Risk of placental abruption in relation to maternal depressive, anxiety and stress symptoms

An analysis of placental chorionic villous and decidual basalis tissue immunoreactivity in patients after cesarean section due to a placenta accreta spectrum disorder and elective cesarean section followed by the depressed mood

An analysis of placental chorionic villous and decidual basalis tissue immunoreactivity in patients after cesarean section due to a placenta accreta spectrum disorder and elective cesarean section followed by a depressed mood.

RESEARCH BACKGROUND

Over the past few years, interest in investigating immune dysfunction in patients with psychiatric disorders has increased. B7-H4 is a molecule with immunosuppressive properties that seems to play a key role in establishing maternal tolerance against fetal antigens. The aim of this study was to compare the B7-H4 immunoreactivity levels in patients after cesarean section.

METHODS

Placental and decidual tissue samples were obtained from 49 women who delivered at Bielański Hospital in Warsaw between 2009 and 2015. Fifteen of the patients developed postpartum depression and 14 had a diagnosis of placenta accreta spectrum. The control group consisted of 20 healthy patients on whom cesarean section was performed due to breech presentation at term.

RESULTS

The highest levels of B7-H4 immunoreactivity were found in the placental chorionic villous and decidual basalis tissue samples of the patients who later developed postpartum depression, while the lowest levels were found in the samples of those patients with a placenta accreta spectrum disorder. The difference between the B7-H4 immunoreactivity levels of these two groups was statistically significant. The B7-H4 expression levels were statistically significantly higher in the women in the postpartum depression group than in the control group.

CONCLUSION

Postpartum depression follows a disturbance of the suppressive milieu responsible for rebalancing the maternal immune system after the initial cytotoxic activation during labor.

Risk of postpartum readmission for depression in relation to ischaemic placental disease: a population-based study

Background

There are limited data on postpartum readmissions for depression in the United States (US). Specifically, the extent to which ischaemic placental disease (IPD) during pregnancy predisposes patients to develop postpartum depression remains poorly understood. We investigated whether IPD is associated with postpartum readmission for new-onset depression in the first year after delivery.

Methods

In this population-based study, the 2010-2018 Nationwide Readmissions Database was utilised to evaluate rates of postpartum readmission for depression within the calendar year of delivery hospitalisation among patients with and without IPD. IPD was defined as preeclampsia, placental abruption, or small for gestational age (SGA) birth. We expressed associations between IPD and depression readmission based on a confounder-adjusted hazards ratio (HR) with a 95% confidence interval (CI).

Findings

Of 33.3 million delivery hospitalisations, 3,027,084 (9.1%) had IPD. The total follow-up among those with and without IPD were 17,855,830 and 180,100,532 person-months, respectively, with a median follow-up of 5.8 months for both groups. Rates of depression readmission were 95.7 (n = 17,095) and 37.5 (n = 67,536) per 100,000 readmissions among patients with and without an IPD, respectively (HR, 2.39; 95% CI, 2.32-2.47); this risk was the highest for preeclampsia with severe features (HR, 3.14; 95% CI, 3.00-3.29). Patients had a greater risk of readmission if they had any two forms of IPD (HR, 3.02; 95% CI, 2.75-3.33), and those with a concurrent diagnosis of preeclampsia and abruption posed the highest risk (HR, 3.23; 95% CI, 2.71-3.86).

Interpretation

These findings suggested that patients with IPD are at a substantially increased risk of readmission for depression within a year following delivery. This study underscores the need for increased surveillance, improved detection, and faster treatment of depression in this vulnerable population.

Funding

This was an unfunded project.

Extracellular vesicles are dynamic regulators of maternal glucose homeostasis during pregnancy

Homeostatic regulation of the maternal milieu during pregnancy is critical for maternal and fetal health. The placenta facilitates critical communication between maternal and fetal compartments, in part, through the production of extracellular vesicles (EVs). EVs enable tissue synchrony via cell-cell and long-distance communication and are at their highest circulating concentration during pregnancy. While much work has been done investigating how physiological challenges in pregnancy affect the fetus, the role of placental communication in maternal health has not been well examined. We previously identified placental O-glycosyl transferase (OGT), a glucose-sensing enzyme, as a target of maternal stress where OGT levels and activity affected the O-glycosylation of proteins critical for EV cargo loading and secretion. Here, we hypothesized that placental OGT plays an essential role in maternal homeostatic regulation during pregnancy via its regulation of maternal circulating EV concentrations. Our studies found that changes to key metabolic factors over the circadian cycle, including glucocorticoids, insulin, and glucose, were significantly associated with changes in circulating EV concentration. Targeting placental OGT in mice, we found a novel significant positive relationship between placental OGT and maternal circulating EV concentration that was associated with improving maternal glucose tolerance during pregnancy. Finally, an intravenous elevation in EVs, matching the concentration of EVs during pregnancy, shifted non-pregnant female glucose sensitivity, blunted glucose variance, and improved synchrony of glucose uptake. These data suggest an important and novel role for circulating EVs as homeostatic regulators important in maternal health during pregnancy.

Understanding Etiologic Pathways Through Multiple Sequential Mediators: An Application in Perinatal Epidemiology

BACKGROUND

Causal mediation analysis facilitates decomposing the total effect into a direct effect and an indirect effect that operates through an intermediate variable. Recent developments in causal mediation analysis have clarified the process of evaluating how-and to what extent-different pathways via multiple causally ordered mediators link the exposure to the outcome.

METHODS

Through an application of natural effect models for multiple mediators, we show how placental abruption might affect perinatal mortality using small for gestational age (SGA) birth and preterm delivery as two sequential mediators. We describe methods to disentangle the total effect into the proportions mediated via each of the sequential mediators, when evaluating natural direct and natural indirect effects.

RESULTS

Under the assumption that SGA births causally precedes preterm delivery, an analysis of 16.7 million singleton pregnancies is consistent with the hypothesis that abruption exerts powerful effects on perinatal mortality (adjusted risk ratio = 11.9; 95% confidence interval = 11.6, 12.1). The proportions of the estimated total effect mediated through SGA birth and preterm delivery were 2% and 58%, respectively. The proportion unmediated via either SGA or preterm delivery was 41%.

CONCLUSIONS

Through an application of causal mediation analysis with sequential mediators, we uncovered new insights into the pathways along which abruption impacts perinatal mortality.

3D printed models in pregnancy and its utility in improving psychological constructs: a case series

Background

3D printing is being utilized in almost every aspect of medicine. 3D printing has especially been used in conjunction with 3D ultrasonography to assist in antenatal assessment and presurgical planning with fetal malformations. As printing capabilities improve and applications are explored there may be more advantages for all parents to visualize and touch 3D printed models of their fetus.

Case presentation

We present three cases involving 3D printed models and four different but interrelated psychological constructs- antenatal depression, antenatal anxiety, maternal-fetal attachment, and paternal-fetal attachment. Each case shows for the first time possible beneficial effects within these prevalent and significant problems.

Conclusions

The degree to which the anxiety, depression, and attachment scores improved after the presentation of the 3D printed models is encouraging. Randomized controlled trials utilizing 3D printed models to improve psychological constructs should be supported considering the findings within these four cases.

Pregnancy Outcomes in Women with Thyroid Diseases

Introduction

Overt hyperthyroidism and hypothyroidism are associated with pregnancy complications; however, most women with these conditions are diagnosed before conception and are under treatment during pregnancy, especially in high-income countries. The purpose of this study was to investigate pregnancy complications among these women.

Methods

A retrospective cohort study was conducted, and data on pregnant women who gave birth to a singleton at Nagoya University Hospital in Japan in 2005-2014 was collected. The pregnancy outcomes were divided and compared among three groups: the control group (n = 3531), the hyperthyroidism group (n = 48), and the hypothyroidism group (n = 61). Additionally, risk factors for placental abruption were evaluated by multivariable logistic regression analysis. Moreover, in hyperthyroidism, thyroid function at the placentation period was compared between placental-related diseases and nonplacental-related disease groups, and the latter group included placental abruption and preeclampsia.

Results

The incidence of placental abruption was higher in hyperthyroidism than in control and hypothyroidism groups. Hyperthyroidism was independently associated with an increased risk of placental abruption (adjusted odds ratio, aOR = 8.21, 95% confidence interval, CI: 1.76-38.34), as well as preeclampsia (aOR = 4.10, 95% CI: 1.13-14.76) and preterm labor (aOR = 3.38, 95% CI: 1.19-9.64). Additionally, thyroid-stimulating hormone (TSH) at the placentation period was significantly lower in the placental-related disease group than in the nonplacental-related disease group (p < 0.05).

Conclusions

Pregnancy outcomes in women with hyperthyroidism and hypothyroidism would be comparable with those without thyroid disease. Hyperthyroidism was an independent risk factor for placental abruption as well as preterm labor and preeclampsia. However, its frequency was extremely low, and further research is required to validate our findings.

Trajectories of antenatal depression and adverse pregnancy outcomes

BACKGROUND

Antenatal depression affects approximately 1 of 7 pregnancies, with an increasing prevalence across gestation. Data regarding the associations between antenatal depression and adverse pregnancy outcomes yielded conflicting results. However, previous studies evaluated the cross-sectional prevalence of depression at various time points and not the depressive symptom trajectory across gestation.

OBJECTIVE

This study aimed to identify whether the trajectory of antenatal depressive symptoms is associated with different risks of adverse pregnancy outcomes.

STUDY DESIGN

This was a secondary analysis of a large multisite prospective cohort of nulliparous women across the United States. The Edinburgh Postpartum Depression Scale was administered at 2 study visits: between 6 and 14 weeks' gestation and between 22 and 30 weeks' gestation. The Edinburgh Postpartum Depression Scale score trajectories were categorized as improved, stable, or worsened based on whether the scores changed by at least 1 standard deviation between the 2 visits. The frequencies of adverse pregnancy outcomes (hypertensive disorders of pregnancy, abruption, cesarean delivery, preterm birth [ie, <37 weeks' gestation], small for gestational age neonates, neonatal intensive care unit admission, and maternal readmission) were compared with depression trajectories across gestation in bivariable and multivariable analyses. Secondary analyses evaluated the frequencies of spontaneous and medically indicated preterm births and frequencies of spontaneous and medically indicated preterm births before 35, 32, and 28 weeks' gestation.

RESULTS

Of the 8784 women who completed the 2 antenatal Edinburgh Postpartum Depression Scale screens, 1141 (13.0%) had improved, 6663 (75.9%) had stable, and 980 (11.2%) had worsened depressive symptom trajectories across gestation. Compared with women with improved or stable depressive symptoms, those with worsened symptoms were more likely to experience preterm birth (8.3% vs 7.4% vs 9.9%, respectively; P=.018). After controlling for potential confounders, worsened depressive symptoms remained associated with more frequent preterm birth (adjusted odds ratio, 1.68; 95% confidence interval, 1.10-2.57).

CONCLUSION

Women with depression symptoms that worsen as pregnancy progresses have increased odds of preterm birth. Future research is warranted to optimize and implement effective prevention, screening, and treatment protocols for antenatal depressive symptoms as a strategy to prevent preterm birth.

Placental abruption in immigrant women in Norway: A population-based study

INTRODUCTION

Placental abruption is a serious complication in pregnancy. Its incidence varies across countries, but the information of how placental abruption varies in immigrant populations is limited. The aims of this study were to estimate the incidence of placental abruption in immigrant women compared with non-immigrants by maternal country and region of birth, reason for immigration, and length of residence.

MATERIAL AND METHODS

We conducted a nationwide population-based study using data from the Medical Birth Registry of Norway and Statistics Norway (1990-2016). The study sample included 1 558 174 pregnancies, in which immigrant women accounted for 245 887 pregnancies and 1 312 287 pregnancies were to non-immigrants. Crude and adjusted odds ratios with 95% CI for placental abruption in immigrant women compared with non-immigrants were estimated by logistic regression with robust standard error estimations (accounting for within-mother clustering). Adjustment variables included year of birth, maternal age, parity, multiple pregnancies, chronic hypertension, and level of education.

RESULTS

The incidence of placental abruption decreased during the study period for both immigrants (from 0.68% to 0.44%) and non-immigrants (from 0.80% to 0.34%). Immigrant women from sub-Saharan Africa had an adjusted odds ratio of 1.35 (95% CI 1.15-1.58) compared with non-immigrants for placental abruption, whereas immigrant women from Ethiopia had an adjusted odds ratio of 2.39 (95% CI 1.67-3.41). We found a small variation in placental abruption incidence by other countries or regions of birth, length of residence, and reason for immigration.

CONCLUSIONS

Immigrant women from sub-Saharan Africa, especially Ethiopia, have increased odds for placental abruption when giving birth in Norway. Reason for immigration and length of residence had little impact on the incidence of placental abruption.

Relation of outbursts of anger and the acute risk of placental abruption: A case-crossover study

BACKGROUND

Roughly, a fourth of all placental abruption cases have an acute aetiologic underpinning, but the causes of acute abruption are poorly understood. Studies indicate that symptoms of stress, depression, and anxiety during pregnancy may be associated with a higher risk of abruption.

OBJECTIVE

We examined the rate of abruption in the 2 hours immediately following outbursts of anger.

METHODS

In a multicentre case-crossover study, we interviewed 663 women diagnosed with placental abruption admitted to one of the seven Peruvian hospitals between January 2013 and August 2015. We asked women about outbursts of anger before symptom onset and compared this with their usual frequency of anger during the week before abruption.

RESULTS

The rate of abruption was 2.83-fold (95% confidence interval [CI] 1.85, 4.33) higher in the 2 hours following an outburst of anger compared with other times. The rate ratio (RR) was lower for women who completed technical school or university (RR 1.38, 95% CI 0.52, 3.69) compared to women with secondary school education or less (RR 3.73, 95% CI 2.32, 5.99, P-homogeneity = .07). There was no evidence that the association between anger episodes and abruption varied by hypertensive disorders of pregnancy (ie preeclampsia/ eclampsia) or antepartum depressive symptoms.

CONCLUSION

There was a higher rate of abruption in the 2 hours following outbursts of anger compared with other times, providing potential clues to the aetiologic mechanisms of abruption of acute onset.

The relationship between prenatal psychological stress and placental abruption in Japan, The Japan Environment and Children's Study (JECS)

Background

Prenatal psychological stress may increase the risk of placental abruption (PA). This study aimed to clarify the effects of psychological distress during pregnancy and exposure to stressful life events in the year before or during pregnancy on the occurrence of PA in Japanese women.

Methods

Using a nationwide prospective birth cohort study, we obtained data from 103,099 women between January 2011 and March 2014. Information on exposure to 14 stressful life events and psychological distress (Kessler 6 scale) was collected using a self-administered questionnaire during pregnancy. Clinical diagnoses of PA were obtained from medical records. A total of 80,799 women with singleton births were analyzed using logistic regression models that adjusted for possible confounders.

Results

PA was diagnosed in 335 (0.4%) women. There was no significant difference in the Kessler 6 score during pregnancy between the PA group and non-PA group. Exposure to the death of a child in the year before or during pregnancy was significantly associated with PA in multigravid women (adjusted odds ratio [aOR] 3.57; 95% confidence interval [CI] 1.50–8.34). A spouse’s loss of employment was significantly associated with PA in parous women (aOR 3.25; 95% CI 1.40–7.56).

Conclusions

This study identified the possible effects of exposure to the death of a child on PA occurrence that adjusted for important confounding factors.

Serotonin-estrogen interactions: What can we learn from pregnancy?

We have reviewed the scientific literature related to four diseases in which to serotonin (5-HT) is involved in the etiology, herein named 5-HT-linked diseases, and whose prevalence is influenced by estrogenic status: depression, migraine, irritable bowel syndrome and eating disorders. These diseases all have in common a sex-dimorphic prevalence, with women more frequently affected than men. The co-occurrence between these 5-HT-linked diseases suggests that they have common physiopathological mechanisms. In most 5-HT-linked diseases (except for anorexia nervosa and irritable bowel syndrome), a decrease in the serotonergic tone is observed and estrogens are thought to contribute to the improvement of symptoms by stimulating the serotonergic system. Human pregnancy is characterized by a unique 5-HT and estrogen synthesis by the placenta. Pregnancy-specific disorders, such as hyperemesis gravidarum, gestational diabetes mellitus and pre-eclampsia, are associated with a hyperserotonergic state and decreased estrogen levels. Fetal programming of 5-HT-linked diseases is a complex phenomenon that involves notably fetal-sex differences, which suggest the implication of sex steroids. From a mechanistic point of view, we hypothesize that estrogens regulate the serotonergic system, resulting in a protective effect against 5-HT-linked diseases, but that, in turn, 5-HT affects estrogen synthesis in an attempt to retrieve homeostasis. These two processes (5-HT and estrogen biosynthesis) are crucial for successful pregnancy outcomes, and thus, a disruption of this 5-HT-estrogen relationship may explain pregnancy-specific pathologies or pregnancy complications associated with 5-HT-linked diseases.

Childhood abuse, intimate partner violence, and placental abruption among Peruvian women

PURPOSE

Experiencing childhood abuse (CA) or intimate partner violence (IPV) has been linked to adverse pregnancy outcomes. We examined whether CA history and current IPV are independently and jointly associated with placental abruption (PA).

METHODS

We recruited 662 PA cases and 665 controls in Lima, Peru. We used multivariate logistic regression to calculate odds ratios (OR), adjusting for age, education, and parity.

RESULTS

Approximately 42% of cases and controls reported CA; 50% of cases and 49% of controls reported IPV. History of any CA was not associated with PA, but history of severe CA was associated with 38% increased odds of PA (adjusted OR [aOR], 1.38; 95% confidence interval (CI), 1.07-1.80), adjusting for IPV. There was a statistically nonsignificant association between severe IPV and odds of PA (aOR, 1.22; 95% CI, 0.92-1.62), adjusting for CA. Women who experienced severe CA and severe IPV had 2.06-fold (95% CI, 1.25-3.40) increased odds of PA compared with women who did not experience severe abuse. The joint effect of CA and IPV was positive but statistically nonsignificant on the multiplicative (aOR, 1.48; 95% CI, 0.79-2.80) and additive scale (relative excess risk due to interaction, 0.70; 95% CI, -0.39 to 1.78).

CONCLUSIONS

Preventing exposure to violence may improve maternal outcomes.

Racial residential segregation and racial disparities in stillbirth in the United States

We examined whether current and/or persistent racial residential segregation is associated with black-white stillbirth disparities among 49,969 black and 71,785 white births from the Consortium on Safe Labor (2002-2008). Black-white segregation was measured using the dissimilarity index and the isolation index, categorized into population-based tertiles. Using hierarchical logistic models, we found low and decreasing levels of segregation were associated with decreased odds of stillbirth, with blacks benefitting more than whites. Decreasing segregation may prevent approximately 900 stillbirths annually among U.S. blacks. Reducing structural racism, segregation in particular, could help reduce black-white stillbirth disparities.

Effect of Vocalization of the Holy Quran With and Without Translation on Pregnancy Outcomes: A Randomized Clinical Trial

Background

During recent decades, research in Iran in the area of the Quran and medical science has been seriously engaged in. With respect to the tendency toward spirituality and alternative medicine, we tried to find other aspects of the influence of the Quran.

Objectives

This study aimed to determine the effect of vocalizations of the Holy Quran with and without translation on the consequences of pregnancy (the prevalence of preterm delivery, caesarean delivery, and neonatal anthropometric indices) in women admitted to health care centers in Urmia, Iran.

Materials and Methods

This was a three-armed parallel-group randomized clinical trial in which 168 pregnant women (25-28 weeks) in their first and second pregnancies were divided into three groups of 56 (Holy Quran with translation, Holy Quran without translation, and control group) by randomized blocking. The intervention was implemented once a week for three weeks in the health center, and on other days of the week, the participants listened at home to a CD they were given. The intervention and the control groups all received routine pregnancy care once a week. These mothers were tracked during their labor. Outcomes including gestational age at delivery, delivery type, and neonatal anthropometric indices were recorded based on the mother’s records.

Results

There was no statistically significant difference between the groups in terms of demographic and obstetric characteristics before the intervention. In comparison with the control group, the probability of preterm delivery was lower in the Holy Quran with translation group (odds ratio: 0.3, CI 95%: 0.1-1.2) and in the Holy Quran without translation group (0.6, 0.2-1.9) as compared to the control group. However, this difference was not statistically significant. Similarly, the probability of caesarean delivery was lower in the Holy Quran with translation group (0.6, 0.3-1.4) and the Holy Quran without translation group (0.5, 0.2-1.2) as compared to the control group. Based on one-way ANOVA, there was no statistically significant difference between the study groups regarding the infants’ anthropometric indices.

Conclusions

Based on the results of this study, despite the lower prevalence of preterm labor and caesarean section in the intervention groups as compared to the control group, no statistically significant effect was seen. This was apparently due to the small sample size.

Post-traumatic stress in pregnant women with primary cytomegalovirus infection and risk of congenital infection in newborns

BACKGROUND

Substantial evidence indicates that perinatal mental disturbances are associated with the risk for negative maternal-newborn outcomes. A neuroendocrine brain-placenta interaction has been described to explain the association between prenatal stress-related disorders and placental abnormalities. Whether these mechanisms may affect the likelihood of mother-to-child transmission (MTCT) of infections has never been investigated.

AIMS

To evaluate the role of psychological factors in cytomegalovirus (CMV) MTCT in pregnant women with primary CMV infection.

METHOD

A cohort of 276 pregnant women with primary CMV infection underwent assessment of (a) reactive psychopathological symptoms, such as current depressive symptoms and ongoing symptoms of post-traumatic stress disorder; and (b) stable personality traits, such as alexithymia and Type D (distressed) personality. Congenital infection was diagnosed by CMV DNA amplification from blood and/or urine and saliva from newborn at birth.

RESULTS

The occurrence of congenital CMV disease in the newborn was independently predicted by post-traumatic stress symptoms during pregnancy.

CONCLUSIONS

Our findings suggest that psychological stress-related disturbances may weaken the physical and immunological barrier against the mother-to-fetus transmission of viruses.

DECLARATION OF INTEREST

We declare that we have no conflicting interests to disclose.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Placental telomere length and risk of placental abruption

OBJECTIVE

To investigate the associations of placental telomere length with placental abruption (PA) risk and interactions between placental telomere length and placental mitochondrial DNA (mtDNA) copy number on PA risk.

MATERIALS AND METHODS

Relative telomere length and mtDNA copy number in placental samples collected from 105 cases and 73 controls were measured in two batches using qRT-PCR. Mean differences in relative telomere length between PA cases and controls were examined. After creating batch-specific median cutoffs for relative telomere length (84.92 and 102.53) and mtDNA copy number (2.32 and 1.42), interaction between the two variables was examined using stratified logistic regression models.

RESULTS

Adjusted mean difference in relative telomere length between PA cases and controls was -0.07 (p > 0.05). Among participants with low mtDNA copy number, participants with short relative telomere length had a 3.07-fold higher odds (95% CI: 1.13-8.38) of PA as compared with participants with long relative telomere length (the reference group). Among participants with high mtDNA copy number, participants with short relative telomere length had a 0.71-fold lower odds (95% CI: 0.28-1.83) of PA as compared with the reference group (interaction p values = 0.03).

CONCLUSION

Findings suggest complex relationships between placental telomere length, mtDNA copy number and PA risk which warrant further larger studies.

History of childhood sexual abuse and risk of prenatal and postpartum depression or depressive symptoms: an epidemiologic review

The objective of this review is to summarize the literature (and to the extent possible, report the magnitude and direction of the association) concerning history of childhood sexual abuse (CSA) and depression or depressive symptoms among pregnant and postpartum women. Publications were identified through literature searches of seven databases (PubMed, EMBASE, PyscINFO, CINAHL, Web of Science, BIOSIS, and Science Direct) using keywords including "child abuse," "depression," "pregnancy," "prenatal," "pregnancy," and "postpartum." The literature search yielded seven eligible studies on the prenatal period and another seven studies on the postpartum period. All but one prenatal study observed statistically significant positive associations of CSA with depression or depressive symptoms during pregnancy. Findings on the association of CSA with postpartum depression or depressive symptoms were inconsistent; pooled unadjusted and adjusted odds ratios were 1.82 (95 % confidence interval (CI) 0.92, 3.60) and 1.20 (95 % CI 0.81, 1.76). In sum, findings suggest a positive association of history of CSA with depression and depressive symptoms in the prenatal period. Findings on the postpartum period were inconsistent. Clinical and public health implications of evidence from the available literature are discussed, as are desirable study design characteristics of future research.

Placental mitochondrial DNA content and placental abruption: a pilot study

BACKGROUND

Mitochondrial biogenesis and adequate energy production are important for embryogenesis and placentation. Previous studies documented alterations in maternal blood mitochondrial DNA (mtDNA) copy number-a marker of mitochondrial dysfunction-in pregnancies complicated by placental abruption. To further understand the role of mitochondrial dysfunction in the pathogenesis of placental abruption, we conducted a pilot study using placental specimen collected from 103 placental abruption cases and 102 non-abruption controls. Real-time quantitative polymerase chain reaction (PCR) was used to assess the relative copy number of mtDNA in DNA extracted from placental samples collected immediately after delivery. Logistic regression procedures were used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Higher odds of placental abruption was observed with increasing mtDNA copy number (p value for trend = 0.05). The odds of placental abruption was elevated among women who delivered placentas with higher mtDNA copy number (≥120.5, the median) as compared with those with lower values (<120.5) (adjusted OR = 2.38; 95% CI 1.11-5.08).

CONCLUSION

We found preliminary evidence for associations of target tissue-specific mitochondrial dysfunction with an adverse perinatal outcome, placental abruption. Larger studies and replication of findings in other populations will further our understanding of relationships between cellular and genomic biomarkers of normal and abnormal placental function and vascular placental disorders.

Diagnostic Validity of the Generalized Anxiety Disorder - 7 (GAD-7) among Pregnant Women

OBJECTIVE

Generalized anxiety disorder (GAD) during pregnancy is associated with several adverse maternal and perinatal outcomes. A reliable and valid screening tool for GAD should lead to earlier detection and treatment. Among pregnant Peruvian women, a brief screening tool, the GAD-7, has not been validated. This study aims to evaluate the reliability and validity of the GAD-7.

METHODS

Of 2,978 women who attended their first perinatal care visit and had the GAD-7 screening, 946 had a Composite International Diagnostic Interview (CIDI). The Cronbach's alpha was calculated to examine the reliability. We assessed the criterion validity by calculating operating characteristics. The construct validity was evaluated using factor analysis and association with health status on the CIDI. The cross-cultural validity was explored using the Rasch Rating Scale Model (RSM).

RESULTS

The reliability of the GAD-7 was good (Cronbach's alpha = 0.89). A cutoff score of 7 or higher, maximizing the Youden Index, yielded a sensitivity of 73.3% and a specificity of 67.3%. One-factor structure of the GAD-7 was confirmed by exploratory and confirmatory factor analysis. Concurrent validity was supported by the evidence that higher GAD-7 scores were associated with poor self-rated physical and mental health. The Rasch RSM further confirmed the cross-cultural validity of the GAD-7.

CONCLUSION

The results suggest that the Spanish-language version of the GAD-7 may be used as a screening tool for pregnant Peruvian women. The GAD-7 has good reliability, factorial validity, and concurrent validity. The optimal cutoff score obtained by maximizing the Youden Index should be considered cautiously; women who screened positive may require further investigation to confirm GAD diagnosis.

Depression, anxiety and stress among pregnant migraineurs in a pacific-northwest cohort

BACKGROUND

The co-occurrence of migraine and unipolar psychiatric disorders has been well documented in non-pregnant populations, however little is known in pregnant populations.

METHODS

A cohort of 1321 women was interviewed during the first trimester of pregnancy. At the time of interview lifetime migraine status was ascertained using International Classification of Headache Disorders diagnostic criteria (ICHD-II). Information regarding unipolar depression, anxiety and stress during pregnancy was collected using the Patient Health Questionnaire Depression Module-9 (PHQ-9), and the Depression Anxiety Stress Scales 21-item Short Form (DASS-21). Multivariable logistic regression procedures were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association of migraine and mood disorders during pregnancy.

RESULTS

Approximately 28.2% (N=372) were classified as having a lifetime history of migraine; among migraineurs 122 were classified as migraineurs with aura and 250 as migraineurs without aura. Compared with non-migraineurs, migraineurs were associated with 1.60-fold increased odds of depression as measured by a PHQ-9 score ≥10 (AOR=1.60; 95% CI: 1.12-2.31). Overall, migraine with aura was more strongly associated with depression than was migraine without aura. Migraineurs, as compared with non-migraineurs, also had higher odds of mood disorders as measured by the DASS-21.

CONCLUSIONS

The comorbidity of mood and migraine disorders in pregnant populations supports the need for integrated mental and physical clinical evaluation, increased vigilance, and treatment of patients with such disorders.

Association of childhood physical and sexual abuse with intimate partner violence, poor general health and depressive symptoms among pregnant women

Objective

We examined associations of childhood physical and sexual abuse with risk of intimate partner violence (IPV). We also evaluated the extent to which childhood abuse was associated with self-reported general health status and symptoms of antepartum depression in a cohort of pregnant Peruvian women.

Methods

In-person interviews were conducted to collect information regarding history of childhood abuse and IPV from 1,521 women during early pregnancy. Antepartum depressive symptomatology was evaluated using the Patient Health Questionnaire-9. Multivariable logistic regression procedures were used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95%CI).

Results

Any childhood abuse was associated with 2.2-fold increased odds of lifetime IPV (95%CI: 1.72–2.83). Compared with women who reported no childhood abuse, those who reported both, childhood physical and sexual abuse had a 7.14-fold lifetime risk of physical and sexual IPV (95%CI: 4.15–12.26). The odds of experiencing physical and sexual abuse by an intimate partner in the past year was 3.33-fold higher among women with a history of childhood physical and sexual abuse as compared to women who were not abused as children (95%CI 1.60–6.89). Childhood abuse was associated with higher odds of self-reported poor health status during early pregnancy (aOR = 1.32, 95%CI: 1.04–1.68) and with symptoms of antepartum depression (aOR = 2.07, 95%CI: 1.58–2.71).

Conclusion

These data indicate that childhood sexual and physical abuse is associated with IPV, poor general health and depressive symptoms in early pregnancy. The high prevalence of childhood trauma and its enduring effects of on women’s health warrant concerted global health efforts in preventing violence.

An integrated web-based mental health intervention of assessment-referral-care to reduce stress, anxiety, and depression in hospitalized pregnant women with medically high-risk pregnancies: a feasibility study protocol of hospital-based implementation

Background

At prevalence rates of up to 40%, rates of depression and anxiety among women with medically complex pregnancies are 3 times greater than those in community-based samples of pregnant women. However, mental health care is not a component of routine hospital-based antenatal care for medically high-risk pregnant women.

Objective

The purpose of this study is to evaluate the effectiveness and feasibility of the hospital-based implementation of a Web-based integrated mental health intervention comprising psychosocial assessment, referral, and cognitive behavioral therapy (CBT) for antenatal inpatients.

Methods

This study is a quasi-experimental design. Pregnant women are eligible to participate if they are (1) <37 weeks gestation, (2) admitted to the antenatal inpatient unit for >72 hours, (3) able to speak and read English or be willing to use a translation service to assist with completion of the questionnaires and intervention, (4) able to complete follow-up email questionnaires, (5) >16 years of age, and (6) not actively suicidal. Women admitted to the unit for induction (eg, <72-hour length of stay) are excluded. A minimum sample of 54 women will be recruited from the antenatal high-risk unit of a large, urban tertiary care hospital. All women will complete a Web-based psychosocial assessment and 6 Web-based CBT modules. Results of the psychosocial assessment will be used by a Web-based clinical decision support system to generate a clinical risk score and clinician prompts to provide recommendations for the best treatment and referral options. The primary outcome is self-reported prenatal depression, anxiety, and stress symptoms at 6-8 weeks postrecruitment. Secondary outcomes are postpartum depression, anxiety, and stress symptoms; self-efficacy; mastery; self-esteem; sleep; relationship quality; coping; resilience; Apgar score; gestational age; birth weight; maternal-infant attachment; infant behavior and development; parenting stress/competence at 3-months postpartum; and intervention cost-effectiveness, efficiency, feasibility, and acceptability. All women will complete email questionnaires at 6-8 weeks postrecruitment and 3-months postpartum. Qualitative interviews with 10-15 health care providers and 15-30 women will provide data on feasibility and acceptability of the intervention.

Results

The study was funded in September, 2014 and ethics was approved in November, 2014. Subject recruitment will begin January, 2015 and results are expected in December, 2015. Results of this study will determine (1) the effectiveness of an integrated Web-based prenatal mental health intervention on maternal and infant outcomes and (2) the feasibility of implementation of the intervention on a high-risk antenatal unit.

Conclusions

This study will provide evidence and guidance regarding the implementation of a Web-based mental health program into routine hospital-based care for women with medically high-risk pregnancies.

Placental genome and maternal-placental genetic interactions: a genome-wide and candidate gene association study of placental abruption

While available evidence supports the role of genetics in the pathogenesis of placental abruption (PA), PA-related placental genome variations and maternal-placental genetic interactions have not been investigated. Maternal blood and placental samples collected from participants in the Peruvian Abruptio Placentae Epidemiology study were genotyped using Illumina's Cardio-Metabochip platform. We examined 118,782 genome-wide SNPs and 333 SNPs in 32 candidate genes from mitochondrial biogenesis and oxidative phosphorylation pathways in placental DNA from 280 PA cases and 244 controls. We assessed maternal-placental interactions in the candidate gene SNPS and two imprinted regions (IGF2/H19 and C19MC). Univariate and penalized logistic regression models were fit to estimate odds ratios. We examined the combined effect of multiple SNPs on PA risk using weighted genetic risk scores (WGRS) with repeated ten-fold cross-validations. A multinomial model was used to investigate maternal-placental genetic interactions. In placental genome-wide and candidate gene analyses, no SNP was significant after false discovery rate correction. The top genome-wide association study (GWAS) hits were rs544201, rs1484464 (CTNNA2), rs4149570 (TNFRSF1A) and rs13055470 (ZNRF3) (p-values: 1.11e-05 to 3.54e-05). The top 200 SNPs of the GWAS overrepresented genes involved in cell cycle, growth and proliferation. The top candidate gene hits were rs16949118 (COX10) and rs7609948 (THRB) (p-values: 6.00e-03 and 8.19e-03). Participants in the highest quartile of WGRS based on cross-validations using SNPs selected from the GWAS and candidate gene analyses had a 8.40-fold (95% CI: 5.8-12.56) and a 4.46-fold (95% CI: 2.94-6.72) higher odds of PA compared to participants in the lowest quartile. We found maternal-placental genetic interactions on PA risk for two SNPs in PPARG (chr3:12313450 and chr3:12412978) and maternal imprinting effects for multiple SNPs in the C19MC and IGF2/H19 regions. Variations in the placental genome and interactions between maternal-placental genetic variations may contribute to PA risk. Larger studies may help advance our understanding of PA pathogenesis.

Loss of a close family member the year before or during pregnancy and the risk of placental abruption: a cohort study from Denmark and Sweden

BACKGROUND

Maternal stress during pregnancy is associated with a modestly increased risk of fetal growth restriction and pre-eclampsia. Since placental abruption shares similar pathophysiological mechanisms and risk factors with fetal growth restriction and pre-eclampsia, we hypothesized that maternal stress may be implicated in abruption risk. We investigated the association between maternal bereavement during pregnancy and placental abruption.

METHOD

We studied singleton births in Denmark (1978-2008) and Sweden (1973-2006) (n = 5,103,272). In nationwide registries, we obtained data on death of women's close family members (older children, siblings, parents, and partners), abruption and potential confounders.

RESULTS

A total of 30,312 (6/1000) pregnancies in the cohort were diagnosed with placental abruption. Among normotensive women, death of a child the year before or during pregnancy was associated with a 54% increased odds of abruption [95% confidence interval (CI) 1.30-1.82]; the increased odds were restricted to women who lost a child the year before or during the first trimester in pregnancy. In the group with chronic hypertension, death of a child the year before or in the first trimester of pregnancy was associated with eight-fold increased odds of abruption (odds ratio 8.17, 95% CI 3.17-21.10). Death of other relatives was not associated with abruption risk.

CONCLUSIONS

Loss of a child the year before or in the first trimester of pregnancy was associated with an increased risk of abruption, especially among women with chronic hypertension. Studies are needed to investigate the effect of less severe, but more frequent, sources of stress on placental abruption risk.

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.

Association of serum vitamin D with symptoms of depression and anxiety in early pregnancy

Abstract Objective: To evaluate associations between early pregnancy 25-hydroxyvitamin D (25[OH]D) concentrations and antepartum depression and anxiety symptoms and potential modifiers thereof.

MATERIALS AND METHODS

In a pregnancy cohort (N=498), we examined cross-sectional associations of early pregnancy (mean=15.4 weeks gestation) serum 25[OH]D concentrations and depression and anxiety symptoms. Symptoms were measured using Depression, Anxiety, and Stress Scales (DASS-21) and Patient Health Questionnaire Depression Module (PHQ-9) instruments. Regression models were fit and effect modification by prepregnancy body mass index and leisure-time physical activity (LTPA) were assessed using interaction terms and stratified analyses.

RESULTS AND DISCUSSION

Mean 25[OH]D concentration was 34.4 ng/mL. Approximately 12% had "moderate" anxiety (score ≥ 10) and depression (score ≥ 10) symptoms by DASS-21 Anxiety and PHQ-9 instruments, respectively. A 1 ng/mL lower 25[OH]D was associated with 0.043 and 0.040 higher DASS-21 Anxiety and PHQ-9 Scores (p-values=0.052 and 0.029, respectively). Participants in the lowest quartile of 25[OH]D (<28.9 ng/mL) had 1.11 higher PHQ-9 scores than those in the highest quartile (≥ 39.5 ng/mL, p<0.05). However, associations were attenuated and statistically insignificant in fully adjusted models. Inverse associations of 25[OH]D with depression symptoms were significant among participants who reported no LTPA, but not among women who reported any LTPA (interaction p=0.018).

CONCLUSIONS

Our study provides modest evidence for inverse cross-sectional associations of early pregnancy maternal vitamin D concentrations with antepartum depression symptoms. We also observed that these associations may be modified by physical activity.

Comparative performance of Patient Health Questionnaire-9 and Edinburgh Postnatal Depression Scale for screening antepartum depression

OBJECTIVE

We sought to evaluate the psychometric properties of two widely used screening scales: the Patient Health Questionnaire (PHQ-9) and Edinburgh Postnatal Depression Scale (EPDS) among pregnant Peruvian women.

METHODS

This cross-sectional study included 1517 women receiving prenatal care from February 2012 to March 2013. A structured interview was used to collect data using PHQ-9 and EPDS. We examined reliability, construct and concurrent validity between two scales using internal consistency indices, factor structures, correlations, and Cohen׳s kappa.

RESULTS

Both scales had good internal consistency (Cronbach׳s alpha>0.8). Correlation between PHQ-9 and EPDS scores was fair (rho=0.52). Based on exploratory factor analysis (EFA), both scales yielded a two-factor structure. EFA including all items from PHQ-9 and EPDS yielded four factors, namely, "somatization", "depression and suicidal ideation", "anxiety and depression", and "anhedonia". The agreement between the two scales was generally fair at different cutoff scores with the highest Cohen׳s kappa being 0.46.

CONCLUSIONS

Both the PHQ-9 and EPDS are reliable and valid scales for antepartum depression assessment. The PHQ-9 captures somatic symptoms, while EPDS detects depressive symptoms comorbid with anxiety during early pregnancy. Our findings suggest simultaneous administration of both scales may improve identification of antepartum depressive disorders in clinical settings.

Study protocol for a randomized, controlled, superiority trial comparing the clinical and cost- effectiveness of integrated online mental health assessment-referral-care in pregnancy to usual prenatal care on prenatal and postnatal mental health and infant health and development: the Integrated Maternal Psychosocial Assessment to Care Trial (IMPACT)

BACKGROUND

Stress, depression, and anxiety affect 15 to 25% of pregnant women. However, fewer than 20% of prenatal care providers assess and treat mental health problems and fewer than 20% of pregnant women seek mental healthcare. For those who seek treatment, the lack of health system integration and existing barriers frequently prevent treatment access. Without treatment, poor prenatal mental health can persist for years and impact future maternal, child, and family well-being.

METHODS/DESIGN

The purpose of this randomized controlled trial is to evaluate the effectiveness of an integrated process of online psychosocial assessment, referral, and cognitive behavior therapy (CBT) for pregnant women compared to usual prenatal care (no formal screening or specialized care). The primary outcome is self-reported prenatal depression, anxiety, and stress symptoms at 6 to 8 weeks postrandomization. Secondary outcomes are postpartum depression, anxiety, and stress symptoms; self-efficacy; mastery; self-esteem; sleep; relationship quality; coping; resilience; Apgar score; gestational age; birth weight; maternal-infant attachment; infant behavior and development; parenting stress/competence; and intervention cost-effectiveness, efficiency, feasibility, and acceptability. Pregnant women are eligible if they: 1) are <28 weeks gestation; 2) speak/read English; 3) are willing to complete email questionnaires; 4) have no, low, or moderate psychosocial risk on screening at recruitment; and 5) are eligible for CBT. A sample of 816 women will be recruited from large, urban primary care clinics and allocation is by computer-generated randomization. Women in the intervention group will complete an online psychosocial assessment, and those with mild or moderate depression, anxiety, or stress symptoms then complete six interactive cognitive behavior therapy modules. All women will complete email questionnaires at 6 to 8 weeks postrandomization and at 3, 6, and 12 months postpartum. Clinic-based providers and researchers conducting chart abstraction and analysis are blinded. Qualitative interviews with 8 to 10 healthcare providers and 15 to 30 intervention group women will provide data on feasibility and acceptability of the intervention. Results of this trial will determine the feasibility and effectiveness of an integrated approach to prenatal mental healthcare and the use of highly accessible computer-based psychosocial assessment and CBT on maternal, infant, and family-based outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01901796.

Prenatal exposure to antidepressants and persistent pulmonary hypertension of the newborn: systematic review and meta-analysis

OBJECTIVE

To examine the risk for persistent pulmonary hypertension of the newborn associated with antenatal exposure to antidepressants.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase, Medline, PsycINFO, and CINAHL from inception to 30 December 2012.

ELIGIBILITY

English language studies reporting persistent pulmonary hypertension of the newborn associated with exposure to antidepressants. Two independent reviewers extracted data and assessed the quality of each article.

RESULTS

Of the 3077 abstracts reviewed, 738 papers were retrieved and seven included. All seven studies were above our quality threshold. Quantitative analysis was only possible for selective serotonin reuptake inhibitors (SSRIs). Although exposure to SSRIs in early pregnancy was not associated with persistent pulmonary hypertension of the newborn (odds ratio 1.23, 95% confidence interval 0.58 to 2.60; P=0.58), exposure in late pregnancy was (2.50, 1.32 to 4.73; P=0.005). Effects were not significant for any of the moderator variables examined, including study design, congenital malformations, and meconium aspiration. It was not possible to assess for the effect of caesarean section, body mass index, or preterm delivery. The absolute risk difference for development of persistent pulmonary hypertension of the newborn after exposure to SSRIs in late pregnancy was 2.9 to 3.5 per 1000 infants; therefore an estimated 286 to 351 women would need to be treated with an SSRI in late pregnancy to result in an average of one additional case of persistent pulmonary hypertension of the newborn.

CONCLUSIONS

The risk of persistent pulmonary hypertension of the newborn seems to be increased for infants exposed to SSRIs in late pregnancy, independent of the potential moderator variables examined. A significant relation for exposure to SSRIs in early pregnancy was not evident. Although the statistical association was significant, clinically the absolute risk of persistent pulmonary hypertension of the newborn remained low even in the context of late exposure to SSRIs.

Effects of prenatal stress on pregnancy and human development: mechanisms and pathways

A growing body of research shows that prenatal stress can have significant effects on pregnancy, maternal health and human development across the lifespan. These effects may occur directly through the influence of prenatal stress-related physiological changes on the developing fetus, or indirectly through the effects of prenatal stress on maternal health and pregnancy outcome which, in turn, affect infant health and development. Animal and human studies suggest that activation of the maternal stress response and resulting changes in endocrine and inflammatory activity play a role in the aetiology of these effects. Ongoing research is focusing on clarifying these mechanisms, understanding the role of racial and cultural factors in these effects, and examining the epigenetic and transgenerational influences of prenatal stress.

Maternal bereavement during pregnancy and the risk of stillbirth: a nationwide cohort study in Sweden

Increasing evidence suggests that maternal stress during pregnancy may influence pregnancy outcomes. In a nationwide Swedish study including almost 3 million births taking place during 1973-2006, we investigated whether maternal bereavement during pregnancy is associated with stillbirth risk. Through individual record linkage between several population-based registers, we obtained information on demographic, health-related, and pregnancy-related factors and deaths of mothers' first-degree relatives. There were 11,071 stillbirths (3.8 per 1,000 births) in the cohort. After adjustment for potential confounders, infants of mothers who had lost any first-degree relative the year before or during pregnancy had an 18% higher risk of stillbirth than unexposed offspring (95% confidence interval (CI): 1.06, 1.31). Corresponding hazard ratios were 1.67 (95% CI: 1.18, 2.36) for maternal loss of an older child, 2.06 (95% CI: 1.44, 2.94) for loss of a sibling, and 1.07 (95% CI: 0.95, 1.21) for loss of a parent. The relationship between maternal bereavement and stillbirth did not vary by time of death or by whether the relative's death was expected or unexpected. Death of a close relative is one of the most severe sources of stress, and future studies need to investigate whether less severe but more common stressors also increase stillbirth risk.

Risk of spontaneous preterm birth in relation to maternal depressive, anxiety, and stress symptoms

OBJECTIVE

To examine the risk of preterm birth (PTB) in relation to maternal psychiatric symptoms during pregnancy in Peruvian women.

STUDY DESIGN

This case-control study included 479 PTB cases and 480 term controls. In-person interviews were conducted to assess women's depressive, anxiety, and stress symptoms using the Patient Health Questionnaire (PHQ-9) and the Depression Anxiety Stress Scales (DASS-21). Multivariable logistic regression procedures were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULTS

Compared with women reporting no or minimal depressive symptoms, the aOR (95% CI) for PTB associated with consecutive severity of depressive symptoms based on the PHQ-9 assessment method were as follows: mild, 2.22 (95% CI 1.64-3.00) and moderate-severe, 3.67 (95% CI 2.09-6.46). The corresponding aORs for normal, mild, and moderate-severe depressive symptoms based on the DASS-21 assessment were 1.00 (reference), 3.82 (95% CI 1.90-7.66), and 2.90 (95% CI 1.66-5.04), respectively. A positive gradient was observed for the odds of PTB with severity of anxiety (Ptrend < 0.001) and stress symptoms (Ptrend < 0.001).

CONCLUSION

The odds of PTB increased in pregnant Peruvian women with psychiatric symptoms. Efforts to screen and treat affected women may modify risks of PTB and possibly other associated disorders.

Now what? Effects of on-site assessment on treatment entry after perinatal depression screening

BACKGROUND

Depression is a frequent accompaniment of the perinatal period. Although screening improves detection of perinatal depression, it does not in itself improve mental health treatment entry and, therefore, does not improve outcomes. This study addresses the feasibility of incorporating diagnostic assessment for depression directly into perinatal care visits and the influence of doing so on entry into mental health treatment.

METHODS

The Perinatal Depression Management Program was implemented in an urban community health center serving a predominantly Hispanic population. The Patient Health Questionnaire (PHQ-9) was administered during perinatal visits. Positive screens (scores ≥10) were followed within the same visit by brief diagnostic assessment and engagement strategies. Chart review was conducted to compare rates of screening, assessment, and treatment entry during a 3-month baseline period before implementation of the intervention (n=141) with a 1-year period after implementation of the intervention (n=400).

RESULTS

Before the intervention, 65.2% of patients completed a PHQ-9, and 10% of patients with positive screens received on-site assessment. None of the patients with identified perinatal depression entered treatment. After model implementation, significantly more (93.5%) completed a PHQ-9, and of patients with positive screens, 84.8% received an on-site assessment. Among patients diagnosed with major depression and offered treatment, 90% entered treatment.

CONCLUSIONS

It is feasible to implement diagnostic assessment for depression within perinatal clinic visits. Doing so may substantially increase entry into mental health treatment for women with perinatal major depression while reducing unnecessary mental health referral of patients with false positive screens.