Lower prenatal vitamin D status and postpartum depressive symptomatology in African American women: Preliminary evidence for moderation by inflammatory cytokines

Vitamin D Deficiency and IL-6: Risk Factors for Preterm Birth in Black Women: A Retrospective Cross-Sectional Study

BACKGROUND

Non-Hispanic Black women have a 1.5 times greater rate of preterm birth (PTB, any birth occurring at <37 wk of gestation) than non-Hispanic White women. Black women are also more likely to have vitamin D deficiency (VDD; 25[OH]D <20 ng/mL) than White women. Vitamin D has anti-inflammatory effects, which may help explain the association of VDD with PTB in Black women.

OBJECTIVES

To examine associations between inflammatory biomarkers and VDD with PTB as an outcome.

METHODS

We used an exploratory retrospective cross-sectional design utilizing data collected as part of the larger Biosocial Impact on Black Births (BIBB) study. A case-control subsample was selected from the BIBB participants who had stored blood plasma available at 8-25 wk of gestation (n = 172). Fifty-nine PTB cases were included in the current study, with a set of matched controls based on maternal age controls at a 1:2 ratio of PTB to term birth (n = 113, 65.6%). Total 25(OH)D and cytokine levels were measured in the plasma.

RESULTS

Seventy percent of women with PTB had VDD compared with 50% of women with term birth who had VDD. Other inflammatory biomarkers were not associated with PTB except for IL-6. The PTB group had higher IL-6 and lower 25(OH)D levels compared with term birth. In adjusted models controlling for IL-6 and other covariates, odds ratios (OR) for VDD remained significant for predicting PTB (OR: 2.45; 95% confidence interval: 1.18, 5.06; P = 0.016).

CONCLUSIONS

Increased VDD was associated with increased risk of PTB among Black women after controlling for IL-6 and other factors. Achieving adequate vitamin D status in early pregnancy may have an important role in PTB prevention as it is a significant predictor of risk after inflammation and other factors are considered. Further investigation is warranted.

Is Serum Vitamin D Associated with Depression or Anxiety in Ante- and Postnatal Adult Women? A Systematic Review with Meta-Analysis

BACKGROUND/OBJECTIVES

To collect evidence from studies that explored the associations between serum vitamin D (25[OH]D) concentrations/status and the presence of depressive/anxiety symptoms in the ante- and/or postnatal periods (PROSPERO-CRD42023390895).

METHODS

Studies that assessed serum 25[OH]D concentrations in adult women during the ante/postnatal periods and those that used valid instruments to identify the experience/severity of depressive/anxiety symptoms were included. Independent researchers performed the identification/selection of studies, data extraction, risk of bias (RoB) assessment, and bibliometric analysis steps.

RESULTS

Of the total of 6769 eligible records, 15 cohort studies [high (n = 3), moderate (n = 7), and low (n = 5) RoB], nine cross-sectional studies [moderate (n = 3) and low (n = 6) RoB], and one case-control study [moderate RoB] were included (n = 25). Depression (n = 24) and anxiety (n = 4) symptoms were assessed. A significant difference in antenatal serum 25[OH]D concentrations between the groups of women with and without depression was identified (mean difference: -4.63 ng/mL; 95% confidence interval [95% CI]: -8.88; -0.38). Postnatal serum 25[OH]D concentrations were found to be, on average, -2.36 ng/mL (95% CI: -4.59; -0.14) lower in women with postnatal depression than in those without. Maternal antenatal anxiety was associated with significantly lower concentrations/deficiency of 25[OH]D in only one included study.

CONCLUSIONS

Based on very low/low-quality evidence, it was observed that reduced serum 25[OH]D concentrations in the ante- and postnatal period are associated with the presence of ante- and postnatal depressive symptoms, respectively. Low/deficient antenatal serum 25[OH]D concentrations may not be related to the presence of anxiety symptoms before childbirth. Well-designed longitudinal studies are needed to explore the estimated pooled effect of these associations.

Associations Between Early-Pregnancy Vitamin D Status and Postpartum Depressive and Anxiety Symptoms

OBJECTIVE

Maternal postpartum depressive and anxiety symptoms are risk factors for subsequent maternal and child mental health problems. Little is known about the potential role of antepartum vitamin D and C-reactive protein (CRP) in the etiology of maternal postpartum affective symptoms. We investigated associations between antepartum vitamin D status and postpartum depressive and anxiety symptoms and whether antepartum CRP mediated these associations.

METHODS

In 2483 participants of the Amsterdam Born Children and their Development prospective cohort, maternal serum vitamin D and CRP were measured at a median of 13 weeks' gestation. Vitamin D status was defined as deficient (≤29.9 nM), insufficient (30-49.9 nM), sufficient (50-79.9 nM), or normal (≥80 nM). Maternal depressive symptoms (Center for Epidemiologic Studies-Depression) and anxiety (State-Trait Anxiety Inventory) were assessed 3 months postpartum.

RESULTS

After adjustments for confounders, vitamin D deficiency was only associated with increased postpartum anxiety symptoms ( B = 0.17, 95% confidence interval [CI] = 0.03-0.30, p = .017) compared to normal vitamin D levels (≥80 nM). In women not taking vitamin D supplementation ( n = 2303), vitamin D deficiency was associated with increased postpartum depressive and anxiety symptoms ( B = 0.14, 95% CI = 0.03-0.28, p = .045; and B = 0.17, 95% CI = 0.03-0.32, p = .015). Antepartum CRP did not mediate these links.

CONCLUSIONS

We found some evidence that antepartum vitamin D deficiency was associated with increased postpartum affective symptoms, especially in women not taking vitamin D supplementation. Clinical trials should determine whether vitamin D supplementation can reduce the risk for postpartum affective disorders.

Causal associations between vitamin D and postpartum depression: A bidirectional mendelian randomization study

Background

Previous epidemiological studies have reported associations between vitamin D and postpartum depression (PPD); however, the findings are inconsistent. This study employs bidirectional Mendelian Randomization (MR) to investigate the causal link between serum 25-hydroxyvitamin D [25(OH)D] levels and PPD. By utilizing genetic data from cohorts, this research aims to provide a more robust understanding of the potential relationship between vitamin D and PPD, addressing a critical gap in the current literature.

Methods

A bidirectional MR analysis was conducted to investigate the genetic association between serum 25(OH)D and PPD using summary statistics extracted from GWAS datasets. The study included data from 15,668 patients with PPD and 376,755 healthy controls of European ancestry. The GWAS data for 25(OH)D were obtained from two studies within the UK Biobank, encompassing 496,946 and 79,366 participants. The primary analysis employed the inverse-variance weighted (IVW) method, while supplementary MR estimates were derived through the MR-Egger and weighted median (WME) methods. Furthermore, sensitivity analyses were implemented to ensure robustness and reliability, including Cochran's Q test, MR-PRESSO, MR-Egger intercept test, and the leave-one-out test.

Results

The MR study revealed no substantial genetic correlation between serum 25(OH)D levels and PPD (OR = 1.065, 95%CI = 0.878-1.293, P = 0.522 for set A; OR = 0.978, 95 % CI = 0.669-1.430, P = 0.910 for set B). Additionally, in the reverse analysis, we did not observe a significant causal impact of PPD on serum 25(OH)D (OR = 1.001, 95%CI = 0.974-1.028, P = 0.951 for set A; OR = 1.011, 95%CI = 0.992-1.031, P = 0.261 for set B). The results obtained from MR-Egger and WME analyses concord with those derived from the IVW method. Conducting leave-one-out tests did not identify any single nucleotide polymorphism that might have influenced the MR results, confirming the robustness and reliability of the findings.

Conclusions

The results suggest the absence of a causal link between vitamin D concentrations and PPD. Inconsistent observations in previous observational studies may be attributed to residual confounding.

Association between Vitamin D Levels During Pregnancy and Postpartum Depression: A Narrative Reviews

Background

Postpartum Depression (PPD) is a serious depression that develops in the first year, with unknown explained reasons. Many studies evaluated the impact of Vitamin D (VD) levels on depression during pregnancy and postnatal. This narrative review aims to review any association between serum VD levels during pregnancy and the development of PPD.

Materials and Methods

PPD data from published trials and research articles (period from 2012 to 2022) were assessed through PubMed, Scopus, Science Direct, and Google Scholar using the following terms: Depression, pregnancy, 25-hydroxyvitamin D (25OH VD), vitamin D deficiency (VDD) and postpartum (PP). Articles were selected manually and with careful tracking to avoid duplication. Articles that investigated any association between VD levels during pregnancy and PPD in the time frame were included in the study, while articles investigating VD levels of PP without depression were excluded.

Results

In this narrative review, five out of seven studies showed an association between PPD and VDD during pregnancy. Danish National Birth Cohort (DNBC), Edinburgh Postnatal Depression Scale (EPDS) and Center for Epidemiologic Studies Depression Scale (CES-D) enrolled among different studies from 3 days to 1 year PP to assess PPD.

Conclusions

Pregnant women with VDD are significantly associated with PPD. Longitudinal follow-up studies are needed to evaluate the association between VDD with PPD. Screening VD levels among pre-postnatal mothers may be essential for awareness programs that can be implemented to promote remission of postnatal depression.

Prenatal mood and anxiety disorders and associated cytokine changes

BACKGROUND

We examined whether women with prenatal mood and anxiety disorders would exhibit differential pro- and anti-inflammatory marker trajectories during the prenatal and postpartum periods compared to women without these disorders.

METHODS

Approximately 179 pregnant women participated in a longitudinal study conducted in two urban areas. Blood samples for inflammatory markers were collected at six study visits. The Structured Clinical Interview for the DSM-IV (SCID) was administered to participants scoring above cutoffs on anxiety and depression. Pregnant women with SCID Axis I diagnoses of mood and/or anxiety disorders were compared to other participants on inflammatory markers. Multilevel modeling tested associations between SCID diagnoses and within-person interleukin (IL)6 and IL10 trajectories.

RESULTS

Prenatal SCID diagnoses were associated with linear, quadratic and cubic change in IL6 from prenatal to postpartum timepoints. Women with a prenatal SCID diagnosis had steeper decreases and increases in IL6 during prenatal and postpartum periods. SCID diagnoses were associated with lower IL10 in mid-pregnancy to postpartum (b = -0.078, SE = 0.019; p = .015).

LIMITATIONS

Future studies would benefit from a larger sample size and a larger number of participants with SCID diagnoses. Future research should also examine whether different prenatal Axis 1 diagnoses are associated with different patterns of immune response in pregnancy.

CONCLUSIONS

Pregnant women with prenatal mood and anxiety disorders had greater fluctuations in IL6 across prenatal and postpartum periods and lower IL10 through pregnancy and postpartum. They may have different proinflammatory states that remain after birth without a reciprocal anti-inflammatory response.

Vitamin D Status as an Important Predictor of Preterm Birth in a Cohort of Black Women

Vitamin D deficiency (25 (OH)D < 20 ng/mL) is a modifiable risk factor that has been associated with an increased risk of preterm birth (PTB) (<37 weeks gestation). Black women are at a high risk for vitamin D deficiency due to higher melanin levels. Vitamin D sufficiency may be protective against PTB risk in Black women. Black participants between 8 and 25 weeks of gestation were included in this nested case-control study. The sample consisted of women who had either PTBs (n = 57) or term births, were selected based on maternal age compared to those who had PTBs (n = 118), and had blood samples available between 8 and 25 weeks of gestation. The women completed questionnaires about depressive symptoms and smoking behavior and had blood collected to determine their vitamin D levels. Gestational age at birth, hypertensive disorders, and body mass index (BMI) were collected from the medical records. The odds of PTB were increased by 3.34 times for participants with vitamin D deficiency after adjusting for hypertensive disorders of pregnancy and depressive symptoms. Vitamin D assessment and supplementation may be an important intervention for preventing PTB in pregnant Black women.

Perinatal depression and serum vitamin D status: A cross-sectional study in urban China

BACKGROUND

Although vitamin D has been found to be associated with perinatal depression, the results are inconsistent. The aim of this cross-sectional study was to examine the association between vitamin D and PND in Chinese pregnant women and lactating women.

METHODS

A total of 1773 participants were included, including 907 lactating women and 866 pregnant women. The Edinburgh Postnatal Depression Scale (EPDS) was used to screen for PND, and those with scores ≥13 were considered to have PND. Serum 25-hydroxyvitamin D concentrations were assessed with high-performance liquid chromatography.

RESULTS

The prevalence of postpartum depression (PPD) and antenatal depression (AD) were 15.9 % and 9.8 %, respectively. Compared with individuals with sufficient vitamin D, those with vitamin D deficiency were associated with a higher prevalence of PPD in lactating women (OR = 1.71, 95%CI: 1.01-2.88, p = 0.044). The serum 25(OH)D of lactating women was inversely associated with the scores of the factor "depressive mood" of the EPDS (ORper 5 ng/mL = -0.10, 95%CI: -0.19 to -0.01, p = 0.032). No significant association between serum 25-hydroxyvitamin D and AD was observed.

LIMITATIONS

First, this study is a cross-sectional design, which can only determine associations but not causality. Secondly, this study only included participants from urban areas. Thirdly, there are still some possible confounding factors that have not been considered.

CONCLUSION

In conclusion, this study suggested a significant association between vitamin D status and PPD; however, the association between vitamin D status and AD was not significant.

Perinatal mood and anxiety disorders: biomarker discovery using plasma proteomics

BACKGROUND

Perinatal mood and anxiety disorders encompass a range of mental health disorders that occur during pregnancy and up to 1 year postpartum, affecting approximately 20% of women. Traditional risk factors, such as a history of depression and pregnancy complications including preeclampsia, are known. Their predictive utility, however, is not specific or sensitive enough to inform clinical decision-making or prevention strategies for perinatal mood and anxiety disorders. Better diagnostic and prognostic models are needed for early identification and referral to treatment.

OBJECTIVE

This study aimed to determine if a panel of novel third-trimester plasma protein biomarkers in pregnant women can be used to identify those who have a high predisposed risk for perinatal mood and anxiety disorders within 3 months postpartum.

STUDY DESIGN

We studied 52 women (n=34 with a risk for perinatal mood and anxiety disorders and n=18 controls) among whom mental health screening was conducted at 2 time points, namely in the third trimester and again at 3 months postdelivery. An elevated perinatal mood and anxiety disorder risk was identified by screening individuals with above-validated cutoffs for depression (Edinburgh Postnatal Depression Scale ≥12), anxiety (Overall Anxiety Severity and Impairment Scale ≥7), and/or posttraumatic stress disorder (Impact of Events Scale >26) at both time points. Plasma samples collected in the third trimester were screened using the aptamer-based SomaLogic SomaScan proteomic assay technology to evaluate perinatal mood and anxiety disorder-associated changes in the expression of 1305 protein analytes. Ingenuity Pathway Analysis was conducted to highlight pathophysiological relationships between perinatal mood and anxiety disorder-specific proteins found to be significantly up- or down-regulated in all subjects with perinatal mood and anxiety disorder and in those with perinatal mood and anxiety disorders and no preeclampsia.

RESULTS

From a panel of 53 significant perinatal mood and anxiety disorder-associated proteins, a unique 20-protein signature differentiated perinatal mood and anxiety disorder cases from controls in a principal component analysis (P<.05). This protein signature included NCAM1, NRCAM, and NTRK3 that converge around neuronal signaling pathways regulating axonal guidance, astrocyte differentiation, and maintenance of GABAergic neurons. Interestingly, when we restricted the analysis to subjects without preeclampsia, a 30-protein signature differentiated perinatal mood and anxiety disorder cases from all controls without overlap on the principal component analysis (P<.001). In the nonpreeclamptic perinatal mood and anxiety disorder group, we observed increased expression of proteins, such as CXCL11, CXCL6, MIC-B, and B2MG, which regulate leucocyte migration, inflammation, and immune function.

CONCLUSION

Participants with perinatal mood and anxiety disorders had a unique and distinct plasma protein signature that regulated a variety of neuronal signaling and proinflammatory pathways. Additional validation studies with larger sample sizes are needed to determine whether some of these molecules can be used in conjunction with traditional risk factors for the early detection of perinatal mood and anxiety disorders.

The association between Vitamin D levels and postpartum depression: a review

According to WHO, Postpartum Depression (PPD) occurs in 10–15% of women after giving birth. Several studies assumed that vitamin D deficiency might worsen PPD symptoms. However, the association between vitamin D levels and PPD is still conflicting. This article summarizes the association between vitamin D levels and PPD. A literature search about Vitamin D levels and PPD from Scopus and PubMed databases was performed in June 2022. Eleven studies were obtained out of 30 studies. Nine out of 11 studies showed that vitamin D levels were significantly associated with PPD. However, the two others showed no significant association. The difference in the blood sample taken and how to assess depression contributes to a different result. The association is related to the role of vitamin D in mood regulation, synthesis of neurotransmitters, stimulating brain receptors, and intercellular neuronal signaling systems.

Seroprevalence and Risk Factors of Sexually Transmitted Blood-Borne Infections among Pregnant Women Attending Antenatal Care in Jirapa, Upper West Region of Ghana

Background

Sexually transmitted blood-borne infections (STBBIs) contribute to negative outcomes of pregnancy. Hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and syphilis infections in pregnancy contribute significantly to maternal and child morbidities and mortalities. This study assessed the prevalence, knowledge, and risk factors of STBBIs (HBV, HCV, HIV, and syphilis) among pregnant women attending antenatal clinics in Jirapa.

Methods

A cross-sectional study design involving 246 pregnant women was employed for the study. A structured questionnaire was used to solicit information about the knowledge, prevalence, and risk factors of STBBIs.

Results

The overall prevalence of STBBIs was 11.4%; HBV prevalence was 9.8% and 0.8% each for HCV, HIV, and syphilis. About 66% of mothers were aware of mother-to-child transmission of infections during pregnancy. Knowledge of transmission of HIV (93.9%), hepatitis (67.1%), and syphilis (53.7%) in pregnancy was relatively high. Knowledge of risk factors for HIV, hepatitis, and syphilis was 97.6%, 74.4%, and 76.0%, respectively. More than 98% of respondents knew about the prevention of HIV, hepatitis, and syphilis. Significant risk factors associated with and predictive of STBBIs were female genital mutilation (FGM) and gravidity.

Conclusion

The occurrence of STBBIs among pregnant women was strongly associated with FGM and gravidity. Public health education should be directed at stopping the practice of FGM and improving reproductive health in the study area.

Relationship between inflammatory biomarkers, vitamin D levels, and depressive symptoms in late pregnancy and during the postpartum period: a prospective, observational study

Background

Perinatal depression impacts maternal and fetal health, and exhibits a high rate of continuity postpartum. Not only does it impair the maternal quality of life, it also increases the risk of adverse birth and developmental problems in offspring. Vitamin D deficiency and excessive inflammation have been associated with perinatal depression. There is a scarcity of evidence regarding the biological causes of maternal depression in Iraq, therefore, the present study aims to assess perinatal depressive symptoms associations with inflammatory markers and vitamin D levels, and to investigate the interaction between vitamin D and the inflammatory markers. A prospective, observational study design was utilized to recruit healthy pregnant women from private obstetrics clinic in Baghdad, Iraq, from April to September 2021. The Edinburgh Postnatal Depression Scale (EPDS) was used to measure depressive symptoms during the third trimester and at 6 months postpartum. Serum levels of interleukin (IL)-6, C-reactive protein (CRP), and 25-hydroxy vitamin D (25-OH-D) were quantified, using a fully automated chemiluminescence immunoassay analyzer.

Results

Eighty patients were eligible for inclusion. The antenatal EPDS scores demonstrated a significant association with square root IL-6 (B = – 0.025, p = 0.040) and no association with CRP or vitamin D levels. The severity of postpartum depressive symptoms tended towards a positive association, with larger increases of CRP concentration (p = 0.065). In contrast, the association between marital relationship quality and CRP was statistically significant (p = 0.001). There was a statistically significant association between CRP and vitamin D concentration (p = 0.041). Antepartum EPDS significantly predicted the postpartum EPDS score (p = 0.000, B = 0.180, R2 for the model = 0.976, CI (0.17–0.19)).

Conclusions

The study findings show a significant association between third trimester depressive symptoms and IL-6 concentration. CRP and vitamin D levels do not correlate with perinatal depressive symptoms and a poor marital relationship significantly elevates the CRP level. In addition, vitamin D level was associated with CRP level and antepartum depressive symptoms predict postpartum EPDS score. Future studies involving a larger population and including women with pregnancy complications would provide a further insight into the role of inflammation and vitamin D deficiency in the etiology of perinatal depression.

Association of VDBP (rs4588 and rs7041) gene polymorphisms with susceptibility to postpartum depression in South Indian population: A cross-sectional study

Low vitamin D levels have been implicated in postpartum depressive disorders (PPD). Our study aimed to demonstrate the association of Vitamin D Binding Protein (VDBP) genetic variants rs7041 and rs4588 with susceptibility to PPD and to investigate their possible relationship with serum vitamin D and VDBP levels in Indian women with PPD. A cross-sectional study involved 330 cases and 330 controls. Depressive symptoms were assessed using Edinburg Postnatal Depression Scale. Genotyping of SNPs was done by Taqman 5'allelic discrimination assay. Estimation of serum 25 hydroxyvitamin D [25(OH) D] and VDBP levels were done by ELISA. Serum total, free and bioavailable 25(OH) D levels were significantly lower in cases compared to controls, with similar levels of VDBP between the two groups. The study results showed that the VDBP rs4588 variant genotype AA was significantly associated with lower circulating levels of total 25(OH) D in cases. Also, the VDBP rs7041 variant TT genotype demonstrated significantly lower levels of total, free and bioavailable 25(OH) D levels in controls. However, VDBP rs7041 and rs4588 variants were not associated with PPD susceptibility. Also, VDBP haplotypes showed no association with PPD susceptibility. Our results demonstrated that VDBP polymorphisms rs4588 and rs7041 and their haplotypes are not associated with PPD susceptibility in the South Indian population. However, vitamin D levels were found to be influenced by the risk genotypes of VDBP SNPs rs4588 and rs7041.

A Systematic Review of Vitamin D during Pregnancy and Postnatally and Symptoms of Depression in the Antenatal and Postpartum Period from Randomized Controlled Trials and Observational Studies

Depression is a common mood disorder associated with childbirth and is hypothesized to be affected by low vitamin D. This systematic review identified two randomized controlled trials (RCT) of vitamin D supplementation for the treatment or prevention of depressive symptoms in the perinatal period, as well as 18 observational studies of vitamin D exposure and depression in the antenatal and postnatal periods. Both RCTs claimed an improvement in depressive symptoms in the vitamin D group, although the sample sizes were too small to draw firm conclusions. The case-control and cohort studies had mixed findings and were limited by study quality. There were inconsistent results within the few studies with a more robust methodology or within samples restricted to women likely to have depression. The current evidence is inconclusive due to the poor quality and heterogeneity of studies, likely contributing to the contradictory findings. Given there are already numerous RCTs of prenatal vitamin D supplementation, we recommend adding an appropriate measure of depression in the perinatal period to assist in resolving the uncertainty.

The Problem of Malnutrition Associated with Major Depressive Disorder from a Sex-Gender Perspective

Major depressive disorder (MDD) is an incapacitating condition characterized by loss of interest, anhedonia and low mood, which affects almost 4% of people worldwide. With rising prevalence, it is considered a public health issue that affects economic productivity and heavily increases health costs alone or as a comorbidity for other pandemic non-communicable diseases (such as obesity, cardiovascular disease, diabetes, inflammatory bowel diseases, etc.). What is even more noteworthy is the double number of women suffering from MDD compared to men. In fact, this sex-related ratio has been contemplated since men and women have different sexual hormone oscillations, where women meet significant changes depending on the age range and moment of life (menstruation, premenstruation, pregnancy, postpartum, menopause…), which seem to be associated with susceptibility to depressive symptoms. For instance, a decreased estrogen level promotes decreased activation of serotonin transporters. Nevertheless, sexual hormones are not the only triggers that alter neurotransmission of monoamines and other neuropeptides. Actually, different dietary habits and/or nutritional requirements for specific moments of life severely affect MDD pathophysiology in women. In this context, the present review aims to descriptively collect information regarding the role of malnutrition in MDD onset and course, focusing on female patient and especially macro- and micronutrient deficiencies (amino acids, ω3 polyunsaturated fatty acids (ω3 PUFAs), folate, vitamin B12, vitamin D, minerals…), besides providing evidence for future nutritional intervention programs with a sex-gender perspective that hopefully improves mental health and quality of life in women.

Immune System Alterations and Postpartum Mental Illness: Evidence From Basic and Clinical Research

The postpartum period is a time associated with high rates of depression and anxiety as well as greater risk for psychosis in some women. A growing number of studies point to aberrations in immune system function as contributing to postpartum mental illness. Here we review evidence from both clinical and animal models suggesting an immune component to postpartum depression, postpartum anxiety, and postpartum psychosis. Thus far, clinical data primarily highlights changes in peripheral cytokine signaling in disease etiology, while animal models have begun to provide insight into the immune environment of the maternal brain and how central inflammation may also be contributing to postpartum mental illnesses. Further research investigating peripheral and central immune function, along with neural and endocrine interactions, will be important in successfully developing novel prevention and treatment strategies for these serious disorders that impact a large portion of new mothers.

Inflammation and the Association of Vitamin D and Depressive Symptomatology

Depression and vitamin D deficiency are major public health problems. The existing literature indicates the complex relationship between depression and vitamin D. The purpose of this study was to examine whether this relationship is moderated or mediated by inflammation. A community sample (n = 7162) from the LIFE-Adult-Study was investigated, for whom depressive symptoms were assessed via the German version of CES-D scale and serum 25-hydroxyvitamin D (25(OH)D) levels and inflammatory markers (IL-6 and CRP levels, WBC count) were quantified. Mediation analyses were performed using Hayes’ PROCESS macro and regression analyses were conducted to test moderation effects. There was a significant negative correlation between CES-D and 25(OH)D, and positive associations between inflammatory markers and CES-D scores. Only WBC partially mediated the association between 25(OH)D levels and depressive symptoms both in a simple mediation model (ab: −0.0042) and a model including covariates (ab: −0.0011). None of the inflammatory markers showed a moderation effect on the association between 25(OH)D levels and depressive symptoms. This present work highlighted the complex relationship between vitamin D, depressive symptoms and inflammation. Future studies are needed to examine the effect of vitamin D supplementation on inflammation and depressive symptomatology for causality assessment.

Maternal Serum Cytokine Concentrations in Healthy Pregnancy and Preeclampsia

The maternal immune response is essential for successful pregnancy, promoting immune tolerance to the fetus while maintaining innate and adaptive immunity. Uncontrolled, increased proinflammatory responses are a contributing factor to the pathogenesis of preeclampsia. The Th1/Th2 cytokine shift theory, characterised by bias production of Th2 anti-inflammatory cytokine midgestation, was frequently used to reflect the maternal immune response in pregnancy. This theory is simplistic as it is based on limited information and does not consider the role of other T cell subsets, Th17 and Tregs. A range of maternal peripheral cytokines have been measured in pregnancy cohorts, albeit the changes in individual cytokine concentrations across gestation is not well summarised. Using available data, this review was aimed at summarising changes in individual maternal serum cytokine concentrations throughout healthy pregnancy and evaluating their association with preeclampsia. We report that TNF-α increases as pregnancy progresses, IL-8 decreases in the second trimester, and IL-4 concentrations remain consistent throughout gestation. Lower second trimester IL-10 concentrations may be an early predictor for developing preeclampsia. Proinflammatory cytokines (TNF-α, IFN-γ, IL-2, IL-8, and IL-6) are significantly elevated in preeclampsia. More research is required to determine the usefulness of using cytokines, particularly IL-10, as early biomarkers of pregnancy health.

Treatment-Resistant Depression Revisited: A Glimmer of Hope

Major Depressive Disorder (MDD) is a highly prevalent psychiatric disorder worldwide. It causes individual suffering, loss of productivity, increased health care costs and high suicide risk. Current pharmacologic interventions fail to produce at least partial response to approximately one third of these patients, and remission is obtained in approximately 30% of patients. This is known as Treatment-Resistant Depression (TRD). The burden of TRD exponentially increases the longer it persists, with a higher risk of impaired functional and social functioning, vast losses in quality of life and significant risk of somatic morbidity and suicidality. Different approaches have been suggested and utilized, but the results have not been encouraging. In this review article, we present new approaches to identify and correct potential causes of TRD, thereby reducing its prevalence and with it the overall burden of this disease entity. We will address potential contributory factors to TRD, most of which can be investigated in many laboratories as routine tests. We discuss endocrinological aberrations, notably, hypothalamic-pituitary-adrenal (HPA) axis dysregulation and thyroid and gonadal dysfunction. We address the role of Vitamin D in contributing to depression. Pharmacogenomic testing is being increasingly used to determine Single Nucleotide Polymorphisms in Cytochrome P450, Serotonin Transporter, COMT, folic acid conversion (MTHFR). As the role of immune system dysregulation is being recognized as potentially a major contributory factor to TRD, the measurement of C-reactive protein (CRP) and select immune biomarkers, where testing is available, can guide combination treatments with anti-inflammatory agents (e.g., selective COX-2 inhibitors) reversing treatment resistance. We focus on established and emerging test procedures, potential biomarkers and non-biologic assessments and interventions to apply personalized medicine to effectively manage treatment resistance in general and TRD specifically.

Postpartum Depression: Current Status and Possible Identification Using Biomarkers

Postpartum depression (PPD) is a serious health issue that can affect about 15% of the female population within after giving birth. It often conveys significant negative consequences to the offsprings. The symptoms and risk factors are somewhat similar to those found in non-postpartum depression. The main difference resides in the fact that PPD is triggered by postpartum specific factors, including especially biological changes in the hormone levels. Patients are usually diagnosed using a questionnaire onsite or in a clinic. Treatment of PPD often involves psychotherapy and antidepressant medications. In recent years, there have been more researches on the identification of biological markers for PPD. In this review, we will focus on the current research status of PPD, with an emphasis on the recent progress made on the identification of PPD biomarkers.

Poor vitamin D status and the risk of maternal depression: a dose-response meta-analysis of observational studies

OBJECTIVE

The association between 25-hydroxyvitamin D (25(OH)D) and maternal depression (MD) is deemed to be inconclusive. The current analysis aimed to quantify the relationship between 25(OH)D serum concentrations, the main indicator of vitamin D nutritional status, and MD.

DESIGN

Dose-response meta-analysis.

SETTING

A systematic search in PubMed, Embase and Web of Science from inception to June 2019.

PARTICIPANTS

Relevant observational studies reporting risk estimates and 95 % CI of random effects for 25(OH)D concentration on MD were identified.

RESULTS

Twelve observational studies with thirteen independent reports involving 10 317 pregnant women were included. Compared with the lowest category of 25(OH)D, the pooled OR for the highest category of MD was 0·49 (95 % CI 0·35, 0·63); a high heterogeneity was observed (P = 0·001, I2 = 82·1 %). A non-linear association between 25(OH)D and MD was found (P for non-linearity = 0·001); the dose-response analysis indicated that the lowest pooled OR was at blood 25(OH)D concentrations of 90-110 nmol/l. Subgroup analyses suggested a stronger association between 25(OH)D and MD in summer time (OR 0·25, 95 % CI 0·08, 0·43) than in other seasons (OR 0·68, 95 % CI 0·52, 0·83) (P for interaction = 0·008). A visual inspection of funnel plot and Begg's and Egger's tests did not indicate any evidence of publication bias.

CONCLUSIONS

Low circulating 25(OH)D is associated with MD, and our analysis suggests that they influence each other. Further randomised controlled trials would be needed to determine the direction of causation.

Risk factors for postpartum depression: An evidence-based systematic review of systematic reviews and meta-analyses

PURPOSE

Postpartum depression (PPD) is the most common psychiatric condition after childbirth which not only effects the mother's health, but also might have impact on child's development and parenting behaviors. Because the etiology of PPD has not been fully cleared, the efforts towards identification of risk factors are crucial for both the children and mother's health.

METHOD

PubMed, EMBASE and PsycINFO databases were searched since inception until July 2019 to collect data about the risk factors of PPD and only systematic review and meta-analysis can be included.

RESULT

To identify the real risk factors, protective factors and controversial factors, nineteen parts of the interpretation were adopted. The risk factors are mainly concentrated in the following aspects: violence and abuse, immigration status, gestational diabetes, cesarean section, depressive history, vitamin D deficiency, obese and overweight, postpartum sleep disruption and poor postpartum sleep, lack of social support, traditional dietary pattern (Japanese, Indian, United Kingdom, and Brazilian dietary pattern), multiple births, preterm and low-birth-weight infants, postpartum anemia, negative birth experience. The controversial factors are serum level of cortisol, thyroid peroxidase autoantibodies status, acculturation, traditional confinement practices. Skin-to-skin care, higher concentrations of DHA in mothers' milk, greater seafood consumption, healthy dietary patterns, multivitamin supplementation, fish and PUFA intake, calcium, Vitamin D, zinc and possibly selenium are protective factors.

CONCLUSION

Thirteen risk factors were identified, but five factors still controversial due to the insufficient of the evidence. What's more, skin-to-skin care and some nutrition related factors are protective factors against PPD.

Is Vitamin D Status Associated with Depression, Anxiety and Sleep Quality in Pregnancy: A Systematic Review

Background

Women's mental health is a significant health issue for pregnant women during and after pregnancy. Postpartum depression (PPD) is defined as the presence of depression in the 1^st year after delivery. This study reviews the relationship between Vitamin D levels, anxiety and poor sleep quality related to pregnancy.

Materials and Methods

A systematic search was conducted on documents presented in PubMed, Scopus, ProQuest, Science Direct, Google Scholar and Web of Science databases until March 2020. Three separate search paths were considered for three different disorders with particular keywords. All observational studies that investigate the relationship between Vitamin D levels and PPD, sleep disorders, and anxiety were selected for inclusion in the study.

Results

Search yielded 14 eligible studies. Quality of most included studies was medium to high. Nine studies reported that Vitamin D deficiency was directly associated to the incidence of PPD and sleep disorders. One study reported an indirect association, and three researches did not observe any association between Vitamin D status, sleep disorders and PPD. One study reported a direct association to anxiety but did not have any relation to PPD.

Conclusions

PPD and sleep quality during pregnancy associated to Vitamin D deficiency directly. Although studies have several limitations, the importance of sufficient Vitamin D status in pregnant women has been addressed in all studies, especially regarding the prevention of PPD, anxiety, and poor sleep quality during the pregnancy.

Neighborhood disorder predicts lower serum vitamin D levels in pregnant African American women: A pilot study

Pregnant African American women are more likely to live in neighborhoods with more disorder (e.g., vacant housing, littler, crime) and to have vitamin D deficiency due to their darker skin pigmentation and poor production of vitamin D [25(OH)D] from ultraviolet rays. However, no study has examined the potential link between neighborhood disorder and 25(OH)D status in African American pregnant women. Forty-one pregnant African American women completed validated questionnaires about perceived neighborhood disorder (6 items; 3-point scale; range 6-18) and with concurrent serum levels of 25-hydroxyvitamin D [25(OH)D] assessed during pregnancy at 18-24 weeks gestation. Higher levels of perceived neighborhood disorder were associated with lower levels of serum 25(OH)D. Pregnant African American women who report higher disorder in their neighborhood may spend less time outside. Health care providers should include assessment of perceived neighborhood disorder. Future research needs to evaluate the relationships among neighborhood disorder and 25(OH)D levels among pregnant African American women.

Increased brain vitamin D receptor expression and decreased expression of cathelicidin antimicrobial peptide in individuals who died by suicide

Vitamin D deficiency is associated with immune dysregulation, increased vulnerability to infections, depression, and suicidal behavior. One mediator of vitamin D-dependent immune regulation and antimicrobial defense is the cathelicidin antimicrobial peptide (LL-37), encoded by the cathelicidin-related antimicrobial peptide (CRAMP) gene. We compared the mRNA expression of the CRAMP gene, the vitamin D receptor (VDR) gene, as well as the CYP27B1 and CYP24A1 genes (involved in vitamin D metabolism) in the dorsolateral prefrontal cortex (dlPFC) and anterior cingulate cortex (ACC) between depressed individuals who died by suicide (n = 15) and matched (age, gender, and post-mortem interval) non-psychiatric controls (n = 15). Gene expression was measured through qRT-PCR with TaqMan® primers and probes, with GAPDH and β-actin genes as endogenous controls. Statistical analyses included t-tests and Pearson correlations. CRAMP mRNA expression was downregulated and VDR mRNA expression was upregulated in both dlPFC and ACC in suicides relative to controls, with no significant differences in expression of CYP24A1 and CYP27B1. To our knowledge, this is the first study on brain cathelicidin expression in the human brain in relationship to suicide. Increased VDR and decreased CRAMP expression are consistent with previously reported associations between vitamin D deficiency, immune dysregulation, and suicidal behavior, and should lead to future studies uncovering novel interactive targets for suicide prevention.

Vitamin D and inflammation in major depressive disorder

BACKGROUND

Increased inflammation is reported in Major Depressive Disorder (MDD), which may be more pronounced in suicidal subjects. Vitamin D deficiency may drive this pro-inflammatory state due to vitamin D's anti-inflammatory effects.

METHODS

We quantified plasma 25-hydroxyvitamin D (25(OH)D) and inflammatory markers interleukin (IL)-6 and tumor necrosis factor (TNF)-α, and other inflammatory indices, neutrophil-to-lymphocyte ratio (NLR) and white blood cell count (WBC) in 48 un-medicated MDD subjects (n = 17 with mild-to-moderate suicidal ideation [SI]) and 54 controls. IL-6 and TNF-α were combined into a composite inflammation score.

RESULTS

There were no significant differences in 25(OH)D levels between MDD and controls (p = 0.24) or between MDD with and without SI (p = 0.61). However, 25(OH)D was negatively correlated with all measured inflammatory markers; these correlations were stronger in MDD subjects, and particularly in those with SI. MDD status significantly moderated the relationships between 25(OH)D and NLR (p = 0.03), and 25(OH)D and WBC (p < 0.05), and SI significantly moderated the relationship between 25(OH)D and NLR (p = 0.03).

LIMITATIONS

The study was cross-sectional, thereby limiting causal inference, and had a small sample size. Only seventeen of the MDD subjects had SI.

CONCLUSION

While 25(OH)D levels did not significantly differ in MDD vs. controls, or in MDD with or without SI, lower 25(OH)D was associated with indices of immune activation in MDD, especially in cases with SI. Although our findings do not address causality, they are consistent with findings that relatively low 25(OH)D levels in MDD are associated with a pro-inflammatory state.

Inflammation (IL-1β) Modifies the Effect of Vitamin D and Omega-3 Long Chain Polyunsaturated Fatty Acids on Core Symptoms of Autism Spectrum Disorder-An Exploratory Pilot Study‡

BACKGROUND

The role of vitamin D and omega-3 long chain polyunsaturated fatty acids (omega-3 LCPUFA) in improving core symptoms of autism spectrum disorder (ASD) in children has been investigated by a few randomised controlled trials and the results are mixed and inconclusive. The response to treatment with these nutrients is heterogenous and may be influenced by inflammatory state. As an exploratory analysis, we investigated whether inflammatory state would modulate the effect of these nutrients on core symptoms of ASD. Methods: Seventy-three New Zealand children with ASD (2.5-8.0 years) completed a 12-month randomised, double-blind, placebo-controlled trial of vitamin D (VID, 2000 IU/day), omega-3 LCPUFA; (OM, 722 mg/day docosahexaenoic acid), or both (VIDOM). Non-fasting baseline plasma interleukin-1β (IL-1β) was available for 67 children (VID = 15, OM = 21, VIDOM = 15, placebo = 16). Children were categorised as having undetectable/normal IL-1β (<3.2 pg/ml, n=15) or elevated IL-1β (≥3.2 pg/mL, n = 52). The Social Responsiveness Scale (SRS) questionnaire was used to assess core symptoms of ASD (baseline, 12-month). Mixed model repeated measure analyses (including all children or only children with elevated IL-1β) were used.

RESULTS

We found evidence for an interaction between baseline IL-1β and treatment response for SRS-total, SRS-social communicative functioning, SRS-awareness and SRS-communication (all P_interaction < 0.10). When all children were included in the analysis, two outcome comparisons (treatments vs. placebo) showed greater improvements: VID, no effect (all P > 0.10); OM and VIDOM (P = 0.01) for SRS-awareness. When only children with elevated IL-1β were included, five outcomes showed greater improvements: OM (P = 0.01) for SRS-total; OM (P = 0.03) for SRS-social communicative functioning; VID (P = 0.01), OM (P = 0.003) and VIDOM (P = 0.01) for SRS-awareness.

CONCLUSION

Inflammatory state may have modulated responses to vitamin D and omega-3 LCPUFA intervention in children with ASD, suggesting children with elevated inflammation may benefit more from daily vitamin D and omega-3 LCPUFA supplementation.

The effect of vitamin D and calcium supplementation on inflammatory biomarkers, estradiol levels and severity of symptoms in women with postpartum depression: a randomized double-blind clinical trial

Objectives: Postpartum depression (PPD) is a major depressive disorder. Vitamin D deficiency may play a role in PPD pathogenesis. This study was designed to determine the effect of vitamin D and calcium supplementation on the severity of symptoms and some related inflammatory biomarkers in women with PPD.Materials and Methods: Eighty-one women with a PPD score >12 participated in this study. A total of 27 patients were randomly assigned into three groups (1:1:1 ratio) to receive either 50,000 IU vitamin D3 fortnightly + 500 mg calcium carbonate daily; or 50,000 IU vitamin D3 fortnightly + placebo of calcium carbonate daily, or placebo of vitamin D3 fortnightly + placebo of calcium carbonate daily (placebo group) for 8 weeks. At the baseline and end of the study, the severity score of PPD, levels of 25-hydroxy vitamin D, calcium, tumor necrosis factor-alpha (TNFα), interleukin 6 (IL6) and estradiol were measured.Results: The PPD score had more reduction in the vitamin D + calcium and vitamin D + calcium placebo groups than that of the placebo group (-1.7 ± 3.44, -4.16 ± 5.90 and 0.25 ± 2.81, respectively; p = 0.008). The effect of vitamin D on the PPD score was larger when vitamin D was given alone than given together with calcium (p = 0.042 and p = 0.004, respectively). No significant differences in estradiol, IL6 and TNFα were observed between the three groups.Discussion: Vitamin D may be effective in improving the clinical symptoms of PPD; however, the mechanism of the effect might not entirely operate through inflammatory and/or hormonal changes.

Effects of Vitamin D3 in Long-Term Ovariectomized Rats Subjected to Chronic Unpredictable Mild Stress: BDNF, NT-3, and NT-4 Implications

The purpose of this study was to explore the antidepressant-like effects of vitamin D₃ at different doses (1.0, 2.5, and 5.0 mg/kg sc) on a model of depression produced by chronic unpredictable mild stress (CUMS) for 28 days in long-term (3 months) ovariectomized (OVX) adult rats. Sucrose preference (SPT), forced swimming (FST) and open-field (OFT) tests were conducted to examine the depression-like state. Serum corticosterone/adrenocorticotrophic hormone (ACTH) levels and hippocampal brain-derived neurotrophic factor (BDNF) and neurotrophin (NT)-3/NT-4 expressions by ELISA kits and/or western blotting were determined to assess the possible mechanisms of the vitamin D₃ effects on the depression-like profile in long-term OVX rats subjected to CUMS. The results showed that vitamin D₃ (5.0 mg/kg), as well as fluoxetine treatment, considerably reversed the depression-like state in the SPT and FST, decreased serum corticosterone/ACTH levels, and increased BDNF and NT-3/NT-4 levels in the hippocampus of long-term OVX rats compared to OVX rats with CUMS (p < 0.05). Thus, a high dose of vitamin D₃ (5.0 mg/kg sc) could improve the depression-like profile in long-term OVX adult female rats subjected to the CUMS procedure, which might be mediated by the regulation of BDNF and the NT-3/NT-4 signaling pathways in the hippocampus, as well as the corticosterone/ACTH levels of the blood serum.

[Inflammatory Biomarkers and Postpartum Depression: A Systematic Review of Literature]

OBJECTIVE

Postpartum Depression (PPD) affects over 15% new mothers. Its etiology is multifactorial and still partly unknown. Some hypotheses suggest a link with inflammation. This review aims to explore the existence of inflammatory biomarkers associated with PPD. The possibility of potential adjunct treatments, linked with these biomarkers, will be discussed.

METHOD

The systematic review of literature was performed using in PubMed, PsycInfo and Embase, and 25 articles were included. Various biomarkers were identified. The most often studied are C-reactive protein (CRP), interleukins 6 and 10, tumor necrosis factor-alpha and interferon-gamma.

RESULTS

Although few results appear as significant during the various testing times, the dosage of some inflammation biomarkers, including CRP, at the very end of pregnancy or immediately after delivery could predict PPD. Interactions between inflammation and the corticotropic axis could explain PPD onset. Epigenetic mechanisms could lead to pro-inflammatory state. Several therapeutics provide interest due to their anti-inflammatory property.

CONCLUSIONS

Further studies are needed to assess these biomarkers value as predictive factors of PPD and to consider adjunct treatments to antidepressants. If this value is confirmed, the inflammatory marker dosage, in particular CRP, could help to provide early screening of women at risk of PPD, parallel of the clinical evaluation. A zinc supplementation could then be offered.

Congenital laryngomalacia: Is it an inflammatory disease? The role of vitamin D

OBJECTIVES/HYPOTHESIS

Laryngomalacia is the most common cause of stridor in infants. The exact pathophysiology is still not well understood. Our objective was to investigate whether laryngomalacia is an inflammatory disease, focusing on the possible role of vitamin D.

STUDY DESIGN

Case-control study.

METHODS

Sixty Egyptian infants and 60 mothers were included in this study. They were divided into four equal groups (n = 30 for each): infants with laryngomalacia (LM-infants), control infants (C-infants), mothers of the infants with laryngomalacia (LM-mothers), and mothers of the control infants (C-mothers). Laryngoscopy was performed and serum 25-hydroxyvitamin D (25[OH]-vitamin-D) and interleukin 6 (IL-6) were estimated.

RESULTS

Significant increase of serum IL-6 associated with a significant decrease in serum 25(OH)-vitamin D was observed in the LM-infants compared to the C-infants (P < .001 for both). LM-mothers had significantly lower 25(OH)-vitamin D status compared to C-mothers (P < .001).

CONCLUSIONS

Deficiency of 25(OH)-vitamin D in LM-infants may result in dysregulation of the immune responses with elevation of a proinflammatory cytokine (IL-6). Laryngomalacia could be an inflammatory disease due to 25(OH)-vitamin D deficiency as evidenced by the high level of IL-6. This finding may open the door to the appropriate prevention, diagnosis, and treatment, especially for moderate to severe laryngomalacia.

LEVEL OF EVIDENCE

3b Laryngoscope, 130:448-453, 2020.

The Relationship Between Vitamin D and Postpartum Depression in Reproductive-Aged Iranian Women

Background: The aim of this study was to evaluate the relationship between vitamin D and postpartum depression in reproductive-aged Iranian women.

Methods and Results: This study was conducted on 120 women (60 with postpartum depression and 60 without) in Izeh, Iran. A socio-demographic questionnaire and Beck Depression Scale were used for data collection. The ELISA method was used for measuring 25-OH vitamin D (ng). The participants were classified according to their vitamin D level as follows: 25-OH-D < 10ng/ml considered as severe deficiency, 10–20n g/ml as moderate insufficiency, 20–30 ng/ml as mild insufficiency and >30ng/ml as normal. Data were analyzed using the independent t-test or Mann-Whitney test, chi-square and logistic regression test. The mean level of vitamin D of women with postpartum depression was lower than that in normal women (16.89±7.05 vs. 21.28±7.13, p=0.001). More than 53% of women with postpartum depression had vitamin D <20 ng/ml compared to 31.7% of women with no depression (p=0.005). Moreover, 16.7% of women with postpartum depression had vitamin D < 10ng/ml compared to only 6.7% in the normal group (p = 0.005). Women with vitamin D less than 20ng/ml compared to vitamin D > 20ng/ml were 3.30 times more likely to have postpartum depression (OR: 3.3, CI: 1.32–8.24, p= 0.01).

Discussion: There is a significant relationship between a low level of vitamin D and postpartum depression among reproductive-aged Iranian women. Health policy makers should pay attention to the measuring vitamin D level as one of the primary tests of pregnant women.

Gestational diabetes mellitus increases the baseline level of procalcitonin in maternal blood but not in umbilical cord blood in late pregnancy: A retrospective case-controlled study

To study the effects of gestational diabetes mellitus (GDM) on the level of procalcitonin (PCT) in maternal blood and umbilical cord blood in late-pregnant women.We retrospectively analyzed 37 pregnant women in late pregnancy who had GDM and compared with those of 97 age-matched normal glucose-tolerant (NGT) pregnant women. The PCT level was converted to a value with normal distribution (LG-PCT) by taking the logarithm of each value to the base 10 (log10).The body mass index (BMI) before delivery, family history of diabetes mellitus (DM), and postpartum blood loss within 24 hours were markedly higher in GDM group than in NGT group, while the gestational age was smaller in GDM group than in NGT group. The maternal blood LG-PCT was significantly higher in GDM group than in NGT group, while the umbilical cord blood LG-PCT was not significantly different between the 2 groups. Multivariate analysis showed that family history of DM, gestational age, and maternal blood LG-PCT were independent risk factors of GDM after adjusting for BMI and postpartum blood loss within 24 hours.GDM increases the baseline level of maternal blood PCT but has little effect on umbilical cord blood PCT.

Development of Postpartum Depression in Pregnant Women with Preeclampsia: A Retrospective Study

Background

Postpartum depression (PPD) and preeclampsia (PE) are both common diseases in obstetrics that affect maternal health and infant development. However, the relationship between the two diseases still requires clarification.

Objective

The purpose of this study was to (1) determine the incidence rate of PPD in patients with PE and (2) identify the association between the prevalence of PPD and the severity of PE.

Methods

We conducted a retrospective analysis of women with and without PE who delivered between January 1, 2017, and August 30, 2018, in the First Affiliated Hospital of Chongqing Medical University. We used a questionnaire survey methodology that included the Edinburgh Postnatal Depression Scale (EPDS) to test the influence of PE on the development of new-onset PPD in the 6 weeks after delivery. We determined PPD based on a score ≥10 on the EPDS. Bivariate analysis was used to compare data between the two groups.

Results

A total of 180 women participated in this study. Thirty-five people screened positive for PPD, while the remaining 145 screened negative. The prevalence of PPD was 26.67% (24/90) in patients with PE, which was two times the prevalence in normal women (12.22%). Multiple logistic regression showed that women who had PE had nearly 3-fold increased odds of PPD compared to normal women and the risk of PPD increased with the aggravation of PE. Patients with severe PE had a more than 4-fold increased risk of screening positive for PPD.

Conclusion

PE was independently associated with PPD. Furthermore, the risk of PPD seemed to increase with the aggravation of PE. Thus, additional prevention efforts and support methods should be provided for women with PE to reduce the incidence of PPD.

Association of antepartum vitamin D deficiency with postpartum depression: a clinical perspective

OBJECTIVE

Postpartum depression affects up to 20 % of new mothers within the first 12 months of parturition. 25-Hydroxyvitamin D (25(OH)D) has known importance in bone health, but it may also play an important role in other functions, including reproduction and fertility, immune function and mental health. This clinical commentary reviews literature evaluating 25(OH)D deficiency during pregnancy and the incidence of postpartum depressive symptomatology.

DESIGN

Narrative review, summary and recommendations.

SETTING/PARTICIPANTS

A literature search revealed five relevant studies of antepartum women, three based in the USA, one in Turkey and one in Iran.

RESULTS

Three of the five studies measured serum 25(OH)D concentrations during the first or second trimester and discovered an association with 25(OH)D deficiency and depressive symptoms postpartum. One study determined an almost significant (P=0·058) inverse relationship with first-trimester 25(OH)D concentration and depressive symptoms postpartum, and the last study, which was a secondary analysis, did not find an association.

CONCLUSIONS

The Endocrine Society recommends routine vitamin D supplementation during pregnancy and lactation due to increased metabolic demand in the mother, but a recent Cochrane review recommended against screening. Vitamin D should be the target of more studies during pregnancy and the postpartum period since it appears to have an important role for both medical and mental health. Vitamin D supplementation is a relatively safe and cost-effective intervention during pregnancy, and it may prove to be important in the prevention of postpartum depression.

Vitamin D deficiency and depressive symptoms in the perinatal period

Depression affects 1 in 7 women during the perinatal period. Women with vitamin D deficiency may be at an increased risk for depression. This study investigated the relationship between maternal and cord blood 25-hydroxyvitamin D (25OHD) and maternal depressive symptoms over the perinatal period. Study objectives were to examine variations and relationships between maternal and cord blood vitamin D levels and maternal depressive symptoms over the perinatal period. At a large medical center in southern California, pregnant women (N = 126) were recruited for this longitudinal cohort study. Depressive symptoms (Edinburgh Postnatal Depression Screen, EPDS) and vitamin D status (25OHD) were measured at three time points in the perinatal period: time 1 (T1; N = 125) EPDS and 25OHD were collected in early pregnancy; time 2 (T2; N = 96) EPDS was conducted in the third trimester with blood collected at time of delivery; and time 3 (T3; N = 88) was collected postpartum. A significant inverse relationship between vitamin D status and depressive symptoms was observed between 25OHD and EPDS scores at all time points in this sample (T1 = - 0.18, P = 0.024; T2 = - 0.27, P = 0.009; T3 = - 0.22, P = 0.019). This association remained after controlling for confounders. Low cord blood 25OHD levels were inversely associated with higher EPDS scores in the third trimester (r = - 0.22, P = 0.02). Clinicians may want to consider screening women diagnosed with vitamin D deficiency for depression and vice versa. Vitamin D may represent an important biomarker for pregnant and postpartum women diagnosed with depression. Further studies examining underlying mechanisms and supplementation are needed.

Association between vitamin D deficiency and antepartum and postpartum depression: a systematic review and meta-analysis of longitudinal studies

PURPOSE

The two previous reviews performed on the association of vitamin D deficiency in pregnancy with antepartum and postpartum depression were limited in reporting forms as they were both systematic reviews and the conclusions were also deemed to be inconclusive. Considering the high prevalence of vitamin D deficiency and depression during and after pregnancy as well as their numerous hazards to pregnancy outcomes, it is of great need to synthesize existing evidence in a more accurate statistical method, so that reliable guidance related to vitamin D supplementation during pregnancy could be provided for clinical decision making.

METHODS

We performed a systematic review and meta-analysis to investigate the association of vitamin D deficiency with antepartum and postpartum depression.

RESULTS

Nine longitudinal studies with 8470 participants were included in the meta-analysis. We found serum 25(OH)D levels < 50 nmol/l was associated with 2.67 times (OR 3.67; 95% CI 1.72-7.85) increased risk of postpartum depression than those 25(OH)D levels ≥ 50 nmol/l, but we did not find a significant association between low vitamin D levels and depressive symptoms during pregnancy with a serum 25(OH)D cut-off level of 30 nmol/l (OR 1.47; 95% CI 0.92-2.36).

CONCLUSIONS

The low status of maternal vitamin D could be an adverse factor for postpartum depression, but the available evidence suggested no association between vitamin D deficiency and depressive symptoms during pregnancy. However, this result should be interpreted with caution owning to the small number of studies. Well-designed intervention studies are also needed to further evaluate the benefits of vitamin D supplementation during pregnancy.

Role of vitamin D in pregnancy and Toll-like receptor pathway

There is a growing concern about the impacts of hypovitaminosis D on the health of pregnant woman, fetal development, childhood, and adult life. Variations in maternal nutrition during gestation and/or lactation play a critical role in the physiological and metabolic development of the fetus and neonate, which can induce phenotypic changes and trigger important consequences throughout life, such as type 2 diabetes, cardiovascular disease, obesity, and hypertension. Vitamin D plays a role in regulating cell proliferation and differentiation and in modulating the innate and adaptive immune response. Also, vitamin D correlates with changes in cytokines, anti and proinflammatory, as well as prevents inflammation induced by changes in myometrial cells mediated by the nuclear factor kappa B pathway. Further investigation is required regarding these relationship.

A systematic review of the associations between maternal nutritional biomarkers and depression and/or anxiety during pregnancy and postpartum

BACKGROUND

Nutritional requirements need to be met in order to adapt to pre- and postnatal changes. Our aim was to systematically review the evidence of associations between nutritional biomarkers and psychological distress during pregnancy and in the first postnatal year.

METHODS

MEDLINE, EMBASE, PsycINFO, Scielo, LILACS, clinicaltrials.gov, International Clinical Trials Registry, Cochrane Library, Scopus and Web of Science databases were searched for articles from inception to 4/15/2016. Studies of maternal nutritional biomarkers in blood (fatty acids/micronutrients/amino acids) and associations with psychological distress (depression/anxiety/stress) were included. Two independent reviewers extracted data based on study designs, participants, outcomes, exposures, and association measures.

RESULTS

Thirty-eight studies were included. A total of 13 studies showed divergent or no associations between serum/plasma/erythrocyte fatty acid concentrations and depression/anxiety during pregnancy and postpartum. Changes in serum cholesterol levels from pregnancy to postpartum showed a significant inverse correlation with depression in one out of three studies. Five out of seven studies found an inverse association between serum vitamin D levels and pre- and postnatal depression. Plasma tryptophan levels were inversely correlated with postnatal depression scores in three out of four studies. We identified that one out of two studies presented no significant association between vitamin B₁₂/folate/ferritin concentrations and depression in postpartum.

LIMITATIONS

There was higher variability between association measures, time and scales of depression and anxiety assessments.

CONCLUSIONS

The majority of high-quality studies suggest that lower vitamin D levels may be associated with postpartum depression. However, further evidence is needed for guiding clinical practice on nutritional biomarkers.

Vitamin D Deficiency and Antenatal and Postpartum Depression: A Systematic Review

Vitamin D has been implicated in antenatal depression (AD) and postpartum depression (PPD) in many studies; however, results have been inconsistent due to the complexity of this association. We searched the MEDLINE, Embase, PsycINFO, and Maternity and Infant Care databases for literature addressing associations between vitamin D and AD and PPD. Two independent authors reviewed titles and abstracts of the search results and selected studies for full review. Data were extracted, and a quality rating was done using the Newcastle-Ottawa Scale (NOS) on the selected studies. A total of 239 studies were identified; 14 were included in the review. The quality assessment of the included studies ranged from moderate to high. Of the studies on PPD, five of nine (55%) showed a significant association between vitamin D and PPD. Five of seven (71%) studies on AD showed a significant association with vitamin D status. As the included studies used different effect estimates and statistical analyses to report the association, it was not possible to transform the existing data into one single effect measure to employ meta-analytic techniques. While results of this systematic review vary, they indicate a significant association between vitamin D status and AD and PD.

A neuro-immune, neuro-oxidative and neuro-nitrosative model of prenatal and postpartum depression

A large body of evidence indicates that major affective disorders are accompanied by activated neuro-immune, neuro-oxidative and neuro-nitrosative stress (IO&NS) pathways. Postpartum depression is predicted by end of term prenatal depressive symptoms whilst a lifetime history of mood disorders appears to increase the risk for both prenatal and postpartum depression. This review provides a critical appraisal of available evidence linking IO&NS pathways to prenatal and postpartum depression. The electronic databases Google Scholar, PubMed and Scopus were sources for this narrative review focusing on keywords, including perinatal depression, (auto)immune, inflammation, oxidative, nitric oxide, nitrosative, tryptophan catabolites (TRYCATs), kynurenine, leaky gut and microbiome. Prenatal depressive symptoms are associated with exaggerated pregnancy-specific changes in IO&NS pathways, including increased C-reactive protein, advanced oxidation protein products and nitric oxide metabolites, lowered antioxidant levels, such as zinc, as well as lowered regulatory IgM-mediated autoimmune responses. The latter pathways coupled with lowered levels of endogenous anti-inflammatory compounds, including ω3 polyunsaturated fatty acids, may also underpin the pathophysiology of postpartum depression. Although increased bacterial translocation, lipid peroxidation and TRYCAT pathway activation play a role in mood disorders, similar changes do not appear to be relevant in perinatal depression. Some IO&NS biomarker characteristics of mood disorders are found in prenatal depression indicating that these pathways partly contribute to the association of a lifetime history of mood disorders and perinatal depression. However, available evidence suggests that some IO&NS pathways differ significantly between perinatal depression and mood disorders in general. This review provides a new IO&NS model of prenatal and postpartum depression.

Postpartum depression and vitamin D: A systematic review

Postpartum depression (PPD) is a prevalent mood disorder estimated to affect 20%-40% of women worldwide after childbirth. In recent studies, the effect of vitamin D on prevention of mood disorders and depression has been investigated, but it is still unclear how vitamin D may affect PPD. The evidence on the relevance between vitamin D deficiency and PPD is inconsistent, and assessment of the recent literature has not previously been carried out. Moreover, there are few clinical studies on PPD and vitamin D supplementation. Five studies have so far assessed the relationship between the levels of vitamin D and PPD. Findings from cohort studies suggest that vitamin-D deficiency is related to the incidence of PPD and vitamin D may play a significant role in the recovery of women with PPD, but it is uncertain whether these actions are the effect of vitamin D on the function of hypothalamic-pituitary-adrenal (HPA) axis, the levels of estradiol, serotonin, pro-inflammatory cytokines, and/or of other mechanisms involved in PPD.

Nutrients and perinatal depression: a systematic review

Pregnancy and lactation deplete nutrients essential to the neurotransmission system. This may be one reason for the increased risk of depression during the perinatal period. The objective of the present review was to systematically review the literature and summarise evidence on whether blood nutrient levels influence the risk of perinatal depression. PubMed, EMBASE and CINAHL databases were searched for studies of any design. A total of twenty-four articles of different designs were included, representing 14 262 subjects. We extracted data on study population, depression prevalence, nutrients examined, deficiency prevalence, timing of assessment, reporting, analysis strategy and adjustment factors. In all, fourteen studies found associations of perinatal depression with lower levels of folate, vitamin D, Fe, Se, Zn, and fats and fatty acids, while two studies found associations between perinatal depression and higher nutrient levels, and eight studies found no evidence of an association. Only ten studies had low risk of bias. Given the methodological limitations and heterogeneity of study approaches and results, the evidence for a causal link between nutritional biomarkers and perinatal depression is still inconclusive. High-quality studies in deficient populations are needed.

Recent advances in understanding maternal perinatal mood disorders

The study of perinatal mental health (mental health during pregnancy and postpartum) is a complex field of study that is of major importance both for the mental and physical health of new mothers and for the neurobehavioral development and long-term functioning of the children they bear. In this review, we cover the most recent additions to this rapidly evolving field. Notable advances include further illumination of the epidemiological patterns and clinical manifestations of perinatal mood disruption; new efficacy data on treatment and prevention; clarifications of the respective contributions of maternal mental illness and psychotropic medication to outcomes of pregnancy, birth, and child development; and updated expert guidelines for screening.

Inflammatory markers in late pregnancy in association with postpartum depression-A nested case-control study

Recent studies indicate that the immune system adaptation during pregnancy could play a significant role in the pathophysiology of perinatal depression. The aim of this study was to investigate if inflammation markers in a late pregnancy plasma sample can predict the presence of depressive symptoms at eight weeks postpartum. Blood samples from 291 pregnant women (median and IQR for days to delivery, 13 and 7-23days respectively) comprising 63 individuals with postpartum depressive symptoms, as assessed by the Edinburgh postnatal depression scale (EPDS≥12) and/or the Mini International Neuropsychiatric Interview (M.I.N.I.) and 228 controls were analyzed with an inflammation protein panel using multiplex proximity extension assay technology, comprising of 92 inflammation-associated markers. A summary inflammation variable was also calculated. Logistic regression, LASSO and Elastic net analyses were implemented. Forty markers were lower in late pregnancy among women with depressive symptoms postpartum. The difference remained statistically significant for STAM-BP (or otherwise AMSH), AXIN-1, ADA, ST1A1 and IL-10, after Bonferroni correction. The summary inflammation variable was ranked as the second best variable, following personal history of depression, in predicting depressive symptoms postpartum. The protein-level findings for STAM-BP and ST1A1 were validated in relation to methylation status of loci in the respective genes in a different population, using openly available data. This explorative approach revealed differences in late pregnancy levels of inflammation markers between women presenting with depressive symptoms postpartum and controls, previously not described in the literature. Despite the fact that the results do not support the use of a single inflammation marker in late pregnancy for assessing risk of postpartum depression, the use of STAM-BP or the novel notion of a summary inflammation variable developed in this work might be used in combination with other biological markers in the future.

Close relationship qualities and maternal peripheral inflammation during pregnancy

OBJECTIVE

Close relationships are associated with pregnancy outcomes, but little is known about the mechanisms involved. This paper examines whether quality of women's close relationships, specifically with romantic partner (RP) and closest friend or family member (CF), is associated with inflammatory biomarkers during the third trimester of pregnancy.

METHODS

90 pregnant women were assessed during the second and third trimester. At both visits they completed self-reports describing the positive and negative aspects of their RP and CF relationships. Peripheral blood was collected during these visits, and used to measure systemic levels of cytokines, including IFNγ, IL10, IL6, IL8 and IL13. An index of inflammatory regulation, as reflected by the ratio of IL6:IL10, was also computed.

RESULTS

Positive (e.g. support, intimacy) and negative (e.g. conflict) aspects of the RP relationship interacted to predict third trimester cytokine values. Specifically, RP relationships relatively low in both positive and negative aspects were associated with lower third trimester anti-inflammatory (IL10, IL13) and anti-viral (IFNγ) cytokines, and a higher IL6:IL10 ratio, controlling for second trimester levels. These associations were independent of demographics, gestational age, weeks between assessment, parity, pre-pregnancy body mass index, maternal stress, distress, depressed mood and RP cohabitation. CF relationship aspects were not associated with inflammatory markers.

CONCLUSIONS

RP relationships relatively low in both positive, e.g. support and intimacy, and negative, e.g. conflict, aspects were associated with a less anti- and more pro-inflammatory cytokine profile during the third trimester. These findings have implications for understanding the associations amongst close relationships, inflammation, and potentially pregnancy outcomes.

Adverse Perinatal Outcomes and Postpartum Multi-Systemic Dysregulation: Adding Vitamin D Deficiency to the Allostatic Load Index

Background Allostatic load (AL) is an index of multi-system physiological "wear-and-tear," operationalizing emergent chronic disease risk and predicting morbidity and mortality. AL has been proposed as an organizing framework for studying pregnancy outcomes and additional AL biomarkers for the study of maternal health would be valuable. Objectives To test whether adverse perinatal outcomes are associated with postpartum AL and if including vitamin D deficiency (serum 25(OH)D < 20 ng/ml) as an additional marker of postpartum AL increases the association. Methods The Community Child Health Network is a community-based participatory research network that enrolled women at birth and followed them for 2 years measuring ten biomarkers (body mass index, waist: hip ratio, pulse, systolic and diastolic blood pressures, cortisol slope, c-reactive protein, hgbA1c, HDL, and total cholesterol) at 6 and 12 months postpartum. A composite of four adverse perinatal outcomes (low birth weight, preterm birth, preeclampsia, and gestational diabetes) was collected from medical charts in a sample of 164 women from one site and serum 25(OH)D status was measured 24-39 weeks postpartum in this cohort. Results Twenty-nine percent experienced one or more of the four adverse perinatal outcomes. Serum 25(OH)D was significantly inversely correlated with the AL index (Spearman's r = -0.247, p = 0.002). Logistic regression results adjusting for maternal age and race showed that adverse outcome was significantly associated with higher postpartum AL (OR 1.53 for a 1-unit increase in AL, 95% CI 1.24-1.89). Adding 25(OH)D deficiency as an 11th component to the AL index improved the model fit (Delta (-2LogL) = 3.955, p = 0.047), and improved the Akaike information criterion (180.32 vs. 184.27). Conclusion Women with adverse perinatal outcomes have higher postpartum AL and adding vitamin D deficiency to the AL index strengthens this association.

Serum leptin level measured 48 h after delivery is associated with development of postpartum depressive symptoms: a 3-month follow-up study

The aim of this study was to assess the possible relationship between leptin status and postpartum depressive symptoms using serum levels of leptin collected 24-48 h after delivery in a cohort Chinese sample. Women delivering a full-term, singleton, and live-born infant in the period from August 2013 to March 2014 were enrolled immediately postpartum. A blood sample was obtained 24-48 h after childbirth to test serum levels of leptin. Participation consisted of a visit in an obstetric unit at 3 months after delivery. The Edinburgh Postnatal Depression Scale (EPDS), completed at 3 months postpartum, was used to classify each woman's depression symptom severity. Demographic, obstetric, behavioral risk, mental health, and psychosocial factors were considered. Multiple logistic regression analyses were used to identify risk factors most predictive of postpartum depressive symptoms. During the study period, 407 individuals were included and completed follow-up. At 3 months, according to EPDS score, 53 women (13.0 %) were considered as postpartum depressive symptoms. Serum leptin levels in women with PPD were significantly greater than those in women without depressive symptoms (36.5 [IQR, 25.5-50.4] vs. 14.5 [IQR, 9.4-22.4] ng/ml, P < 0.0001). Based on the ROC curve, the optimal cutoff value of serum leptin levels as an indicator for predicting of depressive symptoms was projected to be 24.3 ng/mL, which yielded a sensitivity of 88.7 % and a specificity of 73.4 %, with the area under the curve at 0.867 (95 % CI, 0.817-0.916). In multivariate analysis, there was an increased risk of depressive symptoms associated with leptin levels ≥24.3 ng/ml (OR 8.234; 95 % CI, 3.572-15.876; P < 0.0001) after adjusting for possible confounders. Elevated serum leptin levels at delivery could eventually serve as a biological marker for the prediction of depressive symptoms. These associations were independent of other possible variables.