Pregnancy-specific anxiety and gestational length: The mediating role of diurnal cortisol indices

Do not exclude your observations: Negative cortisol awakening responses (CAR) may be biologically relevant

The Cortisol Awakening Response (CAR) is the change in cortisol concentrations within 30-40 minutes after waking from sleep and is frequently used in stress research. Since a positive CAR is expected, we hypothesized that negative values could be associated to an underlying health condition (reflected in hematological parameters) or to environmental exposures such as lead (Pb), which has neuroendocrine effects including altered cortisol diurnal rhythms. Our aim was to analyze the prevalence of negative CAR values and their association with hematological parameters and blood Pb (BPb) levels in pregnant women (n = 900). Cortisol was measured by luminescence immunoassay in two-day saliva samples. CAR was estimated as the difference between the first (time of awakening) and second (45 min after) cortisol concentrations for each collection day and was operationalized as: both days positive (CAR-PP, 23 %), either day with a negative (CAR-NP/PN, 40 %), and both negative (CAR-NN, 37 %). A complete blood count was done using a coulter hematology analyzer. BPb was analyzed by inductively coupled plasma-mass spectrometry. Associations between hematological variables and CAR groups were analyzed using adjusted multinomial logistic regression models. Probabilities were estimated to assess the influence of BPb and hematological variables between CAR groups. The median (25th, 75th) CAR for the first collection day was -2.76 nmol/L (-16.55, 14.62) and -4.14 nmol/L (-17.66, 13.24) for the second day. Women with higher concentrations of leukocytes, eosinophils, basophils, and BPb were more likely to belong to CAR-NN or CAR-NP/PN groups. Compared to women with CAR-PP, those with CAR-NP/PN and CAR-NN had inverse associations for leukocyte levels and higher BPb concentrations. We conclude that negative CAR values could be an indicator of an underlying health condition or associated with environmental exposures such as Pb. Research should consider a thorough assessment of negative CAR values before excluding them from analyses.

Variability in perinatal sleep quality is associated with an atypical cortisol awakening response and increased mood symptoms

OBJECTIVE

Pregnancy is often typified with a decrease in sleep quality, which for many women, progressively worsens across gestation and into the postpartum. A mechanism linking poor sleep with certain adverse pregnancy outcomes is dysregulation of the HPA axis resulting in atypically elevated cortisol production. While total cortisol output normally increases across pregnancy, the cortisol awakening response (CAR), a response to waking up, is influenced by factors such as stress and mood. It attenuates as pregnancy progresses, with normalization in the first weeks after delivery. The goals of the present study were to (1) assess the temporal relationship between sleep quality and cortisol indices across the perinatal period; (2) evaluate whether sleep quality was associated with postpartum mood; and (3) assess whether cortisol mediated these associations.

METHOD

Data were collected as part of the Healthy Babies Before Birth (HB3) study. Sleep quality, depressive and anxiety symptoms, and cortisol from four time-points (8-16 weeks gestation, 30-36 weeks gestation, 6 months postpartum, and 1-year postpartum) were assessed. Participants (N = 223) who had sleep quality (PSQI) and cortisol data from at least 1 of 4 time-points were included in analyses. Three salivary cortisol indices were calculated: cortisol awakening response (CAR), diurnal slope, and area under the curve (AUC). Multi-level models were run to predict cortisol parameters based on deviations and typical maternal sleep quality at each wave as well as mood outcomes.

RESULTS

Multilevel (time, wave, and person) modeling indicated that sleep quality was not associated with any of the cortisol indices, and none significantly varied across time. However, when PSQI scores were higher than the woman's own mean sleep quality, the CAR slope was steeper (+1 point in PSQI, γ=0.18), and when PSQI scores were lower than mean, the CAR slope was flatter (-1 point, γ=0.11). Poorer sleep quality was associated with greater depression severity (γ = 0.367) and anxiety symptoms (γ = 0.120). Cortisol did not mediate the relationship between sleep quality and depression symptoms.

DISCUSSION

Increases in PSQI scores, but not higher mean PSQI scores, were associated with a larger CAR. There was no association between sleep quality and the diurnal slope or AUC. These data suggest that variability in sleep quality is significantly associated with the amount of cortisol secreted upon awakening.

Denis I, Zhu W, Mahaffey B, Lobel M. Anxiety trajectories from pregnancy to one-year postpartum and their contributors during the COVID-19 pandemic

BACKGROUND

Anxiety in the peripartum period (pregnancy through one-year postpartum) has negative impacts on mothers and infants. During the COVID-19 pandemic, high rates of anxiety were reported worldwide, but trajectories for how these symptoms change longitudinally in the peripartum period remain unknown.

METHODS

A total of 1,411 women who were pregnant during the second U.S. COVID-19 surge completed four study questionnaires between December 2020 and March 2022, including assessments of anxiety symptoms (GAD-7) and individual and community-level contributors. Latent Class Growth Mixture Models (LCGMM) were used to identify anxiety trajectories, and multinomial logistic regression was used to identify contributors to class membership.

RESULTS

Three classes of anxiety symptom trajectories were identified. Class 1 (n = 956, 67.8%) experienced minimal/mild anxiety throughout the peripartum period. Class 2 (n = 362, 25.7%) experienced initial moderate anxiety that remained stable. Class 3 (n = 93, 6.6%) experienced initial moderate anxiety that increased to severe in the postpartum period. Stress and history of mental health diagnosis contributed to higher initial levels of anxiety and ongoing social support contributed to lower levels of anxiety. In addition, financial insecurity increased the risk of belonging to Class 3.

CONCLUSIONS

Screening for anxiety symptoms and psychosocial vulnerabilities in the peripartum period is vital, as is early intervention. This is especially the case among women with limited financial and social resources who may experience chronic or worsening anxiety as they transition to parenthood.