A new concept of maternity blues: Is there a subgroup of women with rapid cycling mood symptoms?

Reducing psychiatric illness in the perinatal period: A review and commentary

This brief overview highlights the global crisis of perinatal psychiatric illness (PPI). PPI is a major contributor to many adverse pregnancy, childbirth, and childhood development outcomes. It contributes to billions of dollars in spending worldwide each year and has a significant impact on the individual, their family, and their community. It is also highly preventable. Current recommendations for intervention and management of PPI are limited and vary considerably from country to country. Furthermore, there are several significant challenges asso-ciated with implementation of these recommendations. These challenges are magnified in number and consequence among women of color and/or minority populations, who experience persistent and negative health disparities during pregnancy and the postpartum period. This paper aims to provide a broad overview of the current state of recommendations and implementation challenges for PPI and layout a framework for overcoming these challenges. An equity-informed model of care that provides universal intervention for pregnant women may be one solution to address the preventable consequences of PPI on child and maternal health. Uniquely, this model emphasizes the importance of managing and eliminating known barriers to traditional health care models. Culturally and contextually specific challenges must be overcome to fully realize the impact of improved management of PPI.

Maternity Blues: A Narrative Review

Puerperium is a period of great vulnerability for the woman, associated with intense physical and emotional changes. Maternity blues (MB), also known as baby blues, postnatal blues, or post-partum blues, include low mood and mild, transient, self-limited depressive symptoms, which can be developed in the first days after delivery. However, the correct identification of this condition is difficult because a shared definition and well-established diagnostic tools are not still available. A great heterogenicity has been reported worldwide regarding MB prevalence. Studies described an overall prevalence of 39%, ranging from 13.7% to 76%, according to the cultural and geographical contexts. MB is a well-established risk factor for shifting to more severe post-partum mood disorders, such as post-partum depression and postpartum psychosis. Several risk factors and pathophysiological mechanisms which could provide the foundation of MB have been the object of investigations, but only poor evidence and speculations are available until now. Taking into account its non-negligible prevalence after childbirth, making an early diagnosis of MB is important to provide adequate and prompt support to the mother, which may contribute to avoiding evolutions toward more serious post-partum disorders. In this paper, we aimed to offer an overview of the knowledge available of MB in terms of definitions, diagnosis tools, pathophysiological mechanisms, and all major clinical aspects. Clinicians should know MB and be aware of its potential evolutions in order to offer the most timely and effective evidence-based care.

Mood instability, depression, and anxiety in pregnancy and adverse neonatal outcomes

Background

Antenatal women experience an increased level of mood and anxiety symptoms, which have negative effects on mothers’ mental and physical health as well as the health of their newborns. The relation of maternal depression and anxiety in pregnancy with neonate outcomes is well-studied with inconsistent findings. However, the association between antenatal mood instability (MI) and neonatal outcomes has not been investigated even though antenatal women experience an elevated level of MI. We sought to address this gap and to contribute to the literature about pregnancy neonate outcomes by examining the relationship among antenatal MI, depression, and anxiety and neonatal outcomes.

Methods

A prospective cohort of women (n = 555) participated in this study at early pregnancy (T1, 17.4 ± 4.9 weeks) and late pregnancy (T2, 30.6 ± 2.7 weeks). The Edinburgh Postnatal Depression Scale (EPDS) was used to assess antenatal depressive symptoms, anxiety was measured by the EPDS anxiety subscale, and mood instability was measured by a visual analogue scale with five questions. These mood states together with stress, social support, as well as lifestyle were also examined in relation to neonatal outcomes using chi-square tests and logistic regression models.

Results

Mood instability, depression, and anxiety were unrelated to adverse neonatal outcomes. Only primiparous status was associated with small for gestational age after Bonferroni correction.

Conclusions

We report no associations between antenatal mood symptoms including MI, depression, and anxiety and neonatal outcomes. More studies are required to further explore the relationship between antenatal mood instability, depression, and anxiety and neonatal outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04021-y.

Maternity blues: a risk factor for anhedonia, anxiety, and depression components of Edinburgh Postnatal Depression Scale

Background: Women undergo adaptive physical and psychological changes during pregnancy, which make them vulnerable to psychological disorders.Methods: This study used a prospective observational design and included concurrent validation analysis of the 16-item Maternity Blues Scale (MBS) Dutch version to determine the direction and magnitude on the Edinburgh Postnatal Depression Scale (EPDS) symptoms, including three factors, anhedonia, anxiety, and depression in 320 puerperae early after childbirth.Results: We found a statistically significant correlation between MBS and EPDS global scores (0.22, p < .001). Moreover, Negative affect was significantly correlated with the EPDS global score (0.23, p < .001), anhedonia (0.12, p < .05), and anxiety (0.25, p < .001); Positive affect with the EPDS global score (0.14, p < .05) and depression (0.13, p < .05); and Depression subscale with EPDS global score (0.15, p < .05), anhedonia (0.12, p < .05), and anxiety (0.12, p < .05), and depression (0.12, p < .05). In addition, the subgroup of women (n = 33, 10.3%) with EPDS > 12 presented significantly higher global MBS score (2.51 ± 0.38 versus 2.26 ± 0.38, p = .01), with negative affect (2.88 ± 0.67 versus 2.62 ± 0.38, p=.04), positive affect (2.52 ± 0.69 versus 2.32 ± 0.38, p = .04), and depression (2.09 ± 0.75 versus 1.82 ± 0.36, p = .02).Conclusion: These findings together suggest that women with higher maternity blues scores may represent a distinct subgroup at increased risk of depression.

Human milk cortisol and immune factors over the first three postnatal months: Relations to maternal psychosocial distress

Background

Many biologically active factors are present in human milk including proteins, lipids, immune factors, and hormones. The milk composition varies over time and shows large inter-individual variability. This study examined variations of human milk immune factors and cortisol concentrations in the first three months post-partum, and their potential associations with maternal psychosocial distress.

Methods

Seventy-seven healthy mothers with full term pregnancies were enrolled, of which 51 mothers collected morning milk samples at 2, 6 and 12 weeks post-delivery. Maternal psychosocial distress was assessed at 6 weeks post-delivery using questionnaires for stress, anxiety, and depressive symptoms. Immune factors were determined using multiplex immunoassays and included innate immunity factors (IL1β, IL6, IL12, IFNγ, TNFα), acquired immunity factors (IL2, IL4, IL10, IL13, IL17), chemokines (IL8, Groα, MCP1, MIP1β), growth factors (IL5, IL7, GCSF, GMCSF, TGFβ2) and immunoglobulins (IgA, total IgG, IgM). Cortisol was quantified using liquid chromatography-tandem mass spectrometry. A linear mixed effects model was fit to test whether stress, anxiety, and depressive symptoms individually predicted human milk cortisol concentrations after accounting for covariates. Repeated measurement analyses were used to compare women with high (n = 13) versus low psychosocial distress (n = 13) for immune factors and cortisol concentrations.

Results

Virtually all immune factors and cortisol, with the exception of the granulocyte-macrophage colony-stimulating factor (GMCSF), were detected in the human milk samples. The concentrations of the immune factors decreased during the first 3 months, while cortisol concentrations increased over time. No correlation was observed between any of the immune factors and cortisol. No consistent relationship between postnatal psychosocial distress and concentrations of immune factors was found, whereas higher psychosocial distress was predictive of higher cortisol concentrations in human milk.

Conclusion

In the current study we found no evidence for an association between natural variations in maternal distress and immune factor concentrations in milk. It is uncertain if this lack of association would also be observed in studies with larger populations, with less uniform demographic characteristics, or with women with higher (clinical) levels of anxiety, stress and/or depressive symptoms. In contrast, maternal psychosocial distress was positively related to higher milk cortisol concentrations at week 2 post-delivery. Further investigation on maternal psychosocial distress in relation to human milk composition is warranted.

Mood instability across the perinatal period: A cross-sectional and longitudinal study

BACKGROUND

As a trans-diagnostic concept, mood instability (MI) is significantly linked to a variety of psychiatric disorders in general and clinical samples. However, there is limited research on perinatal MI, even though perinatal women experience an elevated level of MI. In this study, we examined the relationship between perinatal MI and its risk factors, the association between antenatal MI and postpartum depression (PPD), and the trajectory of perinatal MI.

METHODS

A total of 648 women participated in this longitudinal study at three points: T1 (17.4 ± 4.9 weeks pregnant), T2 (30.6 ± 2.7 weeks pregnant), and T3 (4.2 ± 2.1 weeks postpartum). Linear regression was used to examine MI and its risk factors, hierarchical multiple regression was utilized to investigate the relationship between antenatal MI and PPD, and a linear mixed model was employed to examine the trajectory of perinatal MI over T1-T3.

RESULTS

Perinatal depression, history of depression, and stress at T1, T2, and T3, and labor/birth complications at T3 were significant risk factors for MI. MI at T1 was associated with PPD after controlling for important confounders at T1. The trajectory of perinatal MI had a declined trend from early pregnancy to postpartum.

LIMITATIONS

The participants were predominantly Caucasian and with post-secondary education, which may limit the generalization of our findings. A lack of research on perinatal MI limited our ability to discuss the topic in relation to existing literature.

CONCLUSIONS

This study expands our understanding of MI in perinatal women, and indicates that more research is needed.

Systematic Review and Meta-Analysis of the Prevalence of the Maternity Blues in the Postpartum Period

OBJECTIVE

To determine the prevalence of maternity blues among women in the postpartum period.

DATA SOURCES

We conducted our systematic review and meta-analysis by searching the literature for relevant articles published in three international databases, PubMed, Web of Science, and Scopus, from date of inception through December 11, 2019, using the keywords prevalence, incidence, maternity blues, and baby blues.

STUDY SELECTION

From 336 articles initially screened, we included 26 articles in the systematic review and meta-analysis.

DATA EXTRACTION

Two independent reviewers used a standardized form to extract data from eligible articles. We evaluated the quality of individual studies and the overall evidence according to Hoy et al.'s risk of bias tool.

DATA SYNTHESIS

The prevalence of maternity blues in the 26 included studies was 13.7% to 76.0%. Based on the results of the random effects model, the prevalence of maternity blues in 5,667 women was 39.0% (95% confidence interval [32.3, 45.6]; I² = 96.6%). The prevalence of maternity blues among women in Africa was greatest at 49.6%.

CONCLUSION

Considering the great prevalence of maternity blues in women after childbirth, paying attention to the key symptoms of maternity blues and implementing educational programs for health care providers and mothers after childbirth are essential.

The association between the degree of nausea in pregnancy and subsequent posttraumatic stress

Hyperemesis gravidarum (HG) is a pregnancy condition characterised by severe nausea and vomiting during early pregnancy. The experience of HG is for many women a traumatic event. Few studies have investigated a possible association between HG and birth-related posttraumatic stress. The objective of the current study was to assess whether HG increases the risk of birth-related posttraumatic stress symptoms (PTSS). This was a population-based pregnancy cohort study using data from the Akershus Birth Cohort Study (ABC study). A linear mixed model was used to estimate the association between the degree of nausea (no nausea (n = 574), mild nausea (n = 813), severe nausea (n = 522) and HG (hospitalised due to nausea, n = 20)) and PTSS score at 8 weeks and 2 years after birth. At 8 weeks postpartum, women with HG had higher PTSS scores compared to women with no nausea (p = 0.008), women with mild nausea (p = 0.019) and women with severe nausea (p = 0.027). After 2 years, women with HG had higher PTSS scores compared to women with no nausea (p = 0.038). Women with HG had higher PTSS scores following childbirth compared to women with less pronounced symptoms or no nausea at all. After 2 years, women with HG still had higher PTSS scores compared to women with no nausea. Although the overall differences in PTSS scores were small, the results may still be of clinical relevance.

Maternity blues: risk factors in Greek population and validity of the Greek version of Kennerley and Gath's blues questionnaire

Aim: To validate the Greek version of Kennerley and Gath's Blues Questionnaire (BQ) and gather further knowledge on maternity blues (MB) associations with certain clinical and sociodemographic factors in Greek population.Material and methods: 116 postpartum women, who met the inclusion criteria, completed the Blues Questionnaire and the Edinburgh Postnatal Depression Scale on the third day after delivery. Sociodemographic and clinical data were also collected.Results: Fifty women (43.1%) experienced severe MB on the third day postpartum. Lower number of previous births, fewer years of marriage, and husband's occupation were found to be associated with MB occurrence. Of them, years of marriage (odds 0.21, p = .001) and husband's occupation in private sector (odds 1.21, p = .04) were independent predictors of MB in logistic regression analysis. Cronbach's α for the total 28-item Greek version of BQ was 0.85. Cluster analysis in our data showed that the optimal number of clusters of BQ items was 4; these four clusters of items presented similarities with the Bartholomew and Horowitz's four-category model of attachment styles (avoidant - dismissing, preoccupied, secure, avoidant - fearful).Conclusions: The Greek version of Blues Questionnaire is a reliable tool for the detection and measurement of MB. Fewer years of marriage and the economic insecurity seem to have strong impact on the occurrence of MB. Further investigation is needed to evaluate whether the phenomenon of MB is associated with parental or mother-to-infant bonding disorders.

Immediate postpartum mood assessment and postpartum depressive symptoms

BACKGROUND

Negative affect (NA) and positive affect (PA) in the early postpartum period have been associated with postpartum depressive symptoms, but the exact relationship is not well understood. This study aimed to determine if NA and PA in the immediate postpartum period predicted postpartum depressive symptoms over and above well-established predictors (previous trauma, history of depression).

METHODS

Participants were prospectively recruited from a Mother-Baby Unit at a large Midwestern academic medical center in the United States from April 2011 to April 2014. Participants (N=526) completed the Daily Experiences Questionnaire (DEQ), a self-report measure which assessed NA and PA, within three days post-delivery. Participants then reported their depressive symptoms at two weeks (n=364) and twelve weeks postpartum (n=271).

RESULTS

Hierarchical regression analyses indicated that low PA and high NA after birth significantly predicted depressive symptoms early (at 2 weeks) and later (at 12 weeks) in the postpartum period, over and above previous traumatic experiences and history of depression.

LIMITATIONS

The sample was relatively homogenous, and data were from self-report instruments.

CONCLUSIONS

The current study found NA and PA in the days immediately after birth predicted depressive symptoms at multiple time points in the postpartum period. Because the perinatal period places women at a higher risk for depressive symptomatology, prevention and early intervention are critical. Measuring affect in hospitals immediately after birth may provide a more normalized set of items that is predictive of later depression, which will allow physicians to identify those at highest risk for developing depressive symptoms.