly more likely than was the nondistressed group (NDG) to experience fatigue, vomiting and pelvic pain after controlling for background variables. Distressed women who reported weak family support experienced symptoms of nausea and heartburn. The PDG needed more frequent prenatal care than did the NDG and was issued sick leave for up to 42 days longer. Dissatisfaction in the partner relationship and with the division of household tasks and childcare was strongly associated with distress, the development of complications and the need for sick leave.

DISCUSSION

Identification of perinatal distress by midwives and other healthcare professionals is important, since distress may be linked to women's complaints of fatigue, vomiting, pelvic pain and need for prolonged sick leave, and additional prenatal care services will be needed. Perceived dissatisfaction in the partner relationship and with the division of household tasks should also form part of clinical practice and assistance provided.

Maternal psychological distress after severe pregnancy hypertension was associated with increased child behavioural problems at the age of 12

AIM

We examined the association between early maternal psychological distress after severe hypertensive disorders of pregnancy (HDP) and behavioural issues in their 12-year-old offspring.

METHODS

This secondary analyses of a prospective mother-child birth cohort focused on 95 women with severe HDP and their singleton offspring. The mothers were recruited during pregnancy from 2000 to 2003 in Amsterdam, the Netherlands. Maternal distress at child term age and three months post-term was measured using the Symptom Checklist-90. The Child Behaviour Checklist for six years to 18 years was used to quantify social and attention problems in their offspring at 12 years of age. Perinatal and neonatal risk factors were also analysed.

RESULTS

The children were born at a mean age of just under 32 weeks and 90% weighed below the 10th percentile. High psychological distress (score ≥133) affected 45% of the mothers at term age and 44% three months post-term. Child social problems were significantly associated with maternal distress at three months and were highest in cases of high maternal distress in combination with major neonatal morbidity. Child attention problems were associated with maternal anxiety at three months post-term.

CONCLUSION

Early maternal psychological distress after severe maternal HDP was associated with childhood behavioural issues at the age of 12.

Recorded Diagnoses of Depression During Delivery Hospitalizations in the United States, 2000-2015

OBJECTIVE

To describe national, state-specific, and sociodemographic trends in diagnoses of depressive disorders recorded during delivery hospitalizations.

METHODS

Data were analyzed from the National Inpatient Sample (2000-2015) and 31 publicly available State Inpatient Databases (2000-2015) of the Healthcare Cost and Utilization Project. Delivery hospitalizations were identified by using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic and procedure codes for obstetric delivery. Depressive disorders were identified from ICD-9-CM diagnoses codes classified as depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (291.89, 292.84, 293.83, 296.2-296.26, 296.3-296.36, 300.4, and 311). Prevalence rates and average annual rate change were calculated nationally and across 28 states with at least 3 years of data and age, payer source, and race or ethnicity.

RESULTS

The U.S. rate of depressive disorders recorded during delivery hospitalizations increased from 4.1 diagnoses per 1,000 hospitalizations in 2000 to 28.7 in 2015. Rates significantly increased in 27 of the 28 states. Recent (2014-2015) rates were lowest in Hawaii and Nevada (less than 14/1,000) and highest in Vermont, Minnesota, Oregon, and Wisconsin (greater than 49/1,000). Rates in 2015 were highest among those aged 35 years or older, public insurance recipients, and non-Hispanic white women (greater than 31/1,000). The highest annual rate increases were in Vermont and Maine (3.8/1,000 or greater). Non-Hispanic white women, those 35 years of age or older, and public insurance recipients showed the highest annual rate increases during 2000-2015 (1.7/1,000 or greater).

CONCLUSION

During 2000-2015, rates of depressive disorders recorded during delivery hospitalizations increased nationally, in 27 states with available data, and across all sociodemographic categories.

Use of antidepressants and anxiolytics in early pregnancy and the risk of preeclampsia and gestational hypertension: a prospective study

Background

We investigated the association between antidepressant and anxiolytic exposure during the first and early second trimester of pregnancy (< 16 weeks), and hypertensive disorders of pregnancy (including preeclampsia and gestational hypertension) in women with singleton pregnancy.

Methods

This study is based on a large prospective cohort of 7866 pregnant women. We included pregnant women aged 18 years or older without chronic hepatic or renal disease at the time of recruitment. Participants lost to the follow-up, with multiple pregnancies and pregnancy terminations, miscarriages or fetal deaths before 20 weeks of gestation were excluded from the study, as well as women with no data on the antidepressant/anxiolytic medication use during pregnancy. Information concerning antidepressant or anxiolytic medication use was extracted from hospital records after delivery. The associations between their use and the risk of gestational hypertension or preeclampsia were calculated.

Results

The final sample for analysis included 6761 participants including 218 (3.2%) women who were exposed to antidepressant and/or anxiolytic medication before the 16th week of gestation. Forty-one women had a non-medicated depression or anxiety during the pregnancy. Moreover, 195 (2.9%) and 122 (1.8%) women developed gestational hypertension and preeclampsia respectively. When compared to women unexposed to antidepressant/anxiolytic medication, depression and anxiety, those using antidepressant and/or anxiolytic drugs before the 16th week of gestation were at increased risk of preeclampsia (adjusted odd ratio (aOR) 3.09 [CI_95% 1.56–6.12]), especially if they continued their medication after the 16th week (aOR 3.41 [CI_95% 1.66–7.02]) compared to those who did not (1.60 [CI_95% 0.21–12.34]).

Conclusions

Women exposed to antidepressant and/or anxiolytic medication before the 16th week of pregnancy have a 3-fold increased risk for preeclampsia when compared to women unexposed to antidepressant/anxiolytic medication, depression and anxiety. Also, our results suggested that women who stopped their medication before the 16th week of pregnancy could be benefit from reduced preeclampsia risk.

At the forefront of psychoneuroimmunology in pregnancy: Implications for racial disparities in birth outcomes PART 1: Behavioral risks factors

Birth prior to full term is a substantial public health issue. In the US, ˜400,000 babies per year are born preterm (<37 weeks), while>1 million are early term (37-38^6/7 weeks). Birth prior to full term confers risk both immediate and long term, including neonatal intensive care, decrements in school performance, and increased mortality risk from infancy through young adulthood. Risk for low birth weight and preterm birth are 1.5-2 times greater among African Americans versus Whites. Psychosocial stress related to being a member of a discriminated racial minority group contributes substantially to these racial disparities. Providing promising targets for intervention, depressed mood, anxiety, and poor sleep are each linked with exposure to chronic stress, including racial discrimination. A rigorous transdisciplinary approach addressing these gaps holds great promise for clinical impact in addressing racial disparities as well as ameliorating effects of stress on perinatal health more broadly. As will be reviewed in a companion paper, the mechanistic roles of physiological sequelae to stress - including neuroendocrine, inflammatory regulation, biological aging, and the microbiome - also require delineation.

Antenatal predictors of incident and persistent postnatal depressive symptoms in rural Ethiopia: a population-based prospective study

Background

There have been few studies to examine antenatal predictors of incident postnatal depression, particularly in low- and middle-income countries (LMICs). The aim of this study was to investigate antenatal predictors of incident and persistent maternal depression in a rural Ethiopian community in order to inform development of antenatal interventions.

Method

A population-based prospective study was conducted in Sodo district, south central Ethiopia. A locally validated version of the Patient Health Questionnaire (PHQ-9) was used to assess antenatal (second and third trimesters) and postnatal (4–12 weeks after childbirth) depressive symptoms, with a PHQ-9 cut-off of five or more indicating high depressive symptoms. Poisson regression with robust standard errors was used to identify independent predictors of persistence and incidence of postnatal depressive symptoms from a range of antenatal, clinical and psychosocial risk factors.

Result

Out of 1311 women recruited antenatally, 1240 (356 with and 884 without antenatal depressive symptoms) were followed up in the postnatal period. Among 356 women with antenatal depressive symptoms, the elevated symptoms persisted into postnatal period in 138 women (38.8%). Out of 884 women without antenatal depressive symptoms, 136 (15.4%) experienced incident elevated depressive symptoms postnatally. The prevalence of high postnatal depressive symptoms in the follow-up sample was 274 (22.1%). Higher intimate partner violence scores in pregnancy were significantly associated with greater risk of incident depressive symptoms [adjusted Risk Ratio (aRR) = 1.06, 95% CI: 1.00, 1.12]. Each 1-point increment in baseline PHQ-9 score predicted an increased risk of incidence of postnatal depressive symptoms (aRR = 1.29, 95% CI: 1.15, 1.45). There was no association between self-reported pregnancy complications, medical conditions or experience of threatening life events with either incidence or persistence of depressive symptoms.

Conclusion

Psychological and social interventions to address intimate partner violence during pregnancy may be the most important priorities, able to address both incident and persistent depression.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0690-0) contains supplementary material, which is available to authorized users.

Effect of Self-care Before and During Pregnancy to Prevention and Control Preeclampsia in High-risk Women

Our aims to examine the factors influencing self-care for the prevention and control of preeclampsia in high-risk women. The current study is a review where the researcher browsed the available databases such as PubMed, Cochrane, Medline, Google Scholar, Medscape, and relevant research published between 1980 and 2016 were studied. To search for articles, relevant Medical Subject Heading keywords were first determined (Self-care, preeclampsia, prevention.) A total of 350 related articles were first selected, and the findings of 70 were used to compile the present article. The results of the study were classified under two general categories, including (1). Counseling and screening strategies and (2) self-care strategies for the prevention and control of preeclampsia in high-risk women. Screening women at risk for preeclampsia include measures such as measuring their blood pressure, checking for signs of depression, testing for thrombosis, taking a history of preeclampsia, providing preconception counseling about the appropriate age, time of pregnancy, and encouraging weight loss in obese women. This review showed a positive relationship between knowledge about self-care for preeclampsia and its control. The factors influencing preeclampsia self-care include making lifestyle changes, having a healthy diet, learning stress management, performing exercise and physical activities, taking antioxidants, dietary supplements, and calcium and adherence to aspirin and heparin regimens. There is a positive relationship between preconception counseling, screening women at risk for preeclampsia, self-care for the prevention, and control of preeclampsia.

(1) Tweetable abstract self-care in high-risk women is strongly associated with prevention and control of preeclampsia.

Is there an association between maternal anxiety propensity and pregnancy outcomes?

Background

Several studies have shown inconsistent associations between anxiety during pregnancy and adverse pregnancy outcome. This inconsistency may be due to lack of controlling for the timing and type of maternal anxiety. We aimed to isolate a specific type of anxiety - maternal anxiety propensity, which is not directly related to pregnancy, and evaluate its association with adverse pregnancy outcome.

Methods

We conducted a prospective observational study of 512 pregnant women, followed to delivery. The trait anxiety scale of the State-Trait Anxiety Inventories was used in order to detect a propensity towards anxiety. The association between anxiety propensity (defined as trait-anxiety subscale score above 38) and adverse pregnancy outcome was evaluated. Primary outcome was a composite outcome including preterm birth prior to 37 gestational weeks, hypertensive disorders in pregnancy, small for gestational age newborn and gestational diabetes mellitus. Secondary outcomes were each one of the above mentioned gestational complications.

Results

There were no significant between-group differences in adverse pregnancy outcomes, including the rate of preterm birth, hypertensive disorders, small for gestational age, gestational diabetes or a composite outcome of them all.

Conclusion

Anxiety propensity is not associated with adverse pregnancy outcome.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1925-8) contains supplementary material, which is available to authorized users.

The relationship between maternal anxiety and cortisol during pregnancy and birth weight of chinese neonates

BACKGROUND

To determine the relationship between maternal anxiety and cortisol values and birth weight at various stages of pregnancy.

METHODS

Two hundred sixteen pregnant Chinese women were assessed for anxiety and depression and had measurement of morning fasting serum cortisol. Women were assessed either in the first (71), second (72) or third (73) trimester. Birth weights of all children were recorded.

RESULTS

There were significant negative correlations between anxiety level and birth weight of - 0.507 (p < 0.01) and - 0.275 (p < 0.05) in trimesters 1and 2. In trimester 3 the negative relation between anxiety and birth weight of -.209 failed to reach significance (p = 0.070). There was no relation between depression and birth weight in any trimester (p > 0.5 for all). Maternal cortisol was significantly inversely related to birth weight in trimester 1 (r = - 0.322) and with borderline significance in trimester 2 (r = - 0.229). Anxiety score and maternal cortisol were significantly correlated in each trimester (r = 0.551, 0.650, 0.537). When both anxiety score and maternal cortisol were simultaneously included in multiple regression analyses only anxiety score remained significant.

CONCLUSION

Whilst both maternal anxiety score and maternal cortisol are inversely related to birth weight the associations with anxiety score were more robust perhaps indicating the importance of mechanisms other than, or in addition to, maternal cortisol in mediating the effects of anxiety. The findings indicate the importance of measures to reduce maternal anxiety, particularly of a severe degree, at all stages of pregnancy.

TRIAL REGISTRATION

The study was approved by the Ethics Committee of the 1st Affiliated Hospital of Xi'an Jiaotong University.

Physical activity and depressive symptoms during pregnancy among Latina women: a prospective cohort study

BACKGROUND

Latina women are at increased risk for antenatal depressive disorders, which are common during pregnancy and are associated with elevated risk for poor maternal health and birth outcomes. Physical activity is a potential mechanism to reduce the likelihood of depressive symptoms. The purpose of the study was to assess whether total and domain-specific physical activity in early pregnancy reduced risk for elevated antenatal depressive symptoms in mid-late pregnancy in a population of Latina women at high-risk for depression.

METHODS

Data from 820 Latina participants in the prospective cohort study Proyecto Buena Salud was examined using multivariable logistic regression. Total, moderate/vigorous, and domain-specific physical activity (household/caregiving, occupational, sports/exercise, transportation) were assessed using the Pregnancy Physical Activity Questionnaire. The Edinburgh Postnatal Depression Scale was used to assess depressive symptoms and identify women with elevated symptoms indicative of at least probable minor depression and probable major depression.

RESULTS

A total of 25.9% of participants experienced at least probable minor depression and 19.1% probable major depression in mid-late pregnancy. After adjusting for important risk factors, no significant associations were observed between total physical activity (4th Quartile vs.1st Quartile OR = 1.02, 95% CI = 0.61, 1.71; p-trend = 0.62) or meeting exercise guidelines in pregnancy (OR = 0.96, 95% CI = 0.65, 1.41) and at least probable minor depression; similarly, associations were not observed between these measures and probable major depression. There was a suggestion of increased risk of probable major depression with high levels of household/caregiving activity (4th Quartile vs 1st Quartile OR = 1.51, 95% CI = 0.93, 2.46), but this was attenuated and remained not statistically significant after adjustment. When we repeated the analysis among women who did not have elevated depressive symptoms in early pregnancy (n = 596), findings were unchanged, though a nonsignificant protective effect was observed for sport/exercise activity and probable major depression in fully adjusted analysis (OR = 0.63, 95% CI = 0.30, 1.33).

CONCLUSION

Among Latina women at high-risk for antenatal depression, early pregnancy physical activity was not associated with elevated depressive symptoms in mid-to-late pregnancy.

Prevalence and Associated Factors of Perinatal Depression in Ethiopia: A Systematic Review and Meta-Analysis

BACKGROUND

There is no pooled evidence regarding the prevalence and potential associated factors of perinatal depression in Ethiopian community. Hence, the current review aimed to examine the prevalence and associated factors of perinatal depression in Ethiopia.

METHOD

A computerized systematic literature search was made in MEDLINE, Scopus, PubMed, ScienceDirect, and Google Scholar. Each database was searched from its start date to January 2018. All included articles were published in English, which evaluated prevalence and associated factors of perinatal depression in Ethiopia. Pooled estimations with 95% confidence interval (CI) were calculated with DerSimonian-Laird (DL) random-effects model. Publication bias was evaluated by using inspection of funnel plots and statistical tests.

RESULT

Eight observational studies with an overall sample size of 4624 mothers were included in the review. The pooled prevalence of perinatal depression from these studies reported that the prevalence of perinatal depression in Ethiopia is 25.8% [95% CI, 24.6%-27.1%]. A pervious history of depression [RR: 3.78 (95% CI, 2.18-6.57), I2 = 41.6%], poor socioeconomic status [RR: 4.67 (95% CI, 2.89-7.53), I2 = 0%], not living with spouse [RR: 3.76 (95% CI, 1.96-7.38), I2 = 36.4%], having obstetric complications in previous and/or this pregnancy [RR: 2.74 (95% CI, 1.48-5.06), I2 = 67.7%], and having unplanned pregnancy [RR: 2.73 (95% CI, 2.11-3.53), I2 = 0%] were the major factors associated with perinatal depression.

CONCLUSION

The pooled prevalence of perinatal depression in Ethiopia is far above most developed as well as developing countries. Hence, to realize the sustainable development goals (SDGs) outlined by united nation, much attention should be given to improve maternal mental health through reduction of identified modifiable factors. Maternal health programs, polices, and activities should incorporate maternal mental health as a core component.

Diabetes, Prenatal Depression, and Self-Rated Health in Latina Mothers

BACKGROUND

Latinas in the United States have elevated rates of diabetes and prenatal depression (PND). The presence of diabetes and PND can also have a negative effect on women's self-rated health (SRH), a commonly used indicator of health that is consistent with objective health status and is a predictor of mortality. However, the associations between PND, diabetes, and SRH have not been tested, particularly among Latinas, who have elevated risk of both medical conditions. To address this gap, this pilot study tested the association between PND and diabetes using data from Latinas enrolled during their third trimester of pregnancy and explored whether these health conditions were associated with SRH in these women.

METHODS

For this study, the Edinburgh Postnatal Depression Scale was used to determine PND status, self-reported medical history to determine diabetes status, and SRH before and during the current pregnancy in a sample of 34 prenatal Latinas. Participants were invited to take part in the study in their third trimester of pregnancy. Bivariate analyses and logistic regressions were used to test associations between demographic variables, PND, diabetes, and SRH.

RESULTS

There was no significant association between PND and diabetes status in this sample of Latinas. There was a significant difference in SRH from pre-pregnancy to pregnancy, with worse ratings reported during pregnancy. Furthermore, women with PND or diabetes reported worse SRH, even after controlling for pre-pregnancy SRH.

CONCLUSION

SRH is an important and robust variable associated with PND and diabetes in prenatal Latinas, making it an important factor to assess when treating this high-risk group.

Prenatal Selective Serotonin Reuptake Inhibitor Use and Associated Risk for Gestational Hypertension and Preeclampsia: A Meta-Analysis of Cohort Studies

BACKGROUND

To analyze existing cohort studies and provide evidence for the use of prenatal selective serotonin reuptake inhibitor (SSRI) monotherapy and the associated risk of gestational hypertension and preeclampsia.

METHODS

A comprehensive search of English language articles published before 30th April 2017 was conducted on PubMed, EMBASE, and the Web of Science databases. Using data acquired, we summarized the relative risks (RRs) and 95% confidence intervals (CIs) of gestational hypertension and preeclampsia using the random-effects model. Heterogeneity between studies was also assessed with the I² statistic.

RESULTS

Seven cohort studies with 1,108,261 individuals were included for analysis. Compared with nonusers, those undertaking prenatal SSRI monotherapy were more likely to develop gestational hypertension or preeclampsia (summarized RR = 1.21, 95% CI: 1.05-1.40, I² = 71.3%), gestational hypertension (summarized RR = 1.14, 95% CI: 1.00-1.30, I² = 5.7%), and preeclampsia (summarized RR = 1.32, 95% CI: 0.99-1.78, I² = 83.3%). In addition, although subgroup analyses, which were stratified by study design, number of cases, geographic location, duration of SSRI monotherapy, registry databases, and adjustment for potential confounders and risk factors, were consistent with the main findings, not all of these showed statistical significance. No evidence of publication bias was detected.

CONCLUSIONS

Women who receive SSRI monotherapy during pregnancy are at increased risk of gestational hypertension and preeclampsia.

The association between maternal cortisol and depression during pregnancy, a systematic review

Timing of cortisol collection during pregnancy is an important factor within studies reporting on the association between maternal cortisol and depression during pregnancy. Our objective was to further examine the extent to which reported associations differed across studies according to time of maternal cortisol collection during pregnancy. On December 15, 2016, records were identified using PubMed/MEDLINE (National Library of Medicine), EMBASE (Elsevier; 1974-), Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCO), PsycINFO (EBSCO), and Web of Science Core Collection (Thomson Reuters). Unique abstracts were screened using the following inclusion criteria: (1) maternal cortisol assessed during pregnancy; (2) antepartum depression assessed during pregnancy using a screening instrument; (3) reports on the association between maternal cortisol and antepartum depression; (4) provides information on timing of cortisol assessment during pregnancy, including time of day and gestation; and (5) not a review article or a case study. One thousand three hundred seventy-five records were identified, resulting in 826 unique abstracts. Twenty-nine articles met all inclusion criteria. On balance, most studies reported no association between maternal cortisol and antepartum depression (N = 17), and saliva and blood were the most common reported matrices. Morning and second and third trimesters were the most common times of collection during pregnancy. Among studies reporting an association (N = 12), second-trimester and third-trimester cortisol assessments more consistently reported an association and elevated cortisol concentrations were observed in expected recovery periods. Our review adds to the existing literature on the topic, highlighting gaps and strategic next steps.

A psychosocial intervention to reduce gender-based violence and antepartum depressive symptoms in pregnant women in Kisumu County, Kenya: a quasi-experimental study

Introduction

Gender-based violence during pregnancy and its associated adverse health effects are disproportionately higher in developing countries like Kenya where screening for and management of gender-based violence is currently not part of routine antenatal care. This study assessed the effect of a psychosocial intervention on gender-based violence and antepartum depressive symptoms in pregnant women.

Methods

This quasi-experimental study compared gender-based violence and antepartum depression scores of 288 pregnant women in the two arms; one exposed to a psychosocial intervention and another receiving usual antenatal care. We used analysis of covariance to estimate the intervention effect and Chi-square to test the equality of proportions.

Results

The difference between the psychosocial intervention and the usual antenatal care group in the total intimate partner violence and physical violence scores was a significant, with small effect sizes of partial eta = 0.196 and 0.305 respectively. The two arms did not differ in terms of the proportion of women reporting other acts of gender-based violence by intimate and non-intimate partners post-intervention. The intervention group had significantly lower mean depression scores compared to the usual care group, post-intervention, with a medium effect size of 0.500.

Conclusion

This intervention aimed at reduction of gender-based violence and improvement of mental health of pregnant women is promising. Primary health care facilities in resource-constrained settings can take advantage of local capacity to deliver focused non-specialized psychosocial support to pregnant women experiencing violence.

Prevalence and predictors of anxiety disorders amongst low-income pregnant women in urban South Africa: a cross-sectional study

Anxiety is highly prevalent in many populations; however, the burden of anxiety disorders amongst pregnant women in low-resource settings is not well documented. We investigated the prevalence and predictors of antenatal anxiety disorders amongst low-income women living with psychosocial adversity. Pregnant women were recruited from an urban, primary level clinic in Cape Town, South Africa. The Mini-International Neuropsychiatric Interview diagnostic interview assessed prevalence of anxiety disorders. Four self-report questionnaires measured psychosocial characteristics. Logistic regression models explored demographic and socioeconomic characteristics, psychosocial risk factors and psychiatric comorbidity as predictors for anxiety disorders. Amongst 376 participants, the prevalence of any anxiety disorder was 23%. Although 11% of all women had post-traumatic stress disorder, 18% of the total sample was diagnosed with other anxiety disorders. Multivariable analysis revealed several predictors for anxiety including a history of mental health problems (adjusted odds ratio [AOR] 4.11; 95% confidence interval (CI) 2.03-8.32), Major depressive episode (MDE) diagnosis (AOR 3.83; CI 1.99-7.31), multigravidity (AOR 2.87; CI 1.17-7.07), food insecurity (AOR 2.57; CI 1.48-4.46), unplanned and unwanted pregnancy (AOR 2.14; CI 1.11-4.15), pregnancy loss (AOR 2.10; CI 1.19-3.75) and experience of threatening life events (AOR 1.30; CI 1.04-1.57). Increased perceived social support appeared to reduce the risk for antenatal anxiety (AOR 0.95; CI 0.91-0.99). A range of antenatal anxiety disorders are prevalent amongst pregnant women living in low-resource settings. Women who experience psychosocial adversity may be exposed to multiple risk factors, which render them vulnerable to developing antenatal anxiety disorders.

Predictors and Patterns of Psychiatric Treatment Dropout During Pregnancy Among Low-Income Women

Objective This study compared psychiatric treatment discontinuation rates among pregnant women using psychotropic medications, outpatient psychotherapy, or both before conception. Methods Using data from Pennsylvania Medicaid Fee-For-Service and Managed Care Organization claims and Medicaid enrollment, 3030 women were identified who gave birth between 2007 and 2009, had ≥ 1 claim for psychiatric treatment during the 120 days prior to pregnancy, and were enrolled in Medicaid until they delivered. Kaplan-Meier and Cox regression analyses were used to estimate psychiatric treatment dropout rate during pregnancy and examine relationships between treatment dropout and age, race/ethnicity, and pre-pregnancy psychiatric diagnosis and treatment pattern. Results After the first trimester, the probability of discontinuing psychotropic medications was 83 versus 37.8% for cessation of psychotherapy among combined treatment users. Two or more psychotherapy sessions in the 4 months prior to pregnancy were associated with decreased psychotherapy dropout during pregnancy. Psychotherapy during pregnancy was associated with prenatal psychotropic medication adherence. Conclusions To retain women in treatment during pregnancy, when discontinuation from care is common, innovative models of care should consider type of pre-pregnancy mental healthcare and individual characteristics.

Glucocorticoid exposure induces preeclampsia via dampening 1,25-dihydroxyvitamin D3

The pathogenesis of preeclampsia (PE) involves a number of biological processes that may be directly or indirectly affected by glucocorticoid (GC) and vitamin D. GC exposure increases the risk of PE, and 1,25-dihydroxyvitamin D₃ (1,25-(OH)₂D₃) deficiency may result in PE. The purpose of the present study was to confirm the involvement of GC/1,25-(OH)₂D₃ axis in the pathogenesis of PE. In the study, cortisol levels of PE patients were found to be higher than that of non-complicated pregnancies, while 1,25-(OH)₂D₃ were decreased in both PE women and GC-induced PE rats. Mechanically, GC reduced 1,25-(OH)₂D₃ levels via disturbing its biosynthetic and catabolic enzymes, including Cyp3a1,Cyp24a1 and Cyp27b1, especially enhancing the expressions of Cyp3a1, the dominant enzyme for vitamin D degeneration. Moreover, replenishing 1,25-(OH)₂D₃ ameliorated the symptoms and placental oxidative stress of GC-induced rat PE. The protective actions of 1,25-(OH)₂D₃ might be explained by its roles in antagonizing the effects of GC on trophoblast proliferation and apoptosis. Together, these findings suggest that GC exposure could lead to PE via dampening 1,25-(OH)₂D₃ biosynthesis, and GC/1,25-(OH)₂D₃ axis might represent a common pathway through which PE occurs.

Racial/Ethnic Disparities in Antenatal Depression in the United States: A Systematic Review

Objectives More than 10 % of pregnant women in the United States (U.S.) suffer from depression, which has far-reaching consequences on maternal and fetal well-being. There is conflicting evidence regarding the prevalence of antenatal depression among different race and ethnic groups. This systematic review aimed to summarize the existing literature concerning racial/ethnic disparities in the prevalence and correlates of antenatal depression in the U.S. Methods PubMed, CINAHL and PsycINFO databases were searched online for research studies published in English in peer-reviewed journals until March 2015, using a pre-designed search strategy. Eligibility was determined using pre-specified criteria; and quality was assessed. Results Forty-one (41) articles met the criteria; 13 were cross-sectional, and 21 were longitudinal studies. Overall, the prevalence of antenatal depression was 10-30 %; it was higher among non-Hispanic blacks (NHBs) and Hispanics, compared to non-Hispanic whites (NHWs). Few studies looked at the correlates of depression by race/ethnicity. Among employed women, higher depression scores were observed among NHBs, compared to NHWs; while there was no racial difference among unemployed women. Racial difference and race-employment interaction disappeared once discrimination was accounted for. In another study, higher parity, higher stress, and lower self-esteem were significant correlates of depression among NHBs, while less satisfaction with social support, and higher stress predicted higher depression scores among NHWs and Hispanics respectively. Conclusions The findings of our review suggest that not only is antenatal depression a major public health issue that needs to be addressed, but different racial/ethnic groups seem to differ in their vulnerability and risk factors.

Correlation of hypertensive disorders in pregnancy with procedures of in vitro fertilization and pregnancy outcomes

We investigated the correlation of hypertensive disorders in pregnancy with different procedures of in vitro fertilization, and analyzed pregnancy outcomes of patients with hypertensive disorders in pregnancy. A retrospective analysis was performed on the medical records of 658 maternity patients who conceived through in vitro fertilization in Maternal and Child Health Hospital of Wuxi. Patients were divided into two groups according to different fertilization procedures: i) the routine in vitro fertilization-embryo transfer group (IVF-ET group, 377 cases) and ii) intra-cytoplasmic sperm injection-embryo transfer group (ICSI-ET group, 281 cases). Consequently, patients were further divided into two groups according to different embryo transfer cycles: the fresh embryo transfer group (F-ET group, 446 cases) and the frozen-thawed embryo transfer group (T-ET group, 212 cases). Characteristics of patients in each group were evaluated, and incidence of hypertensive disorders in pregnancy resulting from different assisted reproductive technology was compared. Among patients who conceived through IVF, there were 56 cases of hypertensive disorders in pregnancy, including 21 cases of gestational hypertension, 34 cases of pre-eclampsia and 1 case of eclampsia. The odds ratio (OR) of gestational hypertension in the comparison between the ICSI-ET and IVF-ET groups was 2.01 (0.81-4.74), and was reduced to 1.69 (0.70-4.02) after correction. The difference of OR in twin-birth patients of the two groups was statistically significant, but the difference in single-birth patients was not statistically significant. The odds ratio (OR) of gestational hypertension in the comparison between the F-ET and T-ET groups was 0.44 (0.13-1.34), and became 0.49 (0.15-1.51) after correction. The odds ratio of pre-eclampsia in the comparison between the ICSI-ET and IVF-ET groups was 1.36 (0.42-4.18), and was reduced to 1.17 (0.36-3.62) after correction. The odds ratio of pre-eclampsia in the comparison between the F-ET and T-ET groups was 0.93 (0.42-1.96), and became 0.98 (0.44-2.12) after correction. The differences were not statistically significant. The risk of onset of hypertensive disorders in pregnancy has a certain correlation with the ICSI fertilization technology, but has no apparent correlation with embryo transfer cycles.

A Multidimensional Approach to Characterizing Psychosocial Health During Pregnancy

Objectives Domains of psychosocial health have been separately connected to pregnancy outcomes. This study explores the relationship between five domains of psychosocial health and their joint association with prenatal health and pregnancy outcomes. Methods Women from a prospective cohort study in Durham, North Carolina were clustered based on measures of paternal support, perceived stress, social support, depression, and self-efficacy. Clusters were constructed using the K-means algorithm. We examined associations between psychosocial health and maternal health correlates, pregnancy intention, and pregnancy outcomes using Chi square tests and multivariable models. Results Three psychosocial health profiles were identified, with the first (Resilient; n = 509) characterized by low depression and perceived stress and high interpersonal support, paternal support, and self-efficacy. The second profile (Vulnerable; n = 278) was marked by high depression and perceived stress, and low interpersonal support, paternal support, and self-efficacy. The third profile (Moderate, n = 526) fell between the other profiles on all domains. Health correlates, pregnancy intention, and pregnancy outcomes varied significantly across profiles. Women with the vulnerable profile were more likely to have risky health correlates, have an unintended pregnancy, and deliver preterm. Women with the resilient profile had better birth outcomes and fewer deleterious health correlates, preconception and prenatally. Conclusions We posit that vulnerable psychosocial health, deleterious health correlates, and the stress which often accompanies pregnancy may interact to magnify risk during pregnancy. Identifying and intervening with women experiencing vulnerable psychosocial health may improve outcomes for women and their children.

Antenatal depressive symptoms and perinatal complications: a prospective study in rural Ethiopia

BACKGROUND

Antenatal depressive symptoms affect around 12.3% of women in in low and middle income countries (LMICs) and data are accumulating about associations with adverse outcomes for mother and child. Studies from rural, low-income country community samples are limited. This paper aims to investigate whether antenatal depressive symptoms predict perinatal complications in a rural Ethiopia setting.

METHODS

A population-based prospective study was conducted in Sodo district, southern Ethiopia. A total of 1240 women recruited in the second and third trimesters of pregnancy were followed up until 4 to 12 weeks postpartum. Antenatal depressive symptoms were assessed using a locally validated version of the Patient Health Questionnaire (PHQ-9) that at a cut-off score of five or more indicates probable depression. Self-report of perinatal complications, categorised as maternal and neonatal were collected by using structured interviewer administered questionnaires at a median of eight weeks post-partum. Multivariate analysis was conducted to examine the association between antenatal depressive symptoms and self-reported perinatal complications.

RESULT

A total of 28.7% of women had antenatal depressive symptoms (PHQ-9 score ≥ 5). Women with antenatal depressive symptoms had more than twice the odds of self-reported complications in pregnancy (OR=2.44, 95% CI: 1.84, 3.23), labour (OR= 1.84 95% CI: 1.34, 2.53) and the postpartum period (OR=1.70, 95% CI: 1.23, 2.35) compared to women without these symptoms. There was no association between antenatal depressive symptoms and pregnancy loss or neonatal death.

CONCLUSION

Antenatal depressive symptoms are associated prospectively with self-reports of perinatal complications. Further research is necessary to further confirm these findings in a rural and poor context using objective measures of complications and investigating whether early detection and treatment of depressive symptoms reduces these complications.

Risk of preeclampsia after gestational exposure to selective serotonin reuptake inhibitors and other antidepressants: A study from The Norwegian Mother and Child Cohort Study

Purpose

To describe the risk of early‐ and late‐onset preeclampsia across pregnancies exposed to antidepressants and to evaluate the impact of timing and length of gestational exposure to antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), on preeclampsia.

Methods

The Norwegian Mother and Child Cohort, a prospective population‐based study, and the Medical Birth Registry of Norway provided information on antidepressant exposure, depression, and anxiety symptoms in pregnancy, preeclampsia diagnoses, and important covariates. Within a pregnancy cohort of depressed women, we compared the risk of late‐onset preeclampsia between SSRI‐exposed and nonmedicated pregnancies using marginal structural models (weighted) and modified Poisson regression models.

Results

Of the 5887 pregnancies included, 11.1% were exposed at any time before week 34 to SSRIs, 1.3% to serotonin‐norepinephrine reuptake inhibitors, 0.4% to tricyclic antidepressants, and 0.5% to other antidepressants. The risks of early‐ and late‐onset preeclampsia by exposure status in pregnancy were 0.3% and 3.6% (nonmedicated), 0.4% and 3.7% (SSRIs), 1.5% and 4.1% (serotonin‐norepinephrine reuptake inhibitors), and 7.1% and 10.0% (tricyclic antidepressants). Compared with nonmedicated pregnancies, SSRI‐exposed in mid and late gestation had adjusted relative risks for late‐onset mild preeclampsia of 0.76 (95% confidence interval, 0.38‐1.53) and 1.56 (0.71‐3.44) (weighted models), respectively. There was no association between SSRI exposure in pregnancy and severe late‐onset preeclampsia.

Conclusions

We have provided evidence that SSRI use in early and midpregnancy does not substantially increase the risk of late‐onset preeclampsia.

Effect of prenatal exposure to maternal cortisol and psychological distress on infant development in Bengaluru, southern India: a prospective cohort study

BACKGROUND

The mental health status of a pregnant woman and its consequent impact on foetal well being is not given much importance compared to the risk imposed by obstetric complications and medical conditions. Maternal psychological distress is a major public health problem and needs timely detection and intervention to prevent any adverse pregnancy outcome. There is ample evidence from literature that justifies the association of prenatal maternal mental stress and elevated cortisol with delayed infant motor and cognitive development; evidence from India being rather limited. The study aim is to prospectively assess the association of maternal psychological distress and cortisol level with motor and cognitive development of the infant.

METHODS

A sample of 2612 eligible pregnant women who have been registered for antenatal care at selected public sector hospitals in Bengaluru will be recruited after obtaining written informed consent. They will be assessed for the presence of maternal psychological distress in the form of depression and anxiety using appropriate scales and saliva samples will be collected for cortisol estimation during early, mid and late pregnancy. Follow up visits after delivery will be done on day 10, 3 months, 8 months and 12 months. The Bayley Scales of Infant and Toddler Development [BSID] (Third edition) will be used to measure both motor and mental milestones in terms of Psychomotor Development Index (PDI) and Mental Development Index (MDI). Logistic regression model will be used to determine the association between the exposure variables and outcomes which will be reported as Odd's Ratio (OR) and 95% confidence intervals (CI).

DISCUSSION

Our study findings could add to the growing evidence that maternal psychological distress during pregnancy adversely influences growth and development in the offspring and subsequent development of the child. While maternal anxiety and depression can be measured by using self reporting instruments, estimation of maternal endogenous cortisol levels could serve as a biomarker of prenatal psychological stress. Findings from this study could be used to focus upon the burden of mental health problems during pregnancy and to consider steps to scale up prenatal mental health services in health care settings.

Antenatal depressive symptoms and utilisation of delivery and postnatal care: a prospective study in rural Ethiopia

BACKGROUND

Uptake of delivery and postnatal care remains low in Low and Middle-Income Countries (LMICs), where 99% of global maternal deaths take place. However, the potential impact of antenatal depression on use of institutional delivery and postnatal care has seldom been examined. This study aimed to examine whether antenatal depressive symptoms are associated with use of maternal health care services.

METHODS

A population-based prospective study was conducted in Sodo District, Southern Ethiopia. Depressive symptoms were assessed during pregnancy with a locally validated, Amharic version of the Patient Health Questionnaire (PHQ-9). A cut off score of five or more indicated possible depression. A total of 1251 women were interviewed at a median of 8 weeks (4-12 weeks) after delivery. Postnatal outcome variables were: institutional delivery care utilization, type of delivery, i.e. spontaneous or assisted, and postnatal care utilization. Multivariate logistic regression was used to examine the association between antenatal depressive symptoms and the outcome variables.

RESULTS

High levels of antenatal depressive symptoms (PHQ score 5 or higher) were found in 28.7% of participating women. Nearly two-thirds, 783 women (62.6%), delivered in healthcare institutions. After adjusting for potential confounders, women with antenatal depressive symptoms had increased odds of reporting institutional birth [adjusted Odds Ratio (aOR) =1.42, 95% Confidence Interval (CI): 1.06, 1.92] and increased odds of reporting having had an assisted delivery (aOR = 1.72, 95% CI: 1.10, 2.69) as compared to women without these symptoms. However, the increased odds of institutional delivery among women with antenatal depressive symptoms was associated with unplanned delivery care use mainly due to emergency reasons (aOR = 1.62, 95% CI: 1.09, 2.42) rather than planning to deliver in healthcare institutions.

CONCLUSION

Improved detection and treatment of antenatal depression has the potential to increase planned institutional delivery and reduce perinatal complications, thus contributing to a reduction in maternal morbidity and mortality.

Obstetrical, pregnancy and socio-economic predictors for new-onset severe postpartum psychiatric disorders in primiparous women

BACKGROUND

Childbirth is a potent trigger for the onset of psychiatric illness in women including postpartum depression (PPD) and postpartum psychosis (PP). Medical complications occurring during pregnancy and/or childbirth have been linked to postpartum psychiatric illness and sociodemographic factors. We evaluated if pregnancy and obstetrical predictors have similar effects on different types of postpartum psychiatric disorders.

METHOD

A population-based cohort study using Danish registers was conducted in 392 458 primiparous women with a singleton delivery between 1995 and 2012 and no previous psychiatric history. The main outcome was first-onset postpartum psychiatric episodes. Incidence rate ratios (IRRs) were calculated for any psychiatric contact in four quarters for the first year postpartum.

RESULTS

PPD and postpartum acute stress reactions were associated with pregnancy and obstetrical complications. For PPD, hyperemesis gravidarum [IRR 2.69, 95% confidence interval (CI) 1.93-3.73], gestational hypertension (IRR 1.84, 95% CI 1.33-2.55), pre-eclampsia (IRR 1.45, 95% CI 1.14-1.84) and Cesarean section (C-section) (IRR 1.32, 95% CI 1.13-1.53) were associated with increased risk. For postpartum acute stress, hyperemesis gravidarum (IRR 1.93, 95% CI 1.38-2.71), preterm birth (IRR 1.51, 95% CI 1.30-1.75), gestational diabetes (IRR 1.42, 95% CI 1.03-1.97) and C-section (IRR 1.36, 95% CI 1.20-1.55) were associated with increased risk. In contrast, risk of PP was not associated with pregnancy or obstetrical complications.

CONCLUSIONS

Pregnancy and obstetrical complications can increase the risk for PPD and acute stress reactions but not PP. Identification of postpartum women requiring secondary care is needed to develop targeted approaches for screening and treatment. Future work should focus on understanding the contributions of psychological stressors and underlying biology on the development of postpartum psychiatric illness.

Acculturative stress is associated with trajectory of anxiety symptoms during pregnancy in Mexican-American women

Over half of pregnant women report anxiety symptoms and these symptoms may be precipitated by stressful experiences. Anxiety rates may be higher in Mexican-American women who experience sociocultural stressors, such as acculturation, acculturative stress and discrimination. However, the role of such stressors on the trajectory of anxiety symptoms across pregnancy is not yet known. Mexican-American women (n=151) completed surveys across pregnancy about acculturation, acculturative stress, perceived discrimination, and state anxiety. Multilevel modeling found that acculturation (Anglo orientation, b=0.050, SE=0.379, t (137.561)=0.134, p=0.894; Mexican orientation, b=0.775, SE=0.692, t (133.424)=1.121, p=0.264) and perceived discrimination (b=-1.259, SE=0.921, t (137.489)=-1.367, p=0.174) were not associated with the trajectory of anxiety symptoms. However, acculturative stress, even while controlling for perceived stress, was associated with high levels of anxiety symptoms that were elevated early in pregnancy (b=-0.045, SE=0.022, t (135.749)=-2, p=0.047). This work highlights the unique role of acculturative stress in risk for prenatal anxiety in early pregnancy.

Was the Military Operation "Protective Edge" a Risk Factor for Pregnancy Complications?

OBJECTIVE

During July-August 2014, the military operation "Protective Edge" presented Israel with a threat of missile attacks. We aimed to investigate the influence of the "Protective Edge" operation on the rate of pregnancy complications among the population exposed to missile attacks, compared to the population not exposed.

STUDY DESIGN

This was a retrospective study. Pregnancy outcomes were compared between women who during pregnancy were exposed to the stress of the military operation (exposed group, n=4,673) and gave birth at the Wolfson Medical Center, and women who gave birth in the previous year (unexposed group, n=4,735).

RESULTS

Rates of pregnancy complications did not differ between the groups.

CONCLUSION

Exposure to environmental stress during pregnancy, for a period of almost two months, was not found to be associated with increased risk for pregnancy complications.

Interventions to treat mental disorders during pregnancy: A systematic review and multiple treatment meta-analysis

BACKGROUND

For women suffering from an antepartum mental disorder (AMD), there is lack of evidence-based treatment algorithms due to the complicated risk-benefit analysis for both mother and unborn child. We aimed to provide a comprehensive overview of pharmacological and non-pharmacological interventions to treat AMD and performed a meta-analysis of the estimated treatment effect on the psychiatric symptoms during pregnancy.

METHODS

MedLine, PsycINFO and Embase databases were searched by two independent reviewers for clinical trials with a control condition on treatment of women with AMD, i.e. major depressive (MDD), anxiety, psychotic, eating, somatoform and personality disorders. We inventoried the effect of the treatment, i.e. decrease of psychiatric symptoms at the end of the treatment or postpartum. We adhered to the PRISMA-protocol.

FINDINGS

Twenty-nine trials were found involving 2779 patients. Trials studied patients with depressive disorders (k = 28), and anxiety disorders (k = 1). No pharmacological trials were detected. A form of psychotherapy, like Cognitive Behavioural Therapy (g = -0.61; 95%CI:-0.73 to -0.49, I2 = 0%; k = 7) or Interpersonal Psychotherapy (g = -0.67; 95%CI:-1.27 to -0.07; I2 = 79%; k = 4), holds robust benefit for pregnant women with MDD. Body-oriented interventions (g = -0.43; 95%CI:-0.61 to -0.25; I2 = 17%; k = 7) and acupuncture (g = -0.43; 95%CI:-0.80 to -0.06; I2 = 0%; k = 2) showed medium sized reduction of depressive symptoms. Bright light therapy (g = -0.59; 95%CI:-1.25 to 0.06; I2 = 0%; k = 2), and food supplements (g = -0.51; 95%CI:-1.02 to 0.01; I2 = 20%; k = 3) did not show significant treatment effects. One study was found on Integrative Collaborative Care.

CONCLUSIONS

This meta-analysis found a robust moderate treatment effect of CBT for MDD during pregnancy, and to a lesser extent for IPT. As an alternative, positive results were found for body-oriented interventions and acupuncture. No evidence was found for bright light therapy and food supplements. Only non-pharmacological trials on women with MDD were found. Research on a wider range of AMD is needed.

Assessing perinatal depression as an indicator of risk for pregnancy-associated cardiovascular disease

Cardiovascular conditions associated with pregnancy are serious complications. In general, depression is a well-known risk indicator for cardiovascular disease (CVD). Mental distress and depression are associated with physiological responses such as inflammation and oxidative stress. Both inflammation and oxidative stress have been implicated in the pathophysiology of CVDs associated with pregnancy. This article discusses whether depression could represent a risk indicator for CVDs in pregnancy, in particular in pre-eclampsia and peripartum cardiomyopathy (PPCM).

Cerebral white matter lesions, subjective cognitive failures, and objective neurocognitive functioning: A follow-up study in women after hypertensive disorders of pregnancy

OBJECTIVE

Hypertensive disorders of pregnancy, like preeclampsia, are a leading cause of maternal and fetal morbidity/mortality worldwide. Preeclampsia can be complicated by the occurrence of convulsions (eclampsia). Women who experienced (pre)eclampsia more frequently report daily cognitive failures and showed increased emotional dysfunction several years later, but are not impaired on objective neurocognitive testing. In addition, women with preterm preeclampsia more often have cerebral white matter lesions (WML) on follow-up. We aimed to determine whether WML presence is related to cognitive dysfunction, anxiety, and depressive symptoms in (pre)eclamptic women.

METHOD

Forty-one eclamptic, 49 preeclamptic, and 47 control women who had a normotensive pregnancy completed the Cognitive Failures Questionnaire (CFQ), the Hospital Anxiety and Depression Scale (HADS), and a broad neurocognitive test battery (visual perception and speed of information processing, motor functions, working memory, long-term memory, attention, and executive functioning). All underwent cerebral magnetic resonance imaging (MRI), and WML presence was recorded. Median elapsed time since index pregnancy was 6 years. Average age was 40 years.

RESULTS

WML were more prevalent in women who had experienced preterm (pre)eclampsia (<37 weeks; 40%) than in controls (21%, p = .03). In (pre)eclamptic women, CFQ and HADS scores were higher than those in controls (44 ± 16.1 vs. 36 ± 11.0, p < .001, and 11 ± 6.3 vs. 8 ± 5.5, p < .001). There was no difference in objective cognitive performance as measured by neurocognitive tests. Subjective and objective cognitive functioning, anxiety, and depressive symptoms were not related to WML presence.

CONCLUSION

Formerly (pre)eclamptic women report cognitive dysfunction, but do not exhibit overt cognitive impairment when objectively tested on average 6 years following their pregnancy. The presence of WML is not related to objective nor to subjective cognitive impairment, anxiety, and depressive symptoms. Longitudinal studies are needed to study whether the presence of WML is a risk factor for developing objective cognitive impairment in the long term.

Premedication with midazolam prior to cesarean delivery in preeclamptic parturients: A randomized controlled trial

Background:

Anxiety is a concern in obstetrics, especially in preeclamptic mothers. Sedation is not commonly used in parturients for fear of adverse neonatal effect. We investigated maternal and neonatal outcome of midazolam as an adjuvant to spinal anesthesia for elective cesarean delivery.

Methods:

A prospective randomized controlled trial, in which eighty preeclamptic parturients received either an intravenous dose of 0.035 mg/kg of midazolam or an equal volume of normal saline, 30 min before spinal anesthesia. Maternal anxiety was assessed using Amsterdam Preoperative Anxiety and Information Scale (APAIS); postoperative maternal satisfaction was assessed using Maternal Satisfaction Scale for Cesarean Section (MSSCS). Newborns were assessed using Apgar score, Neonatal Neurologic and Adaptive Capacity Score (NACS), and umbilical artery blood gases.

Results:

Mothers premedicated with midazolam showed a lower level of preoperative anxiety and a higher degree of postoperative satisfaction than the control group. There were no between-group differences regarding the neonatal outcome.

Conclusion:

Preeclamptic parturients premedicated with midazolam (0.035 mg/kg) before spinal anesthesia have lower anxiety and higher postoperative satisfaction levels, with no adverse effects on the newborns.

Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries

Maternal depression, a non-psychotic depressive episode of mild to major severity, is one of the major contributors of pregnancy-related morbidity and mortality. Maternal depression (antepartum or post partum) has been linked to negative health-related behaviours and adverse outcomes, including psychological and developmental disturbances in infants, children, and adolescents. Despite its enormous burden, maternal depression in low-income and middle-income countries remains under-recognised and undertreated. In this Series paper, we systematically review studies that focus on the epidemiology of perinatal depression (ie, during antepartum and post-partum periods) among women residing in low-income and middle-income countries. We also summarise evidence for the association of perinatal depression with infant and childhood outcomes. This review is intended to summarise findings from the existing literature, identify important knowledge gaps, and set the research agenda for creating new generalisable knowledge pertinent to increasing our understanding of the prevalence, determinants, and infant and childhood health outcomes associated with perinatal depression. This review is also intended to set the stage for subsequent work aimed at reinforcing and accelerating investments toward providing services to manage maternal depression in low-income and middle-income countries.

Impact of gestational risk factors on maternal cardiovascular system

BACKGROUND

Scarce evidence is available on the potential cardiovascular abnormalities associated with some common gestational complications. We aimed to analyze the potential maternal cardiac alterations related to gestational complications, including body mass index (BMI) >25 kg/m(2), gaining excessive weight, or developing antenatal depression.

METHODS

The design of this study was a secondary analysis of a randomized controlled trial. Echocardiography was performed to assess cardiovascular indicators of maternal hemodynamic, cardiac remodeling and left ventricular (LV) function in 59 sedentary pregnant women at 20 and 34 weeks of gestation.

RESULTS

Starting pregnancy with a BMI >25 kg/m(2), gaining excessive weight, and developing antenatal depression had no cardiovascular impact on maternal health (P value >0.002). Depressed women were more likely to exceed weight gain recommendations than non-depressed women (P value <0.002).

CONCLUSIONS

The evaluated gestational complications seem not to induce cardiovascular alterations in hemodynamic, remodeling and LV function indicators. However, developing antenatal depression increases the risk of an excessive weight gain. This finding is potentially important because excessive weight gain during pregnancy associates with a higher risk of cardiovascular diseases (CVD) later in life.

Ethnicity, Obesity and Emotional Factors Associated With Gestational Hypertension

Identifying factors that can be related to the occurrence of gestational arterial hypertension. The sample was composed by 105 pregnant women in their third trimester of gestation, during the period between September 2013 and August 2014. General assessment questionnaires together with a questionnaire to evaluate anxiety (STAI-A-STATE) were applied; arterial blood pressure values were collected. To classify anxiety, a mean of the final result of all the questionnaires gotten was calculated. Pregnant women who showed scores higher than the mean were considered anxious. All data were analyzed by a logistic regression. The significance level adopted was 0.05. A data analysis allowed us to verify that 92.38% of the pregnant women had an anxious personality STAI-A-STATE and 12.38% of them had a momentary hypertension. The momentary hypertension showed a correlation between the hypertension and the state anxiety score (p = 0.049). The hypertension showed an association with the presence of depression (OR 8.69), obesity (OR 6.45), anxiety (OR 7.77), nausea (OR 12.79) and non-white race (OR 8.18). According to the study realized, the factors non-white race, depression, nausea, obesity and anxiety can be considered risk factors for the occurrence of gestational arterial hypertension. Based on these findings, a high quality prenatal assistance is considered of prime importance.

Safety of Selective Serotonin Reuptake Inhibitors in Pregnancy: A Review of Current Evidence

Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed antidepressant medications worldwide. However, over the past decade, their use during pregnancy, a period of extreme vulnerability to the onset of depression, has become highly concerning to patients and their healthcare providers in terms of safety to the developing fetus. Exposure to SSRIs in pregnancy has been associated with miscarriage, premature delivery, neonatal complications, birth defects-specifically cardiac defects-and, more recently, neurodevelopmental disorders in childhood, specifically autism spectrum disorders. Studies addressing the effect of individual SSRIs indicate a small but higher risk for birth defects with maternal fluoxetine and paroxetine use. Though the excess in absolute risk is small, it may still be of concern to some patients. Meanwhile, antenatal depression itself is associated with adverse perinatal outcomes, and discontinuing antidepressant treatment during pregnancy is associated with a high risk of relapse of depression. Whether the observed adverse fetal effects are related to the mother's medication use or her underlying maternal illness remains difficult to determine. It is important that every pregnant woman being treated with an SSRI (or considering such treatment) carefully weighs the risks of treatment against the risk of untreated depression for both herself and her child. The importance of recognizing a higher risk for the development of adverse outcomes lies in the potential for surveillance and possibly a timely intervention. Therefore, we recommend that pregnant women exposed to any SSRI in early pregnancy be offered options for prenatal diagnosis through ultrasound examinations and fetal echocardiography to detect the presence of birth defects. Tapering off or switching to other therapy in early pregnancy, if appropriate for the individual, may also be considered on a case-by-case basis.

Pregnancy-related anxiety: Evidence of distinct clinical significance from a prospective longitudinal study

BACKGROUND

Pregnancy-related anxiety (PrA) has attracted considerable research attention, but questions remain about its distinctiveness from conventional constructs and measures. In a high psychosocial risk, ethnically diverse sample, we examine the degree to which PrA is distinct from continuous and diagnostic measures of anxiety and worry in terms of longitudinal course, associations with psychosocial and perinatal risk, and prediction of postnatal mood disturbance.

METHODS

345 women oversampled for prenatal anxiety and depression were selected from an urban obstetrics clinic serving a predominantly low-income, ethnically diverse population. PrA was assessed at 20 and 32 weeks gestation; anxiety and depression symptoms were assessed from questionnaire and from clinical interview at 20 and 32 weeks gestation and again at 2 and 6 months postnatally. Data relevant to psychosocial and obstetric risks were ascertained from interview, medical exam, and chart review.

RESULTS

Two distinct factors of PrA were identified, indexing specific concerns about the child's health and about the birth; these two PrA factors showed distinct longitudinal patterns in the prenatal period, and modest associations with general measures of anxiety and depression from questionnaire and clinical interview. PrA was also distinguished from conventional symptom measures in its associated features and prediction of birth weight and postnatal mood.

LIMITATIONS

The sample was at high psychosocial risk and ethnically diverse; findings may not generalize to other samples.

CONCLUSIONS

PrA can be distinguished from general measures of anxiety in pregnancy in terms of longitudinal course, associated features, and prediction to postnatal mood disturbance, and may warrant specific clinical attention.

Stop or go? Preventive cognitive therapy with guided tapering of antidepressants during pregnancy: study protocol of a pragmatic multicentre non-inferiority randomized controlled trial

BACKGROUND

Approximately 6.2 % of women in the USA and 3.7 % of women in the UK, use Selective Serotonin Reuptake Inhibitors (SSRIs) during their pregnancies because of depression and/or anxiety. In the Netherlands, this prevalence is around 2 %. Nonetheless, SSRI use during pregnancy is still controversial. On the one hand SSRIs may be toxic to the intrauterine developing child, while on the other hand relapse or recurrence of depression during pregnancy poses risks for both mother and child. Among patients and professionals there is an urgent need for evidence from randomized studies to make rational decisions regarding continuation or tapering of SSRIs during pregnancy. At present, no such studies exist.

METHODS/DESIGN

'Stop or Go' is a pragmatic multicentre randomized non-inferiority trial among 200 pregnant women with a gestational age of less than 16 weeks who use SSRIs without clinically relevant depressive symptoms. Women allocated to the intervention group will receive preventive cognitive therapy with gradual, guided discontinuation of SSRIs under medical management (STOP). Women in the control group will continue the use of SSRIs (GO). Primary outcome will be the (cumulative) incidence of relapse or recurrence of maternal depressive disorder (as assessed by the Structured Clinical Interview for DSM disorders) during pregnancy and up to three months postpartum. Secondary outcomes will be child outcome (neonatal outcomes and psychomotor and behavioural outcomes up to 24 months postpartum), and health-care costs. Total study duration for participants will be therefore be 30 months. We specified a non-inferiority margin of 15 % difference in relapse risk.

DISCUSSION

This study is the first to investigate the effect of guided tapering of SSRIs with preventive cognitive therapy from early pregnancy onwards as compared to continuation of SSRIs during pregnancy. We will study the effects on both mother and child with a pragmatic approach. Additionally, the study examines cost effectiveness. If non-inferiority of preventive cognitive therapy with guided tapering of SSRIs compared to intended continuation of SSRIs is demonstrated for the primary outcome, this may be the preferential strategy during pregnancy.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR4694 ; registration date: 16-jul-2014.

The Relationship of Restless Legs Syndrome to History of Pregnancy-Induced Hypertension

BACKGROUND

Restless legs syndrome (RLS), a burdensome sleep disorder, has been associated with cardiovascular disease (CVD), hypertension, diabetes, and related disorders. However, the relationship of RLS to history of pregnancy-induced hypertension (PIH), a predictor of subsequent CVD, diabetes, and associated conditions, remains little explored. In this study, we investigated the relationship of RLS to history of PIH in a sample of primary care patients.

METHODS

Participants were women aged ≥40 years drawn from an anonymous survey study of West Virginia primary care patients. Data collected included detailed information on demographics, lifestyle factors, sleep patterns, and reproductive/medical history; the survey also included an RLS diagnostic questionnaire. Women who were pregnant or unsure about their pregnancy status were excluded from the analyses.

RESULTS

Of the 498 participants in the final analytic sample, 24.5% met diagnostic criteria for RLS (17.9% with symptoms ≥once/week, 11.9% with symptoms ≥3 times/week); 73 (16.5% of parous women) reported a history of PIH, defined as physician-diagnosed preeclampsia or gestational hypertension. After adjustment for demographics, lifestyle characteristics, obesity, reproductive history, health conditions, and other factors, those reporting a history of PIH were approximately twice as likely to meet criteria for RLS (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.1, 3.6). These associations increased in magnitude with increasing symptom frequency (adjusted OR for RLS with symptoms ≥3 times/week = 3.8; CI 1.9, 7.6; p for trend = 0.003).

CONCLUSIONS

History of PIH was strongly and positively related to current RLS in this study of primary care patients; these findings further support a possible role for metabolic dysregulation in RLS etiology.

Elevated levels of neuropeptide Y in preeclampsia: A pilot study implicating a role for stress in pathogenesis of the disease

OBJECTIVE

To determine if preeclampsia (PE) is associated with dysregulation of the neuropeptide Y (NPY) system.

METHODS

The study enrolled 114 subjects either with normal pregnancy (NP) or with PE. Systolic blood pressure (SBP) was collected from patients using a standard sphygmomanometer. The PE patients were divided into two groups based on the gestational age (GA) at delivery - placental PE (PLPE, GA <34 weeks) or maternal PE (MTPE, GA ≥34 weeks). NPY was measured in platelet rich plasma (PRP), platelet poor plasma (PPP) and in the serum of NP and PE patients utilizing radioimmunoassay. Serum levels of soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) were measured in NP and PE subjects by ELISA.

RESULTS

SBP was higher in PE compared to NP. Circulating NPY in serum and PRP, as well as NPY content per 100,000 platelets, but not its concentrations in PPP, were elevated in PE, as compared to NP. The highest NPY concentrations were observed in sera and PRP of patients with MTPE. PE patients had also elevated levels of sFlt-1, as compared to NP, although no difference between PLPE and MTPL groups were observed. There was no increase in P1GF in PE patients.

CONCLUSION

Systemic NPY is elevated in PE patients, as compared to NP. This increase is observed in blood fractions containing platelets, suggesting accumulation of the peptide in these cells. NPY concentrations are particularly high in patients with MTPE, underlying differences in etiology between PLPE and MTPE. Our study implicates NPY as a potential target in antihypertensive therapies for PE patients.