The effects of maternal major depression, generalized anxiety disorder, and panic disorder on birth weight and gestational age: a comparative study

High Anxiety Levels before Elective Cesarean Section Can Negatively Affect the Mother and Fetus

BACKGROUND

Both pregnancy and surgery cause anxiety. This situation may negatively affect the health of the mother and baby.

AIM

The effect of anxiety level before cesarean section (CS) on feto-maternal outcomes was investigated.

METHODS

The preoperative anxiety score was determined with the State-Trait Anxiety Inventory (STAI) in 224 pregnant women who were planned for elective CS.

RESULTS

Among patients, 33.5% were in the low anxiety group, 27.2% in the moderate, and 39.3% in the high anxiety group. The average birth weight in the low anxiety group was noticeably higher than that of the high anxiety group (P = 0.018). The mean heart rate at postop 1st and 24th hour in the high anxiety group was higher than the moderate anxiety group (P < 0.028). In addition, diastolic blood pressure (DBP) at the sixth hour in the low anxiety group was found to be lower than in the moderate anxiety group (P < 0.05).

CONCLUSION

According to these results, it was found that an increased anxiety score before CS is associated with low birth weight in the baby, higher heart rate, and DBP in the mother.

Complications and Healthcare Consumption of Pregnant Women with a Migrant Background: Could There be an Association with Psychological Distress?

Objective

Previous studies reported less prenatal healthcare consumption and more perinatal complications in women with a migrant background. Hence, we investigated in a country with free healthcare access whether women with a migrant background differed with respect to pregnancy complications, healthcare consumption and in terms of associations with psychological distress in comparison to native Dutch.

Methods

We included 324 native Dutch and 303 women with a migrant background, who visited two hospitals in Amsterdam for antenatal care between 2014 and 2015. Participants completed the Edinburgh Postnatal Depression Scale, the Hospital Depression and Anxiety Scale, and sociodemographic questions. Complications and healthcare consumption during pregnancy were extracted from medical records. Regression analyses were used with adjustment for covariates.

Results

Except for gestational diabetes [adjusted OR = 3.09; 95% CI = (1.51, 6.32)], no differences were found between groups in perinatal complications [OR = 1.15; 95% CI = (0.80, 1.64)], nor in healthcare consumption [OR = 0.87; 95% CI = (0.63, 1.19)].

Women with a migrant background reported more depressive symptoms [Cohen’s d = 0.25; 95% CI = (0.10, 0.41)], even after adjustment for socio-economic factors. Psychological distress was associated with more hospital admissions during pregnancy. When experiencing depressive symptoms, women with a migrant background had an increased risk to be admitted [OR = 1.11; 95% CI = (1.01, 1.21)].

Conclusions for Practice

This cohort study found no differences in pregnancy-related complications, except for diabetes, nor different healthcare consumption, in women with a migrant background versus native Dutch, in a country with free health care access. However, women with a migrant background experienced more depressive symptoms, and when depressed their risk for hospital admission increased. Additional research is warranted to improve healthcare for this population.

Nausea and vomiting during pregnancy: a possible correlation with obsessive compulsive disorder and alexithymia

The possible correlation between nausea and vomiting during pregnancy (NVP) with obsessive-compulsive disorder (OCD) and alexithymia were examined in this cross-sectional study. A cohort of pregnant women at the first trimester of pregnancy experiencing NVP were divided into three groups, according to severity (mild, moderate and severe) with the Pregnancy Unique Quantification of Emesis and Nausea (PUQE) test. The Maudsley Obsessive Compulsive Disorder Scale (MOCQ) and the Toronto Alexithymia Scale (TAS-20) were applied. Scores of scales were compared in all three groups, and the relationship between NVP severity and OCD and alexithymia was evaluated. On the 110 enrolled pregnant women, 42 had mild, 36 had moderate and 32 had severe NVP. Pregnant women with mild NVP had lower MOCQ scores than those with severe NVP (p = .010). Total scores of TAS-20 were higher among subjects with greater NVP severity (p < .001). PUQE scores were demonstrated significant correlations with MOCQ and total and subsection scores of the TAS-20, regardless of NVP groups. Study results showed that women with more pronounced OCD and/or alexithymia can experience somatic complaints, such as NVP, particularly intense in their first trimester of pregnancies. For this reason, psychotherapy in addition to medical treatments could be recommended to pregnant women with severe NVP.Impact statementWhat is already known on this subject? NVP is a condition experienced by most women, particularly in the first trimester of pregnancy, which can be affected by the psychosomatic condition of the pregnant woman.What do the results of this study add? The severity of nausea and vomiting according to PUQE test were significantly associated with OCD and alexithymia presence in pregnant women during their first trimester period.What are the implications of these findings for clinical practice and/or further research? These findings might demonstrate the symptoms of NVP are correlated to OCD, as well as alexithymia. Longitudinal studies are required to demonstrate the clear causal relationship between NVP and psychiatric symptoms as in OCD and in alexithymia.

Associations Between Maternal Depression, Antidepressant Use During Pregnancy, and Adverse Pregnancy Outcomes: An Individual Participant Data Meta-analysis

OBJECTIVE

To evaluate the associations of depressive symptoms and antidepressant use during pregnancy with the risks of preterm birth, low birth weight, small for gestational age (SGA), and low Apgar scores.

DATA SOURCES

MEDLINE, EMBASE, ClinicalTrials.gov, and PsycINFO up to June 2016.

METHODS OF STUDY SELECTION

Data were sought from studies examining associations of depression, depressive symptoms, or use of antidepressants during pregnancy with gestational age, birth weight, SGA, or Apgar scores. Authors shared the raw data of their studies for incorporation into this individual participant data meta-analysis.

TABULATION, INTEGRATION, AND RESULTS

We performed one-stage random-effects meta-analyses to estimate odds ratios (ORs) with 95% CIs. The 215 eligible articles resulted in 402,375 women derived from 27 study databases. Increased risks were observed for preterm birth among women with a clinical diagnosis of depression during pregnancy irrespective of antidepressant use (OR 1.6, 95% CI 1.2-2.1) and among women with depression who did not use antidepressants (OR 2.2, 95% CI 1.7-3.0), as well as for low Apgar scores in the former (OR 1.5, 95% CI 1.3-1.7), but not the latter group. Selective serotonin reuptake inhibitor (SSRI) use was associated with preterm birth among women who used antidepressants with or without restriction to women with depressive symptoms or a diagnosis of depression (OR 1.6, 95% CI 1.0-2.5 and OR 1.9, 95% CI 1.2-2.8, respectively), as well as with low Apgar scores among women in the latter group (OR 1.7, 95% CI 1.1-2.8).

CONCLUSION

Depressive symptoms or a clinical diagnosis of depression during pregnancy are associated with preterm birth and low Apgar scores, even without exposure to antidepressants. However, SSRIs may be independently associated with preterm birth and low Apgar scores.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42016035711.

Postpartum onset of panic disorder: A metaphor analysis

Prevalence rates of postpartum panic disorder range from 0.5% to 2.9%. New mothers may not know the medical terminology to describe what they are experiencing. Metaphors can provide women with a different voice to help provide a basis for shared understanding with clinicians. The purpose of this secondary qualitative data analysis was to examine the metaphors used by women to describe their panic disorder after birth. Metaphor Identification Procedure was used to analyze the primary dataset. The process revealed the following eight metaphors: caged animal, Coke in my veins, bone-tired, imposter, escape artist, magnifying glass, detective, and hermit.

Citalopram in Treatment of Pregnant Women With Panic Disorder: A Retrospective Study

PURPOSE

The study aimed to investigate efficacy of citalopram in pregnant women with panic disorder.

METHODS

The study data with 22 patients were retrospectively collected from clinical registers. The study was conducted in patients with and without comorbid major depression. The patients were evaluated using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the Clinical Global Impression-Improvement Scale, the Hamilton Depression Rating Scale, and the Hamilton Rating Scale for Anxiety.

FINDINGS

The Hamilton Depression Rating Scale and the Hamilton Rating Scale for Anxiety scores were significantly reduced after treatment with citalopram at 20 mg/d for 8 weeks. The response rate based on Clinical Global Impression-Improvement Scale was 68.2%. Patients with comorbid major depression seemed to have a lower response rate compared with nondepressed patients.

IMPLICATIONS

The current study suggests that citalopram may be beneficial for in pregnant women with panic disorder.

Risk of Preterm Birth and Newborn Low Birthweight in Military Women with Increased Pregnancy-Specific Anxiety

INTRODUCTION

Prenatal maternal anxiety and depression have been implicated as possible risk factors for preterm birth (PTB) and other poor birth outcomes. Within the military, maternal conditions account for 15.3% of all hospital bed days, and it is the most common diagnostic code for active duty females after mental disorders. The majority of women (97.6%) serving on active duty are women of childbearing potential. Understanding the impact that prenatal maternal anxiety and depression can have on PTB and low birthweight (LBW) in a military population is critical to providing insight into biological pathways that alter fetal development and growth. The purpose of the study was to determine the impact of pregnancy-specific anxiety and depression on PTB and LBW within a military population.

MATERIAL AND METHODS

Pregnancy-specific anxiety and depression were measured for 246 pregnant women in each trimester. Individual slopes for seven different measures of pregnancy anxiety and one depression scale were calculated using linear mixed models. Logistic regression, adjusted and unadjusted models, were applied to determine the impact on PTB and LBW.

RESULTS

For each 1/10 unit increase in the anxiety slope as it related to well-being, the risk of LBW increased by 83% after controlling for parity, PTB, and active duty status. Similarly, a 1/10 unit rise in the anxiety slope related to accepting pregnancy, labor fears, and helplessness increased the risk of PTB by 37%, 60%, and 54%, respectively.

CONCLUSIONS

Pregnancy-specific anxiety was found to significantly increase the risk of PTB and LBW in a military population. Understanding this relationship is essential in developing effective assessments and interventions. Results emphasize the importance of prenatal maternal mental health to fetal health and birth outcomes. Further research is needed to determine the specific physiological pathways that link prenatal anxiety and depression with poor birth outcomes.

The course and clinical correlates of panic disorder during the postpartum period: a naturalistic observational study

OBJECTIVE

To investigate the course of panic disorder and its demographic and clinical correlates during the postpartum period.

METHODS

Data were collected from 38 consecutive postpartum women diagnosed with panic disorder. Psychiatric assessments were carried out on the first day after delivery and at 6-8 weeks postpartum. During the first assessment, the Panic and Agoraphobia Scale (PAS), Hospital Anxiety and Depression Scale (HADS), Coping Orientation to Problems Experienced (COPE), Multidimensional Scale of Perceived Social Support (MSPSS), and Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) were administered to the participants. PAS was also administered at the second assessment.

RESULTS

The mean PAS score reduced significantly from baseline to the second assessment. Logistic regression analysis indicated that a shorter duration of panic disorder independently predicted a ≥ 50-point decrease in the severity of panic symptoms during the postpartum period.

CONCLUSION

These findings suggest that patients with a short duration of illness may experience significant alleviation in the severity of panic symptoms during the postpartum period.

A spiritual intervention to reduce stress, anxiety and depression in pregnant women: Randomized controlled trial

We assessed the efficacy of a spiritually-integrated cognitive-behavioral educational group intervention for reducing stress, anxiety, depression, and blood pressure during pregnancy and improving delivery outcomes. A randomized controlled trial was conducted in 84 pregnant women randomly assigned to either the intervention or a control group. Demographic information was collected at baseline, along with measures of religiosity, stress, anxiety, depression, and blood pressure. Our intervention consisted of four 90-minute group sessions over 8 weeks that utilized a spiritually-integrated cognitive-behavioral approach to help participants cope with the stress of pregnancy. Stress, anxiety and depression scores in the intervention group decreased significantly by 41%, 28%, and 41%, respectively, from baseline to 3-month follow-up. There were also significant differences in systolic and diastolic blood pressure between groups at the 3-month follow-up, favoring the intervention group. Between-group differences were also significant for these outcomes. Applying such spiritually-integrated intervention may help to improve the mental and physical health of young, healthy nulliparous pregnant women.

Prenatal symptoms of anxiety and depression associated with sex differences in both maternal perceptions of one year old infant temperament and researcher observed infant characteristics

BACKGROUND

Sex differences in the behaviour of children exposed to prenatal maternal depression and anxiety have been reported. This study compared depression and anxiety symptoms reported by mothers at term with maternal perceptions of one year old male and female infant temperament and with researcher observed infant characteristics, identifying differences for males and females with both approaches.

METHODS

Infant behaviour and temperament was assessed via maternally completed questionnaires including Infant Behavioural Questionnaire Revised - Short form and by researcher administered subcomponents of Laboratory Temperament Assessment Battery and Bayley Scales of Infant Development III.

RESULTS

For female infants, higher prenatal scores for depression and anxiety were associated with maternal perceptions of lower bonding, higher aggression and negativity, and lower soothability (n = 67 mother-infant dyads). In the laboratory assessment, intensity of escape was the only female infant factor significantly associated with maternal mood (n = 41). For male infants, there was minimal association between prenatal mood scores and maternal perceptions (n = 46) whereas in the laboratory assessment (n = 35) depression scores were associated with expressive language, facial interest and facial fear while anxiety scores were associated with expressive and receptive language, parent behaviour and facial fear.

LIMITATIONS

Findings may be restricted to a single ethnicity or mode of delivery. Fewer infants attended the infant assessment. A laboratory setting may mask symptomatology in females.

CONCLUSIONS

Atypical maternal perceptions may present a barrier to the early identification of male infants impacted by maternal depression and anxiety.

Association of antepartum depression, generalized anxiety, and posttraumatic stress disorder with infant birth weight and gestational age at delivery

BACKGROUND

Low- and middle-income countries bear a disproportionate burden of preterm birth (PTB) and low infant birth weight (LBW) complications where affective and anxiety disorders are more common in the antepartum period than in industrialized countries.

OBJECTIVE

To evaluate the extent to which early pregnancy antepartum depression, generalized anxiety disorder, and posttraumatic stress disorder (PTSD) are associated with infant birth weight and gestational age at delivery among a cohort of pregnant women in Peru.

METHODS

Our prospective cohort study consisted of 4408 pregnant women. Antepartum depression, generalized anxiety, and PTSD were assessed in early pregnancy using the Patient Health Questionnaire-9, Generalized Anxiety Disorder Scale-7 and PTSD Checklist - Civilian Version, respectively. Pregnancy outcome data were obtained from medical records. Multivariable linear and logistic regression procedures were used to estimate adjusted measures of association (β coefficients and odds ratios) and 95% confidence intervals (CI).

RESULTS

After adjusting for confounders, women with antepartum generalized anxiety (32.6% prevalence) had higher odds of LBW (adjusted odds ratio (OR)=1.47; 95%CI: 1.10-1.95) and were more likely to deliver small for gestational age (OR = 1.39; 95%CI: 1.01-1.92) infants compared to those without anxiety. Compared to those without PTSD, women with PTSD (34.5%) had higher odds of delivering preterm (OR = 1.28; 95%CI: 1.00-1.65) yet PTSD was not associated with LBW nor gestational age at delivery. Women with antepartum depression (26.2%) were at no increased risk of delivering a preterm, low-birth-weight or small-for-gestational-age infant.

LIMITATIONS

Our ability to make casual inferences from this observational study is limited; however, these findings are consistent with prior studies.

CONCLUSION

Generalized anxiety disorder during pregnancy appeared to increase odds of delivering a low-birth-weight or small-for-gestational-age infant, while PTSD was associated with increased odds of delivering preterm. Our findings, and those of others, suggest antenatal care should be tailored to screen for and provide additional mental health services to patients.

The Use of Antidepressant Medications During Pregnancy and the Risk of Neonatal Seizures: A Systematic Review

PURPOSE

This review examined the current literature about the potential relationship between the use of antidepressants during pregnancy and neonatal seizures.

METHODS

PubMed was searched for English language reports published between January 1, 1996, and October 31, 2018, by using combinations of the following key words: pregnancy, neonatal outcome, neonatal convulsion, neonatal seizure, SSRI, selective serotonin norepinephrine reuptake inhibitor (SNRI), tricyclic antidepressant (TCA), antidepressants, sertraline, fluoxetine, paroxetine, citalopram, escitalopram, fluvoxamine, venlafaxine, mirtazapine, duloxetine, bupropion, amitriptyline, imipramine, and clomipramine.

FINDINGS

A total of 9 relevant studies that met the review criteria were examined. The prevalence rates of neonatal seizures in the antidepressant groups and control groups were 0.30% to 0.91% and 0.10% to 0.30%, respectively. The use of selective serotonin reuptake inhibitors was associated with up to 5-fold increase in the risk of neonatal seizures. Compared with the controls, higher risks were reported in newborns of pregnant women using any antidepressant or tricyclic antidepressants albeit in a limited number of studies. Exposure to antidepressants in the third trimester of pregnancy appeared to be associated more with neonatal seizures compared with earlier exposure.

IMPLICATONS

Although an increased risk of neonatal seizures in newborns antenatally exposed to antidepressants especially selective serotonin reuptake inhibitors may be suggested, the available studies have severe methodological limitations to enable any firm conclusion.

Multilevel Impact of Prenatal Risk and Protective Factors on Stress Biology and Infant Development: Study protocol of BABIP prospective birth cohort from Turkey

Prenatal environment has long-lasting effects on offspring development and health. Research on prenatal stress identified various mechanisms of these effects, from changes in epigenetic and gene expression profiles to Maternal-Placental-Fetal (MPF) stress biology. There is also evidence for the role of additional risk and protective factors influencing the impact of prenatal stress on maternal and infant outcomes. Considering these findings, we present the study protocol of BABIP, a prospective birth cohort from Turkey. The aim of the project is to investigate the effect of prenatal stress on MPF stress biology (i.e. neuroendocrine, immune and metabolic systems), differential DNA methylation and gene expression patterns, and infant birth and developmental outcomes. We are recruiting 150 pregnant women and their babies for a longitudinal project with 4 time points: 20-24 (T1) and 30-34 (T2) weeks of pregnancy, and 1-month (T3) and 4-months (T4) after giving birth. Maternal early and prenatal environment (prenatal stress, early life stress, psychosocial resources, and health-related behaviors) are assessed during pregnancy with MPF stress biology, DNA methylation and gene expression measures. Infant birth outcomes, DNA methylation and development are assessed postpartum. BABIP is the first prospective birth cohort from Turkey with extensive measures on prenatal environment and health. Through investigating the multilevel impact of prenatal stress and related risk and protective factors during and after pregnancy, BABIP will contribute to our understanding of the mechanisms by which prenatal environment influences infant development and health. Being the first such cohort from Turkey, it may also allow identification of prenatal risk and protective factors specific to the context and population in Turkey.

The impact of maternal major depression, anxiety disorders and their comorbidities on gestational age, birth weight, preterm birth and low birth weight in newborns

BACKGROUND

The present study compared the impact of maternal major depression, anxiety disorders and their comorbidities on gestational age and birth weight of infants.

METHODS

A total of 1119 women consisting of 26 women with only major depression, 125 women with only anxiety disorder, 36 women with major depression plus an anxiety disorder and 932 women without any psychiatric disorders were included in the study. Psychiatric diagnoses were determined by means of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

RESULTS

The comorbid group had the highest proportion of newborns with preterm birth and low birth weight. Moreover, these newborns had the lowest birth weight and gestational age.

LIMITATIONS

Cross-sectional study design.

CONCLUSIONS

The study results suggest that comorbidity between major depression and anxiety disorders during pregnancy may have noteworthy negative effects on birth weight and gestational age.

Anxiety, depression, and birth outcomes in a cohort of unmedicated women

BACKGROUND

Even though most of the systematic reviews suggest that depression and anxiety are related to poor neonatal outcomes, it is not yet clear whether a dose-response effect exists.

AIM

The aim of the present study is to evaluate the amount of depressive and anxiety symptoms in a cohort of pregnant women and its effect on their newborns.

METHODS

Two hundred ninety-nine women were assessed for anxiety and depressive disorders and anxious and depressive symptoms at near monthly intervals throughout pregnancy. At the time of delivery, we collected the newborns' gestational age, birth weight and the Apgar score at 1 and 5 min.

RESULTS

Sixty-seven women were diagnosed as depressed and 43 had an anxious disorder. After controlling for confounding variables only the overall levels of anxiety during pregnancy were negatively associated with birth weight (B = -5.76; 95% CI = -10.96, -2.81), suggesting the existence of a "dose-response" effect. The birth outcomes in mildly depressed pregnant women were similar to those of nondepressed women.

CONCLUSION

Anxiety symptoms, beyond a categorical diagnosis, are associated with low birth weight and should be recognized and properly treated during pregnancy.

Maternal body mass index moderates antenatal depression effects on infant birthweight

Obesity and depression are two common medical problems that pregnant women present with in antenatal care. Overweight and obesity at the beginning of the pregnancy, and excessive weight gain during pregnancy, are independent explanatory variables for fetal birthweight and independent risk factors for giving birth to a large for gestational age (LGA) infant. However, the effect of co-morbid depression has received little attention. This study set out to investigate if maternal body mass index (BMI) in early pregnancy moderates antenatal depression effects on infant birthweight. 3965 pregnant women participated in this longitudinal cohort study, where cases (n = 178) had Edinburgh Postnatal Depression Scale (EPDS) score ≥ 17 in gestational week 17 or 32, and remaining women (n = 3787) were used as controls. The influence of maternal BMI and antenatal depressive symptoms on standardized birthweight was evaluated by analysis of covariance, with adjustment for relevant confounders. Depressed women with BMI 25.0 kg/m² or more gave birth to infants with significantly greater standardized birthweight than non-depressed overweight women, whereas the opposite pattern was noted in normal weight women (BMI by antenatal depressive symptoms interaction; F(1,3839) = 6.32; p = 0.012. The increased birthweight in women with co-prevalent overweight and depressive symptoms was not explained by increased weight gain during the pregnancy. Maternal BMI at the beginning of pregnancy seems to influence the association between antenatal depressive symptoms and infant birthweight, but in opposite directions depending on whether the pregnant women is normal weight or overweight. Further studies are needed to confirm our finding.

Loss of offspring Peg3 reduces neonatal ultrasonic vocalizations and increases maternal anxiety in wild-type mothers

Depression and anxiety are the most common mental health conditions during pregnancy and can impair the normal development of mother-infant interactions. These adversities are associated with low birth weight and increased risk of behavioural disorders in children. We recently reported reduced expression of the imprinted gene PATERNALLY EXPRESSED GENE 3 (PEG3) in placenta of human infants born to depressed mothers. Expression of Peg3 in the brain has previously been linked maternal behaviour in rodents, at least in some studies, with mutant dams neglecting their pups. However, in our human study decreased expression was in the placenta derived from the fetus. Here, we examined maternal behaviour in response to reduced expression of Peg3 in the feto-placental unit. Prenatally we found novelty reactivity was altered in wild-type females carrying litters with a null mutation in Peg3. This behavioural alteration was short-lived and there were no significant differences the transcriptomes of either the maternal hypothalamus or hippocampus at E16.5. In contrast, while maternal gross maternal care was intact postnatally, the exposed dams were significantly slower to retrieve their pups and displayed a marked increase in anxiety. We also observed a significant reduction in the isolation-induced ultrasonic vocalizations (USVs) emitted by mutant pups separated from their mothers. USVs are a form of communication known to elicit maternal care suggesting Peg3 mutant pups drive the deficit in maternal behaviour. These data support the hypothesis that reduced placental PEG3 in human pregnancies occurs as a consequence of prenatal depression but leaves scope for feto-placental Peg3 dosage, during gestation, influencing aspects of maternal behaviour.

Neonatal outcomes in pregnant women with untreated and treated panic disorder

OBJECTIVE

The objective of the present study was to compare neonatal outcomes including gestational age, birth weight and hospitalization of newborns of pregnant women with treated with antidepressants and untreated panic disorder.

METHODS

The study sample included 146 pregnant women (44 patients with panic disorder treated with antidepressants, 52 patients with untreated panic disorder, and 50 healthy controls). Panic disorder was diagnosed by means of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.

RESULTS

The highest proportions of preterm birth (28.8%), low birth weight (34.6%) and requirement of neonatal care (25.0%) were observed in infants of untreated patients. Pharmacotherapy group and control subjects had similar neonatal outcomes. Compared with infants of healthy subjects and the pharmacotherapy group, infants of untreated patients had significantly lower birth weight and gestational age at delivery. In addition, newborns of untreated patients had higher rate of hospitalization at the neonatal care unit.

CONCLUSION

Our results suggest that treatment with pharmacotherapy of panic disorder during pregnancy may have beneficial effects on the risk of negative neonatal outcomes due to maternal panic disorder in the infants.

Perinatal anxiety: approach to diagnosis and management in the obstetric setting

Anxiety is common in women during the perinatal period, manifests with various symptoms and severity, and is associated with significant maternal morbidity and adverse obstetric and neonatal outcomes. Given the intimate relationship and frequency of contact, the obstetric provider is positioned optimally to create a therapeutic alliance and to treat perinatal anxiety. Time constraints, absence of randomized controlled trials, mixed quality of data, and concern for potential adverse reproductive outcomes all limit the clinician's ability to initiate informed risk-benefit discussions. Clear understanding of the role of the obstetric provider in the identification, stabilization, and initiation of medication and/or referral to psychotherapy for women with perinatal anxiety disorders is critical to maternal and neonatal wellbeing. Informed by our clinical practice as perinatal psychiatric providers, we have provided a concise summary of current research on the approach to the treatment of perinatal anxiety disorders in the obstetric setting that includes psychotherapy and supportive interventions, primary and adjuvant psychiatric medication, and general prescribing pearls. Medications that we examined include antidepressants, benzodiazepines, sedative-hypnotics, antihistamines, quetiapine, buspirone, propranolol, and melatonin. Further research into management of perinatal anxiety, particularly psychopharmacologic management, is warranted.

Persistence of anxiety symptoms after elective caesarean delivery

BACKGROUND

In the UK, 11.8% of expectant mothers undergo an elective caesarean section (ELCS) representing 92 000 births per annum. It is not known to what extent this procedure has an impact on mental well-being in the longer term.

AIMS

To determine the prevalence and postpartum progression of anxiety and depression symptoms in women undergoing ELCS in Wales.

METHOD

Prevalence of depression and anxiety were determined in women at University Hospital Wales (2015-16; n = 308) through completion of the Edinburgh Postnatal Depression Scale (EPDS; ≥13) and State-Trait Anxiety Inventory (STAI; ≥40) questionnaires 1 day prior to ELCS, and three postpartum time points for 1 year. Maternal characteristics were determined from questionnaires and, where possible, confirmed from National Health Service maternity records.

RESULTS

Using these criteria the prevalence of reported depression symptoms was 14.3% (95% CI 10.9-18.3) 1 day prior to ELCS, 8.0% (95% CI 4.2-12.5) within 1 week, 8.7% (95% CI 4.2-13.8) at 10 weeks and 12.4% (95% CI 6.4-18.4) 1 year postpartum. Prevalence of reported anxiety symptoms was 27.3% (95% CI 22.5-32.4), 21.7% (95% CI 15.8-28.0), 25.3% (95% CI 18.5-32.7) and 35.1% (95% CI 26.3-44.2) at these same stages. Prenatal anxiety was not resolved after ELCS more than 1 year after delivery.

CONCLUSIONS

Women undergoing ELCS experience prolonged anxiety postpartum that merits focused clinical attention.

DECLARATION OF INTEREST

None.

Mindfulness skills during pregnancy: Prospective associations with mother's mood and neonatal birth weight

OBJECTIVES

Mindfulness skills have been associated with better mood and several health related outcomes. Because depressed mood during pregnancy has been related to worse child outcomes, the aim was to examine the association of mindfulness skills during pregnancy with the mother's depressive symptoms, gestational age, and neonatal birth weight.

METHODS

A subsample of 905 pregnant women who participated in the longitudinal cohort HAPPY study (Holistic Approach to Pregnancy and the first Postpartum Year) completed the 12-item Three Facet Mindfulness-Questionnaire-Short Form at 22weeks of gestation. The Edinburgh Depression Scale was completed to assess depressive symptoms at 12, 22 and 32weeks. The obstetric medical records were examined for gestational age and birth weight.

RESULTS

Mindfulness skills Acting with Awareness and Nonjudging at 22weeks were associated with less depressive symptoms at 22weeks and at 32weeks. When controlled for depressive symptoms at 22weeks, the association was still significant for Nonjudging predicting depressive symptoms at 32weeks (Beta=-0.12, p<0.01). Regarding the obstetric medical records, only Nonreacting was (positively) associated with birth weight (Beta=0.09, p<0.01). Controlling for gestational age, sex, parity, depressive symptoms, and health behavior, Nonreacting predicted a normal birth weight (OR=1.12, 95% CI=1.06-1.19), in contrast to low birth weight.

CONCLUSION

It seems that different mindfulness skills during pregnancy are important in predicting mother's depressive symptoms compared to the prediction of child's birth weight. Potential mechanisms are discussed.

Association of Panic Disorder, Generalized Anxiety Disorder, and Benzodiazepine Treatment During Pregnancy With Risk of Adverse Birth Outcomes

IMPORTANCE

Registry data show that maternal panic disorder, or anxiety disorders in general, increase the risk for adverse pregnancy outcomes. However, diagnoses from registries may be imprecise and may not consider potential confounding factors, such as treatment with medication and maternal substance use.

OBJECTIVE

To determine whether panic disorder or generalized anxiety disorder (GAD) in pregnancy, or medications used to treat these conditions, are associated with adverse maternal or neonatal pregnancy outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study conducted between July 1, 2005, and July 14, 2009, recruited women at 137 obstetric practices in Connecticut and Massachusetts before 17 weeks of pregnancy and reassessed them at 28 (±4) weeks of pregnancy and 8 (±4) weeks postpartum. Psychiatric diagnoses were determined by answers to the World Mental Health Composite International Diagnostic Interview. Assessments also gathered information on treatment with medications and confounding factors, such as substance use, previous adverse birth outcomes, and demographic factors.

EXPOSURE

Panic disorder, GAD, or use of benzodiazepines or serotonin reuptake inhibitors.

MAIN OUTCOMES AND MEASURES

Among mothers: preterm birth, cesarean delivery, and hypertensive diseases of pregnancy. Among neonates: low birth weight, use of minor respiratory interventions, and use of ventilatory support.

RESULTS

Of the 2654 women in the final analysis (mean [SD] age, 31.0 [5.7] years), most were non-Hispanic white (1957 [73.7%]), 98 had panic disorder, 252 had GAD, 67 were treated with a benzodiazepine, and 293 were treated with a serotonin reuptake inhibitor during pregnancy. In adjusted models, neither panic disorder nor GAD was associated with maternal or neonatal complications of interest. Most medication exposures occurred early in pregnancy. Maternal benzodiazepine use was associated with cesarean delivery (odds ratio [OR], 2.45; 95% CI, 1.36-4.40), low birth weight (OR, 3.41; 95% CI, 1.61-7.26), and use of ventilatory support for the newborn (OR, 2.85; 95% CI, 1.2-6.9). Maternal serotonin reuptake inhibitor use was associated with hypertensive diseases of pregnancy (OR, 2.82; 95% CI, 1.58-5.04), preterm birth (OR, 1.56; 95% CI, 1.02-2.38), and use of minor respiratory interventions (OR, 1.81; 95% CI, 1.39-2.37). With maternal benzodiazepine treatment, rates of ventilatory support increased by 61 of 1000 neonates and duration of gestation was shortened by 3.6 days; with maternal serotonin reuptake inhibitor use, gestation was shortened by 1.8 days, 152 of 1000 additional newborns required minor respiratory interventions, and 53 of 1000 additional women experienced hypertensive diseases of pregnancy.

CONCLUSIONS AND RELEVANCE

Panic disorder and GAD do not contribute to adverse pregnancy complications. Women may require treatment with medications during pregnancy, which can shorten the duration of gestation slightly. Maternal treatment with a serotonin reuptake inhibitor is also associated with hypertensive disease of pregnancy and cesarean delivery.

Are Major Depression and Generalized Anxiety Disorder Associated With Oligohydramnios in Pregnant Women? A Case-Control Study

PURPOSE

This study examined the prevalence of major depression and generalized anxiety disorder (GAD) in pregnant women with and without a diagnosis of oligohydramnios.

DESIGN AND METHODS

The study sample included 53 pregnant women with a diagnosis of oligohydramnios and 80 healthy pregnant women subjects. Major depression and GAD were diagnosed with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID-I).

FINDINGS

Pregnant women with oligohydramnios had higher scores of depressive and anxiety symptom, and a higher prevalence rate of major depression (24.5% vs. 6.2%) and GAD (30.2% vs. 3.2%).

PRACTICE IMPLICATIONS

The results of the present study suggest that oligohydramnios appears to be associated with both major depression and GAD in pregnant women.

Evaluation of Malondialdehyde, Superoxide Dismutase and Catalase Activity in Fetal Cord Blood of Depressed Mothers

Objective

The umbilical cord consists of two arteries and one vein and it functions in the transport between the maternal and fetal circulation. Biochemical analysis of fetal cord blood (FCB) during delivery could be beneficial in terms of understanding the fetal environment. In this study, we aimed to investigate oxidative parameters like malondialdehyde (MDA), superoxide dismutase (SOD), and catalase (CAT) levels in FCB during delivery.

Methods

We collected FCB samples during caesarean section. Our study included 33 depressed mothers and 37 healthy controls. We investigated MDA, SOD, and CAT levels in FCB samples.

Results

We found no significant difference between groups in terms of MDA (p=0.625), SOD (p=0.940), and CAT (p=0.413) levels.

Conclusion

Our study reveals probable protective effects of the placenta from oxidative stress. Future studies should include larger samples.

Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries

Maternal depression, a non-psychotic depressive episode of mild to major severity, is one of the major contributors of pregnancy-related morbidity and mortality. Maternal depression (antepartum or post partum) has been linked to negative health-related behaviours and adverse outcomes, including psychological and developmental disturbances in infants, children, and adolescents. Despite its enormous burden, maternal depression in low-income and middle-income countries remains under-recognised and undertreated. In this Series paper, we systematically review studies that focus on the epidemiology of perinatal depression (ie, during antepartum and post-partum periods) among women residing in low-income and middle-income countries. We also summarise evidence for the association of perinatal depression with infant and childhood outcomes. This review is intended to summarise findings from the existing literature, identify important knowledge gaps, and set the research agenda for creating new generalisable knowledge pertinent to increasing our understanding of the prevalence, determinants, and infant and childhood health outcomes associated with perinatal depression. This review is also intended to set the stage for subsequent work aimed at reinforcing and accelerating investments toward providing services to manage maternal depression in low-income and middle-income countries.

Depression in pregnancy is associated with decreased glutathione peroxidase activity in fetal cord blood

The investigation of fetal cord blood (FCB) during child delivery has created a novel topic in the field of psychiatric research. The umbilical vein receives nutrients and oxygen from the mother's circulation and transports them to the fetal circulation. Investigating fetal cord blood during delivery is beneficial for understanding the fetal environment. Depression in pregnancy is associated with medical and emotional burdens. In this study, we aimed to investigate glutathione peroxidase (Gpx) and myeloperoxidase (MPO) activity in the FCB of depressed mothers and healthy controls. Our study included 45 depressed mothers and 59 healthy controls. The FCB samples were collected from the umbilical vein during delivery. We found that Gpx levels were significantly decreased in the FCB of depressed mothers than healthy controls, medians were 0.14 U/ml and 0.16 U/ml respectively, Z: -3.567 and p < 0.001. MPO levels were similar in both groups, medians were 1.0 U/L and 1.2 U/L respectively, Z: -1.837 and p:0.066. Depression in pregnancy may be associated with decreased antioxidant levels, and this condition may cause an oxidative load, which may lead to improper brain development. Future studies should be performed in larger samples to clarify our preliminary results.

A Role for the Placenta in Programming Maternal Mood and Childhood Behavioural Disorders

Substantial data demonstrate that the early-life environment, including in utero, plays a key role in later life disease. In particular, maternal stress during pregnancy has been linked to adverse behavioural and emotional outcomes in children. Data from human cohort studies and experimental animal models suggest that modulation of the developing epigenome in the foetus by maternal stress may contribute to the foetal programming of disease. Here, we summarise insights gained from recent studies that may advance our understanding of the role of the placenta in mediating the association between maternal mood disorders and offspring outcomes. First, the placenta provides a record of exposures during pregnancy, as indicated by changes in the placental trancriptome and epigenome. Second, prenatal maternal mood may alter placental function to adversely impact foetal and child development. Finally, we discuss the less well established but interesting possibility that altered placental function, more specifically changes in placental hormones, may adversely affect maternal mood and later maternal behaviour, which can also have consequence for offspring well-being.

Probable preventive effects of placenta from oxidative stress; Evaluation of total antioxidant status, total oxidant status and oxidative stress index in fetal cord blood during the delivery

Depression in pregnancy may have negative effects on birth outcomes. It may also effect the intrauterine environment of the fetus. The umbilical cord is the conduit between the fetus and placenta, and functions in the transport between fetus and mother. Investigating biochemical parameters in fetal cord blood (FCB) during delivery may be helpful to understanding to what the fetus is exposed to, at least in the last trimester. In this study, we aimed to investigate total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress index (OSI) in the FCB of depressed mothers and healthy controls during delivery. Our study included 33 depressed mothers and 37 healthy controls. TAS, TOS, and OSI were measured according to Erel's method. We found that TAS, TOS, and OSI levels were similar in patients and healthy controls; however, the birth weights of depressed patients were significantly lower than those of healthy controls. Our results suggest that the placental barrier may prevent from oxidative stress. Future studies should include blood samples collected simultaneously from mothers during delivery.

Prenatal Maternal Anxiety as a Risk Factor for Preterm Birth and the Effects of Heterogeneity on This Relationship: A Systematic Review and Meta-Analysis

Background. Systematic reviews (SR) and meta-analyses (MA) that previously explored the relationship between prenatal maternal anxiety (PMA) and preterm birth (PTB) have not been comprehensive in study inclusion, failing to account for effects of heterogeneity and disagree in their conclusions. Objectives. This SRMA provides a summary of the published evidence of the relationship between PMA and PTB while examining methodological and statistical sources of heterogeneity. Methods. Published studies from MEDLINE, CINAHL, PsycINFO, and EMBASE, until June 2015, were extracted and reviewed. Results. Of the 37 eligible studies, 31 were used in this MA; six more were subsequently excluded due to statistical issues, substantially reducing the heterogeneity. The odds ratio for PMA was 1.70 (95% CI 1.33, 2.18) for PTB and 1.67 (95% CI 1.35, 2.07) for spontaneous PTB comparing higher levels of anxiety to lower levels. Conclusions. Consistent findings indicate a significant association between PMA and PTB. Due to the statistical problem of including collinear variables in a single regression model, it is hard to distinguish the effect of the various types of psychosocial distress on PTB. However, a prenatal program aimed at addressing mental health issues could be designed and evaluated using a randomised controlled trial to assess the causal nature of different aspects of mental health on PTB.

Prenatal depression and adverse birth outcomes: an updated systematic review

Complications related to preterm birth (PTB) and low birth weight (LBW) are leading causes of infant morbidity and mortality. Prenatal depression is a hypothesized psychosocial risk factor for both birth outcomes. The purpose of this systematic review was to examine evidence published between 1977 and 2013 on prenatal depression and risks of these primary adverse birth outcomes. A systematic search of the PUBMED and PsycINFO databases was conducted to identify studies testing the associations between prenatal depressive symptoms, or diagnoses of depression, and risk of PTB or LBW. We systematically selected 50 published reports on PTB and length of gestation, and 33 reports on LBW and BW. Results were reviewed by two independent reviewers and we evaluated the quality of the evidence with an established systematic review method, the Newcastle Ottawa Scale. We then undertook a narrative synthesis of the results following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Less than a quarter of 50 published reports found that prenatal depression was significantly associated with PTB or gestational age. In contrast, slightly more than half of the 33 reports found that prenatal depression was associated with LBW or BW. When weighing methodological features, we determined that the effects of prenatal depression on LBW are more consistent than effects on length of gestation or PTB. Although the evidence may not be strong enough to support routine depression screening for risk of adverse outcomes, screening to enable detection and timely treatment to reduce risk of postpartum depression is warranted. Further rigorous research on prenatal depression and adverse birth outcomes is needed.

A pharmacological approach to panic disorder during pregnancy

Anxiety disorders and pregnancy may occur concurrently in some women. Although, several epidemiological or clinical studies about anxiety disorders in pregnancy exist, data on their treatment are very limited. Similar to other anxiety disorders, specific pharmacological treatment approaches in pregnant women with panic disorder (PD) have not been discussed in the literature. An important issue in the treatment of pregnant women with any psychiatric diagnosis is the risk-benefit profile of pharmacotherapy. Therefore, the treatment should be individualized. Untreated PD seems to be associated with several negative outcomes in the pregnancy. When the results of current study regarding the safety of pharmacological agents on the fetus and their efficacy in PD were gathered, sertraline, citalopram, imipramine and clomipramine at low doses for pure PD, and venlafaxine appeared to be more favorable than the other potential drugs. However, controlled studies examining optimum dosing, efficacy of antipanic medications and risk-benefit profile of intrauterine exposure to treated or untreated PD are urgently needed.

Birth weight and gestational age in newborns exposed to maternal obsessive-compulsive disorder

We examined the impact of maternal obsessive-compulsive disorder (OCD) on gestational age and birth weight of infants. The sample included 63 mothers (28 patient and 35 controls). OCD and other psychiatric diagnoses were determined with a structured clinical interview. Birth weight and gestational age were lower in the newborns exposed to maternal OCD compared to ones who were not exposed. The results suggest that maternal OCD may negatively affect fetal weight growth and gestational duration.

Low-dose imipramine for treatment of panic disorder during pregnancy: a retrospective chart review

Although imipramine is one of the antidepressants that could be effective in the treatment of panic disorder, data on its usage for this diagnosis in the pregnancy period are limited. This report presents the results of 16 pregnant women with panic disorder without comorbid diagnosis who underwent low-dose imipramine (10-40 mg/d) treatment. According to the Clinical Global Impression-Improvement Scale, 12 (75%) of 16 women responded to the treatment. The results suggest that low-dose imipramine may be useful for the treatment of panic disorder during pregnancy.