Associations between postpartum depression and hypertensive disorders of pregnancy

Joint effects of traffic-related air pollution and hypertensive disorders of pregnancy on maternal postpartum depressive and anxiety symptoms

BACKGROUND

Ambient air pollution has been linked to postpartum depression. However, few studies have investigated the effects of traffic-related NOx on postpartum depression and whether any pregnancy-related factors might increase susceptibility.

OBJECTIVES

To evaluate the association between traffic-related NOx and postpartum depressive and anxiety symptoms, and effect modification by pregnancy-related hypertension.

METHODS

This study included 453 predominantly low-income Hispanic/Latina women in the MADRES cohort. Daily traffic-related NOx concentrations by road class were estimated using the California LINE-source dispersion model (CALINE4) at participants' residential locations and averaged across pregnancy. Postpartum depressive and anxiety symptoms were evaluated by a validated questionnaire (Postpartum Distress Measure, PDM) at 1, 3, 6 and 12 months postpartum. Multivariate linear regressions were performed to estimate the associations at each timepoint. Interaction terms were added to the linear models to assess effect modification by hypertensive disorders of pregnancy (HDPs). Repeated measurement analyses were conducted by using mixed effect models.

RESULTS

We found prenatal traffic-related NOx was associated with increased PDM scores. Specifically, mothers exposed to an IQR (0.22 ppb) increase in NOx from major roads had 3.78% (95% CI: 0.53-7.14%) and 5.27% (95% CI: 0.33-10.45%) significantly higher 3-month and 12-month PDM scores, respectively. Similarly, in repeated measurement analyses, higher NOx from major roads was associated with 3.06% (95% CI: 0.43-5.76%) significantly higher PDM scores across the first year postpartum. Effect modification by HDPs was observed: higher freeway/highway and total NOx among mothers with HDPs were associated with significantly higher PDM scores at 12 months postpartum compared to those without HDPs.

IMPACT

This study shows that prenatal traffic-related air pollution was associated with postpartum depressive and anxiety symptoms. The study also found novel evidence of greater susceptibility among women with HDPs, which advances the understanding of the relationships between air pollution, maternal cardiometabolic health during pregnancy and postpartum mental health. Our study has potential implications for clinical intervention to mitigate the effects of traffic-related pollution on postpartum mental health disorders. The findings can also offer valuable insights into urban planning strategies concerning the implementation of emission control measures and the creation of green spaces.

A Prospective Study of Social Needs Associated with Mental Health among Postpartum Patients Living in Underserved Communities

OBJECTIVE

Given the rising rates of maternal morbidity and mortality in the United States and the contribution of mental illness, especially among individuals living in underresourced communities, the objective was to evaluate the prevalence of unmet health-related social needs and their impact on perinatal mental health outcomes.

STUDY DESIGN

This was a prospective observational study of postpartum patients residing within regions with increased rates of poor perinatal outcomes and sociodemographic disparities. Patients were enrolled in a multidisciplinary public health initiative "extending Maternal Care After Pregnancy (eMCAP)" between October 1, 2020 and October 31, 2021. Unmet health-related social needs were assessed at delivery. Symptoms of postpartum depression and anxiety were evaluated at 1 month postpartum utilizing the Edinburgh Postnatal Depression Scale (EPDS) and Generalized Anxiety Disorder-7 (GAD7) screening tools, respectively. Mean EPDS and GAD7 scores and odds of screening positive (scoring ≥ 10) were compared among individuals with and without unmet health-related social needs with p < 0.05 considered significant.

RESULTS

Of participants enrolled in eMCAP, 603 completed at least one EPDS or GAD7 at 1 month. Most had at least one social need, most commonly dependence on social programs for food (n = 413/603; 68%). Individuals lacking transportation to medical (odds ratio [OR]: 4.0, 95% confidence interval [CI]: 1.2-13.32) and nonmedical appointments (OR: 4.17, 95% CI: 1.08-16.03) had significantly higher odds of screening positive on EPDS while participants lacking transportation to medical appointments (OR: 2.73, 95% CI: 0.97-7.70) had significantly higher odds of screening positive on GAD7.

CONCLUSION

Among postpartum individuals in underserved communities, social needs correlate with higher depression and anxiety screening scores. This highlights the need to address social needs to improve maternal mental health.

KEY POINTS

· Social needs are prevalent among underserved patients.. · Needs can be assessed in a structured or freeform manner.. · Unmet needs correlate with poor mental health outcomes.. · Similar needs correlate with depression and anxiety..

Analysis of influencing factors and the construction of predictive models for postpartum depression in older pregnant women

BACKGROUND

Changes in China's fertility policy have led to a significant increase in older pregnant women. At present, there is a lack of analysis of influencing factors and research on predictive models for postpartum depression (PPD) in older pregnant women.

AIM

To analysis the influencing factors and the construction of predictive models for PPD in older pregnant women.

METHODS

By adopting a cross-sectional survey research design, 239 older pregnant women (≥ 35 years old) who underwent obstetric examinations and gave birth at Suzhou Ninth People's Hospital from February 2022 to July 2023 were selected as the research subjects. When postpartum women of advanced maternal age came to the hospital for follow-up 42 d after birth, the Edinburgh PPD Scale (EPDS) was used to assess the presence of PPD symptoms. The women were divided into a PPD group and a no-PPD group. Two sets of data were collected for analysis, and a prediction model was constructed. The performance of the predictive model was evaluated using receiver operating characteristic (ROC) analysis and the Hosmer-Lemeshow goodness-of-fit test.

RESULTS

On the 42nd day after delivery, 51 of 239 older pregnant women were evaluated with the EPDS scale and found to have depressive symptoms. The incidence rate was 21.34% (51/239). There were statistically significant differences between the PPD group and the no-PPD group in terms of education level (P = 0.004), family relationships (P = 0.001), pregnancy complications (P = 0.019), and mother-infant separation after birth (P = 0.002). Multivariate logistic regression analysis showed that a high school education and below, poor family relationships, pregnancy complications, and the separation of the mother and baby after birth were influencing factors for PPD in older pregnant women (P < 0.05). Based on the influencing factors, the following model equation was developed: Logit (P) = 0.729 × education level + 0.942 × family relationship + 1.137 × pregnancy complications + 1.285 × separation of the mother and infant after birth -6.671. The area under the ROC curve of this prediction model was 0.873 (95%CI: 0.821-0.924), the sensitivity was 0.871, and the specificity was 0.815. The deviation between the value predicted by the model and the actual value through the Hosmer-Lemeshow goodness-of-fit test was not statistically significant (χ2 = 2.749, P = 0.638), indicating that the model did not show an overfitting phenomenon.

CONCLUSION

The risk of PPD among older pregnant women is influenced by educational level, family relationships, pregnancy complications, and the separation of the mother and baby after birth. A prediction model based on these factors can effectively predict the risk of PPD in older pregnant women.

Pre-pregnancy stress induces maternal vascular dysfunction during pregnancy and postpartum

An estimated 20% of women suffer from a stress-related mood disorder including depression and anxiety during and after pregnancy, making these disorders among the most common complications of pregnancy. These stress-related disorders are associated with adverse pregnancy outcomes including gestational hypertension and preeclampsia, which are associated with poor cardiometabolic health postpartum. Despite these associations, the direct impact of stress and related disorders on maternal vascular health, and contributing mechanisms, remain understudied. The aim of this study was to investigate the effect of pre-pregnancy stress on maternal vascular outcomes in a BALB/c mouse model of chronic unpredictable stress. Maternal blood pressure and ex-vivo vascular function were investigated during pregnancy and postpartum. Offspring characteristics were assessed at the end of pregnancy and postpartum. Main findings show that pre-pregnancy stress exposure increased blood pressure during mid and late pregnancy and impaired ex vivo vascular function at the end of pregnancy. These effects persisted into the postpartum period, suggesting a long-term effect of stress on maternal vascular health, which appear to be partially attributable to disruptions in nitric oxide (NO) pathway signaling. These data suggest exposure to stress and related disorders, even prior to pregnancy, can contribute to vascular complications during pregnancy and postpartum.

Foreign Nationality, Family Psychiatry History and Pregestational Neoplastic Disease as Predictors of Perinatal Depression in a Cohort of Healthy Pregnant and Puerperal Women during the COVID-19 Pandemic

Background: Perinatal depression (PND) represents one of the most common mental disorders in the pregnancy and/or postpartum period, with a 5-25% prevalence rate. Our aim was to investigate predictors associated with PND in a cohort of pregnant and puerperal women based in an Italian setting during the COVID-19 pandemic. Methods: We retrospectively recruited 199 (55 pregnant and 144 puerperal) women, afferent to our Perinatal Mental Outpatient Service of Ancona (Italy). Participants were administered an ad hoc case-report form, Whooley Questions (WQ), the General Health Questionnaire-12 (GHQ-12), the Stress Holmes-Rahe scale (HR) and the Edinburgh Postnatal Depression Scale (EPDS). Results: Around 10% of the sample had a confirmed PND. Being a foreigner woman (RR = 3.8), having a positive psychiatric family history (RR = 5.3), a pre-pregnancy medical comorbidity (RR = 1.85) and a comorbid medical illness occurring during the pregnancy (RR = 2) were much likely associated with PND. Multiple linear regression analysis demonstrated that GHQ, medium- and high-risk at the HR, foreign nationality, positive family psychiatric history, and neoplastic disease before conception significantly predicted EPDS [F(1, 197) = 10.086, R² = 0.324, p < 0.001]. Limitations: The sample size, poor heterogeneity in terms of socio-demographic, clinical and gynecological-obstetric characteristics, the cross-sectional design of the study. Conclusions: Our study showed a set of predictors associated with a higher risk for the PND onset, including gestational and pregestational medical disease. Our findings outline the need to screen all fertile women, particularly in gynecological and medical settings, in order to identify at-risk women for PND and promptly suggest a psychiatric consultation.

Highlighting the Mechanistic Relationship Between Perinatal Depression and Preeclampsia: A Scoping Review

BACKGROUND

Although there is scientific literature supporting an association between depression and preeclampsia (PE), little is known about the underlying mechanistic pathways that may explain these observed associations. Thus, this study aimed to outline the relationship between depression and PE, and to highlight the underlying cardiovascular and metabolic risk factors that are common to both.

METHODS

A scoping review of the literature was conducted in Medline, Scopus, and Web of Science.

RESULTS

From 706 articles initially identified, 23 articles met the inclusion criteria and were included in this review. Although some studies reported a positive association between PE and postpartum depressive symptoms, challenges comparing different methodologies, measurement instruments and when measurements were administered, and patient populations do not permit a decisive conclusion. In addition, very few studies addressed potential underlying mechanisms that may be contributing to observed associations; thus, a secondary search was conducted to identify cardiovascular and metabolic risk factors that are common to both depression and PE.

CONCLUSION

The cardiovascular and metabolic risk factors (i.e., increased inflammation and oxidative stress and decreased vascular and endothelial function) common to both depression and PE suggest that these factors may contribute as underlying mechanisms in both conditions. These similarities underscore the importance to better understand these mechanisms so preventative and therapeutic strategies could be developed to improve maternal health.

The prevalence and determinants of postpartum depression (PPD) symptomatology among facility delivered mothers of Dhaka city

BACKGROUND

Postpartum depression (PPD) is among the top mental health issues and affects children's health and cognitive development. This study aimed to identify the prevalence of PPD symptomatology and possible determinants among facility delivered mothers of Dhaka city.

METHOD

A cross-sectional study was conducted among 291 mothers within the 12 months of postpartum during January to May 2019.

RESULTS

The prevalence of PPD symptomatology was 29.9 % among postpartum mothers. Multiple adjusted odds ratios of stepwise logistic regression analyses revealed, mothers age more than 30 years (AOR = 2.56:95 %CI = 1.21-5.39), being a mother for the first time (AOR = 2.08:95 %CI = 1.09-3.96), lost job or couldn't able to do paid work due to pregnancy (AOR = 2.60:95 %CI = 1.25-5.43), hypertension history (AOR = 2.48:95 %CI = 1.20-5.10), neonatal complication (AOR = 2.04:95 %CI = 1.05-3.95), and rare or no support from husband (AOR = 4.12:95 %CI = 2.14-7.95) were identified as significant predictors of PPD. However, having a household income of more than 50,000 Bangladeshi Taka per month (AOR = 0.36:95 %CI = 0.17-0.76) and passing less sedentary hours (AOR = 0.41:95 % CI = 0.23-0.75) were protective factors for PPD.

CONCLUSION

Our study has revealed a relatively high prevalence of PPD symptomatology; therefore, mental health counseling and proper management of cases are essential for bettering mothers and the next generation.

Prevalence and incidence of postpartum depression and environmental factors: The IGEDEPP cohort

BACKGROUND

IGEDEPP (Interaction of Gene and Environment of Depression during PostPartum) is a prospective multicenter cohort study of 3310 Caucasian women who gave birth between 2011 and 2016, with follow-up until one year postpartum. The aim of the current study is to describe the cohort and estimate the prevalence and cumulative incidence of early and late-onset postpartum depression (PPD).

METHODS

Socio-demographic data, personal and family psychiatric history, as well as stressful life events during childhood and pregnancy were evaluated at baseline. Early and late-onset PPD were assessed at 8 weeks and 1 year postpartum respectively, using DSM-5 criteria.

RESULTS

The prevalence of early-onset PPD was 8.3% (95%CI 7.3-9.3), and late PPD 12.9% (95%CI 11.5-14.2), resulting in an 8-week cumulative incidence of 8.5% (95%CI 7.4-9.6) and a one-year cumulative incidence of PPD of 18.1% (95%CI: 17.1-19.2). Nearly half of the cohort (N = 1571, 47.5%) had a history of at least one psychiatric or addictive disorder, primarily depressive disorder (35%). Almost 300 women in the cohort (9.0%) reported childhood trauma. During pregnancy, 47.7% women experienced a stressful event, 30.2% in the first 8 weeks and 43.9% between 8 weeks and one year postpartum. Nearly one in five women reported at least one stressful postpartum event at 8 weeks.

CONCLUSION

Incident depressive episodes affected nearly one in five women during the first year postpartum. Most women had stressful perinatal events. Further IGEDEPP studies will aim to disentangle the impact of childhood and pregnancy-related stressful events on postpartum mental disorders.

Is physical activity in pregnancy associated with prenatal and postnatal depressive symptoms?: Results from MAASTHI cohort study in South India

OBJECTIVE

Physical inactivity leads to depression and other adverse health consequences. Pregnant women are an important subgroup to study the health consequences due to physical inactivity since it can lead to adverse outcomes in pregnancy and even after delivery. Therefore, we aimed at understanding the level of physical activity among pregnant women, prevalence of prenatal and postnatal depressive symptoms and whether level of physical activity is associated with prenatal and postnatal depressive symptoms.

METHODS

In an ongoing cohort study, we measured the physical activity using a validated Physical Activity Level (PAL) questionnaire. We administered the Edinburgh Postnatal Depression Scale (EPDS) during pregnancy and within seven days of delivery to assess depressive symptoms in 1406 women. Associations were adjusted for potential confounders such as maternal age, education, socioeconomic status, gravida, EPDS score during pregnancy, social support, skinfold thickness, blood pressure, blood sugar level.

RESULTS

We found that 7.2% of pregnant women had low levels of physical activity. The prevalence of prenatal and postnatal depressive symptoms was 9.0% and 31.9% respectively. Pregnant women with a low level of physical activity had significantly higher odds of developing postpartum depressive symptoms (OR = 3.15, CI: 1.98-5.02, p < 0.001) when adjusted for potential confounders.

CONCLUSIONS

Moderate level of physical activity among pregnant mothers is essential and has its association with postnatal depressive symptoms. Health care professionals need to counsel pregnant women to assess depressive symptoms at both the prenatal and postpartum period and inform them about the importance of the optimal level of physical activity.

Early- and late-onset postpartum depression exhibit distinct associated factors: the IGEDEPP prospective cohort study

OBJECTIVE

To identify risk factors for early- and late-onset postpartum depression (PPD) among a wide range of variables, including sociodemographic characteristics, childhood trauma, stressful life events during pregnancy and history of personal and family psychiatric disorders, and to assess the contribution of each risk factor.

DESIGN

Nested case-control study in a prospective longitudinal cohort study.

SETTING

Eight maternity departments in the Paris metropolitan area, France.

SAMPLE

A cohort of 3310 women with deliveries between November 2011 and June 2016.

METHODS

Cases were women with early- or late-onset PPD. Controls were women without depression during pregnancy or the postpartum period. Logistic regression adjusted on sociodemographic variables was performed for each outcome and a multivariable model was proposed based on a stepwise selection procedure.

MAIN OUTCOME MEASURES

Early- and late-onset PPD assessed at 2 months and 1 year postpartum, respectively.

RESULTS

Stressful life events during pregnancy have a dose-response relationship with both early- and late-onset PPD.

CONCLUSIONS

Early- and late-onset PPD presented distinct patterns of determinants. These results have important consequences in terms of prevention and specific care.

TWEETABLE ABSTRACT

Early- and late-onset postpartum depression are associated with stressful life events and psychiatric history.

Development and validation of a machine learning algorithm for predicting the risk of postpartum depression among pregnant women

OBJECTIVE

There is a scarcity in tools to predict postpartum depression (PPD). We propose a machine learning framework for PPD risk prediction using data extracted from electronic health records (EHRs).

METHODS

Two EHR datasets containing data on 15,197 women from 2015 to 2018 at a single site, and 53,972 women from 2004 to 2017 at multiple sites were used as development and validation sets, respectively, to construct the PPD risk prediction model. The primary outcome was a diagnosis of PPD within 1 year following childbirth. A framework of data extraction, processing, and machine learning was implemented to select a minimal list of features from the EHR datasets to ensure model performance and to enable future point-of-care risk prediction.

RESULTS

The best-performing model uses from clinical features related to mental health history, medical comorbidity, obstetric complications, medication prescription orders, and patient demographic characteristics. The model performances as measured by area under the receiver operating characteristic curve (AUC) are 0.937 (95% CI 0.912 - 0.962) and 0.886 (95% CI 0.879-0.893) in the development and validation datasets, respectively. The model performances were consistent when tested using data ending at multiple time periods during pregnancy and at childbirth.

LIMITATIONS

The prevalence of PPD in the study data represented a treatment prevalence and is likely lower than the illness prevalence.

CONCLUSIONS

EHRs and machine learning offer the ability to identify women at risk for PPD early in their pregnancy. This may facilitate scalable and timely prevention and intervention, reducing negative outcomes and the associated burden.

Preeclampsia as a risk factor for postpartum depression and psychosis: a systematic review and meta-analysis

Postpartum depression (PPD) and postpartum psychosis (PPP) are serious mental conditions that are usually not diagnosed early enough, leading to delayed treatment. Several studies confirmed an association between preeclampsia (PE) and psychiatric disorders during pregnancy. We conducted a systematic review of the literature aiming to investigate whether women with a history of PE are more likely to develop PPD or PPP, and whether PE is a risk factor for depression outside the perinatal period (PROSPERO protocol number CRD42018114188). We also conducted a meta-analysis to quantitatively assess the severity of depressive symptoms between women with and without a history of PE. A literature search with no year and no language restriction was conducted. The search yielded 950 articles, with 698 remaining after duplicate removal, and 13 being suitable for the systematic review. Eight of the 13 studies found an association between preeclampsia and depression. All studies assessed the impact of PE on depression, and only two studies assessed the impact of PE on PPP. Eight of the studies were included in the meta-analysis, which yielded a higher severity of depressive symptoms postpartum in women with PE. However, these results must be interpreted with caution considering the high heterogeneity of the included studies. Our meta-analysis also showed that women with a history of PE showed higher severity of depressive symptoms outside of the puerperal period. In conclusion, this systematic review and meta-analysis suggest that that PE is not only a risk factor for development of depression, but it is also associated with higher severity of depressive symptoms.

Pregnancy-associated venous insufficiency course with placental and systemic oxidative stress

The development of lower extremity venous insufficiency (VI) during pregnancy has been associated with placental damage. VI is associated with increased oxidative stress in venous wall. We have investigated potential disturbance/dysregulation of the production of reactive oxygen species (ROS) in placenta and its eventual systemic effects through the measurement of malondialdehyde (MDA) plasma levels in women with VI. A total of 62 women with VI and 52 healthy controls (HCs) were studied. Levels of nicotinamide adenine dinucleotide phosphate-oxidase 1 (NOX1), 2 (NOX2), inducible nitric oxide synthase (iNOS), endothelial (eNOS), poly(ADP-ribose) polymerase PARP (PARP) and ERK were measured in placental tissue with immunohistochemistry and RT-qPCR. Plasma and placental levels of MDA were determined by colorimetry at the two study times of 32 weeks of gestation and post-partum. Protein and gene expression levels of NOX1, NOX2, iNOS, PARP and ERK were significantly increased in placentas of VI. eNOS activity was low in both study groups, and there were no significant differences in gene or protein expression levels. Women with VI showed a significant elevation of plasma MDA levels at 32 weeks of gestation, and these levels remained elevated at 32 weeks post-partum. The MDA levels were significantly higher in placentas of women with VI. Placental damage that was found in the women with VI was characterized by overexpression of oxidative stress markers NOX1, NOX2, and iNOS, as well as PARP and ERK. Pregnant women with VI showed systemic increases in oxidative stress markers such as plasma MDA levels. The foetuses of women with VI had a significant decrease in their venous pH as compared to those from HC women. The situation of oxidative stress and cellular damage created in the placenta is in coexpression with the production of a pH acidification.

The dynamic course of peripartum depression across pregnancy and childbirth

OBJECTIVE

Peripartum depression (PPD) pertaining to depression in pregnancy and postpartum is one of the most common complications around childbirth with enduring adverse effects on mother and child health. Although psychiatric symptoms may improve or worsen over time, relatively little is known about the course of PPD symptoms and possible fluctuations.

METHODS

We applied a person-centered approach to examine PPD symptom patterns across pregnancy and childbirth. 824 women were assessed at three time points: first trimester (T1), third trimester (T2), and again at eight weeks (T3) postpartum. We assessed PPD symptoms, maternal mental health history, and childbirth variables.

RESULTS

Growth mixture modeling (GMM) analysis revealed four discrete PPD symptom trajectory classes including chronic PPD (1.1%), delayed (10.2%), recovered (7.2%), and resilient (81.5%). Delivery complications were associated with chronic PPD but also with the recovered PPD trajectory class. History of mental health disorders was associated with chronic PPD and the delayed PPD class.

CONCLUSION

The findings underscore that significant changes in a woman's depression level can occur across pregnancy and childbirth. While a minority of women experience chronic PDD, for others depression symptoms appear to significantly alleviate over time, suggesting a form of recovery. Our findings support a personalized medicine approach based on the woman's symptom trajectory. Future research is warranted to identify the mechanisms underlying modifications in PPD symptoms severity and those implicated in recovery.

Inflammation, depression and cardiovascular disease in women: the role of the immune system across critical reproductive events

Women are at increased risk for developing depression and cardiovascular disease (CVD) across the lifespan and their comorbidity is associated with adverse outcomes that contribute significantly to rates of morbidity and mortality in women worldwide. Immune-system activity has been implicated in the etiology of both depression and CVD, but it is unclear how inflammation contributes to sex differences in this comorbidity. This narrative review provides an updated synthesis of research examining the association of inflammation with depression and CVD, and their comorbidity in women. Recent research provides evidence of pro-inflammatory states and sex differences associated with alterations in the hypothalamic-pituitary-adrenal axis, the renin-angiotensin-aldosterone system and the serotonin/kynurenine pathway, that likely contribute to the development of depression and CVD. Changes to inflammatory cytokines in relation to reproductive periods of hormonal fluctuation (i.e. the menstrual cycle, perinatal period and menopause) are highlighted and provide a greater understanding of the unique vulnerability women experience in developing both depressed mood and adverse cardiovascular events. Inflammatory biomarkers hold substantial promise when combined with a patient's reproductive and mental health history to aid in the prediction, identification and treatment of the women most at risk for CVD and depression. However, more research is needed to improve our understanding of the mechanisms underlying inflammation in relation to their comorbidity, and how these findings can be translated to improve women's health.