Sleep complaints in early pregnancy. A cross-sectional study among women attending prenatal care in general practice

Sleep and its association with depressive and anxiety symptoms during the last weeks of pregnancy: A population-based study

OBJECTIVE

To evaluate the association between sleep characteristics and depressive and anxiety symptoms during the immediate postpartum period.

METHODS

People who had hospital births during 2019 in the municipality of Rio Grande (southern Brazil) were assessed with a standardized questionnaire concerning sociodemographic (eg, age and self-reported skin color) and health-related variables (eg, parity and stillbirth) (n = 2314) 24-48 hours after birth. We used the Munich Chronotype Questionnaire to assess sleep latency, inertia, duration, and chronotype; the Edinburgh Postpartum Depression Scale for depressive symptoms; and the General Anxiety Disorder 7-Item Scale to evaluate anxiety symptoms. We used logistic regression models to calculate odds ratios.

RESULTS

The prevalence of depressive symptoms was 13.7%, and of anxiety symptoms was 10.7%. Depressive symptoms were more likely in those with vespertine chronotype (odds ratios = 1.63; 95% CI: 1.14-2.35) and those with a sleep latency of more than 30 minutes (OR = 2.36; 95% CI: 1.68-3.32). The probability of depressive symptoms decreased by 16% for each additional hour of sleep (OR = 0.84; 95% CI: 0.77-0.92). Sleep inertia of 11-30 minutes increased the probability of anxiety on free days (OR = 1.73; 95% CI: 1.27-2.36) and increased the probability of depressive (OR = 2.68; 95% CI: 1.82-3.83) and anxiety symptoms (OR = 1.69; 95%CI: 1.16-2.44) on workdays.

CONCLUSION

Participants with vespertine chronotype or shorter sleep duration were more likely to have depressive symptoms. Those who took more time to fall asleep or get out of bed were more likely to have both anxiety and depressive symptoms, but the association was stronger for depressive symptoms.

Family wellbeing in general practice: a study protocol for a cluster-randomised trial of the web-based resilience programme on early child development

BACKGROUND

Social, emotional and behavioural problems in early childhood are associated with increased risk for a wide range of poor outcomes associated with substantial cost and impact on society as a whole. Some of these problems are rooted in the early mother-infant relationship and might be prevented. In Denmark, primary health care has a central role in preventive care during pregnancy and the first years of the child's life and general practice provides opportunities to promote a healthy mother-infant relationship in early parenthood.

OBJECTIVE

In the context of standardised antenatal and child development assessments focused on psychosocial wellbeing, we examine the impact of a complex intervention designed to improve maternal mentalisation skills, involving training of general practice clinicians and signposting towards a web-based resource. Joint main outcomes are child socio-emotional and language development at age 30 months measured by parentally reported questionnaires (Communicative Development Inventory and Strengths and Difficulties Questionnaire).

METHODS

The study is a cluster-randomised controlled trial based in general practices in the Capital Region and the Zealand Region of Denmark. Seventy practices were included. Practices were randomised by a computer algorithm in a ratio of 1:1 to intervention or control groups. Each practice was asked to recruit up to 30 women consecutively at their first scheduled antenatal assessment. Clinicians in both groups received one day of training in preventive antenatal and child development consultations with added focus on parental psychosocial well-being, social support, and parent-child interaction. These preventive consultations delivered in both trial arms require enhanced data recording about psychosocial factors. In intervention clinics, clinicians were asked to signpost a web page at three scheduled antenatal consultations and at four scheduled consultations when the child is 5 weeks, 5 months, 1 and 2 years.

DISCUSSION

We hypothesise that the intervention will increase mothers' ability to be sensitive to their child's mental state to an extent that improves the child's language and mental state at 30 months of age measured by parent-reported questionnaires.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04129359. Registered on Oct 16 2019.

The prevalence and associated factors of prenatal depression and anxiety in twin pregnancy: a cross-sectional study in Chongqing, China

Background

Pregnant women expecting twins are more likely to experience stress, which can lead to anxiety and depression. Our aim was to investigate the prevalence of prenatal anxiety and depressive symptoms in women with twin pregnancies and the associated factors.

Methods

In a cross-sectional survey, 210 women with twin pregnancies who satisfied the inclusion and exclusion criteria in two tertiary centers in Southwestern China were asked to complete a basic information form, the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS). To compare statistics with normal distribution in distinct characteristic groups, a paired t-test, and one-way ANOVA were utilized. Binary logistic step regression was used to analyze the associated factors of antenatal anxiety and depressive symptoms.

Results

The 210 women with twin pregnancies (age = 30.8 ± 4.2 years) were between 7 and 37 gestational weeks (29.2 ± 1.2 weeks), were typically well-educated (72.4% had a post-high-school degree), and reasonably affluent (88.1% were above the low-income cutoff). Among them, 34.8% had symptoms associated with clinical levels of anxiety, and 37.1% had symptoms indicating possible depression. The prevalence of co-morbid anxiety and depressive symptoms was 24.3%. Binary stepwise logistic regression analysis showed that previous health status and sleep disturbance during pregnancy were the associated factors of anxiety symptoms in women with twin pregnancies (P < 0.05), whereas age, previous health status, negative life events, and physical activity during pregnancy were the associated factors of depressive symptoms in women with twin pregnancies (P < 0.05).

Conclusion

About one-third of women with twin pregnancies had symptoms of anxiety or depression; these were most strongly predicted by some modifiable factors, suggesting that early preventive mind-body interventions may be a promising strategy to protect against mental health issues for women with twin pregnancies.

Effects of the Covid-19 Pandemic on the Prevalence of Insomnia, Anxiety, and Depression During Pregnancy: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis study aims to determine the effects of the Covid-19 pandemic on the prevalence of insomnia, anxiety, and depression symptoms during pregnancy. Reviews were done through PubMed, EBSCO (Medline, CINAHL), Embase (OVID), Web of Science, PsycINFO, TR Index, Turkish Thesis Center databases using (pregnancy OR pregnant) and (sleep OR sleep disorders OR insomnia), and (anxiety OR depression) keywords between April and May 2021. The meta-analysis included 48 articles (sample: 77,299). It was found that the Covid-19 pandemic did not affect the prevalence of depression symptoms and anxiety during pregnancy, but it increased insomnia. While insomnia ratio was reported 39.6% (95% CI: 0.253-0.560) in the studies conducted before the pandemic, it was reported 88.8% (95% CI: 0.821-0.921) in the studies conducted during the pandemic. This study found that the Covid-19 pandemic did not have effects on depression symptoms and anxiety, but it increased insomnia complaints.

The predictive value of common symptoms in early pregnancy for complications later in pregnancy and at birth

INTRODUCTION

The aim was to investigate whether common pregnancy-related symptoms-nausea, vomiting, back pain, pelvic girdle pain, pelvic cavity pain, vaginal bleeding, itching of vulva, pregnancy itching, leg cramps, uterine contractions and varicose veins-in the first trimester of pregnancy add to the identification of women at high risk of future pregnancy and birth complications.

MATERIAL AND METHODS

Survey data linked to national register data. All women booking an appointment for a first prenatal visit in one of 192 randomly selected General Practices in East Denmark in the period April 2015-August 2016. The General Practices included 1491 women to this prospective study. Two outcomes, pregnancy complications and birth complications, were collected from the Danish Medical Birth Register.

RESULTS

Among the 1413 included women, 199 (14%) experienced complications in later pregnancy. The most serious complication, miscarriage, was experienced by 65 women (4.6%). Other common pregnancy complications were gestational diabetes mellitus (n = 11, 0.8%), gestational hypertension without proteinuria (n = 34, 2.4%), mild to moderate preeclampsia (n = 34, 2.4%) and gestational itching with effect on liver (n = 17, 1.2%). Women who experienced pelvic girdle pain, pelvic cavity pain or vaginal bleeding in the first trimester of pregnancy had a higher risk of pregnancy complications later on in later pregnancy. None of the other examined symptoms showed associations to pregnancy complications. No associations were found between pregnancy-related physical symptoms in first trimester and birth complications.

CONCLUSIONS

Symptoms in early pregnancy do not add much information about the risk of pregnancy or birth complications, although pain and bleeding may give reason for some concern. This is an important message to women experiencing these common symptoms and to their caregivers.

A longitudinal investigation of the influence of psychological factors on nausea and vomiting in early pregnancy

The purpose of this study was to elucidate psychological factors that may influence nausea and vomiting during pregnancy (NVP) progression in early pregnancy based on longitudinal observations. Fifty-nine pregnant women completed the Rhodes Index of Nausea, Vomiting, and Retching (RINVR) and General Health Questionnaire-28 (GHQ-28), and recorded their resting heart rate with photoplethysmography for 5 min to determine heart rate variability (HRV) indexes at 7-9 weeks and 11-13 weeks of gestation with a 4-week interval. GHQ-28 scores (total and subclasses) and HRV indexes at 7-9 weeks were compared among groups classified according to the presence of severe NVP (RINVR ≥ 9 points) at the two measurement points. Among women without severe NVP at 7-9 weeks, women who developed severe NVP at 11-13 weeks had significantly higher levels of anxiety/insomnia in the GHQ-28 subclasses (p = 0.018). The cross-lagged relationship from anxiety/insomnia at 7-9 weeks to RINVR at 11-13 weeks was significant (β = 0.367, p &lt; 0.001). Among women with severe NVP at 7-9 weeks, women whose severe symptoms subsided at 11-13 weeks had significantly higher high-frequency (HF) power (p = 0.010), and women with relatively higher HF power demonstrated a significant reduction in RINVR (interaction effect, p = 0.035). During early pregnancy, women with strong anxiety/insomnia symptoms tend to have NVP symptoms that become more severe as the pregnancy progresses. The higher HF power in women whose severe NVP subsided within 4 weeks suggests a contribution of emotion regulation to early amelioration of NVP.

The association of a past childbirth experience with a variety of early physical and mental symptoms in subsequent pregnancies

BACKGROUND

Some women have a perceived negative experience of childbirth due to various reasons- e.g., obstetric complications or the feeling of loss of control. We do not know enough about the effects of a perceived negative experience of a childbirth on a woman's subsequent pregnancies. The aim of this study was to investigate whether a previously perceived negative childbirth experience affects a woman's physical and mental well-being in a later pregnancy.

METHODS

A prospective cohort study in Danish general practice, based on information about women's childbirth experiences from the Pregnancy Health Record filled in by the general practitioner (GP) and data from an electronic questionnaire completed by the women.

RESULTS

A total of 1288 women were included in the analysis. Women who had given birth before were found to have a significantly higher risk of experiencing nausea, varicose veins and uterine contractions, and a lower risk of pelvic cavity pain in the current pregnancy. Women having given birth before were significantly more likely to assess their physical fitness as poor and to experience poor well-being. Women with a perceived negative experience of childbirth had more sleep problems and a higher prevalence of poor self-rated health than women with unproblematic childbirth experience.

CONCLUSION

This study showed that women with a previously perceived negative experience of childbirth are affected according to their mental health in their subsequent pregnancy.

Sleep disorders in pregnancy

Sleep disturbances are common in pregnancy and affect sleep quality. The maternal body is going through constant physical and physiological changes to adapt to the growing fetus. Sleep disorders may manifest at any point during pregnancy; some may result in adverse maternal or fetal outcomes. A strong clinical suspicion is crucial to identify sleep disorders in pregnancy and their management should be evaluated with a multidisciplinary team approach. In this review, we provide an overview of changes in sleep during pregnancy and summarise the key features of common sleep disorders in pregnancy, including practical tips on their management.

Educational aims

To provide an overview of common sleep disorders in pregnancy and their management options.

To highlight the impact of the physiological changes in pregnancy on sleep.

To outline the type of sleep studies available to investigate sleep disorders in pregnancy.

Association Between Objectively Assessed Sleep and Depressive Symptoms During Pregnancy and Post-partum

Introduction

Sleep problems are common in pregnancy but many studies have relied only on self-reported sleep measures. We studied the association between objectively measured sleep and peripartum depressive symptoms in pregnant women.

Material and Methods

Sleep was assessed using Actiwatch accelerometers in a sample of 163 pregnant women in the late first (weeks 11–15) or early second trimester (weeks 16–19). Depressive symptoms were assessed in gestational weeks 17, 32 and at 6 weeks post-partum using the Edinburgh Postnatal Depression Scale (EPDS). Multiple linear regression and logistic regression analyses, adjusting for age, BMI, pre-pregnancy smoking, ongoing mental health problems, trimester and season of sleep assessment were carried out to test the association between sleep and depression. Sleep was measured by total sleep time and sleep efficiency, whereas depression was indicated by depressive symptoms and depression caseness. Results are presented as unstandardized beta (B) coefficients or adjusted odds ratios (AOR) and 95% confidence intervals (CI).

Results

Total sleep time ranged from 3 to 9 h (mean 7.1, SD 0.9) and average sleep efficiency was 83% (SD 6.0). Women with the shortest total sleep time, i.e., in the lowest quartile (<6.66 h), reported higher depressive symptoms during pregnancy (week 17, B = 2.13, 95% CI 0.30–3.96; week 32, B = 1.70, 95% CI 0.03–3.37) but not post-partum. Their probability to screen positive for depression in gestational week 17 was increased more than 3-fold (AOR = 3.46, 95% CI 1.07–11.51) but unchanged with regards to gestational week 32 or 6 weeks post-partum. Sleep efficiency was not associated with depressive symptoms at any stage of pregnancy or post-partum.

Discussion

In one of the few studies to use objective sleep measures to date, mental health of pregnant women appeared to be affected by shortened sleep, with total sleep time being negatively associated with depressive symptoms in the early second and third trimester. This finding highlights the relevance of identifying and treating sleep impairments in pregnant women early during antenatal care to reduce the risk of concomitant depression.

Lifestyle and Chronic Pain in the Pelvis: State of the Art and Future Directions

During their lifespan, many women are exposed to pain in the pelvis in relation to menstruation and pregnancy. Such pelvic pain is often considered normal and inherently linked to being a woman, which in turn leads to insufficiently offered treatment for treatable aspects related to their pain experience. Nonetheless, severe dysmenorrhea (pain during menstruation) as seen in endometriosis and pregnancy-related pelvic girdle pain, have a high impact on daily activities, school attendance and work ability. In the context of any type of chronic pain, accumulating evidence shows that an unhealthy lifestyle is associated with pain development and pain severity. Furthermore, unhealthy lifestyle habits are a suggested perpetuating factor of chronic pain. This is of specific relevance during lifespan, since a low physical activity level, poor sleep, or periods of (di)stress are all common in challenging periods of women’s lives (e.g., during menstruation, during pregnancy, in the postpartum period). This state-of-the-art paper aims to review the role of lifestyle factors on pain in the pelvis, and the added value of a lifestyle intervention on pain in women with pelvic pain. Based on the current evidence, the benefits of physical activity and exercise for women with pain in the pelvis are supported to some extent. The available evidence on lifestyle factors such as sleep, (di)stress, diet, and tobacco/alcohol use is, however, inconclusive. Very few studies are available, and the studies which are available are of general low quality. Since the role of lifestyle on the development and maintenance of pain in the pelvis, and the value of lifestyle interventions for women with pain in the pelvis are currently poorly studied, a research agenda is presented. There are a number of rationales to study the effect of promoting a healthy lifestyle (early) in a woman’s life with regard to the prevention and management of pain in the pelvis. Indeed, lifestyle interventions might have, amongst others, anti-inflammatory, stress-reducing and/or sleep-improving effects, which might positively affect the experience of pain. Research to disentangle the relationship between lifestyle factors, such as physical activity level, sleep, diet, smoking, and psychological distress, and the experience of pain in the pelvis is, therefore, needed. Studies which address the development of management strategies for adapting lifestyles that are specifically tailored to women with pain in the pelvis, and as such take hormonal status, life events and context, into account, are required. Towards clinicians, we suggest making use of the window of opportunity to prevent a potential transition from localized or periodic pain in the pelvis (e.g., dysmenorrhea or pain during pregnancy and after delivery) towards persistent chronic pain, by promoting a healthy lifestyle and applying appropriate pain management.

Poor sleep quality and its associated factors among pregnant women in Northern Ethiopia, 2020: A cross sectional study

BACKGROUND

Sleep is a physiologic necessity for all humankind. Pregnant women, in particular, need adequate sleep to develop their fetuses as well as save energy required for delivery. A change in sleep quality and quantity is the most common phenomena during pregnancy due to mechanical and hormonal factors. However, there is a scarcity of data about poor sleep quality and its associated factors among pregnant mothers in Ethiopia. Therefore, this study aims to determine the prevalence of poor sleep quality and its associated factors among pregnant mothers at Wadila primary hospital, Ethiopia.

METHODS

Institution based cross-sectional study design was employed on 411 pregnant mothers. Data were collected using a pre-tested interviewer administered questionnaire. SPSS Version 23 for Windows software was used for data analyses. Bivariate analysis was conducted to detect the association between dependent and independent variables, and to choose candidate variables (p < 0.25) for multivariate logistic regression. Statistical significance was set at p-value <0.05.

RESULTS

A total of 411 participants were included in the study making a response rate of 97.4%. Overall, 68.4% of participants found to have poor sleep quality (PSQI>5). Age of the mother [age 20-30 years; AOR = 4.3 CI (1.8, 9.9), p = 0.001, and age >30 years; AOR = 4.7 CI (1.6, 13.9) p = 0.005], gestational age [second trimester, AOR = 2.46, CI (1.2, 4.9), p = 0.01 and third trimester, AOR = 7.5, CI (3.2, 17.8), p = 0.000] and parity [multiparous women; AOR = 2.1(1.24, 3.6) p = 0.006] were predictor variables for poor sleep quality among pregnant mothers.

CONCLUSION

More than two-third of pregnant mothers had poor sleep quality. Advanced maternal age, increased gestational age and multiparty are found to be predictors of poor sleep quality in pregnant women.

Sleep quality in women with nausea and vomiting of pregnancy: a cross-sectional study

BACKGROUND

Nausea and vomiting of pregnancy (NVP) deteriorates many aspects of daily lives of women. However, little is known about associations between NVP and sleep quality.

METHODS

Women attending to routine mid-pregnancy visits in maternity health care clinics in Turku city area and surrounding municipalities, Finland, during 2011-2014, were invited to participate. A cohort of 1203 volunteers (mean age 30 years, mean gestational week 16.6, mean BMI 24.4 kg/m2, nulliparous 46%) was recruited. The severity of NVP in the worst 12-h period of current pregnancy was assessed with Pregnancy Unique Quantification of Emesis Questionnaire (PUQE) and categorized accordingly into no/mild/moderate and severe NVP. Sleep disturbances during the past 3 months were assessed with selected questions (difficulty falling asleep, night awakenings, too early morning awakenings and sleepiness during the day) from Basic Nordic Sleep Questionnaire (BNSQ). In addition, general sleep quality, as well as physical and mental quality of life (QoL) were rated with three visual analog scales (VAS). Associations between PUQE categories (severity of NVP) and sleep disturbances, general sleep quality, physical QoL and mental QoL were evaluated with multinomial regression analysis.

RESULTS

According to PUQE, NVP was most frequently moderate (n = 629, 52.3%), followed by mild (n = 361, 30.0%) and severe (n = 77, 6.4%). Only 11.3% had no NVP (n = 136). The most frequent sleep disturbance was night awakenings (69.9%, n = 837), followed by sleepiness during the day (35.7%, n = 427), too early morning awakenings (12.0%, n = 143) and difficulty falling asleep (7.1%, n = 81). In adjusted analysis (age, parity, body mass index, smoking, employment), more severe NVP was associated with night awakenings (AOR 3.9, 95% CI 1.79-8.47, P < 0.0001) and sleepiness during the day (AOR 4.7, 95% CI 2.20-9.94, P < 0.0001). In VAS, women with more severe NVP rated worse general sleep quality and worse physical and mental QoL. However, in multivariable analysis, the association between the severity of NVP and physical and mental QoL was stronger than that of sleep .

CONCLUSIONS

More severe NVP is associated with sleep disturbances and in close relation to lower physical and mental QoL. Thus, in comprehensive care of women with NVP, also sleep quality should be evaluated.

What factors are most important for the development of the maternal-fetal relationship? A prospective study among pregnant women in Danish general practice

Background

Development of the maternal antenatal attachment (MAA) constitutes an important aspect of the transition into motherhood. Early identification of women at risk of developing a poor MAA provides possibilities for preventive interventions targeting maternal mental health and the emerging mother-infant relationship. In this study, we investigate the relative importance of an extensive set of psychosocial, pregnancy-related, and physiological factors measured in the first trimester of pregnancy for MAA measured in third trimester.

Methods

A prospective study was conducted among pregnant women in Danish general practice (GP). Data were obtained in the first and the third trimester from pregnancy health records and electronic questionnaires associated with routine GP antenatal care visits. The Maternal Antenatal Attachment Scale (MAAS) was used to assess maternal antenatal attachment. The relative importance of potential determinants of maternal antenatal attachment was assessed by the relative contribution of each factor to the fit (R²) calculated from multivariable regression models.

Results

The sample consisted of 1328 women. Low antenatal attachment (Total MAAS ≤ 75) was observed for 513 (38.6%) women. Perceived social support (having someone to talk to and having access to practical help when needed) emerged as the most important determinant. Furthermore, scores on the MAAS decreased with worse self-rated health, poor physical fitness, depression, increasing age, having given birth previously, and higher education.

Conclusion

Pregnant women reporting lack of social support and general low physical and mental well-being early in pregnancy may be at risk for developing a poor MAA. An approach targeting both psychosocial and physiological well-being may positively influence expectant mothers’ successful adaptation to motherhood.

Selection bias in general practice research: analysis in a cohort of pregnant Danish women

OBJECTIVE

The aim of the present study was to examine selection in a general practice-based pregnancy cohort.

DESIGN

Survey linked to administrative register data.

SETTING AND SUBJECTS

In spring 2015, GPs were recruited from two Danish regions. They were asked to invite all pregnant women in their practice who had their first prenatal care visit before 15 August 2016 to participate in the survey.

OUTCOME MEASURES

The characteristics of GPs and the pregnant women were compared at each step in the recruitment process - the GP's invitation, their agreement to participate, actual GP participation, and the women's participation - with an uncertainty coefficient to quantify the step where the largest selection occurs.

RESULTS

Significant differences were found between participating and non-participating practices with regards to practice characteristics such as the number of patients registered with the practice, the age and sex of doctors, and the type of practice. Despite these differences, the characteristics of the eligible patients differed little between participating and non-participating practices. In participating practices significant differences were, however, observed between recruited and non-recruited patients.

CONCLUSION

The skewed selection of patients was mainly caused by a high number of non-participants within practices that actively took part in the study. We recommend that a focus on the sampling within participating practices be the most important factor in representative sampling of patient populations in general practice. Key points Selection among general practitioners (GPs) is often unavoidable in practice-based studies, and we found significant differences between participating and non-participating practices. These include practice characteristics such as the number of GPs, the number of patients registered with the GP practice, as well as the sex and age of the GPs. •Despite this, only small differences in the characteristics of the eligible patients were observed between participating and non-participating practices. •In participating practices, however, significant differences were observed between recruited and non-recruited patients. •Comprehensive sampling within participating practices may be the best way to generate representative samples of patients.