Concurrent levels of maternal salivary cortisol are unrelated to self-reported psychological measures in low-risk pregnant women

The effect of cortisol in early pregnancy on postpartum depressive symptoms

The first months after childbirth are a tremendous challenge for women and, consequently, a time when women's mental health problems often arise. Knowledge of the prenatal predictors of these problems is of fundamental importance in preventing them. This study aimed to test whether first trimester hair cortisol influenced maternal postpartum depressive symptoms. The women (N = 75) were tested twice: in the first trimester of pregnancy and within three months after giving birth. In the first trimester, they had hair samples taken and were examined using a sociodemographic survey and questionnaires: the Edinburgh Postnatal Depression Scale (EPDS), the Perceived Stress Scale (PSS-10), and the Zimbardo Time Perspective Inventory. After delivery, women completed a survey about the course of delivery and their child's health, EPDS, and PSS-10. Low hair cortisol concentration in the first trimester was a predictor of a high level of postpartum depressive symptoms. This relationship was mediated by fatalistic time perspective. The results suggest that low hair cortisol concentration in the first trimester of pregnancy indicates a high probability of postpartum depression, and that low levels of cortisol may be associated with passivity, a sense of lack of control, and helplessness.

Stress before conception and during pregnancy and maternal cortisol during pregnancy: A scoping review

BACKGROUND

Stress before conception and during pregnancy is associated with less favorable maternal and child health. Alterations in prenatal cortisol levels may serve as a central biological pathway linking stress to adverse maternal and child health. Research examining associations between maternal stress from childhood through pregnancy and prenatal cortisol has not been comprehensively reviewed.

METHOD

The current scoping review of 48 papers synthesizes studies reporting on associations between stress before conception and during pregnancy with maternal cortisol in pregnancy. Eligible studies measured childhood, the proximal preconception period, pregnancy, or lifetime stress based on stress exposures or appraisals and measured cortisol in saliva or hair during pregnancy.

RESULTS

Higher maternal childhood stress was associated with higher cortisol awakening responses and alterations in typical pregnancy-specific changes in diurnal cortisol patterns across studies. In contrast, most studies of preconception and prenatal stress reported null associations with cortisol and those reporting significant effects were inconsistent in direction. A few studies found that the associations between stress and cortisol during pregnancy varied as a function of several moderators including social support and environmental pollution.

CONCLUSIONS

Although many studies have evaluated effects of maternal stress on prenatal cortisol, this scoping review is the first to synthesize existing literature on this topic. The association between stress before conception and during pregnancy and prenatal cortisol may depend on the developmental timing of stress and several moderators. Maternal childhood stress was more consistently associated with prenatal cortisol than proximal preconception or pregnancy stress. We discuss methodological and analytic factors that may contribute to mixed findings.

Antenatal maternal intimate partner violence exposure is associated with sex-specific alterations in brain structure among young infants: Evidence from a South African birth cohort

Maternal psychological distress during pregnancy has been linked to adverse outcomes in children with evidence of sex-specific effects on brain development. Here, we investigated whether in utero exposure to intimate partner violence (IPV), a particularly severe maternal stressor, is associated with brain structure in young infants from a South African birth cohort. Exposure to IPV during pregnancy was measured in 143 mothers at 28-32 weeks' gestation and infants underwent structural and diffusion magnetic resonance imaging (mean age 3 weeks). Subcortical volumetric estimates were compared between IPV-exposed (n = 63; 52% female) and unexposed infants (n = 80; 48% female), with white matter microstructure also examined in a subsample (IPV-exposed, n = 28, 54% female; unexposed infants, n = 42, 40% female). In confound adjusted analyses, maternal IPV exposure was associated with sexually dimorphic effects in brain volumes: IPV exposure predicted a larger caudate nucleus among males but not females, and smaller amygdala among females but not males. Diffusivity alterations within white matter tracts of interest were evident in males, but not females exposed to IPV. Results were robust to the removal of mother-infant pairs with pregnancy complications. Further research is required to understand how these early alterations are linked to the sex-bias in neuropsychiatric outcomes later observed in IPV-exposed children.

Maternal hair cortisol concentrations across pregnancy and the early postpartum period in a Puerto Rican sample

OBJECTIVE

Hair cortisol is a noninvasive, long-term biomarker of human stress. Strengths and weaknesses of this biomarker as a proxy measure of perinatal stress are not yet well understood. Hair cortisol data were collected from pregnant women in Puerto Rico to investigate maternal cortisol level variance across pregnancy.

METHODS

In 2017, we recruited 86 pregnant women planning to birth at a large urban hospital. We aimed to collect four hair samples from each participant, one in each trimester and one in the postpartum period.

RESULTS

Median cortisol in the first trimester (n = 82) was 5.7 picograms/milligram (pg/mg) (range: 1.0-62.4). In the second, third, and postpartum periods, the medians were 6.8 pg/mg (1.0-69.5), (n = 46), 20.1 pg/mg (5.6-89.0), (n = 30), and 14.1 pg/mg (1.7-39.8), (n = 9), respectively. These medians disguise a 10-fold and 50-fold variability for two participants. Our sample sizes declined sharply when Hurricane Maria caused major disruptions in services and participants' lives.

CONCLUSION

Maternal hair cortisol concentrations were lower in the first and second trimester than the third trimester and early postpartum period. We also observed a wide range of variation in cortisol levels throughout pregnancy and in the postpartum period.

Pregnant in a Pandemic: Connecting Perceptions of Uplifts and Hassles to Mental Health

How women experience pregnancy as uplifting or a hassle is related to their mental and physical health and birth outcomes. Pregnancy during a pandemic introduces new hassles, but may offer benefits that could affect how women perceive their pregnancy. Surveying 118 ethnically and racially diverse pregnant women, we explore (1) women's traditional and pandemic-related pregnancy uplifts and hassles and (2) how these experiences of pregnancy relate to their feelings of loneliness, positivity, depression, and anxiety. Regressions show that women who experience more intense feelings of uplifts than hassles also feel more positive, less lonely, and have better mental health. Findings suggest that focusing on positive aspects of being pregnant, in general and during a pandemic, might be beneficial for pregnant women's mental health.

Maternal mental distress and cortisol levels in pregnancies with congenital heart disease

OBJECTIVES

Prenatal maternal stress is associated with adverse offspring outcomes, which may be mediated by maternal stress hormones. However, evidence supporting the association between maternal stress and cortisol levels in high-risk pregnancies is limited. This study aims to determine the relationship between self-reported maternal mental distress and maternal salivary cortisol levels in pregnancies complicated by foetal CHD compared with healthy pregnancies.

METHODS

We recruited women with pregnancies complicated by foetal CHD and healthy pregnancies. Maternal saliva was collected between 22 and 40 gestational weeks. Standardized questionnaires measuring stress, depression, and anxiety were completed by patients. Generalized estimating equation was used to evaluate associations between maternal mental distress scales and cortisol levels.

RESULTS

We studied 165 women (55 CHD, 110 controls) and collected 504 cortisol samples (160 CHD, 344 controls). Women carrying CHD foetuses had higher stress, anxiety, and depression scores compared to women carrying healthy foetuses. However, maternal cortisol levels did not significantly differ in CHD and controls. Cortisol levels were higher in women carrying foetuses with functionally single-ventricle versus two-ventricle CHD. In both CHD and controls, there was no significant association between maternal stress, depression or anxiety scores and cortisol levels.

CONCLUSION

Our data suggest that self-reported maternal stress, anxiety, and depression are not associated with maternal salivary cortisol levels in CHD and healthy pregnancies. The impact of maternal mental distress on foetal health may be through other mediating pathways other than maternal cortisol concentrations.

Ontogeny of the Dyad: the Relationship Between Maternal and Offspring Neuroendocrine Function

PURPOSE OF REVIEW

We review ontogeny of the maternal-offspring neuroendocrine relationship in human pregnancy. We present bidirectional genetic, physiological, and behavioral influences that enhance or disrupt HPA activity and its end product cortisol at the individual level and within the dyad.

RECENT FINDINGS

Consistent evidence supports that maternal mood and caregiving behavior are associated with maternal and offspring cortisol levels. Select studies support the buffering effects of antidepressant use and maternal positive affect on offspring cortisol. Growing research highlights evocative effects of fetal neuroendocrine activity, antenatal gene transfer, and infant behavioral distress and risk characteristics on maternal cortisol levels and dyadic attunement. There is potential to advance our understanding of the mother-offspring neuroendocrine relationship by consideration of other neuroactive steroids in addition to cortisol, and to consider developmental timing and measurement source in study design. Future study should emphasize in what context or for whom neuroendocrine attunement is adaptive versus maladaptive for mother and child.

Associations Between Maternal Distress, Cortisol Levels, and Perinatal Outcomes

OBJECTIVE

Stress during pregnancy may decrease gestational age at birth and birth size. We aimed to investigate the associations between maternal subjective stress measures, salivary cortisol, and perinatal outcomes.

METHODS

A cohort of pregnant women (n = 1693) was recruited from eight antenatal care clinics in Stockholm, Sweden. Questionnaires on subjective distress (perceived stress, worry, depression symptoms, sleep quality) and saliva samples for cortisol measurement (morning and evening) were collected in early and late pregnancy. Perinatal outcomes were birth weight, birth length, gestational age, and birth weight for gestational age. We used linear regression to estimate associations adjusted for maternal characteristics.

RESULTS

All associations between subjective distress and cortisol levels were close to null and nonsignificant, for example, exp(β) = 1.001 (95% confidence interval = 0.995 to 1.006) for the morning cortisol level and perceived stress in early pregnancy. Likewise, most associations between distress (subjective and cortisol) and perinatal outcomes were weak and not statistically significant, for example, β = 1.95 (95% confidence interval = -4.16 to 8.06) for perceived stress in early pregnancy and birth weight. An exception was a statistically significant association between birth weight for gestational age and depression symptoms in early pregnancy, with somewhat higher weight with more symptoms (β = 0.08; 95% CI = 0.04 to 0.13). The results were similar for stress in early and late pregnancy.

CONCLUSIONS

We found no association between subjective distress and cortisol measures irrespective of when in pregnancy the measures were taken. Furthermore, we found no evidence for a longitudinal association between psychological measures of stress or cortisol with lower birth weight, birth weight for gestational age, or gestational age.

Prenatal mother-father cortisol linkage predicts infant executive functions at 24 months

The present study investigated associations between prenatal mother-father cortisol linkage and infant executive functions. Data come from an international sample (N = 358) of predominantly white and middle- to upper-class first-time parents. During late pregnancy, parents collected diurnal salivary cortisol samples and reported on levels of psychological stress. At 24 months, children completed a battery of executive function tasks. Parent cortisol linkage was operationalized as the time-dependent, within-dyad association between maternal and paternal diurnal cortisol. Results indicated that prenatal linkage was positively related to infant executive functions, suggesting that stronger mother-father cortisol linkage was associated with higher executive function scores. Additionally, this relation was moderated by paternal average cortisol levels such that executive function scores were lower when fathers had higher average cortisol levels and linkage was weak. This association suggests that elevated paternal cortisol amplifies the negative relation between lower cortisol linkage and lower infant executive function scores. Importantly, these findings were observed while controlling for observational measures of caregiving and self-report measures of psychosocial functioning and infant social-emotional behavior. These results suggest that prenatal linkage of mother's and father's stress physiology plays a potentially important part in programming and regulating infant neurocognitive development.

HPA-axis multilocus genetic profile score moderates the association between maternal prenatal perceived stress and offspring depression in early adulthood

Maternal stress during pregnancy can cause alterations to the fetal hypothalamus-pituitary-adrenal (HPA) axis, a phenomenon known as fetal programming that may have lasting effects on offspring outcomes, including depression. Evidence suggests that these effects may vary with respect to the offspring's genetic risk. Nonetheless, few studies have examined these effects into adulthood, when risk for depression onset is highest. The present study builds upon the extant literature by examining the interaction of maternal prenatal perceived stress (MPPS) and offspring HPA-axis polygenic risk to predict offspring depression in early adulthood. A total of 381 mother-child dyads participated in a prospective, longitudinal study that spanned from pregnancy until offspring were 20 years of age. Polygenic risk was defined by a multilocus genetic profile score (MGPS) that reflected the additive risk of three HPA-axis candidate genes. The results indicated that the interaction of MPPS and HPA-axis MGPS confers risk for offspring depression at age 20, in line with the differential susceptibility model. This interaction may be specific to prenatal stress, as maternal stress during early childhood did not interact with genetic risk to predict depression. These findings provide the first evidence that genetic variants that are associated with the HPA axis may act in a polygenic, additive fashion to moderate the association between fetal programming and adult depression.

Anxiety and depressive symptoms effects on cortisol trajectories from pregnancy to postpartum: Differences and similarities between women and men

Anxiety and depressive symptoms may influence cortisol trajectories in women and men during pregnancy and the postpartum period. Using a multilevel approach, anxiety and depressive symptoms effects on 24-hour urinary free cortisol trajectories from the 2nd trimester to 3-months postpartum were examined in a sample of 66 women and 65 men with no known psychosocial or medical risk (N = 131; 33 (50%) of them were couples that participated in the same assessment waves). Results showed that both anxiety and depressive symptoms influence women's and men's cortisol trajectories from mid-pregnancy to 3-months postpartum. Women with high depressive symptoms and men with high anxiety or high depressive symptoms exhibited less accentuated variations in the 24-hour urinary free cortisol trajectories compared with women with low depressive symptoms and men with low anxiety or depressive symptoms, respectively. These effects were significant for women's cortisol trajectories from the 2nd to the 3rd pregnancy trimester and for men's cortisol trajectories throughout the entire period. The effect of anxiety and depressive symptoms on HPA axis functioning and cortisol production during pregnancy and postpartum, seems to be sex-specific. Reproductive-related alterations (associated with gestation, parturition and lactation) in women's HPA axis functioning may explain these sex-specific effects.

Neurobiology of peripartum mental illness

At least one in seven pregnant or recently postpartum women will experience a mental illness such as an anxiety disorder, depressive disorder, or substance use disorder. These mental illnesses have detrimental effects on the health of the mother, child, and family, but little is known about the hypothalamic and other neural correlates of maternal mental health concerns. The transition to parenthood alone is a time of remarkable neural plasticity, so it is perhaps not surprising that current research is showing that maternal mental illness has unique neural profiles. Furthermore, the neural systems affected by peripartum mental illness overlap and interact with the systems involved in maternal caregiving behaviors, and mother-infant interactions are, therefore, highly susceptible to disruption. This review discusses what we know about the unique neural changes occurring during peripartum mental illness and the role of the hypothalamus in these illnesses. With an improved understanding of the neural correlates of maternal mental health and disease, we will be better equipped to predict risk, develop effective treatments, and ultimately prevent suffering for millions of parents during this critical time in life.

The bloom is (slightly) off the rose: the motherhood effect on psychological functioning in successive pregnancies

Objective: To examine the maternal psychological state during the course of two successive pregnancies.Methods: The sample consisted of 73 women drawn from a larger maternal-fetal cohort that participated during two pregnancies. Women completed self-report psychological questionnaires at 24, 30, and 36 weeks gestation to index maternal depressive symptoms, trait anxiety, and pregnancy hassles and uplifts. Analyses examined stability of maternal symptoms across successive pregnancies in the same women.Results: Antenatal symptoms of depression and anxiety exhibited strong intra-individual stability between successive pregnancies. Mean differences in maternal symptoms were not detected for either at 24, 30, or 36 weeks gestation, excepting elevated anxiety symptoms at the mid-point due to greater fluctuation in maternal anxiety during the prior pregnancy. Subsequent pregnancies were associated with less intense uplifting feelings about the pregnancy on each measurement occasion.Conclusions: Findings suggest marked consistency in maternal psychological orientation across subsequent pregnancies, though parity also plays a role in the maternal experience.

Effect of Maternal Distress on Perceptions of Infant Behavior May Differ in Chinese-American and European-American Mothers and Infants

OBJECTIVE

This study examined the associations between maternal distress (symptoms of depression and anxiety) and observer and maternal ratings of infant temperament in Chinese-American (CA) and European-American (EA) 4-month-old infants (N = 114 dyads).

METHODS

Maternal distress was obtained through self-reported symptoms of depression and anxiety. Mothers reported infant temperament (distress at limitations, soothability, and fear) through the short form of the Infant Behavior Questionnaire-Revised. To obtain observer-rated infant reactivity, infants were administered a battery of visual and auditory stimuli in the laboratory, in which infant behaviors (fret/cry, limb activity, and arching of the back) were coded.

RESULTS

Maternal distress accounted more for the maternal perception of her infant among EA mothers than among CA mothers, but the relation was only observed for soothability. Higher maternal distress was associated with maternal report of lower soothability for EA mothers. Observer-rated infant reactivity, but not maternal distress, was positively associated with EA and CA maternal report of distress at limitations. Observer-rated infant negativity was associated with somewhat higher ratings of infant fear for EA mothers, although this association for EA mothers was not significantly different from CA mothers.

CONCLUSIONS

Potential biases in maternal report of infant behavior due to effects from maternal distress may not be generalizable across cultures but may vary because of cultural norms for emotional experience and expectations for infant behavior. EA mothers' ratings of infant distress and soothability, but not fear, may be influenced by maternal distress.

Couples becoming parents: Trajectories for psychological distress and buffering effects of social support

BACKGROUND

Becoming a parent is a time of both joy and stress. Associations between exposure to postnatal depression and negative child outcomes underscore the importance of understanding trajectories and correlates of perinatal depression and anxiety.

METHODS

In a study of 438 expectant couples (from the UK, USA and Netherlands) tracked across four time-points (third trimester, 4, 14 and 24 months), we used dyadic latent growth curve modeling (LGCM) of self-reported symptoms of anxiety and depression (CES-D, GHQ, STAI) to investigate the affective impact of becoming a parent.

RESULTS

Confirmatory factor analyses of anxious-depressive symptoms revealed a single latent factor with measurement invariance across time and parent. Dyadic LGCM intercepts showed greater prenatal problems in mothers compared with fathers. LGCM slopes revealed stable maternal problems but worsening paternal problems. Both intercepts and slopes showed significant within-couple associations. Controlling for prenatal salivary cortisol levels and perinatal couple relationship quality, support from friends attenuated mothers' psychological distress and support from family reduced fathers' psychological distress across the transition to parenthood.

LIMITATIONS

Our sample was low risk (i.e., predominantly well-educated and affluent and no history of serious mental illness), limiting the generalizability of findings. In addition, the inverse association between psychological distress and social support may, in part, reflect the use of self-report for both measures.

CONCLUSIONS

The international dyadic longitudinal design strengthens conclusions regarding variation in trajectories of psychological distress in both mothers and fathers. Crucially, social support appears pivotal in enabling new parents to flourish.

The Cumulative Risk of Chemical and Nonchemical Exposures on Birth Outcomes in Healthy Women: The Fetal Growth Study

Metals, stress, and sociodemographics are commonly studied separately for their effects on birth outcomes, yet often jointly contribute to adverse outcomes. This study analyzes two methods for measuring cumulative risk to understand how maternal chemical and nonchemical stressors may contribute to small for gestational age (SGA). SGA was calculated using sex-specific fetal growth curves for infants of pregnant mothers (n = 2562) enrolled in the National Institute of Child Health and Human Development (NICHD) Fetal Growth Study. The exposures (maternal lead, mercury, cadmium, Cohen's perceived stress, Edinburgh depression scores, race/ethnicity, income, and education) were grouped into three domains: metals, psychosocial stress, and sociodemographics. In Method 1 we created cumulative risk scores using tertiles. Method 2 employed weighted quantile sum (WQS) regression. For each method, logistic models were built with three exposure domains individually and race/ethnicity, adjusting for age, parity, pregnancy weight gain, and marital status. The adjusted effect of overall cumulative risk with three domains, was also modeled using each method. Sociodemographics was the only exposure associated with SGA in unadjusted models ((odds ratio) OR: 1.35, 95% (confidence interval) CI: 1.08, 1.68). The three cumulative variables in adjusted models were not significant individually, but the overall index was associated with SGA (OR: 1.17, 95% CI: 1.02, 1.35). In the WQS model, only the sociodemographics domain was significantly associated with SGA. Sociodemographics tended to be the strongest risk factor for SGA in both risk score and WQS models.

The relationship between salivary cortisol and perinatal depression in women undergoing termination of pregnancy for fetal anomaly: A prospective cohort study

BACKGROUND

The hypothalamic-pituitary-adrenal axis plays a crucial role in the neurobiological pathways for depression. The aim of this study was to determine the relationship between salivary cortisol and depression in women before and after termination of pregnancy due to fetal anomaly.

STUDY DESIGN

A prospective cohort study was conducted. One-way ANOVA and linear correlation were conducted to analyse the relationship between salivary cortisol and depression before and after termination of pregnancy.

RESULTS

No significant difference in morning and evening cortisol levels between women underwent TOP for fetal anomaly without depression and those with depression, but the women underwent TOP for fetal anomaly had significantly higher levels of morning and evening cortisol than women with healthy pregnancy. Cortisol awakening response was lower in women underwent termination of pregnancy, than in women with normal pregnancy; lower in women underwent termination of pregnancy with depression than in those women without depression. Cortisol awakening response also had a negative correlation with depression, and the correlation coefficients for cortisol awakening response and depression after TOP (R = 0.461) were higher than the correlation coefficients for cortisol awakening response and depression before TOP(R = 0.238).

CONCLUSIONS

Our results were not only useful to support the hypothesis that hypothalamic-pituitary-adrenal axis functioning would turn hypoactive, with depression progressing to increase in severity, but also helpful with insights into the predictive effects of cortisol awakening response in depression after TOP. We suggest that further research should be conducted on the relationship between salivary cortisol and depression before and after TOP for fetal anomaly.

Behavioural dysfunctions of 10-year-old children born extremely preterm associated with corticotropin-releasing hormone expression in the placenta

AIM

To evaluate the relationship between corticotropin-releasing hormone (CRH) expression in the placenta and the risk of school-related dysfunctions at the age of 10 years among children born extremely preterm (EP).

METHODS

Corticotropin-releasing hormone expression was measured in the placenta of 761 EP children, who had the following assessments at the age of 10 years: Differential Ability Scales, Oral and Written Language Scales, the Wechsler Individual Achievement Test-III, NEPSY-II and the Child Symptom Inventory-4. We evaluated whether lowest and highest quartiles of CRH mRNA were associated with undesirable scores on these assessments. With 272 evaluations, we would expect 14 to be significant at p < 0.05.

RESULTS

Only 16 associations were statistically significant. On the other hand, seven of these were social limitations among girls whose placenta CRH mRNA was in the top quartile. Adjusting for delivery indication or restricting the sample to one delivery indication group resulted in few differences.

CONCLUSION

Overall, placenta CRH mRNA concentrations in the top or bottom quartiles were not associated with increased risks of dysfunctions 10 years later. Girls whose placenta CRH expression was in the top quartile, however, were at increased risk of seven indicators/correlates of social limitations.

Prenatal stress and models explaining risk for psychopathology revisited: Generic vulnerability and divergent pathways

The present review revisits three hypothesized models that potentially could explain how prenatal maternal stress influences fetal development, birth outcomes, and subsequent developmental psychopathology. These models were mostly based on animal models, and new evidence for these models from human studies is evaluated. Furthermore, divergent trajectories from prenatal exposure to adversities to offspring affected outcomes are reviewed, including the comparison of studies on prenatal maternal stress with research on maternal substance use and maternal malnutrition during pregnancy. Finally, new directions in research on the mechanism underlying prenatal stress effects on human offspring is summarized. While it is concluded that there is abundant evidence for the negative associations between prenatal maternal stress and offspring behavioral, brain, and psychopathological outcomes in humans, there is no consistent evidence for specific mechanisms or specific outcomes in relation to stress exposure in utero. Rather, principles of multifinality and equifinality best describe the consequences for the offspring, suggesting a generic vulnerability and different pathways from prenatal adversities to developmental psychopathology, which complicates the search for underlying mechanisms. New and promising directions for research are provided to get a better understanding of how prenatal stress gets under the skin to affect fetal development.

Prenatal stress and the development of psychopathology: Lifestyle behaviors as a fundamental part of the puzzle

Maternal psychological stress, depression, and anxiety during pregnancy (prenatal stress; PNS) are thought to impact fetal development with long-term effects on offspring outcome. These effects would include physical and mental health, including psychopathology. Maternal sleep, diet, and exercise during pregnancy are lifestyle behaviors that are understudied and often solely included in PNS studies as confounders. However, there are indications that these lifestyle behaviors may actually constitute essential mediators between PNS and fetal programming processes. The goal of this theoretical review was to investigate this idea by looking at the evidence for associations between PNS and sleep, diet, and exercise, and by piecing together the information on potential underlying mechanisms and causal pathways through which these factors may affect the offspring. The analysis of the literature led to the conclusion that sleep, diet, and exercise during pregnancy, may have fundamental roles as mediators between PNS and maternal pregnancy physiology. By integrating these lifestyle behaviors into models of prenatal programming of development, a qualitatively higher and more comprehensive understanding of the prenatal origins of psychopathology can be obtained. The review finalizes by discussing some of the present challenges facing the field of PNS and offspring programming, and offering solutions for future research.

Maternal antenatal mood and child development: an exploratory study of treatment effects on child outcomes up to 5 years

Effective treatment of maternal antenatal depression may ameliorate adverse neurodevelopmental outcomes in offspring. We performed two follow-up rounds of children at age 2 and age 5 whose mothers had received either specialized cognitive-behavioural therapy or routine care for depression while pregnant. Of the original cohort of 54 women, renewed consent was given by 28 women for 2-year follow-up and by 24 women for 5-year follow-up. Child assessments at the 2-year follow-up included the Parenting Stress Index (PSI), Bayley Scales of Infant Development (BSID-III) and the Child Behaviour Checklist (CBCL). The 5-year follow-up included the Wechsler Preschool and Primary Scales of Intelligence (WPPSI-III) and again the CBCL. Treatment during pregnancy showed significant benefits for children's development at age 2, but not at age 5. At 2 years, intervention effects were found with lower scores on the PSI Total score, Parent Domain and Child domain (d=1.44, 1.47, 0.96 respectively). A non-significant trend favoured the intervention group on most subscales of the CBCL and the BSID-III (most notably motor development: d =0.52). In contrast, at 5-year follow-up, no intervention effects were found. Also, irrespective of treatment allocation, higher depression or anxiety during pregnancy was associated with higher CBCL and lower WPPSI-III scores at 5 years. This is one of the first controlled studies to evaluate the long-term effect of antenatal depression treatment on infant neurodevelopmental outcomes, showing some benefit. Nevertheless, caution should be taken interpreting the results because of a small sample size, and larger studies are warranted.

Associations between maternal psychological distress and salivary cortisol during pregnancy: A mixed-models approach

BACKGROUND

Maternal psychological distress during pregnancy is related to adverse child behavioral and emotional outcomes later in life, such as ADHD and anxiety/depression. The underlying mechanisms for this, however, are still largely unknown. The hypothalamic-pituitary-adrenal (HPA)-axis, with its most important effector hormone cortisol, has been proposed as a mechanism, but results have been inconsistent. The current study investigated the association between maternal psychological distress (i.e. anxiety and depressive symptoms) and maternal cortisol levels during pregnancy using a mixed models approach.

METHOD

During three pregnancy trimesters, mothers (N = 170) collected four salivary samples for two consecutive days. Mothers reported symptoms of anxiety and depression three times during pregnancy (at 13.3 ± 1.1, 20.2 ± 1.5, and 33.8 ± 1.5 weeks of pregnancy, respectively) using the anxiety subscale of the Symptom Checklist (SCL-90), the Spielberger State and Trait Anxiety Inventory (STAI), and the Edinburgh Postnatal Depression Scale (EPDS). Specific fears and worries during pregnancy were measured with the short version of the Pregnancy Related Anxiety Questionnaire (PRAQ-R).

RESULTS

We found a significant effect of SCL-90 anxiety subscale on cortisol levels at awakening (p = .008), indicating that mothers with higher anxiety showed lower cortisol at awakening. Maternal psychological variables explained 10.5% of the variance at the person level in awakening cortisol level, but none in the overall diurnal cortisol model.

CONCLUSION

More research is necessary to unravel the underlying mechanisms of the association between maternal psychological distress and cortisol and the search for mechanisms other than the HPA-axis should be continued and extended.

The effect of gestational period on the association between maternal prenatal salivary cortisol and birth weight: A systematic review and meta-analysis

BACKGROUND

Studies exploring the relations between maternal stress and fetal development show an association between increased maternal stress and adverse birth outcomes. A frequently proposed mechanism linking maternal prenatal stress and adverse birth outcomes is heightened concentrations of maternal cortisol. To date, studies exploring this association have reported conflicting results because of the diverse approaches taken to measuring cortisol and the wide variety of possible birth outcomes explored. To add clarity to the growing body of literature, this systematic review and meta-analysis reports empirical findings on the association between maternal prenatal salivary cortisol and newborn birth weight.

METHODS

Searches for relevant papers published up until November 2017 were run in MEDLINE, EMBASE, PsycINFO, and CINAHL. Non-English language papers were included and experts were contacted when necessary. We included data from human observational studies that were designed or had an underlying intention to measure maternal prenatal salivary cortisol and newborn birth weight. We only included data from measurements of salivary cortisol to prevent rendering of the review unsuitable for meta-analysis. Two independent reviewers assessed study eligibility and quality. For every maternal-fetal dyad, an area under the curve with respect to ground (AUCg) of maternal cortisol was calculated to determine a Pearson's correlation coefficient with a continuous measure of newborn birth weight. Correlation coefficients were then pooled across all stages of gestation. To examine if there are critical gestational periods in which the fetus may be more susceptible to elevated concentration of maternal salivary cortisol, a meta-analysis was performed on separate correlations calculated from gestational trimesters.

RESULTS

Nine studies with a total of 1606 maternal-fetal dyads demonstrated a negative correlation between pooled maternal salivary cortisol and birth weight (-0.24, 95% CI -0.28 to -0.20), but there was a high degree of heterogeneity between studies (I² = 88.9%). To investigate heterogeneity, subgroup analysis by trimester of the pooled correlation between salivary cortisol and birth weight was performed with the following correlations found: first trimester, -0.18 (95% CI -0.32 to -0.03, I² = 97.3%); second trimester, -0.20 (95% CI -0.28 to -0.12, I² = 98.3%); and third trimester, -0.30 (95% CI -0.33 to -0.26, I² = 85.4%).

DISCUSSION

A consistently negative association was observed between maternal cortisol and infant birth weight. The review highlights specific gaps in the literature on the relationship between maternal prenatal salivary cortisol and newborn birth weight. Although a significant negative correlation was found, substantial heterogeneity of effects and the likelihood of publication bias exist. The third trimester was revealed as a possible critical gestational period for heightened maternal cortisol concentration to affect birth weight. Challenges faced in this body of research and recommendations for future research are discussed.

Maternal hypothalamus-pituitary-adrenal (HPA) system activity and stress during pregnancy: Effects on gestational age and infant's anthropometric measures at birth

BACKGROUND

Prenatal maternal stress might be a risk for the developing fetus and may have long-lasting effects on child and adult vulnerability to somatic and psychiatric disease. Over-exposure of the unborn to excess glucocorticoids and subsequent alteration of fetal development is hypothesized to be one of the key mechanisms linking prenatal stress with negative child outcome.

METHODS

In this prospective longitudinal study, mothers-to-be (n = 405) in late pregnancy (36.8 ± 1.9 weeks of gestational age) and their singleton neonates were studied. We investigated the impact of different prenatal stress indices derived from six stress variables (perceived stress, specific prenatal worries, negative life events, symptoms of depression, trait anxiety, neuroticism) and diurnal maternal saliva cortisol secretion on gestational age and anthropometric measures at birth.

RESULTS

Maternal prenatal distress during late gestation was associated with significant reduction in birth weight (-217 g; p = .005), birth length (-1.2 cm; p = .005) and head circumference (-0.8 cm; p = .001). Prenatal stress was modestly but significantly associated with altered diurnal cortisol pattern (flattened cortisol decline and higher evening cortisol), which in turn was significantly related to reduced length of gestation. No evidence for a profound interaction between maternal cortisol level in late pregnancy and infant's anthropometric measures at birth (i.e., birth weight, length, head circumference) was found.

CONCLUSION

Prenatal stress is associated with flattened circadian saliva cortisol profiles and reduced infant's anthropometric measures at birth. HPA system activity during pregnancy may be related to low gestational age. The effect of prenatal stress might be partly mediated by maternal-placental-fetal neuroendocrine mechanisms especially the dysregulation of diurnal cortisol profile.

Newborn infants' hair cortisol levels reflect chronic maternal stress during pregnancy

Cortisol obtained from hair samples represents a retrospective biomarker of chronic stress experienced by the subject in previous months. Although hair cortisol levels have been used to study the relationship between maternal and neonatal stress levels in primates, this has not yet been performed in humans using a longitudinal design and focusing specifically on this association. Therefore, the objective of this study was to determine whether a relationship existed between maternal psychological stress and hair cortisol levels during pregnancy and postpartum, and neonatal hair cortisol levels. The sample consisted of 80 pregnant women and their 80 newborn infants. We conducted a longitudinal assessment of hair cortisol levels, psychological stress, anxiety, and depression in the three trimesters of pregnancy and postpartum. After childbirth, neonatal hair cortisol levels were also measured. We found that maternal hair cortisol levels in the first trimester negatively predicted neonatal hair cortisol levels. Perceived stress in the third trimester of pregnancy also predicted lower neonatal cortisol, whereas pregnancy-specific stress in the same trimester had a positive relation with neonatal cortisol. Cortisol is essential for embryonic and fetal development; consequently, if fetal synthesis of cortisol is affected by high maternal cortisol levels, such development could be impaired.

An evaluation of distal hair cortisol concentrations collected at delivery

Distal hair segments collected at delivery may allow for the assessment of maternal cortisol secretion in early pregnancy, an important time window for fetal development. Therefore, an investigation of the validity of distal hair cortisol concentrations is warranted. We examined the concordance between proximal and distal hair cortisol concentrations (HCC), both representing the first trimester of pregnancy. The study population was comprised of a random sample of 97 women participating in the Pregnancy Outcomes Maternal and Infant Study, a prospective cohort study of pregnant women attending prenatal clinics in Lima, Peru. Each participant provided two hair samples: once at enrollment [mean gestational age (GA) = 13.1 weeks] and again at full-term delivery (mean GA = 39.0 weeks). Hair segments reflecting the first trimester were: 3 cm hair segments closest to the scalp on the first hair sample (proximal) and 6-9 cm from the scalp on the second hair sample (distal). HCC was determined using Luminescence Immunoassay. A subset (N = 28) had both hair segments additionally analyzed using liquid chromatography tandem mass spectrometry (LC-MS/MS). HCC values were log-transformed (logHCC), and proximal-distal differences tested using paired sample t-tests. Concordance was evaluated within and across assay types. LogHCC, measured using immunoassay, in distal hair segments was lower compared to proximal hair segments (1.35 versus 1.64 respectively; p = .02). No difference was observed using LC-MS/MS (1.99 versus 1.83, respectively; p=.33). Proximal-distal concordance was low within assay (immunoassay: Pearson = 0.27 and κ = 0.10; LC-MS/MS: Pearson = 0.37 and κ = 0.07). High correlation was observed across assays for both distal (Pearson = 0.78, p < .001; κ = 0.64) and proximal segments (Pearson = 0.96, p < .001; κ = 0.75). In conclusion, distal first-trimester hair segments collected at delivery have lower absolute HCC compared to HCC in proximal first trimester hair segments collected in early pregnancy, and are poorly concordant with HCC in proximal segments. Findings may inform the design of future studies.

Limited association between markers of stress during pregnancy and fetal growth in 'Born into Life', a new prospective birth cohort

AIMS

We aimed to investigate the associations between perceived maternal stress or salivary cortisol levels during pregnancy and birthweight.

METHODS

In 2010-2012, we recruited 92 women living in Stockholm, Sweden, and followed them from before conception and through pregnancy and childbirth. Their Perceived Stress Scale (PSS) scores and salivary cortisol levels were collected at 26-28 gestational weeks. Birthweight was collected from medical records. Linear regression analyses and Pearson correlations were performed between the PSS scores or cortisol levels and birthweight, respectively, adjusted for gestational age.

RESULTS

No significant associations were found between PSS scores or cortisol levels and birthweight. There was a trend towards higher salivary cortisol levels among infants with lower birthweights, and this effect was attenuated after adjusting for gestational age. Morning cortisol levels (r = -0.31, p = 0.01), the decline in cortisol levels (r = -0.26, p = 0.03) and evening cortisol levels (r = -0.21, p = 0.09) were negatively correlated with PSS scores.

CONCLUSION

Maternal stress during pregnancy was not associated with birthweight. The inverse correlation between PSS scores and cortisol levels may indicate other mechanisms for maternal stress on child outcomes than the previous explanation of hypothalamic-pituitary-adrenal axis activity.

Allostatic load: A theoretical model for understanding the relationship between maternal posttraumatic stress disorder and adverse birth outcomes

BACKGROUND

Adverse birth outcomes such as preterm birth and low birth weight are significant public health concerns and contribute to neonatal morbidity and mortality. Studies have increasingly been exploring the predictive effects of maternal posttraumatic stress disorder (PTSD) on adverse birth outcomes. However, the biological mechanisms by which maternal PTSD affects birth outcomes are not well understood. Allostatic load refers to the cumulative dysregulations of the multiple physiological systems as a response to multiple social-ecological levels of chronic stress. Allostatic load has been well documented in relation to both chronic stress and adverse health outcomes in non-pregnant populations. However, the mediating role of allostatic load is less understood when it comes to maternal PTSD and adverse birth outcomes.

OBJECTIVE

To propose a theoretical model that depicts how allostatic load could mediate the impact of maternal PTSD on birth outcomes.

METHOD

We followed the procedures for theory synthesis approach described by Walker and Avant (2011), including specifying focal concepts, identifying related factors and relationships, and constructing an integrated representation. We first present a theoretical overview of the allostatic load theory and the other 4 relevant theoretical models. Then we provide a brief narrative review of literature that empirically supports the propositions of the integrated model. Finally, we describe our theoretical model.

FINDINGS/CONCLUSIONS

The theoretical model synthesized has the potential to advance perinatal research by delineating multiple biomarkers to be used in future. After it is well validated, it could be utilized as the theoretical basis for health care professionals to identify high-risk women by evaluating their experiences of psychosocial and traumatic stress and to develop and evaluate service delivery and clinical interventions that might modify maternal perceptions or experiences of stress and eliminate their impacts on adverse birth outcomes.

Evaluating Stress during Pregnancy: Do We Have the Right Conceptions and the Correct Tools to Assess It?

Gestational stress is believed to increase the risk of pregnancy failure and perinatal and adult morbidity and mortality in both the mother and her child or children. However, some contradictions might arise from methodological issues or even from differences in the philosophical grounds that guide the studies on gestational stress. Biased perspectives could lead us to use and/or design inadequate/incomplete panels of biochemical determinations and/or psychological instruments to diagnose it accurately during pregnancy, a psychoneuroimmune-endocrine state in which allostatic loads may be significant. Here, we review these notions and propose a model to evaluate and diagnose stress during pregnancy.

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.

Determinants of cortisol during pregnancy - The ABCD cohort

BACKGROUND

Psychosocial stress during pregnancy has been proposed as a major contributor of glucocorticoid-mediated programming of the fetal hypothalamic-pituitary adrenal (HPA) axis, with later adverse health consequences. However, evidence linking maternal stress to maternal cortisol values during pregnancy is inconclusive. A possible explanation for this is that other maternal factors overshadow any potential effects of stress on cortisol levels. We studied a large cohort of pregnant women with extensive data on pregnancy characteristics to determine the respective contributions of biological, environmental and psychosocial stress factors to cortisol levels in pregnancy.

METHODS

We used data from 3039 women from the Amsterdam Born Children and their Development-study cohort. Serum cortisol was measured in blood, collected at the first prenatal visit, at different gestational ages (median=91days, range=40-256days), and at various time points during the day (median=11:45h, range=08:00-18:30h). We assessed associations between maternal serum cortisol in pregnancy and biological factors, lifestyle factors and stress factors, including depression, anxiety, pregnancy-related anxiety, work stress, parenting stress and fatigue.

RESULTS

In multivariable analysis, variables that were associated with higher cortisol levels in pregnancy were lower maternal age [1.5nmol/l, 95%CI (0.6-2.4)], being nulliparous [21.5 nmol/l (15.9-27.1)], lower pre-pregnancy body mass index (BMI) [1.3nmol/l (0.3-2.4)], higher C-reactive protein (CRP) [1.0nmol/l (0.4-1.5)], carrying a female fetus [9.2nmol/l (1.8-16.5)], non-smoking [14.2nmol/l (0.6-27.7)], sufficient sleep [8.5nmol/l (0.9-16.1)], and being unemployed [12.7nmol/l (2.2-23.2)]. None of the psychosocial stressors was significantly associated with serum cortisol levels in pregnancy. A total of 32% of all variance in cortisol was explained by gestational age, maternal age, time of day, parity, pre-pregnancy BMI, CRP, fetal sex, smoking behavior, self-reported sleep sufficiency, and employment.

CONCLUSIONS

Our data suggest that maternal cortisol during pregnancy is mainly affected by biological and lifestyle factors, but not by psychosocial factors. We suggest that psychosocial stress in pregnancy might program the fetus through other mechanisms than through altering maternal cortisol levels.

Systematic review of maternal voice interventions demonstrates increased stability in preterm infants

We systematically reviewed how effectively maternal voice interventions supported the clinical outcomes and development of preterm infants. A total of 512 preterm infants were included in 15 studies with different designs, from January 2000 to July 2015. Live and recorded maternal voice interventions were associated with the physiologic and behavioural stabilisation of preterm infants, with fewer cardiorespiratory events, but the evidence was insufficient to evaluate the long-term effects. Well-defined determinants and clear setting conditions are needed for such interventions.

CONCLUSION

Further research that investigates the long-term efficacy and effects of live maternal voices on preterm infant development is needed.

Maternal anxiety and physiological reactivity as mechanisms to explain overprotective primiparous parenting behaviors

In this study, we sought to determine whether the affective and physiological experience of primiparous, or first-time, motherhood is distinct from multiparous motherhood, how the child's level of inhibited temperament impacts it, and if such a temperament results in overprotective parenting behaviors. A total of 117 mothers and their 24-month-old toddlers participated in novelty tasks designed to elicit parenting behaviors and toddler's typical fear reactions. Mothers also completed a battery of questionnaires. Results suggest that primiparous mothers experienced more worry, which was associated with increased overprotective parenting behaviors. Primiparous mothers also demonstrated greater physiological (i.e., cortisol) reactivity while watching their first-born children interact with novel stimuli, but how this related to overprotective parenting was dependent on the child's level of inhibition. Specifically, primiparous mothers displayed more cortisol reactivity with their uninhibited toddlers, which indirectly linked parity to less overprotective parenting behaviors. Primiparous mothers of highly inhibited toddlers displayed greater overprotective parenting behaviors, independent of maternal cortisol reactivity. The results indicate that the transition to motherhood is a unique experience associated with greater worry and physiological reactivity and is meaningfully influenced by the toddler's temperament. Distinctions in both observed and self-reported overprotective parenting are evident through considering the dynamic interaction of these various aspects. (PsycINFO Database Record

Cortisol response to the Trier Social Stress Test in pregnant women at risk for postpartum depression

Antepartum depression and anxiety are risk factors for postpartum depression (PPD). Postpartum abnormalities in hypothalamic-pituitary-adrenal (HPA) reactivity are associated with PPD. It is not known if antepartum HPA abnormalities exist in women at risk for PPD (AR-PPD). We measured salivary cortisol response to the Trier Social Stress Test (TSST) in 44 (24 AR-PPD, 20 healthy comparison) pregnant women. Depression and anxiety were measured using the Edinburgh Postnatal Depression Scale (EPDS) and Spielberger State-Trait Anxiety Inventory-State (STAI-S). We analyzed longitudinal changes in cortisol using generalized estimating equation methods to control for the correlation within subjects at the six TSST time points. Group differences in area under the curve (AUC) were examined. A majority (70.8 %) of the AR-PPD had prior depression. EPDS total score was higher in AR-PPD vs. comparison women (mean EPDS = 9.8 ± 4.9 vs. mean EPDS = 2.4 ± 2.0 respectively, p < 0.001). Mean STAI-S total score was higher in AR-PPD vs. comparison women at all TSST time points and over time (z = 2.71, df = 1, p = 0.007). There was no significant difference in cortisol concentration over time between groups. We observed no detectable difference in cortisol response to psychosocial stress induced by the TSST despite clinically significant between-group differences in current/past depression and current symptomatology.

Severity and timing: How prenatal stress exposure affects glial developmental, emotional behavioural and plasma neurosteroid responses in guinea pig offspring

Prenatal stress has been associated with a variety of developmental changes in offspring, notably those associated with brain development and subsequent risk for neuropathologies later in life. Recently, the importance of the timing and the severity of the stressor during pregnancy has been emphasized with neurosteroids including allopregnanolone implicated in the regulation of stress and also for endogenous neuroprotection in offspring. Prenatal stress was induced using strobe light exposure in pregnant guinea pigs (term 71days) in three defined stress exposure groups (Gestational Age (GA)35-65, GA50-65 and GA60-65). Stress was induced for 2h (9-11am) every 5days via strobe light exposure. A fetal cohort were euthanased at term with fetal brains and plasma collected. Anxiety-like behaviour was evaluated at 18 days of age in a separate cohort of offspring with brains and plasma collected at 21days of age. Markers for mature oligodendrocytes and reactive astrocytes were measured in the CA1 region of the hippocampus and the subcortical white matter. The neurosteroid allopregnanolone was measured by radioimmunoassay in offspring plasma. In the CA1 region of the hippocampus, fetuses from all stress groups showed reduced expression of mature oligodendrocytes and reactive astrocytes. By juvenility, all male stress exposure groups had recovered to levels of unaffected controls with the exception of the GA35-65 stress group. In juvenile females, mature oligodendrocyte marker expression was reduced in all stress groups and reactive astrocyte expression was reduced in the GA35-65 and GA60-65 stress groups by juvenility. Increased reactive astrocyte expression was also apparent in the subcortical white matter in both sexes both at term and at juvenility. Prenatally stressed offspring spent less time exploring in the object exploration test and also entered the inner zone of the open field less than controls at 18days of age. Circulating allopregnanolone concentrations were significantly reduced in GA35-65 and GA 60-65 stress exposed fetuses with those in the GA35-65 stress group remaining reduced by juvenility. This study has shown the effects of differing levels of prenatal stress severity and timing on glial development, emotional behaviour and plasma allopregnanolone concentrations in offspring.

Perinatal maternal depression and cortisol function in pregnancy and the postpartum period: a systematic literature review

BACKGROUND

Perinatal depression has a significant impact on both mother and child. However, the influence of hormonal changes during pregnancy and the postpartum period remains unclear. This article provides a systematic review of studies examining the effects of maternal cortisol function on perinatal depression.

METHOD

A systematic search was conducted of six electronic databases for published research on the relationship between cortisol and perinatal depression. The databases included; MEDLINE complete, PsychINFO, SCOPUS, Psychology and Behavioural Sciences, Science Direct and EBSCO, for the years 1960 to May 2015. Risk of bias was assessed and data extraction verified by two investigators.

RESULTS

In total, 47 studies met criteria and studies showed considerable variation in terms of methodology including sample size, cortisol assays, cortisol substrates, sampling processes and outcome measures. Those studies identified as higher quality found that the cortisol awakening response is positively associated with momentary mood states but is blunted in cases of major maternal depression. Furthermore, results indicate that hypercortisolemia is linked to transient depressive states while hypocortisolemia is related to chronic postpartum depression.

DISCUSSION AND CONCLUSION

Future research should aim to improve the accuracy of cortisol measurement over time, obtain multiple cortisol samples in a day and utilise diagnostic measures of depression. Future studies should also consider both antenatal and postnatal depression and the differential impact of atypical versus melancholic depression on cortisol levels, as this can help to further clarify the relationship between perinatal depression and maternal cortisol function across pregnancy and the postpartum period.

Dysregulation of 11beta-hydroxysteroid dehydrogenases: implications during pregnancy and beyond

Glucococorticoids play a critical role in the developmental programing and fetal growth. Key molecules mediating and regulating tissue-specific glucocorticoid actions are 11beta-hydroxysteroid dehydrogenase (11beta-HSD) type 1 and 2 isozymes, both of which are expressed in the placenta and the fetal membranes. 11beta-HSD1 is implicated in the pathogenesis of metabolic syndrome and its dysregulation has been observed in pregnancy-related complications (pre-eclampsia, intrauterine growth restriction). Interestingly, preliminary clinical data have associated certain 11beta-HSD1 gene polymorphisms with hypertensive disorders in pregnancy, suggesting, if confirmed by further targeted studies, it's potential as a putative prognostic marker. Animal studies and observations in humans have confirmed that 11beta-HSD2 insufficiency is related with pregnancy adversity (pre-eclampsia, intrauterine growth restriction, preterm birth). Importantly, down-regulation or deficiency of placental 11beta-HSD2 is associated with significant restriction in fetal growth and low-birth weight, and unfavorable cardio-metabolic profile in adulthood. The potential association of 11beta-HSD1 tissue-specific dysregulation with gestational diabetes, as well as the plausible utility of 11beta-HSD2, as a biomarker of pregnancy adversity and later life morbidity, are emerging areas of intense scientific interest and future investigation.

The Association of Hair Cortisol with Self-Reported Chronic Psychosocial Stress and Symptoms of Anxiety and Depression in Women Shortly after Delivery

BACKGROUND

Psychosocial stress during pregnancy including anxiety and depression is known to have adverse health effects on newborns. However, measuring these psychological constructs is complex with psychological, endocrinological, and physiological systems being affected. Hair cortisol concentrations (HCC), assumed to reflect long-term endocrine consequences of stress exposure, represent a promising instrument for epidemiological research. However, the association between HCC and questionnaire-based instruments is unclear.

METHODS

In the Ulm SPATZ Health Study, mothers were recruited shortly after delivery in the University Medical Centre Ulm, Germany between April 2012 and May 2013. HCC of 768 participants were determined in scalp-near 3 cm maternal hair segments, assumed to reflect cortisol exposure over the last trimester of pregnancy. Chronic stress, anxiety, and depressive symptomatology were self-reported in questionnaire-based instruments. Spearman correlation coefficients between HCC and these instruments as well as means of HCC in highly and low stressed subgroups were calculated.

RESULTS

HCC were not correlated with self-reported chronic stress, anxiety, or depressive symptomatology. Furthermore, the investigation of sub-populations did not reveal substantial differences of HCC across highly and low stressed women.

CONCLUSIONS

HCC were not found to correlate with self-reports of chronic stress, anxiety, or depressive symptomatology. Among other things, these findings could reflect problems with questionnaire-based assessments obtained shortly after delivery such as recall bias and/or suggest that associations between cortisol secretion and psychosocial stress are difficult to detect due to, e.g. a strong physiological increase of cortisol in the last trimester.

Prenatal and Postpartum Evening Salivary Cortisol Levels in Association with Peripartum Depressive Symptoms

BACKGROUND

The biology of peripartum depression remains unclear, with altered stress and the Hypothalamus-Pituitary-Adrenal axis response having been implicated in its pathophysiology.

METHODS

The current study was undertaken as a part of the BASIC project (Biology, Affect, Stress, Imaging, Cognition), a population-based longitudinal study of psychological wellbeing during pregnancy and the postpartum period in Uppsala County, Sweden, in order to assess the association between evening salivary cortisol levels and depressive symptoms in the peripartum period. Three hundred and sixty-five pregnant women from the BASIC cohort were recruited at pregnancy week 18 and instructed to complete a Swedish validated version of the Edinburgh Postnatal Depression Scale at the 36th week of pregnancy as well as the sixth week after delivery. At both times, they were also asked to provide evening salivary samples for cortisol analysis. A comprehensive review of the relevant literature is also provided.

RESULTS

Women with postpartum EPDS score ≥ 10 had higher salivary evening cortisol at six weeks postpartum compared to healthy controls (median cortisol 1.19 vs 0.89 nmol/L). A logistic regression model showed a positive association between cortisol levels and depressive symptoms postpartum (OR = 4.1; 95% CI 1.7-9.7). This association remained significant even after controlling for history of depression, use of tobacco, partner support, breastfeeding, stressful life events, and sleep problems, as possible confounders (aOR = 4.5; 95% CI 1.5-14.1). Additionally, women with postpartum depressive symptoms had higher postpartum cortisol levels compared to both women with depressive symptoms antenatally and controls (p = 0.019 and p = 0.004, respectively).

CONCLUSIONS

Women with depressive symptoms postpartum had higher postpartum cortisol levels, indicating an altered response of the HPA-axis in postpartum depression.

The gestational foundation of sex differences in development and vulnerability

Despite long-standing interest in the role of sex on human development, the functional consequences of fetal sex on early development are not well-understood. Here we explore the gestational origins of sex as a moderator of development. In accordance with the focus of this special issue, we examine evidence for a sex differential in vulnerability to prenatal and perinatal risks. Exposures evaluated include those present in the external environment (e.g., lead, pesticides), those introduced by maternal behaviors (e.g., alcohol, opioid use), and those resulting from an adverse intrauterine environment (e.g., preterm birth). We also provide current knowledge on the degree to which sex differences in fetal neurobehavioral development (i.e., cardiac and motor patterns) are present prior to birth. Also considered are contemporaneous and persistent sex of fetus effects on the pregnant woman. Converging evidence confirms that infant and early childhood developmental outcomes of male fetuses exposed to prenatal and perinatal adversities are more highly impaired than those of female fetuses. In certain circumstances, male fetuses are both more frequently exposed to early adversities and more affected by them when exposed than are female fetuses. The mechanisms through which biological sex imparts vulnerability or protection on the developing nervous system are largely unknown. We consider models that implicate variation in maturation, placental functioning, and the neuroendocrine milieu as potential contributors. Many studies use sex as a control variable, some analyze and report main effects for sex, but those that report interaction terms for sex are scarce. As a result, the true scope of sex differences in vulnerability is unknown.

Stress During Pregnancy

High levels of stress during pregnancy are associated with a number of adverse psychological and physiological outcomes for mother and child. These effects seem to be transmitted in part by one of the major stress-responsive systems, namely the hypothalamic-pituitary-adrenal (HPA) axis, which includes the hormone cortisol. However, as inconsistent study results indicate, methodology poses a substantial challenge to the investigation of stress during pregnancy. For example, although measures of maternal psychological stress and stress hormones are independently related to adverse pregnancy outcome, they seldom have been found to correlate with one another directly. Repeated measurement of psychological and biological responses to acute standardized stress challenges appears to reveal stronger associations. This article reviews the literature on experienced stress and stress hormones in pregnant women and presents studies that used standardized stress challenges (e.g., the Trier Social Stress Test, the cortisol response to morning awakening) to examine maternal stress reactivity more systematically. This review also takes a look at the few studies that examined the protective effects of psychological and psychosocial resources or stress interventions on experienced stress and stress hormones in pregnant women. Overall, results indicate that baseline stress hormone levels advance incrementally during gestation, presumably to prepare mother and fetus for delivery, while responses to acute stress appear to be increasingly attenuated. Moreover, the acute maternal stress response seems to be predictive of neonatal birth outcome and maternal well-being postpartum. Preliminary findings also suggest that much can be done toward coping with stress during pregnancy. Further research and a closer collaboration between science and clinical practice are required.

Spatial working memory and attention skills are predicted by maternal stress during pregnancy

INTRODUCTION

Experimental evidence in rodents shows that maternal stress during pregnancy (MSDP) negatively impacts spatial learning and memory in the offspring. We aim to investigate the association between MSDP (i.e., life events) and spatial working memory, as well as attention skills (attention shifting and attention focusing), in humans. The moderating roles of child sex, maternal anxiety during pregnancy and postnatal care are also investigated.

METHODS

Participants were 236 mother-child dyads that were followed from the second trimester of pregnancy until 4 years postpartum. Measurements included questionnaires and independent observations.

RESULTS

MSDP was negatively associated with attention shifting at 18 months when concurrent maternal anxiety was low. MSDP was associated with poorer spatial working memory at 4 years of age, but only for boys who experienced poorer postnatal care.

CONCLUSION

Consistent with results observed in rodents, MSDP was found to be associated with spatial working memory and attention skills. These results point to postnatal care and maternal anxiety during pregnancy as potential targets for interventions that aim to buffer children from the detrimental effects of MSDP.

24-h urinary free cortisol from mid-pregnancy to 3-months postpartum: gender and parity differences and effects

BACKGROUND

Pregnancy and postpartum have been associated to several physiological changes; however, empirical evidence was almost exclusively obtained in primiparous women and few studies focus on hormonal changes in men and second-time parents. The main aim of this study is to examine 24-h urinary free cortisol from mid-pregnancy to 3-months postpartum, comparing women/men and first/second-time parents.

METHODS

Twenty-six women and 22 men (N=48) were recruited from an antenatal obstetric unit in Porto, Portugal. 24-h urinary free cortisol was measured at the 2nd and 3rd trimester and at 3-months postpartum. Repeated measures analyses of variance were conducted, in order to analyze 24-h urinary free cortisol patterns of change over this period. Gender and parity were included in the analyses as potential modifiers, in order to compare women and men, and first- and second-time parents.

RESULTS

An increase from the 2nd to the 3rd trimester (p=.006) and a decrease from the 3rd trimester to 3-months postpartum (p=.005) were reported in all parents' 24-h urinary free cortisol. The interaction effects for Time*Gender (p=.03) and Time*Parity (p=.02) were found. Women and first-time parents revealed higher levels, while men and second-time parents showed lower 24-h urinary free cortisol levels at the 2nd trimester than at 3-months postpartum.

CONCLUSIONS

Findings appear to clarify the direction, as well as, the timing, gender and parity extension of 24-h urinary free cortisol changes from mid-pregnancy to 3-months postpartum. The same pattern of change in all parents' 24-h urinary free cortisol from mid-pregnancy to 3-months postpartum is consistent with the proposed role of hormones in preparation to parenting. Gender and parity differences and effects on 24-h urinary free cortisol are also consistent with cortisol as a stress biomarker for higher challenges associated to pregnancy and childbirth in women and first-time parents versus higher demands related to after childbirth parenting in men and second-time parents.

Posttraumatic stress disorder, smoking, and cortisol in a community sample of pregnant women

BACKGROUND

The prevalence of posttraumatic stress disorder (PTSD) in the United States is higher among pregnant women than women generally. PTSD is related to adverse birth outcomes via physiological and behavioral alterations, such as smoking.

METHODS

We utilize salivary cortisol measures to examine how traumatic stress, smoking and the hypothalamic-pituitary-adrenal axis interact. Pregnant women (n=395) gave cortisol specimens as part of a cohort study of PTSD and pregnancy at three health systems in the Midwestern United States. Women were divided into three groups: nonsmokers, quitters (who stopped smoking during pregnancy), and pregnancy smokers. Mean cortisol values at three points, sociodemographics, trauma history, and PTSD were compared across groups. We assessed the association of smoking group and PTSD with late afternoon cortisol levels.

RESULTS

Smokers, quitters, and nonsmokers differed on demographic risk factors and PTSD symptom load. Late afternoon and bedtime cortisol measures were significantly positively correlated with smoking in pregnancy, with smokers with PTSD presenting the highest cortisol levels. Regression analysis showed that smoking in pregnancy was associated with higher late afternoon cortisol in an additive manner with PTSD symptoms.

CONCLUSIONS

Smoking appears to have a different relationship with cortisol level for those with and without PTSD. This is the first study to show additive effects of smoking and PTSD on cortisol levels in pregnant women. Since high cortisol, smoking, and PTSD have been shown to adversely affect perinatal outcomes, and since those continuing to smoke in pregnancy had the highest PTSD symptom load, PTSD-specific smoking cessation programs in maternity settings are warranted.

Glucocorticoids and fetal programming part 1: Outcomes

Fetal development is a critical period for shaping the lifelong health of an individual. However, the fetus is susceptible to internal and external stimuli that can lead to adverse long-term health consequences. Glucocorticoids are an important developmental switch, driving changes in gene regulation that are necessary for normal growth and maturation. The fetal hypothalamic-pituitary-adrenal (HPA) axis is particularly susceptible to long-term programming by glucocorticoids; these effects can persist throughout the life of an organism. Dysfunction of the HPA axis as a result of fetal programming has been associated with impaired brain growth, altered behaviour and increased susceptibility to chronic disease (such as metabolic and cardiovascular disease). Moreover, the effects of glucocorticoid-mediated programming are evident in subsequent generations, and transmission of these changes can occur through both maternal and paternal lineages.

Obesity and mental disorders during pregnancy and postpartum: a systematic review and meta-analysis

OBJECTIVE

To evaluate the prevalence and risk of antenatal and postpartum mental disorders among obese and overweight women.

DATA SOURCES

Seven databases (including MEDLINE and ClinicalTrials.gov) were searched from inception to January 7, 2013, in addition to citation tracking, hand searches, and expert recommendations.

METHODS OF STUDY SELECTION

Studies were eligible if antenatal or postpartum mental disorders were assessed with diagnostic or screening tools among women who were obese or overweight at the start of pregnancy. Of the 4,687 screened articles, 62 met the inclusion criteria for the review. The selected studies included a total of 540,373 women.

TABULATION, INTEGRATION, AND RESULTS

Unadjusted odds ratios were pooled using random-effects meta-analysis for antenatal depression (n=29), postpartum depression (n=16), and antenatal anxiety (n=10). Obese and overweight women had significantly higher odds of elevated depression symptoms than normal-weight women and higher median prevalence estimates. This was found both during pregnancy (obese odds ratio [OR] 1.43, 95% confidence interval [CI] 1.27-1.61, overweight OR 1.19, 95% CI 1.09-1.31, median prevalence: obese 33.0%, overweight 28.6%, normal-weight 22.6%) and postpartum (obese OR 1.30, 95% CI 1.20-1.42, overweight OR 1.09, 95% CI 1.05-1.13, median prevalence: obese 13.0%, overweight 11.8%, normal-weight 9.9%). Obese women also had higher odds of antenatal anxiety (OR 1.41, 95% CI 1.10-1.80). The few studies identified for postpartum anxiety (n=3), eating disorders (n=2), or serious mental illness (n=2) also suggested increased risk among obese women.

CONCLUSION

Health care providers should be aware that women who are obese when they become pregnant are more likely to experience elevated antenatal and postpartum depression symptoms than normal-weight women, with intermediate risks for overweight women.