Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes

Mood and anxiety problems in perinatal Indigenous women in Australia, New Zealand, Canada, and the United States: a critical review of the literature

We conducted a review of research literature related to anxiety, depression, and mood problems in Indigenous women in Canada, the United States (including Hawaii), Australia, and New Zealand. Quantitative and qualitative research studies published between 1980 and March 2010 were reviewed. The initial search revealed 396 potential documents, and after being checked for relevance by two researchers, data were extracted from 16 quantitative studies, one qualitative research article, and one dissertation. Depression is a common problem in Indigenous pregnant and postpartum women; however, the prevalence and correlates of anxiety and mood disorders are understudied. The review identified four key areas where further research is needed: (a) longitudinal, population-based studies; (b) further validation and modification of appropriate screening tools; (c) exploration of cultural diversity and meaning of the lived experiences of antenatal and postpartum depression, anxiety, and mood disorders; and (d) development of evidence-informed practices for researchers and practitioners through collaborations with Aboriginal communities to better understand and improve mental health of women of childbearing age.

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.

Complementary and alternative medicine therapies for perinatal depression

Complementary and alternative medicine therapies are increasingly sought out by people with psychiatric disorders. In this chapter, we review the evidence for several commonly used CAM therapies (i.e. omega-3 fatty acids, folate, S-adenosyl-methionine, St John's Wort, bright light therapy, exercise, massage, and acupuncture) in the treatment of perinatal depression. A number of these treatments may be reasonable to consider for women during pregnancy or postpartum, but the safety and efficacy of these relative to standard treatments must still be systematically determined. Evidence-based use of complementary and alternative medicine therapies treatments for perinatal depression is discussed. Adequately powered systematic studies are necessary to determine the role of complementary and alternative medicine therapies in the treatment of perinatal depression.

Prenatal maternal depression is associated with low birth weight through shorter gestational age in term infants in Korea

BACKGROUND

Maternal prenatal depression is associated with lower offspring birth weight, yet the impact of gestational age on this association remains inadequately understood.

AIMS

We aimed to investigate the effect of prenatal depression on low birth weight, gestational age, and weight for gestational age at term.

STUDY DESIGN

Prospective cohort study.

SUBJECT

Data were collected from 691 women in their third trimester of pregnancy who went on to give birth to a singleton at term without perinatal complications. One hundred and fifty-two women had a Center for Epidemiologic Studies Depression Scale-10 score ≥10 and were classed as prenatally depressed.

OUTCOME MEASURES

Low birth weight (<2500g), gestational age at birth, and birth weight percentile for gestational age.

RESULTS

Offspring of prenatally depressed women were more likely to be low birth weight (Odds ratio [OR] 2.94, 95% confidence interval [CI] 1.14-7.58) than offspring of prenatally non-depressed women, but the association was attenuated (OR 1.66, 95% CI 0.55-5.02) when adjusted for gestational age. Offspring of prenatally depressed women had lower gestational age in weeks (OR for one week increase in gestational age: 0.66, 95% CI 0.47-0.93) than offspring of prenatally non-depressed women. There was no association between prenatal depression and birth weight percentile for gestational age.

CONCLUSIONS

Prenatal depression was not associated with low birth weight at term, but was associated with gestational age, suggesting that association between maternal depression and birth weight may be a reflection of the impact of depression on offspring gestational age.

MomMoodBooster web-based intervention for postpartum depression: feasibility trial results

Background

Postpartum depression (PPD)—the most common complication of childbirth—is a significant and prevalent public health problem that severely disrupts family interactions and can result in serious lasting consequences to the health of women and the healthy development of infants. These consequences increase in severity when left untreated; most women with PPD do not obtain help due to a range of logistical and attitudinal barriers.

Objective

This pilot study was designed to test the feasibility, acceptability, and potential efficacy of an innovative and interactive guided Web-based intervention for postpartum depression, MomMoodBooster (MMB).

Methods

A sample of 53 women who satisfied eligibility criteria (<9 months postpartum, ≥18 years of age, home Internet access and use of personal email, Edinburgh Postnatal Depression Survey score of 12-20 or Patient Health Questionnaire score from 10-19) were invited to use the MMB program. Assessments occurred at screening/pretest, posttest (3 months following enrollment), and at 6 months follow-up.

Results

All six sessions of the program were completed by 87% (46/53) of participants. Participants were engaged with the program: visit days (mean 15.2, SD 8.7), number of visits (mean 20.1, SD 12.2), total duration of visits in hours (mean 5.1, SD 1.3), and number of sessions viewed out of six (mean 5.6, SD 1.3) all support high usage. Posttest data were collected from 89% of participants (47/53) and 6-month follow-up data were collected from 87% of participants (46/53). At pretest, 55% (29/53) of participants met PHQ-9 criteria for minor or major depression. At posttest, 90% (26/29) no longer met criteria.

Conclusions

These findings support the expanded use and additional testing of the MMB program, including its implementation in a range of clinical and public health settings.

Trial Registration

Clinicaltrials.gov NCT00942721; http://clinicaltrials.gov/ct2/show/NCT00942721 (Archived by WebCite at http://www.webcitation.org/6KjYDvYkQ).

Depression during pregnancy: a risk factor for adverse neonatal outcomes? A critical review of the literature

OBJECTIVE

We reviewed studies of maternal depression and preterm birth (PTB), low birthweight (LBW) and small-for-gestational-age (SGA) in the context of methodological differences between studies and potential limitations.

METHODS

We conducted a literature search of PubMed (1996-2011) for English-language studies of maternal depression and (1) PTB and gestational age (GA), (2) LBW and birthweight (BW) and (3) SGA. Thirty-six studies met eligibility criteria.

RESULTS

Elevated depression levels, particularly in early- to mid-pregnancy, appear to increase risk of PTB and SGA. Findings suggest an increased risk for LBW, but were less consistent. Methodological differences and limitations likely contributed to conflicting findings. A wide range of depression measures were used with the majority of studies utilizing measures not designed, or validated, for pregnant women. Studies failed to assess depression at multiple pregnancy time points, thus constraining the ability to assess the impact of duration and pattern of exposure to depression. Antidepressant use and co-morbid psychosocial factors were rarely considered as potential confounders or effect modifiers.

CONCLUSIONS

Studies suggest that depression during pregnancy may be an important risk factor for PTB and SGA, and possibly LBW. Improved study methodology is needed to elucidate the consequence of maternal depression on adverse birth outcomes.

Screening for perinatal depression

Perinatal depression is prevalent, under-diagnosed and can have serious long-term effects on the wellbeing of women, their partners and infants. In the absence of active identification strategies, most women with perinatal depression will neither seek nor receive help. To enable early detection and timely intervention, universal screening is coming to be seen as best practice in many settings. Although the strength of recommendations and the preferred methods of identification vary in different countries (e.g. the Edinburgh Postnatal Depression Scale, brief case-finding questions), appropriate training for health professionals in wider psychosocial assessment is essential to maximise usefulness while minimising potential harms. Clear pathways of systematic follow up of all positive screening results with a diagnostic procedure and access to effective treatment are centrally important both for the clinical effectiveness of screening and for health system costs. It is also necessary to further build on the emerging evidence base for the clinical effectiveness of screening.

Association between maternal antenatal depression and infant development: a hospital-based prospective cohort study

OBJECTIVE

To examine the association between antenatal depression and infant development after controlling for confounding factors.

METHODS

A hospital-based prospective cohort study (Hokkaido Study on Environment and Children's Health) was conducted between July 2002 and October 2005 in Sapporo, Japan. Of 309 mothers who delivered at Sapporo Toho Hospital during the study period and who agreed with the clinical assessment of depression, 154 mother-infant pairs were eligible for analysis. Antenatal depression was assessed between the second and third trimesters using the Edinburgh Postnatal Depression Scale (EPDS), and infant development was assessed at 6 months by the Bayley Scales of Infant Development II (BSID-II). Data on potential confounders, including socioeconomic status, birth complications, postnatal depression and child care environment, were obtained from medical records and self-administered questionnaires. Univariable and multivariable analyses were conducted in which the EPDS score was entered as an independent variable and the BSID-II scores as a dependent variable, adjusting for confounders.

RESULTS

Although the antenatal EPDS score tended to be related to the BSID-II score in the univariable analysis, this correlation was lost in the multivariable analysis. However, based on a series of linear regression analyses, antenatal depression was found to be significantly related to shorter gestational age (β = -0.25, 95 % confidence interval (CI) [-1.20, -0.17]), and shorter gestational age was significantly related to a lower BSID-II (mental development) score (β = 0.23, 95 % CI [0.00, 0.00]).

CONCLUSIONS

Gestational age is an important confounder in the association between maternal antenatal depression and infant development. A delay in infant development may be related to a shorter gestational period caused by maternal depression during pregnancy.

Path analysis associations between perceived social support, stressful life events and other psychosocial risk factors during pregnancy and preterm delivery

BACKGROUND

Although several socio-medical risk factors have been identified for preterm labor, there is a gap in understanding the underlying etiology of preterm labor.

OBJECTIVES

The current study aimed to analyze the relationship pathway of perceived social support, stressful life events, and other psychosocial risk factors during pregnancy with incidence of preterm labor.

MATERIALS AND METHODS

In a prospective cohort study in four hospitals in Tehran, 500 pregnant women in their 24th to 28th gestational weeks were studied. They filled out a self-report questionnaire on perceived social support, depression, anxiety, stress and stressful life events. Sociodemographic characteristics were also assessed. The participants were followed up until labor, and the data about mother and the newborn were collected after labor. The data were analyzed by SPSS 16 and Lisrel 8.8 software programs using pathway analysis.

RESULTS

The final path model fit well (CFI = 0.96; RMSEA = .064). The results showed that depression, anxiety, and stress (β = -0.18) directly, and stressful life events indirectly (β= -0.0396) had the most predict on gestational age at labor. Perceived social support, directly through socioeconomic status (β=0.25), and indirectly through stress, depression and anxiety (β= -0.26) affected the gestational age at birth (β= 0.0468).

CONCLUSIONS

The current study showed that supporting pregnant mother moderates psychological problems such as stress, anxiety, and depression, and hence reduces preterm labor.

The effects of maternal depression and maternal selective serotonin reuptake inhibitor exposure on offspring

It has been estimated that 20% of pregnant women suffer from depression and it is well-documented that maternal depression can have long-lasting effects on the child. Currently, common treatment for maternal depression has been the selective serotonin reuptake inhibitor medications (SSRIs) which are used by 2–3% of pregnant women in the Nordic countries and by up to 10% of pregnant women in the United States. Antidepressants cross the placenta and are transferred to the fetus, thus, the question arises as to whether children of women taking antidepressants are at risk for altered neurodevelopmental outcomes and, if so, whether the risks are due to SSRI medication exposure or to the underlying maternal depression. This review considers the effects of maternal depression and SSRI exposure on offspring development in both clinical and preclinical populations. As it is impossible in humans to study the effects of SSRIs without taking into account the possible underlying effects of maternal depression (healthy pregnant women do not take SSRIs), animal models are of great value. For example, rodents can be used to determine the effects of maternal depression and/or perinatal SSRI exposure on offspring outcomes. Unraveling the joint (or separate) effects of maternal depression and SSRI exposure will provide more insights into the risks or benefits of SSRI exposure during gestation and will help women make informed decisions about using SSRIs during pregnancy.

Prevalence of antidepressant use during pregnancy in Denmark, a nation-wide cohort study

AIM

The aim of this study was to assess the prevalence and patterns of exposure to antidepressants before, during and after pregnancy in a cohort including all pregnant women in Denmark between 1997 and 2010.

METHODS

We performed a retrospective cohort study including 912 322 pregnancies. Information was retrieved from the Danish Birth Registry and The Register of Medicinal Product Statistics to identify women redeeming an antidepressant prescription during pregnancy. Exposure periods were based on standard treatment doses and dispensed pack sizes.

RESULTS

We identified 19 740 pregnancies exposed to an antidepressant at some point during pregnancy. The rate of exposure increased from 0.2% in 1997 to 3.2% in 2010. We found that the rate of exposure was halved during the first 3 months of pregnancy. In contrast, we describe a clear increase in exposure after pregnancy among pre-delivery treatment-naïve women.

CONCLUSIONS

In spite of uncertainty concerning antidepressants' safety during pregnancy we find a 16-fold increase in exposure rates between 1997 and 2010. The rates describe a sharp decrease in exposure during pregnancy that is probably caused by physicians' hesitation to prescribe antidepressants and women's fear of unwanted effects on the unborn child. More studies are needed to clarify the consequences of antidepressant discontinuation during pregnancy.

Predictors of infant foster care in cases of maternal psychiatric disorders

PURPOSE

Our aim was to investigate the factors associated with mother-child separation at discharge, after joint hospitalization in psychiatric mother-baby units (MBUs) in France and Belgium. Because parents with postpartum psychiatric disorders are at risk of disturbed parent-infant interactions, their infants have an increased risk of an unstable early foundation. They may be particularly vulnerable to environmental stress and have a higher risk of developing some psychiatric disorders in adulthood.

METHODS

This prospective longitudinal study of 1,018 women with postpartum psychiatric disorders, jointly admitted with their infant to 16 French and Belgian psychiatric mother-baby units (MBUs), used multifactorial logistic regression models to assess the risk factors for mother-child separation at discharge from MBUs. Those factors include some infant characteristics associated with personal vulnerability, parents' pathology and psychosocial context.

RESULTS

Most children were discharged with their mothers, but 151 (15 %) were separated from their mothers at discharge. Risk factors independently associated with separation were: (1) neonatal or infant medical problems or complications; (2) maternal psychiatric disorder; (3) paternal psychiatric disorder; (4) maternal lack of good relationship with others; (5) mother receipt of disability benefits; (6) low social class.

CONCLUSIONS

This study highlights the existence of factors other than maternal pathology that lead to decisions to separate mother and child for the child's protection in a population of mentally ill mothers jointly hospitalized with the baby in the postpartum period.

Risk factors for depression and anxiety among pregnant women in Hospital Tuanku Bainun, Ipoh, Malaysia

INTRODUCTION

Anxiety and depression are prevalent during pregnancy. Estimates of the prevalence of anxiety and depression during pregnancy vary according to the criteria used, variable methodologies and population characteristics.

METHODS

A cross-sectional survey design was used. A total of 175 antenatal mothers participated. Their socio-demographic and obstetric histories were recorded. The Hospital Anxiety and Depression Scale (HADS) and Mini International Neuropsychiatric Interview (M.I.N.I.) were used.

RESULTS

The prevalence of anxiety and depression disorders among antenatal mothers using diagnostic clinical interview were 9.1% and 8.6%, respectively. Factors associated with antenatal anxiety were marital status (being unmarried), positive history of mental illness, gestational age (<20 weeks), unplanned pregnancy and depressive comorbidity. However, only gestational age of less than 20 weeks and depressive disorder remained significant factors in the multivariate analysis.

DISCUSSION

The prevalence rate of antenatal depression detected by HADS screening was comparable to the rate from diagnostic interview, but there was a slight overestimation for antenatal anxiety. Nonetheless, HADS as a screening tool offers a practical solution for detecting these two conditions in a busy antenatal clinic or a large epidemiological survey. In view of the deleterious effects of antenatal anxiety and depression on mothers and children, these two conditions should be screened and managed appropriately.

Women's decision-making regarding medication use in pregnancy for anxiety and/or depression

AIM

To increase understanding of women's decision-making process concerning the medication use for anxiety and/or depression while pregnant.

BACKGROUND

Anxiety and depression affects many pregnant women, yet the decision to take psychotropic medication is complex and possibly subject to social oppression.

DESIGN

Cross-sectional descriptive survey design.

METHODS

A web-based survey was used to collect data from a convenience sample of 143 pregnant women over 3 months beginning in early 2011. An independent t-test was conducted to determine differences in satisfaction between women with high and low levels of emancipated decision-making (EDM). A multiple regression analysis was conducted to determine which subscales of the emancipation scale best predict level of satisfaction with the decision.

FINDINGS

The majority of respondents were White, between 25-34 years of age. The group with lower levels of emancipation reported lower mean satisfaction scores compared with those with higher levels of emancipation. Regression analysis showed that the three subscale emancipation model was a statistically significant predictor of satisfaction with the decision and accounted for 54% of the variance in satisfaction. The subconcept of personal knowledge was most predictive of satisfaction with decision.

CONCLUSIONS

Women may be able to overcome oppressive forces by using an EDM process. EDM allows them to make a decision that feels right for them and to feel satisfied with the decision.

Alleviating distress during antepartum hospitalization: a randomized controlled trial of music and recreation therapy

BACKGROUND

Pregnant women who are placed on hospitalized bed rest experience increased antepartum-related distress. We sought to examine the efficacy of a single session music or recreation therapy intervention to reduce antepartum-related distress among women with high-risk pregnancies experiencing extended antepartum hospitalizations.

METHODS

In a randomized, single-blinded study, participants (n = 80) received 1 hour of music or recreation therapy or were placed in an attention-control group. Antepartum-related distress was measured by the Antepartum Bedrest Emotional Impact Inventory, which was administered before and after the intervention and at a follow-up period between 48 and 72 hours.

RESULTS

Significant associations were found between the delivery of music and recreation therapy and the reduction of antepartum-related distress in women hospitalized with high-risk pregnancies. These statistically significant reductions in distress persisted over a period of up to 48-72 hours.

CONCLUSIONS

Single session music and recreation therapy interventions effectively alleviate antepartum-related distress among high-risk women experiencing antepartum hospitalization and should be considered as valuable additions to any comprehensive antepartum program.

Antidepressant use in pregnancy: a critical review focused on risks and controversies

OBJECTIVE

Conflicting data have led to controversy regarding antidepressant use during pregnancy. The objectives of this study are to i) review the risks of untreated depression and anxiety, ii) review the literature on risks of exposure to antidepressants during pregnancy, iii) discuss the strengths and weaknesses of the different study designs used to evaluate those risks, and iv) provide clinical recommendations.

METHOD

MEDLINE/PubMed was searched for reports and studies on the risk of first-trimester teratogenicity, postnatal adaptation syndrome (PNAS), and persistent pulmonary hypertension (PPHN) with in utero antidepressant exposure.

RESULTS

While some individual studies suggest associations between some specific major malformations, the findings are inconsistent. Therefore, the absolute risks appear small. PNAS occurs in up to 30% of neonates exposed to antidepressants. In some studies, PPHN has been weakly associated with in utero antidepressant exposure, while in other studies, there has been no association.

CONCLUSION

Exposures of concern include that of untreated maternal illness as well as medication exposure. It is vital to have a careful discussion, tailored to each patient, which incorporates the evidence to date and considers methodological and statistical limitations. Past medication trials, previous success with symptom remission, and women's preference should guide treatment decisions.

Maternal mental disorders in pregnancy and the puerperium and risks to infant health

Prenatal and postnatal period presents the highest prevalence of mental disorders in women’s lives and depression is the most frequent one, affecting approximately one in every five mothers. The aggravating factor here is that during this period psychiatric symptoms affect not only women’s health and well-being but may also interfere in the infant’s intra and extra-uterine development. Although the causes of the relationship between maternal mental disorders and possible risks to a child’s health and development remain unknown, it is suspected that these risks may be related to the use of psychotropic drugs during pregnancy, to substance abuse and the mother’s lifestyle. Moreover, after delivery, maternal mental disorders may also impair the ties of affection (bonding) with the newborn and the maternal capacity of caring in the post-partum period thus increasing the risk for infant infection and malnutrition, impaired child growth that is expressed in low weight and height for age, and even behavioral problems and vulnerability to presenting mental disorders in adulthood. Generally speaking, research on this theme can be divided into the type of mental disorder analyzed: studies that research minor mental disorders during pregnancy such as depression and anxiety find an association between these maternal disorders and obstetric complications such as prematurity and low birth weight, whereas studies that evaluate severe maternal mental disorders such as schizophrenia and bipolar disorder have found not only an association with general obstetric complications as well as with congenital malformations and perinatal mortality. Therefore, the success of infant growth care programs also depends on the mother’s mental well being. Such findings have led to the need for new public policies in the field of maternal-infant care geared toward the population of mothers. However, more research is necessary so as to confirm the association between all factors with greater scientific rigor.

Effect of prenatal administration of venlafaxine on postnatal development of rat offspring

About 3% of pregnant women are treated with antidepressant drugs during gestation. After delivery the number of treated women increases to 5 to 7%. Most prescribed antidepressants in pregnancy are selective serotonin re-uptake inhibitors and/or serotonin and noradrenaline re-uptake inhibitors, such as fluoxetine, paroxetine, sertraline, citalopram and venlafaxine (VENF). Despite the fact that VENF has been assigned to pregnancy category C by the FDA, experimental studies with this drug are rare. The aim of this pilot study was to investigate the effect of prenatal administration of VENF on early postnatal development of rat offspring and selected biochemical variables at weaning of pups. Pregnant female Wistar rats were treated with VENF from day 15 to 20 of gestation at the doses of 7.5, 37.5 and 70 mg/kg. Females were allowed to spontaneously deliver their pups. After delivery the pups were inspected for viability, gross malformation and they were weighed on day 0, 4 and 21 post partum. On day 21 post partum, the pups were killed, brains were removed from the skulls and blood samples were collected for biochemical assay (proteins, glucose-GOD, glucose-HEX, lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase and total antioxidant status). The study showed that prenatal VENF administration resulted in a mild maternal intoxication manifested by decreased body weight gain of pregnant females. There was no effect of the drug tested on the body and brain weights of offspring. No obvious morphological alterations were observed in the delivered pups. Similarly, there were no changes in the selected biochemical variables determined.

Obstetric outcome after intervention for severe fear of childbirth in nulliparous women - randomised trial

OBJECTIVE

To compare the numbers of vaginal deliveries and delivery satisfaction among women with fear of childbirth randomised to either psychoeducation or conventional surveillance during pregnancy.

DESIGN

Randomised controlled trial.

SETTING

Maternity unit of Helsinki University Central Hospital.

POPULATION

Fear of childbirth was screened during early pregnancy by the Wijma Delivery Expectancy Questionnaire (W-DEQ-A). Of 4575 screened nulliparous women, 371 (8.1%) scored ≥ 100, showing severe fear of childbirth.

METHODS

Women with W-DEQ-A ≥ 100 were randomised to intervention (n = 131) (psychoeducative group therapy, six sessions during pregnancy and one after childbirth) or control (n = 240) (care by community nurses and referral if necessary) groups. Obstetric data were collected from patient records and delivery satisfaction was examined by questionnaire.

MAIN OUTCOME MEASURES

Delivery mode and satisfaction.

RESULTS

Women randomised to the intervention group more often had spontaneous vaginal delivery (SVD) than did controls (63.4% versus 47.5%, P = 0.005) and fewer caesarean sections (CSs) (22.9% versus 32.5%, P = 0.05). SVD was more frequent and CSs were less frequent among those who actually participated in intervention (n = 90) compared with controls who had been referred to consultation (n = 106) (SVD: 65.6% versus 47.2%, P = 0.014; CS: 23.3% versus 38.7%, P = 0.031). Women in intervention more often had a very positive delivery experience (36.1% versus 22.8%, P = 0.04, n = 219).

CONCLUSIONS

To decrease the number of CSs, appropriate treatment for fear of childbirth is important. This study shows positive effects of psychoeducative group therapy in nulliparous women with severe fear of childbirth in terms of fewer CSs and more satisfactory delivery experiences relative to control women with a similar severe fear of childbirth.

Validation of the Patient Health Questionnaire (PHQ)-9 for prenatal depression screening

The study was designed to validate the Patient Health Questionnaire (PHQ-9) for depression risk identification among pregnant women. Pregnant women were routinely administered the Prenatal Risk Overview, a comprehensive psychosocial screening interview, which included the PHQ-9, at their prenatal intake appointment at three community clinics. Study participants completed the Structured Clinical Interview for DSM-IV (SCID) at a later appointment. PHQ-9 risk classifications were cross-tabulated with SCID diagnostic categories to examine concordance, sensitivity, specificity, and positive and negative predictive values. The study sample included 745 women. Prevalence of a current major depressive episode was 3.6 %; an additional 7.0 % were classified as meeting subdiagnostic criteria of three or more depressive symptoms. A PHQ-9 score cutoff of 10 yielded sensitivity and specificity rates of 85 and 84 %, respectively, for a depression diagnosis and 75 and 88 % for a subdiagnosis, respectively. Positive predictive value was higher for the expanded group (43 %) than that of the diagnosis-only group (17 %). The PHQ-9, embedded within a multidimensional risk screening interview, effectively identified pregnant women who met criteria for current depression. The moderate risk score cutoff also identified women with subdiagnostic symptom levels who may benefit from interventions to alleviate their distress and improve pregnancy outcomes.

Neonatal outcomes after late-gestation exposure to selective serotonin reuptake inhibitors

OBJECTIVE

This study aimed to investigate neonatal outcomes after prenatal exposure to selective serotonin reuptake inhibitors (SSRIs) during late-gestation.

METHODS

A retrospective cohort study was conducted using linked records from the Women's and Children's Health Network in South Australia, Australia, including the Perinatal Statistics Collection and the Hospital Pharmacy Dispensing Records. Women were eligible to participate if they gave birth to singleton, live-born infants between September 2000 and December 2008 (n = 33,965). Women were excluded if they received a dispensing for antidepressants other than SSRIs (n = 93) or an antipsychotic (n = 81). We estimated odds ratios (ORs) and 95% confidence intervals (CIs) for preterm delivery, low birth weight, small-for-gestational age, neonatal hospitalization and length of hospital admission, adjusting for sociodemographic, lifestyle, and medical factors.

RESULTS

Two hundred twenty-one women received a dispensing for an SSRI during pregnancy, 1566 had a psychiatric illness but did not receive a dispensing for an SSRI, and 32,004 did not have a psychiatric illness and did not receive a dispensing for an SSRI. Compared to infants of women with a psychiatric illness but no SSRI use, infants of women exposed to SSRIs had an increased risk of preterm delivery (adjusted OR, 2.68; 95% CI, 1.83-3.93), low birth weight (adjusted OR, 2.26; 95% CI, 1.31-3.91), admission to hospital (adjusted OR, 1.92; 95% CI, 1.39-2.65), and length of hospital stay longer than 3 days (adjusted OR, 1.93; 95% CI, 1.11-3.36) but not small-for-gestational age (adjusted OR, 1.13; 95% CI, 0.65-1.94). Psychiatric illness but no SSRI use during pregnancy was only associated with an increased likelihood of neonatal hospital admission (adjusted OR, 1.21; 95% CI, 1.07-1.38).

CONCLUSIONS

These results add to the growing body of evidence of an association between SSRI exposure during pregnancy and a range of adverse neonatal outcomes, but the potential for confounding according to severity of underlying maternal psychiatric illness requires further investigation.

Living Smart, Living Fit

Background: Depression and obesity/overweight during pregnancy are important public health concerns, as they are frequently associated with poor birth outcomes. The Living Smart, Living Fit® (LSLF) program was an intervention program initiated in 2008 to provide comprehensive care to low-income pregnant and postpartum women with elevated body mass index (BMI) and depressive symptoms. It linked patients to clinical care coordinators trained in motivational interviewing who promoted participation in a portfolio of mental and physical wellness activities. Objective: The objective of this study was to evaluate the effectiveness of LSLF in improving depression, BMI, birth weight, and smoking status among low-income perinatal patients. Methods: Women with Patient Health Questionnaire (PHQ-9) depression scores ≥10 and/or BMI >25 kg/m2 at their prenatal intake visit were eligible for enrollment into the LSLF program. Enrolled participants met with clinical care coordinators who encouraged engagement in a portfolio of LSLF activities that included pregnancy/family, physical health, and mental health interventions. Outcomes were measured at the 6-week postpartum visit and included change in PHQ-9 scores, change in BMI, birth weight, and change in smoking status. Results: Of the 107 enrollees, 86% participated in some LSLF activity. Participation in pregnancy/family related activities was significantly associated with decreased PHQ-9 scores. Participation in mental health services was significantly associated with increased birth weight. No changes in BMI or smoking status were associated with LSLF involvement. Conclusions: The findings of this pilot study indicate that pregnant women with depression or obesity/overweight can benefit from care coordination and a portfolio of activities for mental and physical wellness. The LSLF program provides a model for delivering this patient-centered comprehensive support. Further research should include more controlled trials to better evaluate the effectiveness of LSLF intervention.

Relaxation therapy for preventing and treating preterm labour

BACKGROUND

Preterm birth (PTB) is a leading cause of perinatal mortality and morbidity. Although the pathogenesis of preterm labour (PTL) is not well understood, there is evidence about the relationship between maternal psychological stress and adverse pregnancy outcomes. Relaxation or mind-body therapies cover a broad range of techniques, e.g. meditation, massage, etc. There is no systematic review investigating the effect of relaxation techniques on preventing PTL and PTB. This review does not cover hypnosis as this is the subject of a separate Cochrane review.

OBJECTIVES

To assess the effectiveness of relaxation therapies for preventing or treating PTL and preventing PTB.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (14 December 2011), CENTRAL (2011, Issue 4 of 4), CINAHL (1982 to 14 December 2011) and contacted study authors for additional information.

SELECTION CRITERIA

Randomized controlled trials, cluster- and quasi-randomized trials comparing relaxation techniques with usual care, no treatment or sham interventions to prevent or treat PTL.

DATA COLLECTION AND ANALYSIS

Two review authors (B Khianman (BK) and P Pattanittum (PP)) independently assessed all search results for potential inclusion studies. Disagreements were resolved by discussion with a third review author (J Thinkhamrop (JT)). Data were independently extracted onto the standardized data collection form by BK and PP and checked for accuracy. Two review authors independently assessed the risk of bias of all included studies. All differences were resolved by discussion with JT. Mean difference (MD) and its 95% confidence intervals (CI) were calculated for continuous outcomes and risk ratio (RR) and 95% CI for dichotomous data.

MAIN RESULTS

Eleven randomized controlled trials with a total of 833 women were included in this review. However, the results of this review are based on single studies with small numbers of participants.The majority of included studies reported insufficient information on sequence generation, allocation concealment as well as blinding. There were no included studies that assessed PTL or PTB as the primary outcome. The included studies were different in terms of intervention, practice, and time, and there were no clear coherent hypotheses.For women not in PTL, the benefits of relaxation was found in one study for maternal stress (Anxiety Stress Scale) at 26 to 29 weeks gestational age (mean difference (MD) -7.04; 95% confidence interval (CI) -13.91 to -0.17). In addition, there were some beneficial effects of relaxation including baby birthweight (MD 285.00 g; 95% CI 76.94 to 493.06); type of delivery; (vaginal delivery; risk ratio (RR) 1.52; 95% CI 1.13 to 2.04), (cesarean section; RR 0.38; 95% CI 0.19 to 0.78); maternal anxiety (MD -15.79; 95% CI -18.33 to -13.25); and stress (MD -13.08; 95% CI -15.29 to -10.87) when applying relaxation therapy together with standard treatment. For women in PTL, the results for the main outcome of PTB in the intervention and control groups from a single study were not different (RR 0.95; 95% CI 0.57 to 1.59). The MD of birthweight in grams from the fixed-effect model from two included studies was MD -5.68; (95% CI -174.09 to 162.74).

AUTHORS' CONCLUSIONS

According to the results of this review, there is some evidence that relaxation during pregnancy reduces stress and anxiety. However, there was no effect on PTL/PTB. These results should be interpreted with caution as they were drawn from included studies with limited quality.

Effects of depressive and anxiety symptoms during pregnancy on pregnant, obstetric and neonatal outcomes: a follow-up study

Antenatal clinics can expect at least one in five pregnant women to experience mental health problems, especially depression and anxiety. The present study aims to estimate the effects of the antenatal depressive and anxiety symptoms on pregnant, obstetric and neonatal outcomes. This was a prospective cohort study of 527 pregnancies and their neonates. Whether the women were with or without symptoms of depression and anxiety was determined by the Hospital Anxiety and Depression Scale (HADS). All the participants were followed to delivery. The prevalence of antenatal depressive and/or anxiety was 11.0%. The antenatal depressive and/or anxiety symptoms during pregnancy can increase the risk of prolonged pregnancy (RR =4.080, 95% CI: 1.249-13.325), especially in primiparous women.

Perceived social support interacts with prenatal depression to predict birth outcomes

Prenatal depression has been linked to adverse reproductive outcomes including preterm labor and delivery, and low birth weight. Social support also has been linked to birth outcomes, and may buffer infants from the adverse impact of maternal depression. In this prospective study, 235 pregnant women completed questionnaires about depression and social support. Clinical interviews were administered to assess for DSM-IV axis I disorders. Following delivery, birth outcomes were obtained from medical records. Babies of depressed mothers weighed less, were born earlier and had lower Apgar scores than babies of nondepressed mothers. Depressed women had smaller social support networks and were less satisfied with support from social networks. We found no direct associations between perceived social support and birth weight. However, depressed women who rated their partners as less supportive had babies who were born earlier and had lower Apgar scores than depressed mothers with higher perceived partner support. Women's perception of partner support appears to buffer infants of depressed mothers from potential adverse outcomes. These results are notable in light of the low-risk nature of our sample and point to the need for continued depression screening in pregnant women and a broader view of risk for adverse birth outcomes. The results also suggest a possible means of intervention that may ultimately lead to reductions in adverse birth outcomes.

Postpartum Depression Prevention for Reservation-Based American Indians: Results from a Pilot Randomized Controlled Trial

BACKGROUND: Postpartum depression is a devastating condition that affects a significant number of women and their offspring. Few preventive interventions have targeted high risk youth, such as American Indians (AIs). OBJECTIVE: To evaluate the feasibility of a depression prevention program for AI adolescents and young adults. METHODS: Expectant AI women (mean age = 18.15; N = 47) were randomized (1:1) to either the Living in Harmony program (LIH, an 8 lesson cognitive-behaviorally based program) or an Educational-Support program (ES, an 8 lesson education program). Both interventions were delivered by AI paraprofessionals. Adolescents were evaluated during their pregnancy at baseline, at post-intervention, and at 4, 12, and 24 weeks postpartum. The primary outcome measure was the Center for Epidemiological Studies-Depression scale (CES-D). Additional measures of depression included the onset of major depressive disorder (MDD; assessed via computerized diagnostic interview) and the Edinburgh Postpartum Depression Scale (EPDS). Secondary outcomes included changes in mothers' global functioning and social support. RESULTS: At all post intervention assessments, mothers in both groups showed similar reductions in depressive symptoms and similar rates of MDD (0 and 6% in LIH and ES respectively). Both groups of participants also showed similar improvements in global functioning. No changes in either group were found on the measure of social support. CONCLUSIONS: Findings suggest that both paraprofessional-delivered interventions may reduce symptoms of depression among AIs. Replication with a larger sample, a usual care control condition, blinded evaluators, and a longer follow-up is needed.

Aerobic exercise training during pregnancy reduces depressive symptoms in nulliparous women: a randomised trial

QUESTION

Does supervised aerobic exercise during pregnancy reduce depressive symptoms in nulliparous women?

DESIGN

Randomised trial with concealed allocation, blinded assessors, and intention-to-treat analysis.

PARTICIPANTS

80 nulliparous, pregnant women attending for prenatal care at one of three tertiary hospitals in Cali, Colombia.

INTERVENTION

The experimental group completed a 3-month supervised exercise program, commencing at 16 to 20 weeks of gestation. Each session included walking (10 min), aerobic exercise (30 min), stretching (10 min), and relaxation (10 min). The control group continued usual activities and performed no specific exercise.

OUTCOME MEASURES

The primary outcome was symptoms of depression assessed by the Center for Epidemiological Studies Depression Scale (CES-D) at baseline and immediately after the 3-month intervention.

RESULTS

74 women completed the study. After the 3-month intervention, the experimental group reduced their depressive symptoms on the CES-D questionnaire by 4 points (95% CI 1 to 7) more than the control group.

CONCLUSIONS

A supervised 3-month program of primarily aerobic exercise during pregnancy reduces depressive symptoms.

TRIAL REGISTRATION

NCT00872365.

Coping style and depressive symptomatology during pregnancy in a private setting sample

AIM

To evaluate the association of antenatal depressive symptomatology (AD) with life events and coping styles, the hypothesis was that certain coping strategies are associated to depressive symptomatology.

METHODS

We performed a cross sectional study of 312 women attending a private clinic in the city of Osasco, São Paulo from 27/05/1998 to 13/05/2002. The following instruments were used: Beck Depression Inventory (BDI), Holmes and Rahe Schedule of Recent Events (SSRS), Folkman and Lazarus Ways of Coping Questionnaire and questionnaire with social-demographic and obstetric data.

INCLUSION CRITERIA

women with no past history of depression, psychiatric treatment, alcohol or drug abuse and no clinical-obstetrical complications. Odds ratios and 95% CI were used to examine the association between AD (according to BDI) and exposures variables. Hypothesis testing was done with Chi2 tests and ap value < .05.

RESULTS

AD occurred in 21.1% of pregnant women. By the univariate analyses, education, number of pregnancies, previous abortion, husband income, situation of marriage and score of SSRS were associated with AD. All coping styles were associated with AD, except seeking support and positive reappraisal. By the multivariate analyses, four coping styles were kept in the final model: confront (p = .039), accepting responsibility (p < .001), escape-avoidance (p = .002), problem-solving (p = .005).

CONCLUSIONS

AD was highly prevalent and was associated with maladaptive coping styles.

Patterns of depression and treatment in pregnant and postpartum women

OBJECTIVE

To determine the course of depression and the effects of treatment during pregnancy and into the postpartum period.

METHOD

This is a longitudinal study of a community sample of 649 pregnant women who were assessed in early pregnancy (17.4 ± 4.9 weeks), late pregnancy (30.6 ± 2.7 weeks), and postpartum (4.2 ± 2.1 weeks) with the Edinburgh Postnatal Depression Scale (EPDS). Women who scored 12 or more on the EPDS were encouraged to seek assessment and treatment. We used generalized estimating equation modelling to determine the predicted mean depression scores, taking age, ethnicity, history of depression, and previous and present treatment status into account.

RESULTS

The unadjusted prevalence of depression (EPDS ≥ 12) was 14.1% (n = 91) in early pregnancy, 10.4% (n = 62) in late pregnancy, and 8.1% (n = 48) postpartum. Twelve per cent of women were engaged in treatment. The predicted mean EPDS score decreased over the course of the pregnancy into the postpartum period, most significantly when women were engaged in counselling or taking psychotropic medication. Counselling was the more common method of treatment during pregnancy and medication in the postpartum period. Women who were depressed and untreated were more likely to be younger, more stressed, have less support, have a history of depression, and use alcohol.

CONCLUSIONS

We confirm that depressive symptoms improve over the course of the pregnancy into the postpartum period, particularly for women who receive treatment. Our study is unique as it takes the history of depression, present and past treatment status, and the longitudinal nature of the data into account.

The simplified Edinburgh Postnatal Depression Scale (EPDS) for antenatal depression: is it a valid measure for pre-screening?

The identification of antenatal depression is critical but poorly conducted. The aim of this study was to construct a simplified depression survey scale and to verify its efficacy as a pre-screening for antenatal depression. A total of 494 pregnant women in the third trimester of gestation who had received antenatal care at Seoul St. Mary's Hospital from July 2009 to June 2010 were included. The Edinburgh Postnatal Depression Scale (EPDS) questionnaire was completed by them. The subjects were randomly divided into two groups: 250 of training set and 244 of validation set. We designed a simplified questionnaire comprising two items of EPDS using the training set. We then validated its efficacy with the training set and reaffirmed the results with the validation set. The sum of item 5 (scare or panic) and item 8 (sadness or misery) explained 75.5% of the total score of the EPDS (AUC = 0.947). Using a score of 3 as a cut-off value of the simplified scale, sensitivity was 92.4% and specificity was 86.3%. The positive and negative predictive values were 56.2% and 98.4%, retrospectively. This study suggests that the simplified EPDS can be an efficient instrument to rule out depression during pregnancy.

When she says "no" to medication: psychotherapy for antepartum depression

Many women suffering from major depressive disorder during pregnancy are hesitant to initiate or continue antidepressant treatment during preconception planning, conception, pregnancy, and lactation (perinatal period). Over the past few decades, various psychotherapeutic approaches have been found to be efficacious for depression in general population research. Several observational and quasi-experimental studies also suggest that psychotherapy can be a safe first-line treatment for perinatal women with mild to moderate depression. This article summarizes findings to date regarding the use of psychotherapy for depression occurring during pregnancy and describes the adaptations made to tailor the treatment to the unique needs of women in the perinatal period.

The Swedish validation of Edinburgh Postnatal Depression Scale (EPDS) during pregnancy

BACKGROUND

Around 10-15% of women suffer from depressive illness during pregnancy or the first year postpartum. Depression during pregnancy constitutes a risk for prenatal stress and preterm birth. No validated screening instrument for detecting depression during pregnancy was available in Swedish.

AIMS

We aimed to validate the Edinburgh Postnatal Depression Scale (EPDS) against DSM-IV criteria for depression during pregnancy, establish a reliable cut-off and estimate the correlation between the EPDS and HAD-S (Hospital Anxiety and Depression Scale).

METHODS

In a population-based community sample of 1175 pregnant women, 918 women (78%) answered questionnaires with the EPDS and HAD-S. In all, 121 were interviewed using the PRIME-MD (Primary Care Evaluation of Mental disorders) for diagnosing depression. Women were interviewed in mean gestational week 13 (range 8-21). For the EPDS, a receiver operating characteristic (ROC) curve was calculated for prediction of depression. Pearson's correlation coefficient was used to investigate the association between EPDS and HAD-S scores.

RESULTS

The optimal cut-off score on the EPDS scale for detecting depression was ≥13 (standard error coefficient of 1.09 and c-statistics of 0.84) giving a sensitivity of 77% and specificity of 94%. The EPDS scores correlated strongly with the HAD-S, Pearson's correlation was 0.83 (P < 0.0001).

CONCLUSIONS

This study confirms that the EPDS is a valid screening instrument for detection of depressive symptoms during pregnancy. The EPDS shows persuasive measuring outcomes with an optimal cut-off at ≥13.

CLINICAL IMPLICATIONS

Healthcare for pregnant women should consider screening procedures and follow-up routines for depressive symptoms.

Stigma and attitudes towards antenatal depression and antidepressant use during pregnancy in healthcare students

Depression in pregnancy or antenatal depression (AD) occurs in approximately one in five women, with potentially deleterious effects to the mother and fetus. People are encouraged to get treatment for depression; however, pregnant women can experience stigma when they reach out for help with depression. Research indicates that healthcare professionals hold stigma against patients who experience mental health conditions, including depression. The public, as well as healthcare professionals may have negative attitudes towards antidepressant use during pregnancy, despite evidence that many antidepressants are relatively safe for use in pregnancy. The objective of this project was to determine what knowledge and opinions healthcare students may hold towards antenatal depression and its treatment, and whether further knowledge and experience lessened the stigma. Medical, pharmacy, and nursing students (n = 309) were given a scenario regarding a woman with AD based on Corrigan's Attribution Questionnaire and asked seven questions based on the scenario that assessed their level of stigma and questions related to treatment. Each student group demonstrated some stigma towards the woman and all groups lacked knowledge regarding treatment of AD. Overall, the nursing students were the most stigmatizing of the three groups. The study demonstrates that healthcare students hold stigma towards people with mental health problems, including pregnant depressed women. It points to a need to increase education about antenatal depression and its treatment.

Prior psychiatric inpatient care and risk of cesarean sections: a registry study

This study of 17,443 childbearing women, investigated the relationship between hospital admissions 5 years prior to index birth, type of mental disorders and risk factors for mode of delivery. Hospital based electronic perinatal medical records between 2001 and 2006, were linked with the Swedish National Inpatient Care Registry 1996-2006. Of all the women, 39.3% had had inpatient care prior to index birth (27.3% had had obstetric, 10.1% somatic, and 1.9% psychiatric inpatient care). Diagnoses of mental disorders at psychiatric admission (n=333) were categorized into five groups: personality/behavioral/unspecified disorder (30.9%), affective disorders and 'suicide attempt' (28.9%), neurotic/somatoform disorders (18.9%), substance use (17.1%) and schizophrenia (4.2%). Women with history of psychiatric care were more often smokers, below age 24 and single (p<0.001, respectively), had more markers of mental ill-health in pregnancy records (p≤0.001), compared to women without such previous care, and fewer were nulliparous (p<0.001). The results show that women with prior psychiatric inpatient care and those with identified mental ill-health in pregnancy records, were associated with increased adjusted risks of cesarean sections. Identifying a woman?s mental health status in pregnancy may predict and prevent emergency cesarean section.

Maternal bodies and medicines: a commentary on risk and decision-making of pregnant and breastfeeding women and health professionals

BACKGROUND

The perceived risk/benefit balance of prescribed and over-the-counter (OTC) medicine, as well as complementary therapies, will significantly impact on an individual's decision-making to use medicine. For women who are pregnant or breastfeeding, this weighing of risks and benefits becomes immensely more complex because they are considering the effect on two bodies rather than one. Indeed the balance may lie in opposite directions for the mother and baby/fetus. The aim of this paper is to generate a discussion that focuses on the complexity around risk, responsibility and decision-making of medicine use by pregnant and breastfeeding women. We will also consider the competing discourses that pregnant and breastfeeding women encounter when making decisions about medicine.

DISCUSSION

Women rely not only on biomedical information and the expert knowledge of their health care professionals but on their own experiences and cultural understandings as well. When making decisions about medicines, pregnant and breastfeeding women are influenced by their families, partners and their cultural societal norms and expectations. Pregnant and breastfeeding women are influenced by a number of competing discourses. "Good" mothers should manage and avoid any risks, thereby protecting their babies from harm and put their children's needs before their own - they should not allow toxins to enter the body. On the other hand, "responsible" women take and act on medical advice - they should take the medicine as directed by their health professional. This is the inherent conflict in medicine use for maternal bodies.

SUMMARY

The increased complexity involved when one body's actions impact the body of another - as in the pregnant and lactating body - has received little acknowledgment. We consider possibilities for future research and methodologies. We argue that considering the complexity of issues for maternal bodies can improve our understanding of risk and public health education.

The use of psychosocial stress scales in preterm birth research

Psychosocial stress has been identified as a potential risk factor for preterm birth. However, an association has not been found consistently, and a consensus on the extent to which stress and preterm birth are linked is still lacking. A literature search was performed with a combination of keywords and MeSH terms to detect studies of psychosocial stress and preterm birth. Studies were included in the review if psychosocial stress was measured with a standardized, validated instrument and if the outcomes included either preterm birth or low birthweight. Within the 138 studies that met inclusion criteria, 85 different instruments were used. Measures that had been designed specifically for pregnancy were used infrequently, although scales were sometimes modified for the pregnant population. The many different measures that have been used may be a factor that accounts for the inconsistent associations that have been observed.

Are major depression and generalized anxiety disorder associated with intrauterine growth restriction in pregnant women? A case-control study

OBJECTIVE

This study examined the prevalence of major depression and generalized anxiety disorder in pregnant women with and without a diagnosis of intrauterine growth restriction (IUGR).

METHOD

The study sample included 56 pregnant women with a diagnosis of IUGR and 92 control subjects. IUGR was determined by means of ultrasound assessment and was defined as estimated fetal weight, by ultrasound scan, which falls below the 10th percentile for the gestational age. Psychiatric evaluations were performed with depression and anxiety symptom scales and with structured clinical interviews.

RESULTS

Pregnant women with IUGR had higher scores of depressive and anxiety symptom scores and had a higher prevalence rate of major depression and generalized anxiety disorder.

CONCLUSIONS

According to the results of the present study, both major depression and generalized anxiety disorder appear to be associated with IUGR in pregnant women.

Psychiatric symptoms and proinflammatory cytokines in pregnancy

OBJECTIVE

Clinical studies suggest that psychiatric symptoms, particularly depression, anxiety, and trauma, may be associated with inflammation, as indexed by proinflammatory cytokines. Such a link may be especially significant in pregnancy and may shed additional light on the etiology of perinatal mood disorders.

METHODS

We prospectively observed 145 women selected from a community obstetric clinic serving a primarily low-income, high-psychosocial risk population. Women without evidence of medical high-risk pregnancies were screened (including psychiatric and trauma histories) and then assessed in detail (e.g., mood symptoms) at approximately 18 and 32 weeks' gestation. Blood was drawn to measure key proinflammatory markers, interleukin 6 and tumor necrosis factor α (TNF-α). Data on pregnancy and obstetric outcome were derived from medical records.

RESULTS

There was considerable stability of cytokine levels within individuals and a significant mean increase across pregnancy observed for interleukin 6 (p < .001) and TNF-α (p < .001). History of trauma was associated with significantly elevated TNF-α levels (F(1,135) = 4.43, p < .05), controlling for psychosocial and obstetric covariates. In contrast, elevated measures of depression and anxiety were unrelated to proinflammatory cytokines (p > .1). Exploratory analyses indicated that neither psychiatric symptoms nor proinflammatory cytokines predicted birth weight, gestational age, or obstetric complications.

CONCLUSIONS

These findings suggest that antecedent trauma may be associated with persistently elevated TNF-α levels during pregnancy. The evidence that a generalized proinflammatory state was associated with symptoms of depression or anxiety in pregnant women was not found.

Pulmonary vascular effects of serotonin and selective serotonin reuptake inhibitors in the late-gestation ovine fetus

Maternal use of selective serotonin (5-HT) reuptake inhibitors (SSRIs) is associated with an increased risk for persistent pulmonary hypertension of the newborn (PPHN), but little is known about 5-HT signaling in the developing lung. We hypothesize that 5-HT plays a key role in maintaining high pulmonary vascular resistance (PVR) in the fetus and that fetal exposure to SSRIs increases 5-HT activity and causes pulmonary hypertension. We studied the hemodynamic effects of 5-HT, 5-HT receptor antagonists, and SSRIs in chronically prepared fetal sheep. Brief infusions of 5-HT (3-20 μg) increased PVR in a dose-related fashion. Ketanserin, a 5-HT 2A receptor antagonist, caused pulmonary vasodilation and inhibited 5-HT-induced pulmonary vasoconstriction. In contrast, intrapulmonary infusions of GR127945 and SB206553, 5-HT 1B and 5-HT 2B receptor antagonists, respectively, had no effect on basal PVR or 5-HT-induced vasoconstriction. Pretreatment with fasudil, a Rho kinase inhibitor, blunted the effects of 5-HT infusion. Brief infusions of the SSRIs, sertraline and fluoxetine, caused potent and sustained elevations of PVR, which was sustained for over 60 min after the infusion. SSRI-induced pulmonary vasoconstriction was reversed by infusion of ketanserin and did not affect the acute vasodilator effects of acetylcholine. We conclude that 5-HT causes pulmonary vasoconstriction, contributes to maintenance of high PVR in the normal fetus through stimulation of 5-HT 2A receptors and Rho kinase activation, and mediates the hypertensive effects of SSRIs. We speculate that prolonged exposure to SSRIs can induce PPHN through direct effects on the fetal pulmonary circulation.

The age-dependent effects of selective serotonin reuptake inhibitors in humans and rodents: A review

The selective serotonin reuptake inhibitor (SSRI) Prozac® (fluoxetine) is widely prescribed for the treatment of depression and anxiety-related disorders. While extensive research has established that fluoxetine is safe for adults, safety is not guaranteed for (unborn) children and adolescents. Some clinical studies have reported adverse outcomes, such as premature birth, neonatal cardiovascular abnormalities, and pulmonary hypertension in children whose mothers used SSRIs during pregnancy. In addition, several reports show that adolescent fluoxetine treatment increases risk for suicidal behavior. Despite these studies, fluoxetine is not contraindicated in the treatment of depressed pregnant women and adolescents. Longitudinal research in humans is limited because of ethical reasons and time constraints, and to overcome these limitations, rodents are used to increase insight in the age-dependent effects of fluoxetine exposure. It has been established that neonatal and adolescent fluoxetine exposure leads to paradoxical anxiety- and depression-like features in later life of rats and mice, although in some studies adolescent fluoxetine exposure was without effects. These age-dependent outcomes of fluoxetine may be explained by serotonin's neurotrophic effects, which may vary according to the developmental stage of the brain due to epigenetic modifications. Here we review the existing evidence for the age-dependent effects of fluoxetine in humans and rodents, address the gaps in our current knowledge and propose directions for future research. Given the overlap between human and rodent findings, rodents provide heuristic value in further research on the age-dependent effects of SSRIs.

Perinatal mental health

Pregnancy is the time during which physiological and psychological preparation for motherhood takes place. It has long been considered a blessed time, free of psychiatric disorders. However, there is now strong evidence that major depressive disorder may occur not only after birth but even during the prepartum. Most often, mental illness during this period is underestimated, not assessed, therefore not diagnosed, and consequently goes untreated. Reviewing the literature on the negative impact of both maternal and infant health in case of perinatal depression, we underline that recognizing and treating prenatal depression will lead to preventive and curative treatments for mothers, enhance infant health, and therefore positively influence mother-infant relationships.

Serotonin transporter occupancy in rats exposed to serotonin reuptake inhibitors in utero or via breast milk

Rigorous data regarding fetal central nervous system (CNS) exposure after antidepressant exposure are sparse. The magnitude of serotonin reuptake inhibitor (SRI) CNS exposure was measured in three groups of rats using ex vivo autoradiography of the serotonin transporter (SERT): 1) in utero, 2) postnatal clearance after birth, and 3) exposure through lactation. Rats were exposed to one of five SRI-type antidepressants (escitalopram, fluoxetine, paroxetine, sertraline, and venlafaxine) administered continuously via osmotic minipumps to pregnant or nursing dams. Dam dosing was adjusted to reflect the 50th and 85th percentiles of serum concentrations observed in pregnant women. Embryonic day 21 rat pups exposed in utero exhibited >80% SERT occupancy in brain tissue, which is equivalent to that of the pregnant dam and similar to that reported for human pharmacotherapy. Venlafaxine was the exception with occupancies ranging from 61 to 92% across different litters. The magnitude of SERT occupancy is essentially equivalent between dams and fetuses. By postnatal day 4, high SERT occupancy was observed only in fluoxetine-exposed pups (41-92% occupancy). Significantly less, but measurable, exposure occurred via breast milk exposure even in the absence of detectable drug concentrations in nursing pup sera. Pups exposed to SRIs via breast milk for 3 or 7 days exhibited varying SERT occupancies (0-57% depending on the individual medication and dam dose). These data highlight the need for animal modeling of fetal and nursing infant drug exposure using clinically meaningful dosing strategies and appropriate CNS measures to develop rational treatment guidelines that systematically minimize fetal and neonatal medication exposure in humans.

Psychiatric disorders and treatment in low-income pregnant women

AIMS

This study estimated the prevalence of twenty-two 12-month and lifetime psychiatric disorders in a sample of 744 low-income pregnant women and the frequency that women with psychiatric disorders received treatment.

METHOD

To identify psychiatric disorders, the Diagnostic Interview Schedule (DIS) was administered to Medicaid or Medicaid-eligible pregnant women enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). The sample was stratified by the rural or urban location of the WIC sites in southeastern Missouri and the city of St. Louis. Eligible women were enrolled at each site until their numbers were proportional to the racial distribution of African American and Caucasian pregnant women served there.

RESULTS

The 12-month prevalence of one or more psychiatric disorders was 30.9%. Most common were affective disorders (13.6%), particularly major depressive disorder (8.2%) and bipolar I disorder (5.2%). Only 24.3% of those with a psychiatric disorder reported that they received treatment in the past year. Lifetime prevalence of at least one disorder was 45.6%, with affective disorders being the most frequent (23.5%). Caucasian women were more likely than African Americans to have at least one 12-month disorder, with the difference largely accounted for by nicotine dependence. Higher prevalence of lifetime disorders was also found in Caucasian women, particularly affective disorders and substance use disorders. There were no differences in the prevalence of 12-month or lifetime psychiatric disorders by the urban or rural residence of subjects.

CONCLUSIONS

With nearly one third of pregnant women meeting criteria for a 12-month psychiatric disorder and only one fourth receiving any type of mental health treatment, comprehensive psychiatric screening during pregnancy is needed along with appropriate treatment.