Maternal psychophysiological change during the second half of gestation

Emotion dysregulation and reward responsiveness as predictors of autonomic reactivity to an infant cry task among substance-using pregnant and postpartum women

Maternal substance use may interfere with optimal parenting, lowering maternal responsiveness during interactions with their children. Previous work has identified maternal autonomic nervous system (ANS) reactivity to parenting-relevant stressors as a promising indicator of real-world parenting behaviors. However, less is known about the extent to which individual differences in emotion dysregulation and reward processing, two mechanisms of substance use, relate to maternal ANS reactivity in substance-using populations. The current study examined associations among emotion dysregulation, reward responsiveness, and ANS reactivity to an infant cry task among 77 low-income and substance-using women who were either pregnant (n = 63) or postpartum (n = 14). Two indicators of ANS functioning were collected during a 9 min computerized infant cry task (Crybaby task): respiratory sinus arrhythmia (RSA) and pre-ejection period. Mothers also completed self-reported measures of emotion dysregulation and reward responsiveness. Analyses revealed that trait emotion regulation was associated with RSA reactivity to the Crybaby task, such that greater emotion dysregulation was associated with greater RSA reduction during the infant cry task than lower emotion dysregulation. Reward responsiveness was not significantly associated with either indicator of ANS reactivity to the task. Findings revealed distinct patterns of associations linking emotion dysregulation with ANS reactivity during a parenting-related computerized task, suggesting that emotion regulation may be a key intervention target for substance-using mothers.

Predicting postpartum depressive symptoms by evaluating self-report autonomic nervous system reactivity during pregnancy

OBJECTIVE

Altered self-reported autonomic reactivity is associated with worse mental health in the general population. Although dysfunctional changes in ANS during pregnancy have been investigated in relation to depressive symptoms, no studies addressed the relationship between self-report autonomic reactivity during pregnancy and depressive symptoms after the delivery. The present study aimed to assess the impact of prepartum self-reported autonomic reactivity on the development of postpartum depressive symptoms.

METHODS

In this longitudinal study, 170 women were assessed during pregnancy (i.e., second or third trimester) and after childbirth (i.e., one month after the delivery). Self-reported autonomic reactivity was assessed through the Body Perception Questionnaire - Short Form that evaluates the autonomic functions related to organs above (i.e., supradiaphragmatic reactivity) and below (i.e., subdiaphragmatic reactivity) the diaphragm. In addition, prepartum and postpartum depressive symptoms were evaluated using the Patient Health Questionnaire - 9.

RESULTS

Findings showed that higher prepartum supradiaphragmatic reactivity predicted higher depressive symptoms in the postpartum period (β = 0.112, p = 0.009) after controlling for prepartum depressive symptomatology and other potential covariates.

CONCLUSIONS

Evaluation of self-reported autonomic activity may be a useful tool to identify antenatally women at risk of postpartum depressive symptoms. Future studies are needed to evaluate the effectiveness of interventions aimed at reducing the threat-responsive autonomic reactivity at rest and improving adaptive autonomic regulation to prevent postpartum depression.

Comprehensive evaluation of machine learning algorithms for predicting sleep-wake conditions and differentiating between the wake conditions before and after sleep during pregnancy based on heart rate variability

Introduction

Perinatal women tend to have difficulties with sleep along with autonomic characteristics. This study aimed to identify a machine learning algorithm capable of achieving high accuracy in predicting sleep-wake conditions and differentiating between the wake conditions before and after sleep during pregnancy based on heart rate variability (HRV).

Methods

Nine HRV indicators (features) and sleep-wake conditions of 154 pregnant women were measured for 1 week, from the 23rd to the 32nd weeks of pregnancy. Ten machine learning and three deep learning methods were applied to predict three types of sleep-wake conditions (wake, shallow sleep, and deep sleep). In addition, the prediction of four conditions, in which the wake conditions before and after sleep were differentiated-shallow sleep, deep sleep, and the two types of wake conditions-was also tested.

Results and Discussion

In the test for predicting three types of sleep-wake conditions, most of the algorithms, except for Naïve Bayes, showed higher areas under the curve (AUCs; 0.82-0.88) and accuracy (0.78-0.81). The test using four types of sleep-wake conditions with differentiation between the wake conditions before and after sleep also resulted in successful prediction by the gated recurrent unit with the highest AUC (0.86) and accuracy (0.79). Among the nine features, seven made major contributions to predicting sleep-wake conditions. Among the seven features, "the number of interval differences of successive RR intervals greater than 50 ms (NN50)" and "the proportion dividing NN50 by the total number of RR intervals (pNN50)" were useful to predict sleep-wake conditions unique to pregnancy. These findings suggest alterations in the vagal tone system specific to pregnancy.

Anxiety in pregnancy and stress responsiveness: An exploratory study of heart rate variability, cortisol, and alpha-amylase in the third trimester

The present study aimed to explore the association between anxiety symptoms, including sleep, and physiological stress responsiveness in pregnant women with and without anxiety, as identified by psychiatric diagnosis. Fifty-four pregnant women with (n = 25) and without (n = 29) anxiety completed a laboratory cognitive stressor (the Stroop Color-Word Task) during the third trimester. Heart rate variability (HRV) (as the root mean square of successive differences, RMSSD) was recorded during baseline, stressor, and recovery periods. Salivary cortisol (sCORT) and alpha amylase (sAA) were measured at four timepoints surrounding the stressor task. Psychometric scales (Penn State Worry Questionnaire [PSWQ], Perceived Stress Scale [PSS], Spielberg Trait Anxiety Inventory Scale [STAI], and Pittsburgh Sleep Quality Index [PSQI]) were collected. Women in the anxiety group exhibited significantly less rebound in HRV (RMSSD, change of 4-ms difference, p = .025) from baseline to recovery following the Stroop than did those in the non-anxiety group. Neither neuroendocrine measure (sCORT, sAA) differed between groups at any measurement period. Across the recording period, lower reported sleep quality (PSQI, p = .0092) and higher subjective stress (PSS, p = .039) were associated with lower RMSSD. The findings suggest that women with and without anxiety in late pregnancy display differences in the degree of autonomic rebound as indicated by HRV following a stressor. In addition, levels of HRV over time were associated with subjective perceptions of increased stress and poor sleep. PREGNANCY AND ANXIOUS: The Role of the Immune and Endocrine Systems (NCT03664128).

The validity of the residuals approach to measuring resilience to adverse childhood experiences

BACKGROUND

Resilience is broadly defined as the ability to maintain or regain functioning in the face of adversity. Recent work to harmonise the quantification and definition of resilience quantifies resilience as the residual variance in psychosocial functioning that remains after accounting for adversity exposure. However, there have been no published studies that have formally investigated the validity of this approach. Considering this, we examine the construct and predictive validity of the residuals approach using participants from the Avon Longitudinal Study of Parents and Children (ALSPAC), a multigenerational, longitudinal cohort study.

METHODS

We regressed exposures of adolescent adversity on adolescent psychopathology scores using the Strength and Difficulties Questionnaire and obtained the residual variance. We investigated construct validity by analysing whether previously identified demographic and resilience factors significantly predicted resilience. Predictive validity of resilience was investigated by comparing the predictive power of resilience with other determinants of psychosocial functioning on two developmental outcomes: depressive symptoms at 18 years, measured by the Short Moods and Feelings Questionnaire, and NEET (Not in Employment, Education or Training) status at 17 and 23 years. The associations between depressive symptoms at 18, resilience, ACEs and covariates were tested using multiple linear regression. NEET status at 17 and 23 were run as separate binary multiple logistic regression models to test associations with resilience and known demographics previously associated with NEET status.

RESULTS

Seven previously identified protective factors, including self-esteem, positive sibling relationship, temperament, and positive perception of school, significantly predicted resilience to adolescent psychopathology, thus providing strong construct validity. Resilience significantly predicted a reduction in depressive symptoms at 18 years, and significantly decreased the likelihood of having NEET status at both 17 years and 23 years, even after taking into account early childhood adversity and other risk factors. None of the socioeconomic factors were significantly associated with resilience.

CONCLUSIONS

Our study demonstrates that the residuals method of operationalising resilience has good construct and predictive validity yet recommend replication studies. It has the potential to advance research into the mechanisms and modifiability of resilience.

TRIAL REGISTRATION

Not applicable.

Cardiac vagal control in response to acute stress during pregnancy: Associations with life stress and emotional support

Life stressors during pregnancy can disrupt maternal stress regulation and negatively impact offspring health. Despite the important role of cardiac vagal control (e.g., heart rate variability; HRV) in stress regulation, few studies have investigated how life stressors and emotional support influence vagal control during pregnancy. This study aimed to (a) characterize patterns of cardiac vagal control in response to a stressor administered in pregnancy, and (b) examine the effects of life stress and emotional support on vagal control during rest, reactivity, and recovery. Participants included 191 pregnant women (79% Black; 21% White) living in an urban U.S. city (73% receiving public assistance). Heart rate (HR) and HRV (indexed by RMSSD) were recorded continually during the preparation, task, and recovery periods of the Trier Social Stress Test (TSST). Participants reported recent life stressors (e.g., relationship problems, financial hardship) and emotional support. Piecewise growth curve modeling was used to model rates of reactivity and recovery, adjusting for gestational age at time of assessment and recent health problems. Life stress predicted greater HR and HRV reactivity to the TSST as well as greater HRV recovery (vagal rebound). However, associations were only evident for women reporting high emotional support. Results suggest that pregnant women living with frequent life stressors may exhibit more rapid autonomic responses to acute stress, including more rapid vagal rebound after stressors, potentially reflecting physiological adaptation to anticipated high-stress environments; emotional support may enhance these responses. Studies are needed to investigate long-term health outcomes related to this stress response pattern.

Influences of adversity across the lifespan on respiratory sinus arrhythmia during pregnancy

There is limited understanding of factors across the lifespan that influence pregnant women's respiratory sinus arrhythmia (RSA), which could have implications for their health and offspring development. We examined associations among 162 English- and Spanish-speaking pregnant women's childhood maltreatment history, emotion dysregulation, recent life stress, and resting RSA during the third trimester. Moderated mediation analyses indicated that more severe childhood maltreatment history (95% confidence interval (CI) [0.26, 0.63]) and higher emotion dysregulation (95% CI [0.001, 0.006]) predicted more stress during pregnancy, and childhood maltreatment history interacted with emotion dysregulation to predict resting RSA (95% CI [-0.04, -0.0003]). Exploratory analyses revealed that women's health-related stress during pregnancy mediated the relation between emotion dysregulation and RSA regardless of childhood maltreatment severity (95% CI [-0.007, -0.002]). These findings suggest that women's resting RSA during pregnancy may reflect physical and emotional stress accumulation across the lifespan and that relations between early life adversity and prenatal psychophysiology may be buffered by protective factors, such as emotion regulation. In addition, these findings underscore the importance of distinguishing between types of prenatal stress. Given the implications for women's health and offspring development, we urge researchers to continue exploring factors associated with pregnant women's psychophysiology.

Heart rate variability in late pregnancy: exploration of distinctive patterns in relation to maternal mental health

Exploration of photoplethysmography (PPG), a technique that can be translated to the clinic, has the potential to assess the autonomic nervous system (ANS) through heart rate variable (HRV) in pregnant individuals. This novel study explores the complexity of mental health of individuals in a clinical sample responding to a task in late pregnancy; finding those with several types of past or current anxiety disorders, greater trait anxiety, or greater exposure to childhood traumatic events had significantly different HRV findings from the others in the cohort. Lower high frequency (HF), a measure of parasympathetic activity, was found for women who met the criteria for the history of obsessive-compulsive disorder (OCD) (p = 0.004) compared with women who did not meet the criteria for OCD, and for women exposed to greater than five childhood traumatic events (p = 0.006) compared with those exposed to four or less childhood traumatic events. Conversely higher low frequency (LF), a measure thought to be impacted by sympathetic system effects, and the LF/HF ratio was found for those meeting criteria for a panic disorder (p = 0.006), meeting criteria for social phobia (p = 0.002), had elevated trait anxiety (p = 0.006), or exposure to greater than five childhood traumatic events (p = 0.004). This study indicates further research is needed to understand the role of PPG and in assessing ANS functioning in late pregnancy. Study of the impact of lower parasympathetic functioning and higher sympathetic functioning separately and in conjunction at baseline and in relation to tasks during late pregnancy has the potential to identify individuals that require more support and direct intervention.

Maternal buprenorphine treatment during pregnancy and maternal physiology

BACKGROUND

Buprenorphine, used for opioid use disorder (OUD) treatment during pregnancy, provides unknown effects on maternal physiological activity. The primary aim of this report is to document acute effects of buprenorphine administration on indicators of maternal autonomic functioning. Effects of maternal buprenorphine dose and other substance exposures on maternal measures were examined, as were neonatal abstinence syndrome (NAS) outcomes.

METHODS

Forty-nine pregnant, buprenorphine-maintained women yielded maternal physiologic information (heart rate and variability, electrodermal activity, and respiratory rate) at 24, 28, 32 and 36 weeks gestation. Monitoring at trough and peak maternal medication levels was implemented to ascertain acute physiologic effects of buprenorphine administration.

RESULTS

Buprenorphine administration accelerated maternal heart rate and reduced variability at two gestational ages (24 and 36 weeks) and suppressed sympathetic (electrodermal) activation at 24, 28 and 32 weeks at times of peak maternal medication levels. Maternal autonomic parameters were unrelated to polysubstance exposure with the exception of cigarette smoking. Heavier smoking dampened maternal heart rate variability across gestation and potentiated reactivity to buprenorphine at 24 and 36 weeks. Heavier smoking was also associated with reduced electrodermal activity at 36 weeks. Buprenorphine dose was unrelated to observed effects. Larger degree of maternal heart rate reactivity to buprenorphine administration was related to more severe NAS expression.

CONCLUSIONS

These findings detail the maternal autonomic response to buprenorphine administration but also illustrate the significant effect of concurrent cigarette use on maternal autonomic regulation. This suggests the importance of smoking-reduction strategies in the comprehensive, medication-assisted treatment of women with OUD.

Intergenerational transmission of emotion dysregulation: Part I. Psychopathology, self-injury, and parasympathetic responsivity among pregnant women

The World Health Organization recently reported that maternal mental health is a major public health concern. As many as one in four women suffer from psychiatric disorders at some point during pregnancy or the first postpartum year. Furthermore, self-injurious thoughts and behaviors (SITBs) represent one of the leading causes of death among women during this time. Thus, efforts to identify women at risk for serious forms of psychopathology and especially for SITBs are of utmost importance. Despite this urgency, current single-diagnostic approaches fail to recognize a significant subset of women who are vulnerable to perinatal stress and distress. The current study was among the first to investigate emotion dysregulation-a multilevel, transdiagnostic risk factor for psychopathology-and its associations with stress, distress, and SITBs in a sample of pregnant women (26-40 weeks gestation) recruited to reflect a range of emotion dysregulation. Both self-reported emotion dysregulation and respiratory sinus arrhythmia, a biomarker of emotion dysregulation, demonstrated expected associations with measures of mental health, including depression, anxiety, borderline personality pathology, and SITBs. In addition, self-reported emotion dysregulation was associated with blunted respiratory sinus arrhythmia responsivity to an ecologically valid infant cry task. Findings add to the literature considering transdiagnostic risk during pregnancy using a multiple-levels-of-analysis approach.

Guided imagery for treating hypertension in pregnancy

BACKGROUND

Hypertension (high blood pressure) in pregnancy carries a high risk of maternal morbidity and mortality. Although antihypertensive drugs are commonly used, they have adverse effects on mothers and fetuses. Guided imagery is a non-pharmacological technique that has the potential to lower blood pressure among pregnant women with hypertension. Guided imagery is a mind-body therapy that involves the visualisation of various mental images to facilitate relaxation and reduction in blood pressure.

OBJECTIVES

To determine the effect of guided imagery as a non-pharmacological treatment of hypertension in pregnancy and its influence on perinatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, and two trials registers (October 2018). We also searched relevant conference proceedings and journals, and scanned the reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs). We would have included RCTs using a cluster-randomised design, but none were identified. We excluded quasi-RCTs and cross-over trials.We sought intervention studies of various guided imagery techniques performed during pregnancy in comparison with no intervention or other non-pharmacological treatments for hypertension (e.g. quiet rest, music therapy, aromatherapy, relaxation therapy, acupuncture, acupressure, massage, device-guided slow breathing, hypnosis, physical exercise, and yoga).

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed the trials for inclusion, extracted data, and assessed risk of bias for the included studies. We checked extracted data for accuracy, and resolved differences in assessments by discussion. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included two small trials (involving a total of 99 pregnant women) that compared guided imagery with quiet rest. The trials were conducted in Canada and the USA. We assessed both trials as at high risk of performance bias, and low risk of attrition bias; one trial was at low risk for selection, detection, and reporting bias, while the other was at unclear risk for the same domains.We could not perform a meta-analysis because the two included studies reported different outcomes, and the frequency of the intervention was slightly different between the two studies. One study performed guided imagery for 15 minutes at least twice daily for four weeks, or until the baby was born (whichever came first). In the other study, the intervention included guided imagery, self-monitoring of blood pressure, and thermal biofeedback-assisted relaxation training for four total hours; the participants were instructed to practice the procedures twice daily and complete at least three relief relaxation breaks each day. The control groups were similar - one was quiet rest, and the other was quiet rest as bed rest.None of our primary outcomes were reported in the included trials: severe hypertension (either systolic blood pressure of 160 mmHg or higher, or diastolic blood pressure of 110 mmHg or higher); severe pre-eclampsia, or perinatal death (stillbirths plus deaths in the first week of life). Only one of the secondary outcomes was measured.Low-certainty evidence from one trial (69 women) suggests that guided imagery may make little or no difference in the use of antihypertensive drugs (risk ratio 1.27, 95% confidence interval 0.72 to 2.22).

AUTHORS' CONCLUSIONS

There is insufficient evidence to inform practice about the use of guided imagery for hypertension in pregnancy.The available evidence for this review topic is sparse, and the effect of guided imagery for treating hypertension during pregnancy (compared with quiet rest) remains unclear. There was low-certainty evidence that guided imagery made little or no difference to the use of antihypertensive drugs, downgraded because of imprecision.The two included trials did not report on any of the primary outcomes of this review. We did not identify any trials comparing guided imagery with no intervention, or with another non-pharmacological method for hypertension.Large and well-designed RCTs are needed to identify the effects of guided imagery on hypertension during pregnancy and on other relevant outcomes associated with short-term and long-term maternal and neonatal health. Trials could also consider utilisation and costs of health service.

Maternal parity and perinatal cortisol adaptation: The role of pregnancy-specific distress and implications for postpartum mood

INTRODUCTION

Compared to women who have given birth before (i.e., multiparas), those giving birth for the first time (i.e., primiparas) show higher cortisol levels. Psychological factors may play a role; hypothalamic-pituitary-adrenal activation is a well-described stress response. Primiparity also predicts greater risk for postpartum depression, which may be related to greater correspondence between cortisol and mood following prenatal cortisol elevations. The current study examined associations among parity, perinatal cortisol adaptation, pregnancy-specific distress, and postpartum mood.

METHODS

This longitudinal study assayed serum cortisol levels among 137 women at early, mid-, and late pregnancy and postpartum. Pregnancy-specific distress and depressive symptoms were assessed. Maternal age, race, body mass index, sleep quality, depressive symptoms, and sampling time of day were statistically controlled.

RESULTS

Primiparous women showed higher cortisol levels than multiparous women during mid- (χ² = 11.8, p < 0.01) and late pregnancy (χ² = 18.9, p < 0.01) and higher distress across pregnancy (F_1,126 = 22.1, p < 0.01). Mediation analyses demonstrated that the association between parity and prenatal cortisol (per area under the curve; AUC) was partially accounted for by distress (ab = 1.0, 95%CI [0.05, 2.9]). Prenatal cortisol (per AUC) did not predict postpartum depressive symptoms (b* = 0.03, p = 0.81), with no difference by parity (b* = 0.03, p = 0.91). At postpartum, a significant interaction between parity and cortisol (b* = 0.40, p = 0.03) revealed no significant association between cortisol and mood among multiparas (b* = -0.11, p = 0.28) but a trend toward a positive association among primiparas (b* = 0.24, p = 0.06).

DISCUSSION

Cortisol levels and pregnancy-specific distress are higher in primiparas versus multiparas, with pregnancy-specific distress partially mediating the association between parity and cortisol levels. Cortisol levels and mood display correspondence at postpartum in primiparous but not multiparous women. While observational studies must be interpreted with caution due to potential unmeasured confounders, these findings suggest that future studies examining mechanisms underlying perinatal and postpartum hypothalamic-pituitary-adrenal perturbations and designing interventions aimed at preventing related complications should carefully consider potential differences by parity.

Developmental origins of the human hypothalamic-pituitary-adrenal axis

INTRODUCTION

The developmental origins of disease or fetal programming model predicts that intrauterine exposures have life long consequences for physical and psychological health. Prenatal programming of the fetal hypothalamic-pituitary-adrenal (HPA) axis is proposed as a primary mechanism by which early experiences are linked to later disease risk. Areas covered: This review describes the development of the fetal HPA axis, which is determined by an intricately timed cascade of endocrine events during gestation and is regulated by an integrated maternal-placental-fetal steroidogenic unit. Mechanisms by which stress-induced elevations in hormones of maternal, fetal, or placental origin influence the structure and function of the emerging fetal HPA axis are discussed. Recent prospective studies documenting persisting associations between prenatal stress exposures and altered postnatal HPA axis function are summarized, with effects observed beginning in infancy into adulthood. Expert commentary: The results of these studies are synthesized, and potential moderating factors are discussed. Promising areas of further research highlighted include epigenetic mechanisms and interactions between pre and postnatal influences.

Reduced vagal tone in women with the FMR1 premutation is associated with FMR1 mRNA but not depression or anxiety

Background

Autonomic dysfunction is implicated in a range of psychological conditions, including depression and anxiety. The fragile X mental retardation-1 (FMR1) premutation is a common genetic mutation that affects ~1:150 women and is associated with psychological vulnerability. This study examined cardiac indicators of autonomic function among women with the FMR1 premutation and control women as potential biomarkers for psychological risk that may be linked to FMR1.

Methods

Baseline inter-beat interval and respiratory sinus arrhythmia (a measure of parasympathetic vagal tone) were measured in 35 women with the FMR1 premutation and 28 controls. The women completed anxiety and depression questionnaires. FMR1 genetic indices (i.e., CGG repeat, quantitative FMRP, FMR1 mRNA, activation ratio) were obtained for the premutation group.

Results

Respiratory sinus arrhythmia was reduced in the FMR1 premutation group relative to controls. While depression symptoms were associated with reduced respiratory sinus arrhythmia among control women, these variables were unrelated in the FMR1 premutation. Elevated FMR1 mRNA was associated with higher respiratory sinus arrhythmia.

Conclusions

Women with the FMR1 premutation demonstrated autonomic dysregulation characterized by reduced vagal tone. Unlike patterns observed in the general population and in study controls, vagal activity and depression symptoms were decoupled in women with the FMR1 premutation, suggesting independence between autonomic regulation and psychopathological symptoms that is atypical and potentially specific to the FMR1 premutation. The association between vagal tone and mRNA suggests that molecular variation associated with FMR1 plays a role in autonomic regulation.

STUDIES IN FETAL BEHAVIOR: REVISITED, RENEWED, AND REIMAGINED

Among the earliest volumes of this monograph series was a report by Lester Sontag and colleagues, of the esteemed Fels Institute, on the heart rate of the human fetus as an expression of the developing nervous system. Here, some 75 years later, we commemorate this work and provide historical and contemporary context on knowledge regarding fetal development, as well as results from our own research. These are based on synchronized monitoring of maternal and fetal parameters assessed between 24 and 36 weeks gestation on 740 maternal-fetal pairs compiled from eight separate longitudinal studies, which commenced in the early 1990s. Data include maternal heart rate, respiratory sinus arrhythmia, and electrodrmal activity and fetal heartrate, motor activity, and their integration. Hierarchical linear modeling of developmental trajectories reveals that the fetus develops in predictable ways consistent with advancing parasympathetic regulation. Findings also include:within-fetus stability (i.e., preservation of rank ordering over time) for heart rate, motor, and coupling measures; a transitional period of decelerating development near 30 weeks gestation; sex differences in fetal heart rate measures but not in most fetal motor activity measures; modest correspondence in fetal neurodevelopment among siblings as compared to unrelated fetuses; and deviations from normative fetal development in fetuses affected by intrauterine growth restriction and other conditions. Maternal parameters also change during this period of gestation and there is evidence that fetal sex and individual variation in fetal neurobehavior influence maternal physio-logical processes and the local intrauterine context. Results are discussed within the framework of neuromaturation, the emergence of individual differences, and the bidirectional nature of the maternal-fetal relationship.We pose a number of open questions for future research. Although the human fetus remains just out of reach, new technologies portend an era of accelerated discovery of the earliest period of development

Sexually dimorphic adaptations in basal maternal stress physiology during pregnancy and implications for fetal development

There is clear evidence of reciprocal exchange of information between the mother and fetus during pregnancy but the majority of research in this area has focussed on the fetus as a recipient of signals from the mother. Specifically, physiological signals produced by the maternal stress systems in response to the environment may carry valuable information about the state of the external world. Prenatal stress produces sex-specific adaptations within fetal physiology that have pervasive and long-lasting effects on development. Little is known, however, about the effects of sex-specific fetal signals on maternal adaptations to pregnancy. The current prospective study examined sexually dimorphic adaptations within maternal stress physiology, including the hypothalamic-adrenal-pituitary (HPA) axis and the autonomic nervous system (ANS) and associations with fetal growth. Using diurnal suites of saliva collected in early and late pregnancy, we demonstrate that basal cortisol and salivary alpha-amylase (sAA) differ by fetal sex. Women carrying female fetuses displayed greater autonomic arousal and flatter (but more elevated) diurnal cortisol patterns compared to women carrying males. Women with flatter daytime cortisol trajectories and more blunted sAA awakening responses also had infants with lower birth weight. These maternal adaptations are consistent with sexually dimorphic fetal developmental/evolutionary adaptation strategies that favor growth for males and conservation of resources for females. The findings provide new evidence to suggest that the fetus contributes to maternal HPA axis and ANS regulation during pregnancy and that these systems also contribute to the regulation of fetal growth.

Depression and Anxiety in Women During Pregnancy in Slovenia

Objective

The aim of the study was to evaluate the prevalence of elevated depression and anxiety among pregnant women and to examine its correlation with medical complications and socio-demographic characteristics.

Methods

The study is based on a cross-sectional design of a sample of 348 women in three trimesters of pregnancy who received routine obstetrical care at the University Medical Centre Ljubljana, Department of Obstetrics and Gynaecology. The responding women filled out a questionnaire on socio-demographic variables, the Centre for Epidemiologic Studies Depression Scale CES-D and the State Trait Anxiety Inventory STAI.

Results

21.7% of pregnant women were identified as suffering from elevated depression symptomatology, 15.7% reported high state anxiety and 12.5% had high trait anxiety. No significant differences in depression and anxiety across pregnancy trimesters were found. The women who have suffered from health complications during previous pregnancies showed higher state anxiety; those experiencing complications during their current pregnancy reported more intense symptoms of depression and of state and trait anxiety than women free of complications. Less educated, lower income and mothers of many children in the third pregnancy trimester reported more intensive symptoms of depression and trait anxiety.

Conclusions

Elevated depression and anxiety are frequent among pregnant women. The results draw attention to the need for early detection and treatment of depression and anxiety during pregnancy.

Enhanced response to music in pregnancy

Given a possible effect of estrogen on the pleasure-mediating dopaminergic system, musical appreciation in participants whose estrogen levels are naturally elevated during the oral contraceptive cycle and pregnancy has been investigated (n = 32, 15 pregnant, 17 nonpregnant; mean age 27.2). Results show more pronounced blood pressure responses to music in pregnant women. However, estrogen level differences during different phases of oral contraceptive intake did not have any effect, indicating that the observed changes were not related to estrogen. Effects of music on blood pressure were independent of valence, and dissonance elicited the greatest drop in blood pressure. Thus, the enhanced physiological response in pregnant women probably does not reflect a protective mechanism to avoid unpleasantness. Instead, this enhanced response is discussed in terms of a facilitation of prenatal conditioning to acoustical (musical) stimuli.

Physiological reactivity of pregnant women to evoked fetal startle

OBJECTIVE

The bidirectional nature of mother-child interaction is widely acknowledged during infancy and childhood. Prevailing models during pregnancy focus on unidirectional influences exerted by the pregnant woman on the developing fetus. Prior work has indicated that the fetus also affects the pregnant woman. Our objective was to determine whether a maternal psychophysiological response to stimulation of the fetus could be isolated.

METHODS

Using a longitudinal design, an airborne auditory stimulus was used to elicit a fetal heart rate and motor response at 24 (n=47) and 36 weeks (n=45) of gestation. Women were blind to condition (stimulus versus sham). Maternal parameters included cardiac (heart rate) and electrodermal (skin conductance) responses. Multilevel modeling of repeated measures with 5 data points per second was used to examine fetal and maternal responses.

RESULTS

As expected, compared to a sham condition, the stimulus generated a fetal motor response at both gestational ages, consistent with a mild fetal startle. Fetal stimulation was associated with significant, transient slowing of maternal heart rate coupled with increased skin conductance within 10s of the stimulus at both gestational ages. Nulliparous women showed greater electrodermal responsiveness. The magnitude of the fetal motor response significantly corresponded to the maternal skin conductance response at 5, 10, 15, and 30s following stimulation.

CONCLUSION

Elicited fetal movement exerts an independent influence on the maternal autonomic nervous system. This finding contributes to current models of the dyadic relationship during pregnancy between fetus and pregnant woman.

Biological aspects of postpartum depression

In comparison with the vast epidemiological literature on postpartum depression (PPD), relatively few studies have examined the biological aspects of the disorder. However, research into the biological mechanisms of PPD is a challenging task, as normal pregnancy and the postpartum period cause adaptive endocrine changes, which would otherwise be considered pathological in nonpregnant women. This review focuses on the adaptive changes of childbearing and nursing, which ultimately may put women at increased risk of PPD. In light of the normal physiology, the authors also attempt to describe the current evidence of the biological changes associated with the development of depression in the postpartum period, including ovarian steroids, the hypothalamic-pituitary-adrenal axis, the serotonergic neurotransmitter system, the thyroid system and inflammatory markers. In addition, current knowledge on candidate genes associated with PPD is reviewed.

Maternal stress in pregnancy: considerations for fetal development

There is significant current interest in the degree to which prenatal exposures, including maternal psychological factors, influence child outcomes. Studies that detect an association between prenatal maternal psychological distress and child developmental outcomes are subject to a number of interpretative challenges in the inference of causality. Some of these are common to many types of prenatal exposures that must necessarily rely on observational designs. Such challenges include the correlation between prenatal and postnatal exposures and the potential role of other sources of shared influence, such as genetic factors. Others are more specific to this area of research. These include confounding between maternal report of child outcomes and the maternal psychological attributes under study, difficulties in distinguishing maternal stress from more ubiquitous aspects of maternal personality, and the lack of association between cortisol and measures of maternal psychological stress. This article considers these methodological issues and offers an additional methodology focused on fetal neurobehavior for discerning potential mechanisms that may mediate associations between maternal psychological functioning and the developing fetal nervous system.

Symptoms of depression during pregnancy are associated with increased systolic blood pressure responses towards infant distress

A mother's response towards her infant's distress is important for the mother-infant relationship and infant development. There is evidence that maternal responses are impaired in depressed mothers. Further understanding of how depression disrupts maternal responses is important to direct treatment strategies. There is evidence that maternal responses develop during pregnancy. Further understanding of the relationship between depression and maternal responses during pregnancy is therefore important. We have previously found that depression during pregnancy is associated with reduced attentional engagement with infant distress but is unclear whether this is an insensitive or avoidance response. In the current study, we investigated the impact of anhedonic symptoms of depression on pregnant women's autonomic response towards infant distress. We found that women experiencing anhedonic depressive symptoms during pregnancy had significantly larger systolic blood pressure responses towards infant distress (β, 1.6 mmHg, 95 % CI 0.5 to 2.6, p = 0.004) than non-depressed pregnant women. These results suggest that anhedonic symptoms during pregnancy may be associated with increased sympathetic sensitivity. This suggests that depression is not, at a sympathetic level at least, associated with insensitivity to infant distress and rather depression may be associated with an abnormally sensitive response.

Decreased startle modulation during anticipation in the postpartum period in comparison to late pregnancy

Knowledge about healthy women’s psychophysiological adaptations during the large neuroendocrine changes of pregnancy and childbirth is essential in order to understand why these events have the potential to disrupt mental health in vulnerable individuals. This study aimed to compare startle response modulation, an objective psychophysiological measure demonstrated to be influenced by anxiety and depression, longitudinally across late pregnancy and the postpartum period. The acoustic startle response modulation was assessed during anticipation of affective images and during image viewing in 31 healthy women during gestational weeks 36–39 and again at 4 to 6 weeks postpartum. No startle modulation by affective images was observed at either time point. Significant modulation during anticipation stimuli was found at pregnancy assessment but was reduced in the postpartum period. The women rated the unpleasant images more negative and more arousing and the pleasant images more positive at the postpartum assessment. Self-reported anxiety and depressive symptoms did not change between assessments. The observed postpartum decrease in modulation of startle by anticipation suggests a relatively deactivated defense system in the postpartum period.

Physiological blunting during pregnancy extends to induced relaxation

There is accumulating evidence that pregnancy is accompanied by hyporesponsivity to physical, cognitive, and psychological challenges. This study evaluates whether observed autonomic blunting extends to conditions designed to decrease arousal. Physiological and psychological responsivity to an 18-min guided imagery relaxation protocol in healthy pregnant women during the 32nd week of gestation (n=54) and non-pregnant women (n=28) was measured. Data collection included heart period (HP), respiratory sinus arrhythmia (RSA), tonic and phasic measures of skin conductance (SCL and NS-SCR), respiratory period (RP), and self-reported psychological relaxation. As expected, responses to the manipulation included increased HP, RSA, and RP and decreased SCL and NS-SCR, followed by post-manipulation recovery. However, responsivity was attenuated for all physiological measures except RP in pregnant women, despite no difference in self-reported psychological relaxation. Findings support non-specific blunting of physiological responsivity during pregnancy.

Sympathetic reactivity in late pregnancy is related to labour onset in women

Stress regulation during pregnancy is considered to be connected to the timing of labour initiation. Although increasing knowledge is emerging on the regulation of parturition, there is currently no way to predict the start of spontaneous labour in women. The main aim of this study was to assess pain threshold and the sympathetic nervous system response to cold pain in relation to the onset of labour in healthy pregnant women. Ninety-three pregnant women were recruited and assessed for skin conductance (SC) activity during a cold pressor test in gestational week 38. Pain threshold and cold endurance were also measured and the results were compared with data obtained from hospital records. Seventy-four women had a spontaneous labour onset and a valid SC measurement. SC activity during the cold pressor test decreased significantly with the number of days left to spontaneous parturition. This may indicate a gradual decrease in sympathetic autonomic nervous system reactivity even during the last weeks of pregnancy. Measuring SC activity during mild stress provocation is a rapid and non-invasive means to study variation in sympathetic reactivity during pregnancy, and may be useful in research on stress regulation in pregnancy and its relation to labour initiation.

Giving birth to a new brain: hormone exposures of pregnancy influence human memory

Mammalian pregnancy produces alterations in maternal physiology that are necessary for maintaining gestation, fetal development and parturition. These changes also may prepare the maternal brain for the unique demands of motherhood. Parous rodents exhibit long-term changes in neurological structure and function and human work suggests that other landmark events in the reproductive cycle, such as menarche and menopause, influence cognition. However, the influence of pregnancy on the human brain remains to be elucidated. This study indicates that verbal recall memory (but not recognition or working memory) diminishes during human pregnancy and that these decrements persist after parturition. Further, prenatal glucocorticoids and estrogen are associated with these alterations. To meet the challenges of motherhood, the female brain may be remodeled, a process that appears to be initiated prenatally. However, it is not often that adaptation is achieved without an associated cost. For the human, in the case of the new maternal brain, diminished memory performance may reflect such a cost.

Maternal, obstetric variables, perceived stress and health-related quality of life among pregnant women in Macao, China

OBJECTIVE

to identify associations between demographic, socio-economic and obstetric variables and health-related quality of life with perceived stress among Macao Chinese pregnant women.

DESIGN

a cross-sectional, exploratory quantitative study.

SETTING

an antenatal clinic of a university-affiliated regional public hospital in Macao.

PARTICIPANTS

a community-based sample (n = 1151) of pregnant women in the second trimester of pregnancy.

MEASUREMENTS

perceived stress was measured using the Perceived Stress Scale, and health-related quality of life was measured using the standard Short Form-12 Health Survey.

FINDINGS

a multiple linear regression analysis revealed that pregnant women who were younger (β = 0.085, p = 0.002), single, divorced, separated or cohabiting (β = 0.067, p < 0.009), had a lower level of education (β = 0.079, p = 0.003), worked long hours (β = 0.102, p < 0.001) or who had an unplanned pregnancy (β = 0.063, p = 0.014) with late initiation of antenatal care (β = 0.066, p = 0.008) or poor physical (β = -0.501, p < 0.001) or mental (β = -0.115, p < 0.001) health-related quality of life had higher levels of perceived stress.

CONCLUSION

preliminary information was provided about Macao pregnant women who had higher perceived stress during pregnancy that was associated with the demographic, socio-economic, obstetric and health-related quality-of-life variables.

IMPLICATIONS FOR PRACTICE

the development of a checklist or structured questions for clinical situations is necessary, and programmes of stress management should be tailor made during pregnancy.

Nutritional influences on maternal autonomic function during pregnancy

The objective of this study was to identify influences on longitudinal changes in autonomic function during pregnancy. We studied 195 low-income Peruvian women who were subjects in a randomized controlled trial of zinc supplementation and fetal neurobehavioral development. Maternal cardiorespiratory status and electrodermal activity were assessed at 20, 24, 28, 32, 36, and 38 weeks’ gestation over a 50-min session. At baseline (10–16 weeks), and at 28 and 36 weeks’ gestation, mass and height, arm and calf circumferences, and skinfold thicknesses were assessed, and blood was taken to measure hemoglobin, hematocrit, and plasma zinc concentration. Measures of heart period (HP), respiratory period (RP), respiratory sinus arrhythmia (RSA), skin conductance level (SCL), and mean arterial pressure (MAP) were analyzed using longitudinal models. Having a hemoglobin concentration <10.5 g·dL–1 at 28 weeks was associated with shorter HP and RP and lower RSA, and change in hemoglobin from baseline to 36 weeks was associated with decreased SCL. Further, 3 measures were associated with variation in fat or fat-free mass in the calf; RSA was negatively associated with changes in calf muscle area over pregnancy, while changes in calf fat area were positively associated with MAP and SCL. Variability in autonomic function during the second half of pregnancy is associated with hematologic status and changes in lower limb body composition across pregnancy.

The effect of obesity on heart rate (heart period) and physiologic parameters during pregnancy

Obesity and excess gestational weight gain (EGWG) in pregnancy increase the risk for adverse maternal and infant outcomes. Along with careful monitoring of weight gain during pregnancy, early identification of a maladaptive response to the changes of pregnancy may help to avoid adverse outcomes. Simple physiologic markers such as resting heart rate (HR), heart period (HP), and blood pressure (BP) may be powerful predictors of cardiovascular adaptation to pregnancy. This article summarizes the current state of the science regarding the effect of obesity (body mass index [BMI] > or =30 kg/m(2)) and EGWG in pregnant women at rest in laboratory settings. The impact of differences in weight gain (kg and BMI) on pregnancy outcomes is also examined. A search was conducted for articles published from 1985 to 2006 reporting data on body weight and HR or HP at rest from randomized controlled trials or controlled trials conducted in laboratory settings involving pregnant women at low or high risk for adverse pregnancy outcomes who were obese or had EGWG. A meta-analysis was conducted on the 23 studies meeting inclusion criteria to explore the relation of BMI to HR, HP, and physiologic parameters. Autonomic responsiveness was found to be diminished in obese women with a BMI > 30 kg/m(2) and in women with high risk for adverse pregnancy outcomes, which may indicate a maladaptive autonomic response that is imbalanced and disorganized and that reduces adaptation to environmental demands.

Diurnal rhythm of cortisol during late pregnancy: associations with maternal psychological well-being and fetal growth

Maternal psychological functioning during pregnancy affects both maternal and fetal well-being. The hypothalamic-pituitary-adrenal (HPA) axis provides one mechanism through which maternal psychosocial factors may be transduced to the fetus. However, few studies have examined maternal psychological factors or birth outcomes in relation to the diurnal pattern of cortisol across the day. The current study examined maternal psychological well-being, parity status, and birth weight in relation to the maternal cortisol diurnal rhythm in a group of 98 low-risk pregnant women (51 primiparae). At 36 weeks gestation, participants completed both pregnancy-specific and general self-report measures of psychological functioning and provided saliva samples at 8:00, 12:00, and 16:00 h on 2 consecutive working days for the assay of cortisol. The expected diurnal decline in salivary cortisol was observed. Higher trait anxiety was associated with a flatter afternoon decline for all mothers. For primiparae, steeper morning cortisol declines were associated with lower infant birth weight. The findings suggest that regulation of the HPA axis may differ by parity status with downstream implications for fetal growth and development.

Continuity in self-report measures of maternal anxiety, stress, and depressive symptoms from pregnancy through two years postpartum

This study examined stability and change in maternal anxiety, stress and depression both during the second half of pregnancy and from pregnancy to six weeks and two years postpartum. Self-report measures included those designed to measure mood and state as well as more persistent attributes. Longitudinal data were collected from 137 women during pregnancy, 120 at six weeks, and 97 at two years. There was significant individual stability in scores on specific measures during pregnancy (range in Pearson rs=0.30-0.86) and from pregnancy through two years postpartum (rs=0.30-0.74). Comparable levels of convergence among measures of different constructs both within pregnancy and over time were also demonstrated, suggesting lack of precision in measurement instruments designed for specific constructs. Despite intra-individual stability, changes in mean levels were also observed over time with somewhat different patters for each variable. However, maternal parity was an important contributor to both level and trajectory. A summary composite score showed an elevated level of psychological distress during pregnancy in multiparous women, followed by a decline through two years postpartum; primiparous women displayed a gradual increase in distress [main effect F (1,87)=3.97, p < 0.05; time interaction F (2,174)= 7.15, p < 0.001] to multiparous levels by two years. Results are discussed in terms of a "motherhood" effect on psychological distress.

Maternal psychological distress during pregnancy in relation to child development at age two

Concern exists that a constellation of negative maternal emotions during pregnancy generates persistent negative consequences for child development. Maternal reports of anxiety, pregnancy-specific and nonspecific stress, and depressive symptoms were collected during mid-pregnancy and at 6 weeks and 24 months after birth in a sample of healthy women with low risk pregnancies. Developmental assessment and cardiac vagal tone monitoring were administered to 94 children at age 2. Higher levels of prenatal anxiety, nonspecific stress, and depressive symptoms were associated with more advanced motor development in children after postnatal control for each psychological measure; anxiety and depression were also significantly and positively associated with mental development. Mild to moderate levels of psychological distress may enhance fetal maturation in healthy populations.

Fear of Childbirth and Pregnancy-Related Anxiety in Women Conceiving With Assisted Reproduction

OBJECTIVE

To compare the prevalence and predictors of severe fear of childbirth and pregnancy-related anxiety in groups of assisted reproduction treatment (ART) and spontaneously conceiving women with singleton pregnancies.

METHODS

The ART group (n = 367, nulliparous 260) represented a cohort from five Finnish infertility clinics in 1999. The control group (n = 379, nulliparous 135) was enrolled in this study by consecutive sampling the same year. Fear of childbirth was assessed by means of the revised version of the Fear-of-Childbirth Questionnaire and pregnancy-related anxiety by means of the Pregnancy Anxiety Scale at gestational week 20 +/- 3.2 (mean+/-standard deviation).

RESULTS

The frequency of severe fear of childbirth and anxiety (classified as total scores in the 90th percentile or higher in the revised Fear of Childbirth Questionnaire and Pregnancy Anxiety Scale) did not differ between the groups. Nulliparity was associated with more frequent severe anxiety only in the controls. In nulliparous participants, a partnership of more than 5 years decreased the risk of severe fear of childbirth (odds ratio 0.3, 95% confidence interval 0.2-0.7). In the nulliparous ART group, a long duration of infertility (7 or more years) increased the risk of severe fear of childbirth (odds ratio 4.4, 95% confidence interval 1.2-16.9).

CONCLUSION

Women conceiving after ART do not experience severe fear of childbirth or pregnancy-related axiety more often than spontaneously conceiving controls. However, a long duration of infertility is an independent risk factor regarding severe fear of childbirth.

LEVEL OF EVIDENCE

II-2.