Maternal morbidities and postpartum depression: an analysis using the 2007 and 2008 Pregnancy Risk Assessment Monitoring System

Prenatal electrocardiogram testing and postpartum depression: A population-based cohort study

Background

Cardiovascular symptoms in pregnancy may be a clue to psychological distress. We examined whether electrocardiogram testing in pregnant women is associated with an increased risk of subsequent postpartum depression.

Methods

We conducted a population-based cohort study of pregnant women who delivered in Ontario, Canada comparing women who received a prenatal ECG to women who did not.

Results

In total, 3,238,218 women gave birth during the 25-year study period of whom 157,352 (5%) received an electrocardiogram during prenatal care. Receiving an electrocardiogram test was associated with a one-third relative increase in the odds of postpartum depression (odds ratio 1.34; 95% confidence interval 1.29-1.39, p < 0.001).

Conclusion

The association between prenatal electrocardiogram testing and postpartum depression suggests a possible link of organic disease with mental illness, and emphasizes that cardiovascular symptoms may be a clinical clue to the presence of an underlying mood disorder.

Gestational diabetes and risk of postpartum depressive symptoms: A meta-analysis of cohort studies

BACKGROUND

Previous studies suggested that gestational diabetes may increase the risk of postpartum depression, but the results are inconclusive. We aimed to systematically assess the association between gestational diabetes and risk of postpartum depressive symptoms by a meta-analysis of cohort studies.

METHODS

We searched multiple electronic databases for studies that investigated gestational diabetes and risk of postpartum depressive symptoms (including diagnosis of postpartum depression) on December 21, 2018. Pooled relative risks (RRs) and confidence intervals (CIs) of the included articles were calculated using the random-effect model and publication bias was detected using the Egger's and Begg's tests.

RESULTS

We obtained 10 cohort studies with a total population of 2,000,002. Women with gestational diabetes compared with those without it had a significantly increased risk of developing postpartum depressive symptoms (pooled RR = 1.32, 95% CI: 1.09-1.60). There was a high degree of heterogeneity across studies (I² = 69.1%, P for heterogeneity = 0.001). The association appeared to be remarkably modified by study design, and the pooled RRs for prospective and retrospective cohort studies were 1.95 (95% CI: 1.48, 2.57) and 1.16 (95% CI: 1.12, 1.21), respectively (P for interaction = 0.003). In addition, no evidence of heterogeneity was observed in either retrospective cohort studies (I² = 0%, P for heterogeneity = 0.55) or prospective cohort studies (I² = 22.1%, P for heterogeneity = 0.27).

CONCLUSION

Women with gestational diabetes are at an increased risk of developing postpartum depressive symptoms. Future well-designed prospective studies are needed to confirm our results.

The association between gestational diabetes and postpartum depression: A systematic review and meta-analysis

AIMS

Postpartum period is a critical period for mothers, which is often accompanied by increased risk of depression. Many studies have evaluated the relationship between gestational diabetes (GDM) and postpartum depression (PPD), but contradictory results have been reported. Therefore, the present study was conducted to investigate the relationship between GDM and PPD.

METHODS

This systematic review and meta-analysis was conducted based on PRISMA Guideline. We searched all the relevant epidemiological studies in international databases of Scopus, PubMed, Science Direct, Embase, Web of Science, CINAHL, Cochrane Library, EBSCO, and Google scholar search engine using the MeSH Keywords in English without time limit until 2018. The heterogeneity of the studies was calculated using the I² index and Cochran's Q test. Relative risk (RR) and 95% confidence interval (CI) were extracted from each study. The results of the study were analyzed using the random effects model and Comprehensive Meta-Analysis Software Version 2.

RESULTS

A total of 18 studies with a sample size of 2,370,958 were reviewed. Meta-analysis results showed that GDM significantly increased the risk of PPD, and RR was 1.59 (95% CI: 1.22-2.07, p = 0.001). The RR for 15 cohort studies, 2 cross-sectional studies and 1 case-control study was 1.67 (95% CI: 1.22-2.28), 1.37 (95% CI: 0.91-2.05), and 1.29 (95% CI: 0.98-1.68), respectively.

CONCLUSIONS

GDM can be a risk factor for PPD. Therefore, PPD examination in pregnant women with GDM seems to be necessary.

Case Report of the Incidence of Maternal Depression at a Community Level III, 39-Bed NICU

Postpartum depression (PPD) is a vastly undetected, underdiagnosed, and untreated mental health concern for all mothers with infants. Having an infant in the neonatal intensive care unit (NICU) has an even higher impact on mothers’ mental health, predisposing them to a higher rate of PPD. The aim of this project was to identify the incidence of PPD in a Level III NICU to determine appropriate intervention strategies. All mothers with NICU infants 14 to 20 days were invited to complete the 10-question Edinburgh Postnatal Depression Screening (EPDS). The EPDS was scored, and a NICU social worker discussed the results and offered resources for those with scores of ≥10. The incidence of positive screens at our institution was 71.9% for an EPDS score with a cutoff ≥10, and 50% for an EPDS score with a cutoff ≥13. Simple strategies, including routine screening, PPD groups, and NICU support groups, were implemented. All NICUs should know the incidence of mothers’ PPD. Acting on this information flows downstream to improving the health of the infant and family.

Racial and ethnic differences in the relationship between antenatal stressful life events and postpartum depression among women in the United States: does provider communication on perinatal depression minimize the risk?

OBJECTIVE

Multi-state population-based studies exploring the racial/ethnic differences in the prevalence and correlates of postpartum depression (PPD), which affects 10-20% of women in the US, are rare. The aim of this study was to examine the racial/ethnic disparities in the relationship between antenatal stressful life events and PPD among US women and to explore whether antenatal health care provider communication on perinatal depression was associated with a lower risk.

METHODS

Data from the 2009-2011 Pregnancy Risk Assessment Monitoring System (PRAMS) were used. For each racial/ethnic group, the distribution of PPD was compared according to different levels of the stressors and socio-demographic, pre-pregnancy, antenatal, delivery, and neonatal characteristics. Multivariable logistic regression analyses were performed with PPD as the outcome and all variables that were significant in bivariate analyses as predictors.

RESULTS

Eleven percent of 87,565 women met the criteria for PPD with the prevalence ranging from 7.9% among Asian/Pacific Islanders to 14% among American Indian/Alaska Natives. Irrespective of race/ethnicity, having many bills to pay and having more than usual arguments with husband/partner were risk factors for PPD. Among non-Hispanic black (NHB) women, having a husband/partner who did not want the pregnancy was associated with PPD (adjusted odds ratio [aOR]: 1.47; 95% confidence interval [CI]: 1.14, 1.90), and among non-Hispanic whites (NHWs), drug/drinking problems of someone close was associated with PPD (aOR: 1.37; 95% CI: 1.21, 1.55). Provider communication was inversely associated with PPD among NHWs (aOR: 0.77; 95% CI: 0.69, 0.85) and NHBs (aOR: 0.74; 95% CI: 0.60, 0.93).

CONCLUSION

The protective effect of provider communication on PPD suggests the benefit of a simple conversation about perinatal depression during antenatal care. Furthermore, risk factors for PPD varied by race/ethnicity suggesting that these vulnerabilities should be taken into consideration in identifying women at-risk for PPD.

Pregnancy, perinatal and postpartum complications as determinants of postpartum depression: the Rhea mother-child cohort in Crete, Greece

AIMS

Few epidemiological studies evaluated associations between perinatal complications and maternal mood at the early postpartum period and the findings are inconsistent. We aimed at investigating a wide range of complications during pregnancy, at delivery, and at the early postpartum period as determinants of postpartum depression (PPD) at 8 weeks postpartum.

METHODS

A total of 1037 women who enrolled in the Rhea mother-child cohort in Crete, Greece participated in the present study. Information on pregnancy, perinatal and postpartum complications was obtained from clinical records or by questionnaires. Postpartum depressive symptoms were assessed at 8 weeks postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Multivariable linear and logistic regression models were fit to estimate the association between pregnancy, perinatal and postpartum complications and maternal depressive symptoms, adjusting also for potential confounders.

RESULTS

The prevalence of women with probable depression (EPDS score ≥ 13) was 13.6% at 8 weeks postpartum. Gestational hypertension and/or preeclampsia (β coefficient 1.86, 95% CI: 0.32, 3.41) and breastfeeding difficulties (β coefficient 0.77, 95% CI: 0.02, 1.53) were significantly associated with higher PPD symptoms. Sleep patterns during pregnancy, such as sleep deprivation (OR = 3.57, 95% CI: 1.91, 6.67) and snoring (OR = 1.81, 95% CI: 1.11, 2.93), and breastfeeding duration less than 2 months (OR = 1.77, 95% CI: 1.19, 2.64) were significantly associated with increase in the odds for PPD. Some other complications, such as unplanned pregnancy and hospitalisation during pregnancy were also associated with EPDS score, but these associations were explained by socio-demographic characteristics of the mother.

CONCLUSIONS

We found that several pregnancy, perinatal and postpartum complications may have an adverse effect on maternal mood at the early postpartum period. These findings have considerable implications for developing effective prevention and early psychoeducational intervention strategies for women at risk of developing PPD.

Sociodemographic, obstetric characteristics, antenatal morbidities, and perinatal depressive symptoms: A three-wave prospective study

Objectives

This study aimed (1) to investigate the pattern of perinatal depressive symptoms, and (2) to determine the relationships between sociodemographic characteristics, obstetric factors, antenatal morbidities, postnatal conditions, and perinatal depressive symptoms using a structural equation model (SEM).

Method

A three-wave prospective longitudinal design was used for 361 women in their second trimester, third trimester, and at six weeks postpartum. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess the depressive symptoms.

Results

The intensity of depressive symptoms was the highest in the second trimester among the three waves. The SEM showed that unmarried status, unplanned pregnancy, gestational diabetes, and headache were significantly associated with EPDS in the first and second waves. The EPDS in the first wave was able to predict the EPDS in the second and third waves. The SEM has satisfactorily fit with the data (chi-square/degree of freedom = 1.42, incremental fit index = 0.91, Tucker-Lewis index = 0.90, comparative fit index = 0.91, and root mean square error of approximation = 0.03).

Conclusion

The findings highlight the significance of monitoring depressive symptoms in the second trimester. Findings from this study could be useful in the design of effective intervention among women with unmarried status, unplanned pregnancy, gestational diabetes, and headache in order to reduce risk of perinatal depressive symptoms.

Obstetric risk factors for depression during the postpartum period in South Korea: a nationwide study

OBJECTIVE

Postpartum depression is related to many adverse effects in both mothers and their children; therefore, proper screening and early interventions are needed. This study aims to identify the risk factors of postpartum depression. Our primary focus is on obstetric risk factors.

METHODS

This study is a cross-sectional study which we extracted the data of women who gave birth between January 1st, 2010 and December 31st, 2012 from the Health Insurance Review and Assessment service (HIRA) database. We analyzed the data using multivariable logistic regression models.

RESULTS

A total of 17,483 (1.4%) women suffered from depression during the postpartum period. Younger (<20years) and advanced maternal age (≥35years), primiparity, previous depression, peripartum hysterectomy, uterine artery embolization, preterm delivery, placental abruption, cesarean delivery, induced labor, and preeclampsia were found to increase the likelihood of having depression after delivery.

CONCLUSIONS

Our findings suggest that there are several risk factors that lead women to postpartum depression. Therefore, early detection and well-management of the symptoms and risk factors for postpartum depression along with social support can help both physical and psychological conditions of women after childbirth.

A Literature Review of Alternative Therapies for Postpartum Depression

Postpartum depression is a debilitating disorder that requires greater awareness and treatment. Depending on severity of symptoms, standard treatment calls for individual psychotherapy and medication. Although postpartum depression can lead to negative health outcomes for women and their offspring, numerous barriers prevent women from receiving appropriate care. A review of the literature shows that nontraditional modes of psychotherapy dominate recent studies, whereas data for other complementary options are severely lacking. Further research is needed to help identify cost-effective alternative therapies for treating postpartum depression. Combined with prevention and screening, treatment options that suit women's varied situations and preferences must be explored to increase reception and adherence to treatment and, ultimately, to improve outcomes.

Preconception gynecological risk factors of postpartum depression among Japanese women: The Japan Environment and Children's Study (JECS)

BACKGROUND

Postpartum depression is one of the major causes of disability among women who are on their childbearing years. Identifying people at risk of postpartum depression may improve its management. The objective of this study was to determine the probable association between postpartum depression and some preconception gynecological morbidities.

METHODS

Data from a nationwide birth cohort study, the Japan Environment and Children's study (JECS), up to one month of postpartum were analyzed. To assess postpartum depression, the Edinburgh Postnatal Depression Scale (EPDS) was used; 11 preconception gynecological morbidities were considered as risk factors. Covariates included psychiatric illness history, psychosocial factors, some pregnancy adverse outcomes, birth outcomes, socio-demographic and health behavioral factors.

RESULTS

Except for the prevalence of previous miscarriage, leiomyoma and polycystic ovarian syndrome, depressive women had more gynecological morbidities compared to non-depressive ones. In logistic regression model, endometriosis (OR, 1.27; 95%CI: 1.15-1.41), dysmenorrhea (OR, 1.13; 95%CI: 1.06-1.21) and abnormal uterine bleeding (OR, 1.21; 95%CI: 1.15-1.29) were associated with postpartum depression.

LIMITATIONS

CONCLUSION: Women with endometriosis and menstrual problems were at risk of developing postpartum depression. This study suggests a perinatal mental health screening for predisposed women.

Relationship between depression and diabetes in pregnancy: A systematic review

AIM

To systematically review the literature on women with both diabetes in pregnancy (DIP) and depression during or after pregnancy.

METHODS

In this systematic literature review, PubMed/MEDLINE and EMBASE were searched (13 November 2015) using terms for diabetes (type 1, type 2, or gestational), depression, and pregnancy (no language or date restrictions). Publications that reported on women who had both DIP (any type) and depression or depressive symptoms before, during, or within one year after pregnancy were considered for inclusion. All study types were eligible for inclusion; conference abstracts, narrative reviews, nonclinical letters, editorials, and commentaries were excluded, unless they provided treatment guidance.

RESULTS

Of 1189 articles identified, 48 articles describing women with both DIP and depression were included (sample sizes 36 to > 32 million). Overall study quality was poor; most studies were observational, and only 12 studies (mostly retrospective database studies) required clinical depression diagnosis. The prevalence of concurrent DIP (any type) and depression in general populations of pregnant women ranged from 0% to 1.6% (median 0.61%; 12 studies). The prevalence of depression among women with gestational diabetes ranged from 4.1% to 80% (median 14.7%; 16 studies). Many studies examined whether DIP was a risk factor for depression or depression was a risk factor for DIP. However, there was no clear consensus for either relationship. Importantly, we found limited guidance on the management of women with both DIP and depression.

CONCLUSION

Given the increasing prevalence of diabetes and depression, high-quality research and specific guidance for management of pregnant women with both conditions are warranted.

Comorbid trajectories of postpartum depression and PTSD among mothers with childhood trauma history: Course, predictors, processes and child adjustment

BACKGROUND

Both postpartum depression and posttraumatic stress disorder (PTSD) have been identified as unique risk factors for poor maternal psychopathology. Little is known, however, regarding the longitudinal processes of co-occurring depression and PTSD among mothers with childhood adversity. The present study addressed this research gap by examining co-occurring postpartum depression and PTSD trajectories among mothers with childhood trauma history.

METHODS

177 mothers with childhood trauma history reported depression and PTSD symptoms at 4, 6, 12, 15 and 18 months postpartum, as well as individual (shame, posttraumatic cognitions, dissociation) and contextual (social support, childhood and postpartum trauma experiences) factors.

RESULTS

Growth mixture modeling (GMM) identified three comorbid change patterns: The Resilient group (64%) showed the lowest levels of depression and PTSD that remained stable over time; the Vulnerable group (23%) displayed moderately high levels of comorbid depression and PTSD; and the Chronic High-Risk group (14%) showed the highest level of comorbid depression and PTSD. Further, a path model revealed that postpartum dissociation, negative posttraumatic cognitions, shame, as well as social support, and childhood and postpartum trauma experiences differentiated membership in the Chronic High-Risk and Vulnerable. Finally, we found that children of mothers in the Vulnerable group were reported as having more externalizing and total problem behaviors.

LIMITATIONS

Generalizability is limited, given this is a sample of mothers with childhood trauma history and demographic risk.

CONCLUSIONS

The results highlight the strong comorbidity of postpartum depression and PTSD among mothers with childhood trauma history, and also emphasize its aversive impact on the offspring.

Oxytocin receptor DNA methylation in postpartum depression

The oxytocin receptor (OXTR) is a key regulator of stress and anxiety and may be regulated by both psychosocial risk factors and gonadal hormones, making it an attractive candidate for study in postpartum depression (PPD). The objective of this study was to investigate both serum hormone and PPD specific DNA methylation variation in the OXTR. Illumina HM450 microarray data generated in a prospective PPD cohort identified significant associations (P=0.014) with PPD in an intronic region in the OXTR located 4bp proximal to an estrogen receptor (ER) binding region. Pyrosequencing confirmed moderate evidence for an interaction of CpGs in the region with childhood abuse status to mediate PPD. These CpGs located on chr3 at positions 8810078 and 8810069 exhibited significant associations with postpartum depression scores from an independent cohort of 240 women with no prior psychiatric history. Hormone analysis suggested a PPD specific negative correlation of DNA methylation in the region with serum estradiol levels. Estradiol levels and OXTR DNA methylation exhibited a significant interaction to associate with the ratio of allopregnanolone to progesterone. Cumulatively, the data corroborate our previous hypotheses of a PPD specific increased sensitivity of epigenetic reprogramming at estrogen target genes and suggests that OXTR epigenetic variation may be an important mediator of mood relevant neuroactive steroid production.

Association between Hospital Birth Volume and Maternal Morbidity among Low-Risk Pregnancies in Rural, Urban, and Teaching Hospitals in the United States

Objectives This study aims to examine the relationship between hospital birth volume and multiple maternal morbidities among low-risk pregnancies in rural hospitals, urban non-teaching hospitals, and urban teaching hospitals, using a representative sample of U.S. hospitals. Study Design Using the 2011 Nationwide Inpatient Sample from 607 hospitals, we identified 508,146 obstetric deliveries meeting low-risk criteria and compared outcomes across hospital volume categories. Outcomes include postpartum hemorrhage (PPH), chorioamnionitis, endometritis, blood transfusion, severe perineal laceration, and wound infection. Results Hospital birth volume was more consistently related to PPH than to other maternal outcomes. Lowest-volume rural (< 200 births) and non-teaching (< 650 births) hospitals had 80% higher odds (adjusted odds ratio [AOR] = 1.80; 95% CI = 1.56-2.08) and 39% higher odds (AOR = 1.39; 95% CI = 1.26-1.53) of PPH respectively, than those in corresponding high-volume hospitals. However, in urban teaching hospitals, delivering in a lower-volume hospital was associated with 14% lower odds of PPH (AOR = 0.86; 95% CI = 0.80-0.93). Deliveries in rural hospitals had 31% higher odds of PPH than urban teaching hospitals (AOR = 1.31; 95% CI = 1.13-1.53). Conclusions Low birth volume was a risk factor for PPH in both rural and urban non-teaching hospitals, but not in urban teaching hospitals, where higher volume was associated with greater odds of PPH.

Untreated depression in the first trimester of pregnancy leads to postpartum depression: high rates from a natural follow-up study

BACKGROUND

This is a natural follow-up study that presents the postpartum results of women who experienced depression during pregnancy.

METHODS

This study involved 78 women diagnosed with depression in the first trimester of pregnancy. All patients were diagnosed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) in the first trimester and all were referred to a psychiatric center for treatment. Of the 78, 73 were contacted postpartum and reassessed by SCID-I. Treatment anamnesis was evaluated retrospectively.

RESULTS

The women were divided into two groups at the postpartum evaluation according to anamnesis of psychiatric treatment. Twenty-one of the 73 (28.7%) had received treatment during pregnancy (treated group). Fifty-two women had not been treated (untreated group). In the treated group, no postpartum depression was determined (0%). In the untreated group, 92% (n=48) of women had a depressive disorder postpartum (P<0.01). In addition, scores regarding depression, functionality, and perceived social support were worse postpartum for the untreated group.

CONCLUSION

Untreated depression during pregnancy is an important predictor of postpartum depression. This natural follow-up study is important because it presents very striking rates of postpartum depression. Referral of patients with depression during pregnancy to psychiatric treatment should be provided and is strongly encouraged.