Trauma and traumatic stress in a sample of pregnant women

"Women Friendly": A Childbirth Preparation Intervention in Israel for Women with Symptoms of Post-Traumatic Stress Disorder

Pregnant women with symptoms of post-traumatic stress disorder (PTSD), who have experienced traumatic events such as sexual abuse and traumatic births, are particularly vulnerable to experiencing extreme fear of childbirth complications during labor and traumatic deliveries. In this commentary, we review the literature on this group of women and their specific needs during pregnancy and childbirth. We present a childbirth preparation intervention for pregnant women with PTSD symptoms, "Women Friendly", designed in Israel and gradually becoming available in the community and Israeli hospitals. This intervention is intended for women with high levels of fear of childbirth who are unmotivated or unable to undergo traditional psychotherapy that focuses on exposure to and processing of past traumatic event(s). It is based on birth-oriented thinking, principles of positive psychology, and trauma-informed care. In addition to the five sessions offered to pregnant women, medical staff are provided with 19 training sessions on the "Women Friendly" approach. Qualitative and quantitative research should examine the effectiveness of this intervention. Should results be encouraging, this intervention could be more widely implemented in Israel and abroad and applied in broader contexts, such as gynecological check-ups and medical examinations, interventions, and surgery.

Psychometric properties of the Greek Version of the Traumatic Event Scale (TES) (Version A) among low-risk pregnant women

BACKGROUND

The Traumatic Event Scale (TES) is one of the most often used instruments for the assessment of the Posttraumatic Stress Disorder (PTSD) symptomatology during pregnancy which is linked with adverse effects. The aim of the study was to assess the psychometric properties of the TES (version A) in a sample of Greek pregnant women.

METHODS

Two hundred one low risk pregnant women in their second or third trimester were invited to participate in the study. Participants completed a number of questionnaires including the Greek versions of TES-A, State-Trait Anxiety Inventory (STAI), Coping Orientations to Problems Experienced (Brief COPE), Perceived Stress Scale (PSS-10) and Edinburgh Postnatal Depression Scale (EPDS). Confirmatory factor analysis (CFA) was conducted in order to test how well the already TES-A five-factor model fits the data from Greece.

RESULTS

Participants' average age was 34.2 years (SD = 4.3 years). Through CFA the already five-factor structure of the TES-A (Anticipation of trauma, Intrusion, Avoidance, Resignation, Hyperstimulation) was applied to our sample. All five factors were significantly and positively correlated with each other. All Cronbach's alpha were over 0.7, indicating acceptable reliability of the factors. Relatively convergent validity, all factors of the Greek version of the TES-A were significantly associated with stress, anxiety, depression and coping strategies.

CONCLUSION

The Greek version of TES-A is detected to be a valid and reliable instrument of prenatal Posttraumatic Stress Disorder (PTSD) symptomatology among low-risk Greek pregnant women.

Cumulative trauma predicts hair cortisol concentrations and symptoms of depression and anxiety in pregnant women-an investigation of community samples from Greece, Spain and Perú

Exposure to traumatic experiences across lifespan shapes the functioning of the hypothalamic pituitary adrenal (HPA) axis and sets individuals at risk to develop symptoms of depression and anxiety. Particularly, HPA axis regulation and the psychological health of the expectant mother have been of interest, as the health of the unborn child may be affected through changes in gestational biology. The present study investigated the potential associations between lifetime trauma, current symptoms (depression and anxiety) and hair cortisol concentrations (HCC) in pregnant women. A total of 149 pregnant women were interviewed in public outpatient clinics with varying gestational age in Greece, Spain and Perú. Lifetime trauma exposure and current symptoms of depression and anxiety were assessed. HCC was measured in scalp-near hair segments (2 cm length) reflecting cumulative cortisol secretion of the past two months. Results showed that trauma load is negatively associated with HCC and higher symptoms of depression and anxiety. There was a negative association between HCC and symptoms. The present findings support the notion that cumulative trauma exposure exerts long-lasting effects on the expectant mother's HPA axis activity functioning and mental health and may thereby potentially create risk trajectories for the unborn child via changes in gestational biology.

Association between Ancestry-Specific 6q25 Variants and Breast Cancer Subtypes in Peruvian Women

BACKGROUND

Breast cancer incidence in the United States is lower in Hispanic/Latina (H/L) compared with African American/Black or Non-Hispanic White women. An Indigenous American breast cancer-protective germline variant (rs140068132) has been reported near the estrogen receptor 1 gene. This study tests the association of rs140068132 and other polymorphisms in the 6q25 region with subtype-specific breast cancer risk in H/Ls of high Indigenous American ancestry.

METHODS

Genotypes were obtained for 5,094 Peruvian women with (1,755) and without (3,337) breast cancer. Associations between genotype and overall and subtype-specific risk for the protective variant were tested using logistic regression models and conditional analyses, including other risk-associated polymorphisms in the region.

RESULTS

We replicated the reported association between rs140068132 and breast cancer risk overall [odds ratio (OR), 0.53; 95% confidence interval (CI), 0.47-0.59], as well as the lower odds of developing hormone receptor negative (HR-) versus HR+ disease (OR, 0.77; 95% CI, 0.61-0.97). Models, including HER2, showed further heterogeneity with reduced odds for HR+HER2+ (OR, 0.68; 95% CI, 0.51-0.92), HR-HER2+ (OR, 0.63; 95% CI, 0.44-0.90) and HR-HER2- (OR, 0.77; 95% CI, 0.56-1.05) compared with HR+HER2-. Inclusion of other risk-associated variants did not change these observations.

CONCLUSIONS

The rs140068132 polymorphism is associated with decreased risk of breast cancer in Peruvians and is more protective against HR- and HER2+ diseases independently of other breast cancer-associated variants in the 6q25 region.

IMPACT

These results could inform functional analyses to understand the mechanism by which rs140068132-G reduces risk of breast cancer development in a subtype-specific manner. They also illustrate the importance of including diverse individuals in genetic studies.

The association between maternal lifetime interpersonal trauma experience and perceived mother-infant bonding

BACKGROUND

Interpersonal traumas are common among expectant and new mothers and are found to have considerable impacts on women's mental health. These experiences may disrupt maternal perceptions of the mother-infant relationship, which is essential for healthy infant development, but findings are inconsistent. This study aims to explore associations between lifetime interpersonal traumas and their impact on self-reported mother-infant bonding.

METHODS

Secondary data analysis of a representative cohort of 453 women attending at a South London maternity service. Lifetime interpersonal trauma experience and its association with self-reported mother-infant bonding (Postpartum Bonding Questionnaire) was assessed in uni- and multivariable linear regressions, the latter adjusted to account for antenatal depressive and posttraumatic symptoms, measured using the Edinburgh Postnatal Depression Scale and Posttraumatic Stress Disorder Scale, and key sociodemographic risk factors.

RESULTS

Maternal lifetime trauma was not associated with perceived difficulties in mother-infant bonding at three months postnatal; however antenatal depressive symptoms, both with continuous EPDS score (0.33, 95% CI 0.17-0.50, p<0.001) and clinical cut-off ≥13 (4.26, 95% CI 2.02-6.49, p<0.001) were associated with self-reported bonding difficulties.

LIMITATIONS

The composite trauma measurement did not allow for a comprehensive assessment of individual trauma types.

CONCLUSIONS

There was no evidence for a link between maternal lifetime trauma experiences and self-reported bonding difficulties. However, an association between antenatal depressive symptoms and perceived postpartum bonding impairment was found. This highlights the importance of identification and treatment of depressive symptoms during pregnancy and offering women support in facilitating a positive mother-infant relationship.

A longitudinal study exploring the evolution of pain during pregnancy and after delivery: does worry matter?

The aim of this study is to evaluate the evolution of pain through pregnancy until after delivery, as well as to explore the mediating role of pregnancy worries in this evolution of pain. We conducted a longitudinal cohort study. The convenience sample was evaluated on four separate occasions: in the first trimester of pregnancy (pain), during the third trimester (pain and worry), during labor (pain), and after birth (< 24 h; pain). The final sample included 120 pregnant women with a mean age of 31.29 years (SD = 4.9; range = [22, 42 years]). The results evidenced changes in pain over time (F = 13.31, p < .001). Pain severity increased in the third trimester compared to the first trimester (t =  - 4.60; 95% CI = [- 1.31, - 0.52]; p < .001), while pain during the third trimester and pain after delivery were comparable (t =  - 0.94; 95% CI = [- 1.02, 0.36]; p = .35). Pain during labor was uncorrelated with all other pain measures, so it was not included in the model. The results of the mediation analyses indicated a total effect of pain during pregnancy (first and third trimester) and worry on pain severity after delivery (B = 0.35; SE = 0.14; t = 2.43; 95% CI = [0.06, 0.65]; p = .017). Pregnancy worries (B = 0.14; SE = 0.07; 95% CI = [0.06, 0.29]), but not pain during the third trimester (B = 0.03; SE = 0.12; 95% CI = [- 0.17, 0.31]) mediated the relationship between pain during the first trimester and pain after delivery. These results support the need to reduce worry in pregnant mothers, especially when pain during the first trimester is high, to reduce the risk of pain after delivery.

Generalized Anxiety Disorder, Depressive Symptoms and the Occurrence of Stressors Events in a Probabilistic Sample of Pregnant Women

The aim of the study is to verify the association between GAD, the severity of depressive symptoms and stressors in pregnant women between the first and second trimester. Cross-sectional study, part of a cohort that followed 980 women during the gestational period of a city in southern Brazil. We performed bivariate analysis using the t-test and chi-square. The variables that presented p ≤ 0.20 were taken for multivariate analysis, through logistic regression, in order to control possible confounding factors. The Mini International Neuropsychiatric Interview Plus was used to evaluate GAD, the severity of depressive symptoms was investigated through the Beck Inventory of Depression II, and stress events according to the Social Readjustment Assessment Scale of Holmes e Rahe. The sample consisted of 980 women. Women with mild depression symptoms had 9.8 (IC95% 4.6;21.0) times more GAD, those with moderate symptoms had 27.5 (IC95% 12.5;60.0) times more GAD, and those with severe symptoms had 52.9 (IC95% 19.1;146.5) times more GAD when compared to pregnant women with no symptoms or minimal symptoms. Regarding the stressful events, the pregnant women who presented GAD had an increase of 1.0 (IC95% 1.0;1.1) point in the mean of occurrence of stressor events when compared to those without GAD. These findings highlight the need for prevention strategies and interventions to promote maternal mental health, which benefit the development of infants in the long term.

Screening for perinatal depression with the Patient Health Questionnaire depression scale (PHQ-9): A systematic review and meta-analysis

OBJECTIVES

Perinatal depression (PND) is a prevalent and disabling problem both during pregnancy and the postpartum period. The legacy screening measure has been the Edinburgh Postnatal Depression Scale (EPDS). This systematic review examines the validity of the PHQ-9 as a screener for PND.

METHODS

The following databases were searched from January 2001 (when the PHQ-9 was first published) through June 2020: MEDLINE, Embase, and PsychInfo. Studies that compared the PHQ-9 to a criterion standard psychiatric interview were used to determine the operating characteristics of sensitivity, specificity and area under the curve (AUC). Studies comparing the PHQ-9 to the EPDS and other depression scales evaluated convergent validity.

RESULTS

A total of 35 articles were eligible for criterion (n = 10) or convergent (n = 25) validity. Meta-analysis of the 7 criterion validity studies using the standard PHQ-9 cut point ≥10 showed a pooled sensitivity, specificity and AUC of 0.84, 0.81 and 0.89, respectively. Operating characteristics of the PHQ-9 and EPDS were nearly identical in head-to-head comparison studies. The median correlation between the PHQ-9 and EPDS was 0.59, and categorical agreement was moderate.

CONCLUSIONS

The PHQ-9 appears to be a viable option for perinatal depression screening with operating characteristics similar to the legacy EPDS.

Polygenic prediction and GWAS of depression, PTSD, and suicidal ideation/self-harm in a Peruvian cohort

Genome-wide approaches including polygenic risk scores (PRSs) are now widely used in medical research; however, few studies have been conducted in low- and middle-income countries (LMICs), especially in South America. This study was designed to test the transferability of psychiatric PRSs to individuals with different ancestral and cultural backgrounds and to provide genome-wide association study (GWAS) results for psychiatric outcomes in this sample. The PrOMIS cohort (N = 3308) was recruited from prenatal care clinics at the Instituto Nacional Materno Perinatal (INMP) in Lima, Peru. Three major psychiatric outcomes (depression, PTSD, and suicidal ideation and/or self-harm) were scored by interviewers using valid Spanish questionnaires. Illumina Multi-Ethnic Global chip was used for genotyping. Standard procedures for PRSs and GWAS were used along with extra steps to rule out confounding due to ancestry. Depression PRSs significantly predicted depression, PTSD, and suicidal ideation/self-harm and explained up to 0.6% of phenotypic variation (minimum p = 3.9 × 10^-6). The associations were robust to sensitivity analyses using more homogeneous subgroups of participants and alternative choices of principal components. Successful polygenic prediction of three psychiatric phenotypes in this Peruvian cohort suggests that genetic influences on depression, PTSD, and suicidal ideation/self-harm are at least partially shared across global populations. These PRS and GWAS results from this large Peruvian cohort advance genetic research (and the potential for improved treatments) for diverse global populations.

Association of brain-derived neurotrophic factor levels and depressive symptoms in young adults with acne vulgaris

BACKGROUND

Brain-derived neurotrophic factor (BDNF) is one of the proteins that contributes to the survival, growth, maintenance of neurons, and plays important roles in the pathophysiology of depression. It has been reported that depression is closely associated with the pathogenesis of acne vulgaris disease. But, there is no report of serum BDNF levels in patients with acne vulgaris. The study aimed to determine the potential association between BDNF and depressive symptoms in young adults with acne vulgaris.

METHODS

In this analytical cross-sectional study, the serum BDNF levels were measured in peripheral blood samples of 20 consecutive acne vulgaris patients with depression and 98 consecutive acne vulgaris patients without depression and also compared it with a 59 healthy control group by using a ELISA. The potential correlation between the BDNF levels, interleukin-6 (IL-6), tumour necrosis factor-alpha (TNF-α), and depressive symptoms such as nine-item patient health questionnaire (PHQ-9) and Athens insomnia scale (AIS) were evaluated with multivariate logistic regression analysis.

RESULTS

Our results showed that levels of BDNF expression were lower in consecutive acne vulgaris patients when compared with healthy control (P < 0.05). There was a negative correlation between levels of BDNF and the PHQ-9 scores (r = - 0.486, P < 0.001). Furthermore, acne vulgaris patients with depression showed lower serum BDNF levels (10.96 ± 2.12 ng/ml) compared with acne vulgaris patients without depression (13.85 ± 2.47 ng/ml), as well as with healthy control (14.35 ± 2.70 ng/mg; both P < 0.05). No difference was found in serum BDNF levels between healthy control and acne vulgaris patients without depressive symptoms (z = 0.964, P > 0.05). Similarly, the overall area under the curve of receiver operating characteristic was 0.82, indicating the highly conserving of serum BDNF levels as an biomarker for screening of depression in young adults with acne vulgaris (72% sensitivity and 85% specificity).

CONCLUSION

Serum BDNF levels were decreased and negatively associated with depressive symptoms in young Chinese adults with acne vulgaris.

Maternal Lifetime Trauma and Birthweight: Effect Modification by In Utero Cortisol and Child Sex

OBJECTIVES

To evaluate associations between maternal lifetime traumatic stress and offspring birthweight and examine modifying effects of third trimester cortisol and fetal sex.

STUDY DESIGN

Analyses included 314 mother-infant dyads from an ethnically mixed pregnancy cohort. Maternal lifetime trauma was reported via the Life Stressor Checklist-Revised. Fenton birthweight for gestational age z-scores (BWGA-z) were calculated. A 3-cm scalp-nearest maternal hair segment collected at birth was assayed to reflect cumulative third trimester cortisol secretion. Multivariable regression was used to investigate associations between maternal lifetime trauma and BWGA-z and examine 2- and 3-way interactions with cortisol and fetal sex. Because subjects with low or high cortisol levels could represent susceptible populations, varying coefficient models that relax the linearity assumption on cortisol level were used to assess the modification of maternal lifetime trauma associations with BWGA-z as a function of cortisol.

RESULTS

Women were primarily minorities (41% Hispanic, 26% black) with ≤12 years education (63%); 63% reported ≥1 traumatic event. Prenatal cortisol modified the association between maternal lifetime trauma and birthweight. Women with higher lifetime trauma and increased cortisol had significantly lower birthweight infants in males; among males exposed to the 90th percentile of cortisol, a 1-unit increase in trauma score was associated with a 0.19-unit decrease in BWGA-z (95% CI, -0.34 to -0.04). Associations among females were nonsignificant, regardless of cortisol level.

CONCLUSIONS

These findings underscore the need to consider complex interactions among maternal trauma, disrupted in utero cortisol production, and fetal sex to fully elucidate intergenerational effects of maternal lifetime trauma.

Realizing Women Living with HIV's Reproductive Rights in the Era of ART: The Negative Impact of Non-consensual HIV Disclosure on Pregnancy Decisions Amongst Women Living with HIV in a Canadian Setting

To better understand the structural drivers of women living with HIV's (WLWH's) reproductive rights and choices, this study examined the structural correlates, including non-consensual HIV disclosure, on WLWH's pregnancy decisions and describes access to preconception care. Analyses drew on data (2014-present) from SHAWNA, a longitudinal community-based cohort with WLWH across Metro-Vancouver, Canada. Multivariable logistic regression was used to model the effect of non-consensual HIV disclosure on WLWH's pregnancy decisions. Of the 218 WLWH included in our analysis, 24.8% had ever felt discouraged from becoming pregnant and 11.5% reported accessing preconception counseling. In multivariable analyses, non-consensual HIV disclosure was positively associated with feeling discouraged from wanting to become pregnant (AOR 3.76; 95% CI 1.82-7.80). Non-consensual HIV disclosure adversely affects WLWH's pregnancy decisions. Supporting the reproductive rights of WLWH will require further training among general practitioners on the reproductive health of WLWH and improved access to women-centred, trauma-informed care, including non-judgmental preconception counseling.