Pre-eclampsia and first-onset postpartum psychiatric episodes: a Danish population-based cohort study

Pregnancy and birth complications and long-term maternal mental health outcomes: A systematic review and meta-analysis

BACKGROUND

Few studies have examined the associations between pregnancy and birth complications and long-term (>12 months) maternal mental health outcomes.

OBJECTIVES

To review the published literature on pregnancy and birth complications and long-term maternal mental health outcomes.

SEARCH STRATEGY

Systematic search of Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (Embase), PsycInfo®, PubMed® and Web of Science from inception until August 2022.

SELECTION CRITERIA

Three reviewers independently reviewed titles, abstracts and full texts.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and appraised study quality. Random-effects meta-analyses were used to calculate pooled estimates. The Meta-analyses of Observational Studies in Epidemiology (MOOSE) guidelines were followed. The protocol was prospectively registered on the International Prospective Register of Systematic Reviews (PROSPERO: CRD42022359017).

MAIN RESULTS

Of the 16 310 articles identified, 33 studies were included (3 973 631 participants). Termination of pregnancy was associated with depression (pooled adjusted odds ratio, aOR 1.49, 95% CI 1.20-1.83) and anxiety disorder (pooled aOR 1.43, 95% CI 1.20-1.71). Miscarriage was associated with depression (pooled aOR 1.97, 95% CI 1.38-2.82) and anxiety disorder (pooled aOR 1.24, 95% CI 1.11-1.39). Sensitivity analyses excluding early pregnancy loss and termination reported similar results. Preterm birth was associated with depression (pooled aOR 1.37, 95% CI 1.32-1.42), anxiety disorder (pooled aOR 0.97, 95% CI 0.41-2.27) and post-traumatic stress disorder (PTSD) (pooled aOR 1.75, 95% CI 0.52-5.89). Caesarean section was not significantly associated with PTSD (pooled aOR 2.51, 95% CI 0.75-8.37). There were few studies on other mental disorders and therefore it was not possible to perform meta-analyses.

CONCLUSIONS

Exposure to complications during pregnancy and birth increases the odds of long-term depression, anxiety disorder and PTSD.

Predictive factors and treatment of postpartum mania: a representative case

Postpartum mania and psychosis puts both the person giving birth and their child at significant risk, so predicting its onset and determining effective treatment is crucial. Here, a representative case is presented of a patient started on an antidepressant during her pregnancy who suffered a postpartum manic episode with psychosis. The case describes many of the risk factors and treatment issues faced by clinicians when caring for patients with these symptoms in the postpartum period. Subsequent discussion provides guidance for clinicians to help predict postpartum mania and reviews factors that may increase the risk of its onset. The evidence for psychiatric treatment is also reviewed to both prevent and treat postpartum mania and psychosis.

Antepartum Psychosis in the Setting of Preeclampsia With Severe Features: A Case Report

The peripartum period, which can be further delineated into postpartum and antepartum periods, poses a heightened risk for psychiatric symptoms. While much is known about the risk of psychiatric symptoms in the postpartum period, antepartum psychosis remains exceedingly rare and poorly understood. This report presents a unique case of a 34-year-old pregnant woman with a past psychiatric history significant for recurrent major depressive disorder, generalized anxiety disorder, and substance use disorder of alcohol and marijuana, who developed preeclampsia with severe features and acute psychosis during the antepartum period. We explore the contributing factors to her presentation and discuss how each might have played a role in her symptoms. Although research exists on the connection between mood disorders and hypertensive disorders of pregnancy, studies that address the relationship between psychosis and hypertensive pregnancies are limited. Overall, the potential link between hypertensive disorders in pregnancy and peripartum psychosis has limited research and warrants further study.

Pregnancy and birth complications associations with long-term adverse maternal mental health outcomes: a systematic review and meta-analysis protocol

Background

Existing studies have established an association between pregnancy, birth complications, and mental health in the first few weeks postpartum. However, there is no clear understanding of whether pregnancy and birth complications increase the risk of adverse maternal mental outcomes in the longer term. Research on maternal adverse mental health outcomes following pregnancy and birth complications beyond 12 months postpartum is scarce, and findings are inconsistent.

Objective

This systematic review and meta-analysis will examine the available evidence on the association between pregnancy and birth complications and long-term adverse maternal mental health outcomes.

Methods and analysis

We will include cohort, cross-sectional, and case-control studies in which a diagnosis of pregnancy and/or birth complication (preeclampsia, pregnancy loss, caesarean section, preterm birth, perineal laceration, neonatal intensive care unit admission, major obstetric haemorrhage, and birth injury/trauma) was reported and maternal mental disorders (depression, anxiety disorders, bipolar disorders, psychosis, and schizophrenia) after 12 months postpartum were the outcomes. A systematic search of PubMed, Embase, CINAHL, PsycINFO, and Web of Science will be conducted following a detailed search strategy until August 2022. Three authors will independently review titles and abstracts of all eligible studies, extract data using pre-defined standardised data extraction and assess the quality of each study using the Newcastle-Ottawa Scale. We will use random-effects meta-analysis for each exposure and outcome variable to calculate overall pooled estimates using the generic inverse variance method. This systematic review will follow the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.

Ethical consideration

The proposed systematic review and meta-analysis is based on published data; ethics approval is not required. The results will be presented at scientific meetings and publish in a peer-reviewed journal.

PROSPERO registration

CRD42022359017.

Evaluation of Postpartum Midwifery Care in Greece Based on Patient-Reported Outcomes Using the MMAYpostpartum Questionnaire: A Cross-Sectional Study

Background The midwife's role throughout pregnancy and delivery management is essential, with multiple healthcare systems even following a midwife-led model of care. Of particular interest is the improvement and optimisation of midwifery postpartum care, which in Greece is empirically known to have decreased in quality, both due to the economic crisis and the recent pandemic. Aims To collect patient-reported outcomes with regard to the quality of midwifery services in Greece, ascertain baseline patient characteristics that may affect quality assessment, identify key areas for improvement, and propose patient subgroups who would most benefit from more specialized care. Setting and design A prospective, cross-sectional, questionnaire-based survey using the Measurement of Midwifery quality postpartum (MMAYpostpartum) questionnaire was conducted in public and private postpartum care centers in Greece. Methods The MMAYpostpartum questionnaire was distributed to 316 eligible women who received postpartum midwifery care in a healthcare center in Greece during the past three years. Multivariate linear regression was performed to examine significant correlations between baseline parameters and questionnaire scores. Results Ultimately, 204 answers were collected and analyzed. The patient's mean age was 35.5 years, and the mean body mass index (BMI) was 23.5. Overall, submitted scores were lower than those observed in the literature. A statistically significant correlation between older age, delivery at a public hospital, a history of hospitalization during pregnancy, and a lower midwifery service score was demonstrated. No other factors had a statistically significant effect on the quality score. Conclusions Delivery at public healthcare centers, older maternal age, and a history of hospitalization during pregnancy are significant predictors of a lower perceived quality of midwifery care. Thus, such patient subgroups may constitute potential targets for more meticulous midwifery care when resource setting prohibits the overall improvement of quality. Further research is required to collect additional data on patient insight and to test the present observations in a clinical setting.

Risk of postpartum readmission for depression in relation to ischaemic placental disease: a population-based study

Background

There are limited data on postpartum readmissions for depression in the United States (US). Specifically, the extent to which ischaemic placental disease (IPD) during pregnancy predisposes patients to develop postpartum depression remains poorly understood. We investigated whether IPD is associated with postpartum readmission for new-onset depression in the first year after delivery.

Methods

In this population-based study, the 2010-2018 Nationwide Readmissions Database was utilised to evaluate rates of postpartum readmission for depression within the calendar year of delivery hospitalisation among patients with and without IPD. IPD was defined as preeclampsia, placental abruption, or small for gestational age (SGA) birth. We expressed associations between IPD and depression readmission based on a confounder-adjusted hazards ratio (HR) with a 95% confidence interval (CI).

Findings

Of 33.3 million delivery hospitalisations, 3,027,084 (9.1%) had IPD. The total follow-up among those with and without IPD were 17,855,830 and 180,100,532 person-months, respectively, with a median follow-up of 5.8 months for both groups. Rates of depression readmission were 95.7 (n = 17,095) and 37.5 (n = 67,536) per 100,000 readmissions among patients with and without an IPD, respectively (HR, 2.39; 95% CI, 2.32-2.47); this risk was the highest for preeclampsia with severe features (HR, 3.14; 95% CI, 3.00-3.29). Patients had a greater risk of readmission if they had any two forms of IPD (HR, 3.02; 95% CI, 2.75-3.33), and those with a concurrent diagnosis of preeclampsia and abruption posed the highest risk (HR, 3.23; 95% CI, 2.71-3.86).

Interpretation

These findings suggested that patients with IPD are at a substantially increased risk of readmission for depression within a year following delivery. This study underscores the need for increased surveillance, improved detection, and faster treatment of depression in this vulnerable population.

Funding

This was an unfunded project.

Association Between Mental Health and Reproductive System Disorders in Women: A Systematic Review and Meta-analysis

Importance

Reproductive system and mental health disorders are commonly comorbid in women. Although the causes of this overlap remain elusive, evidence suggests potential shared environmental and genetic factors associated with risk.

Objective

To investigate the comorbidity between psychiatric and reproductive system disorders, both as broad diagnostic categories and among specific pairs of diagnoses.

Data Source

PubMed.

Study Selection

Observational studies published between January 1980 and December 2019 assessing prevalence of psychiatric disorders in women with reproductive system disorders and prevalence of reproductive system disorders in women with psychiatric disorders were included. The study did not include psychiatric and reproductive disorders triggered by life events (eg, trauma, infection, surgery) to address potential confounding.

Data Extraction and Synthesis

A search yielded 1197 records, of which 50 met the inclusion criteria for the qualitative and 31 for the quantitative synthesis in our study. A random-effects model was used for data synthesis and Egger test and I2 to assess study bias and heterogeneity. Data were analyzed from January to December 2022. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline.

Main Outcomes and Measures

Psychiatric and reproductive system disorders.

Results

A total of 1197 records were identified, of which 50 met the inclusion criteria for qualitative and 31 for quantitative synthesis. Diagnosis of a reproductive system disorder was associated with a 2- to 3-fold increased odds of having a psychiatric disorder (lower bound odds ratio [OR], 2.00; 95% CI, 1.41-2.83; upper bound OR; 2.88; 95% CI, 2.21-3.76). The analysis focused on specific diagnoses described in the literature and found that polycystic ovary syndrome was associated with increased odds of depression (population-based studies OR, 1.71; 95% CI, 1.19-2.45; clinical studies OR, 2.58; 95% CI, 1.57-4.23) and anxiety (population-based studies OR, 1.69; 95% CI, 1.36-2.10; clinical studies OR, 2.85; 95% CI, 1.98-4.09). Chronic pelvic pain was also associated with both depression (OR, 3.91; 95% CI, 1.81-8.46) and anxiety (OR, 2.33; 95% CI, 1.33-4.08). Few studies investigated risk of other reproductive system disorders in women with psychiatric disorders, or reverse associations (risk of reproductive system disorder among women with a psychiatric diagnosis).

Conclusions and Relevance

In this systematic review and meta-analysis, a high rate of reported co-occurrence between psychiatric and reproductive disorders overall was observed. However, data for many disorder pairs were limited. The available literature focused overwhelmingly on affective disorders in polycystic ovary syndrome, overlooking a substantial portion of disease overlap. As such, the associations between the majority of mental health outcomes and conditions of the female reproductive system are largely unknown.

Rheumatoid arthritis and the risk of postpartum psychiatric disorders: a Nordic population-based cohort study

BACKGROUND

Postpartum psychiatric disorders (PPD) are common complications of childbirth. A common explanation for their development is that the psychological, hormonal, and immune changes associated with pregnancy and parturition may trigger psychiatric symptoms postpartum. Rheumatoid arthritis (RA) is characterized by abnormalities in the activity of the hypothalamic-pituitary-adrenal axis and of the immune system, but its association with PPD is unknown. We analyzed whether women with RA before childbirth have an increased risk of PPD.

METHODS

We conducted a large population-based cohort study including mothers of singleton births in the Danish (1995-2015), Finnish (1997-2013), and Swedish Medical Birth Registers (2001-2013) (N = 3,516,849). We linked data from the Medical Birth Registers with data from several national socioeconomic and health registers. Exposure was defined as having a diagnosis of RA before childbirth, while the main outcome was a clinical diagnosis of psychiatric disorders 90 days postpartum. We analyzed the association between RA and PPD using Cox proportional hazard models, stratified by a personal history of psychiatric disorders.

RESULTS

Among women without a history of psychiatric disorders, the PPD incidence rate was 32.2 in the exposed and 19.5 per 1000 person-years in the unexposed group; women with RA had a higher risk of overall PPD than their unexposed counterparts [adjusted hazard ratio (HR) = 1.52, 95% confidence intervals (CI) 1.17 to 1.98]. Similar associations were also observed for postpartum depression (HR = 1.65, 95% CI 1.09 to 2.48) and other PPD (HR = 1.59, 95% CI 1.13 to 2.24). Among women with a history of psychiatric disorders, the incidence rate of overall PPD was 339.6 in the exposed and 346.6 per 1000 person-years in the unexposed group; RA was not associated with PPD. We observed similar associations between preclinical RA (RA diagnosed after childbirth) and PPD to those corresponding to clinical RA.

CONCLUSIONS

Rheumatoid arthritis was associated with an increased PPD risk in women without, but not in those with a psychiatric history. If our findings are confirmed in future studies, new mothers with RA may benefit from increased surveillance for new-onset psychiatric disorders postpartum.

Psychiatric Symptoms in Women with High-risk Pregnancy in the Postpartum Period: A Case-control Study

OBJECTIVE

 Psychiatric symptoms are common mental issues in pregnancy and the postpartum period. There is limited information regarding the psychiatric symptoms of women with high-risk pregnancy in the postpartum period. This study aimed to compare the severity of psychiatric symptoms and psychological distress in women with high-risk and low-risk pregnancies in the postpartum period.

METHODS

 This case-control study examined 250 women in the postpartum period in two groups with low-risk (n = 112) and high-risk (n = 138) pregnancies. Women completed the Brief Symptom Inventory-53 (BSI-53) and the Risk Postnatal Psychosocial Depression Risk Questionnaire (PPDRQ).

RESULTS

 The mean severity of psychiatric symptoms in women with high-risk pregnancies was significantly higher than that in women with low-risk pregnancies (39.34 ± 17.51 vs. 30.26 ± 17.08). Additionally, the frequency of psychological distress in women with high-risk pregnancies was approximately twice higher than that in women with low-risk pregnancies (30.3% vs. 15.2%). Furthermore, the risk factors for depression in women with high-risk pregnancies were almost 1.5 times (59.8% vs. 39.8%) higher than the factors in women with low-risk pregnancies. The results of the logistic analysis indicated that high-risk pregnancies could be twice the odds ratio of developing postpartum psychological distress (ß = 2.14, 95% CI 1.4-6.3, p= 0.036).

CONCLUSION

 Psychiatric symptoms and the psychological distress index are higher in postpartum women with high-risk pregnancies than in postpartum women with low-risk pregnancies. The study suggests that obstetricians and pregnant women's health care providers should strongly consider screening of psychiatric symptoms in women with high-risk pregnancies both during pregnancy and after delivery as the women's routine care priorities.

Preeclampsia history and postpartum risk of cerebrovascular disease and cognitive impairment: Potential mechanisms

Hypertensive disorders of pregnancy such as preeclampsia, eclampsia, superimposed preeclampsia, and gestational hypertension are major causes of fetal and maternal morbidity and mortality. Women with a history of hypertensive pregnancy disorders have increased risk of stroke and cognitive impairments later in life. Moreover, women with a history of preeclampsia have increased risk of mortality from diseases including stroke, Alzheimer's disease, and cardiovascular disease. The underlying pathophysiological mechanisms are currently not fully known. Here, we present clinical, epidemiological, and preclinical studies focused on evaluating the long-term cerebrovascular and cognitive dysfunction that affect women with a history of hypertensive pregnancy disorders and discuss potential underlying pathophysiological mechanisms.

Pregnancy and birth complications associations with long-term adverse maternal mental health outcomes: a systematic review and meta-analysis protocol

Background: Existing studies have established an association between pregnancy, birth complications, and mental health in the first few weeks postpartum. However, there is no clear understanding of whether pregnancy and birth complications increase the risk of adverse maternal mental outcomes in the longer term. Research on maternal adverse mental health outcomes following pregnancy and birth complications beyond 12 months postpartum is scarce, and findings are inconsistent. Objective: This systematic review and meta-analysis will examine the available evidence on the association between pregnancy and birth complications and long-term adverse maternal mental health outcomes. Methods and analysis: We will include cohort, cross-sectional, and case-control studies in which a diagnosis of pregnancy and/or birth complication (preeclampsia, pregnancy loss, caesarean section, preterm birth, perineal laceration, neonatal intensive care unit admission, major obstetric haemorrhage, and birth injury/trauma) was reported and maternal mental disorders (depression, anxiety disorders, bipolar disorders, psychosis, and schizophrenia) after 12 months postpartum were the outcomes. A systematic search of PubMed, Embase, CINAHL, PsycINFO, and Web of Science will be conducted following a detailed search strategy until August 2022. Three authors will independently review titles and abstracts of all eligible studies, extract data using pre-defined standardised data extraction and assess the quality of each study using the Newcastle-Ottawa Scale. We will use random-effects meta-analysis for each exposure and outcome variable to calculate overall pooled estimates using the generic inverse variance method. This systematic review will follow the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Ethical consideration: The proposed systematic review and meta-analysis is based on published data; ethics approval is not required. The results will be presented at scientific meetings and publish in a peer-reviewed journal. PROSPERO registration: CRD42022359017

Health-related quality of life among postpartum women with preeclampsia, southern Ethiopia: a prospective cohort study

Background

Preeclampsia affects the health of the mother and the fetus during pregnancy and childbirth. To date, little is known about the impact of preeclampsia on postpartum health-related to quality of life (HRQoL) in the Sidama region of southern Ethiopia. This study aimed to measure the HRQoL and its contributing factors among postpartum women with preeclampsia in the Sidama region.

Methods

A prospective cohort study was conducted by enrolling pregnant women at ≥20 weeks of gestation up until the 37th week of gestation. We then followed them until 12 weeks after delivery. A locally validated, World Health Organization Quality-of-Life-BREF (WHOQOL-BREF) tool was used to assess participants’ HRQoL at two time points; the 6th and 12th weeks postpartum. Assessment of HRQoL of participants was based on total scores on the WHOQoL-BREF. Higher scores on the WHOQoL-BREF reflected a higher HRQoL. Multiple linear regression analyses were performed to evaluate the contributing factors to HRQoL. The level of significance was determined at a p-value of < 0.05.

Results

The HRQoL of postpartum women with preeclampsia significantly improved over time from 6 (151 ± 17) to 12 weeks (167 ± 18), p < 0.001). However, the overall HRQoL scores were lower (156 ± 16, p < 0.001) among women with preeclampsia compared to normotensive women (181 ± 21). An experience of early neonatal death was found to have a significant negative effect on the HRQoL of women with preeclampsia [β = − 2.1, 95% CI: − 3.43– − 0.85] compared to normotensive women who did not have early neonatal death. At 6 weeks of the postpartum period, the physical domain was found to have a significantly higher contribution to the lower HRQoL [β = 1.04, 95% CI: 0.88–1.12] compared to normotensive women, while other factors were constant.

Conclusions

The HRQoL of women with preeclampsia improved over time from 6 to 12 weeks in the postpartum period. Lower HRQoL was observed among postpartum women with preeclampsia, especially among those who experienced preterm birth or early neonatal death. The effects of preeclampsia on the HRQoL of postpartum women should be considered in redesigning postnatal care intervention services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-02061-2.

The Fibrinolytic System in Peripartum Depression

The relationship between depression and reduced fibrinolytic activity reflects the role of tissue plasminogen activator and plasmin in brain remodeling underlying resilience, depression remission, and reward processing, rather than the dissolution of fibrin clots. Individuals who experience depression demonstrate hippocampal and prefrontal cortex atrophy, as well as impaired neuronal connectivity. Brain-derived neurotrophic factor (BDNF), synthesized as a precursor that is activated through cleavage by tissue plasminogen activator and plasmin, influences adult neurogenesis and neuronal plasticity in the hippocampus and prefrontal cortex. Depression is associated with decreased brain levels of BDNF, due to reduced activity of tissue plasminogen activator and plasmin. Tissue plasminogen activator and plasmin also mediate the release of dopamine, a neurotransmitter implicated in motivation and reward. Peripartum depression defines a depressive episode that occurs during pregnancy or in the first month after delivery, reinforcing the concept that postpartum depression may be a continuum of antenatal depression. This article describes the fibrinolytic status in the healthy brain, in stress and depression, emphasizing the links between biological markers of depression and defective fibrinolysis. It also discusses the association between hypofibrinolysis and risk factors for perinatal depression, including polycystic ovary syndrome, early miscarriage, preeclampsia, stressful life events, sedentariness, eating habits, gestational and type 2 diabetes, and antithyroid peroxidase antibodies. In addition, it reviews the evidence that antidepressant medications and interventions as diverse as placebo, psychotherapy, massage, video game playing, regular exercise, dietary modifications, omega 3 fatty acid supplementation, neurohormones, and cigarette smoking may reduce depression by restoring the fibrinolytic activity. Last, it suggests new directions for research.

Fleur G, Mukona L, Hernandez E, Lamberty N. Peripartum Complications as Risk Factors for Postpartum Psychosis: A Systemic Review

The aim of this research paper is to conduct a systematic review of periparturient complications as risk factors of postpartum psychosis. The investigation of risk factors for maternal psychosis following childbirth is complicated by the risk of confounding by a previous psychiatric history; therefore, this systematic review focuses on labor complications as risk factors among women without any previous psychiatric hospitalizations or diagnoses.

Articles were collected and analyzed from the PubMed, MEDLINE, and Cochrane Review Library databases, as well as Clinicaltrials.gov, in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Article abstracts and article titles of the identified publications were screened independently by all seven authors, and studies were selected if they met the following inclusion criteria: patients were diagnosed with postpartum psychosis per the guidelines in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-V), DSM-IV or World Health Organization’s ICD-10 Classification of Mental and Behavioral Disorders; patients presented with no prior psychiatric diagnoses, hospitalizations or history; and the study evaluated the association of periparturient complications to first-onset postpartum psychosis, excluding narrative reviews, systematic reviews, or meta-analyses.

Fifteen case-control, cohort, and case report studies, with thousands of patients, were selected to investigate the correlation between perinatal complications and first-onset post-partum psychosis. Obstetric complications during childbirth significantly predisposed for postpartum psychosis in certain individual studies but did not reveal an association in others.

More studies must be implemented to elaborate on this limited scope.

Cohort profile: the Olmsted County hypertensive disorders of pregnancy (HDP) cohort using the Rochester Epidemiology Project

PURPOSE

The Olmsted County hypertensive disorders of pregnancy (HDP) cohort is a population-based retrospective study designed to compare the incidence of HDP on a per-pregnancy and per-woman basis and to identify associations between HDP with ageing-related diseases, as well as accumulation of multimorbidity.

PARTICIPANTS

Using the Rochester Epidemiology Project (REP) medical records-linkage system, a cohort was collected consisting of women who gave birth in Olmsted County between 1976 and 1982. After exclusions, a per-pregnancy cohort of 7544 women with 9862 pregnancies between 1976 and 1982 was identified, and their delivery information was manually reviewed. A subset of these women comprised the per-woman cohort of 4322 pregnancies from 1839 women with delivery information available throughout the entirety of their childbearing years, along with decades of follow-up data available for research via the REP.

FINDINGS TO DATE

By constructing both per-pregnancy and per-woman cohorts, we reported a doubling of HDP incidence rates when assessed on a per-woman basis compared with rates observed on a per-pregnancy basis. Moreover, in addition to finding that women with a history of HDP developed specific diseases at higher rates and at early ages, we also discovered that a history of HDP is associated with accelerated ageing, through accumulation of multimorbidity.

FUTURE PLANS

In addition to these outcomes described above, many other potential outcomes of interest for studies of HDP can be ascertained from accessing the electronic health records (EHR) and billing systems available through the REP. These data can include all International Classification of Diseases (ICD)-9 and ICD-10 and Current Procedural Terminology coded diagnoses and procedures, healthcare utilisation, including office visits, hospitalisations and emergency room visits, and full text of the EHR that is available for chart abstraction or for natural language processing of the clinical notes.

C-L Case Conference: A 33-year-old Bhutanese Woman with Postpartum Hallucinations

We present the care of a 33-year-old pre-eclamptic Bhutanese woman who presented with post-partum hallucinations. We discuss our concern for postpartum psychosis versus a culturally appropriate phenomenon, with her diagnostic picture complicated by our use of interpreters and the intersection of culture and medicine. Top experts in the consultation-liaison (CL) field provide guidance for this clinical scenario based on their experience and a review of the available literature. This case highlights both the impact of language barriers and the challenges of interpreting psychiatric symptoms within a cultural context. Key teaching points include differential diagnoses for postpartum hallucinations, the importance of interpreting patient presentations within their unique cultural contexts and identities, and the impact of language interpretation on patient care. Specifically, we offer guidance on differentiating postpartum psychosis from a culturally appropriate phenomenon.

Immune System Alterations and Postpartum Mental Illness: Evidence From Basic and Clinical Research

The postpartum period is a time associated with high rates of depression and anxiety as well as greater risk for psychosis in some women. A growing number of studies point to aberrations in immune system function as contributing to postpartum mental illness. Here we review evidence from both clinical and animal models suggesting an immune component to postpartum depression, postpartum anxiety, and postpartum psychosis. Thus far, clinical data primarily highlights changes in peripheral cytokine signaling in disease etiology, while animal models have begun to provide insight into the immune environment of the maternal brain and how central inflammation may also be contributing to postpartum mental illnesses. Further research investigating peripheral and central immune function, along with neural and endocrine interactions, will be important in successfully developing novel prevention and treatment strategies for these serious disorders that impact a large portion of new mothers.

Design and Evaluation of a Postpartum Depression Ontology

OBJECTIVE

Postpartum depression (PPD) remains an understudied research area despite its high prevalence. The goal of this study is to develop an ontology to aid in the identification of patients with PPD and to enable future analyses with electronic health record (EHR) data.

METHODS

We used Protégé-OWL to construct a postpartum depression ontology (PDO) of relevant comorbidities, symptoms, treatments, and other items pertinent to the study and treatment of PPD.

RESULTS

The PDO identifies and visualizes the risk factor status of variables for PPD, including comorbidities, confounders, symptoms, and treatments. The PDO includes 734 classes, 13 object properties, and 4,844 individuals. We also linked known and potential risk factors to their respective codes in the International Classification of Diseases versions 9 and 10 that would be useful in structured EHR data analyses. The representation and usefulness of the PDO was assessed using a task-based patient case study approach, involving 10 PPD case studies. Final evaluation of the ontology yielded 86.4% coverage of PPD symptoms, treatments, and risk factors. This demonstrates strong coverage of the PDO for the PPD domain.

CONCLUSION

The PDO will enable future researchers to study PPD using EHR data as it contains important information with regard to structured (e.g., billing codes) and unstructured data (e.g., synonyms of symptoms not coded in EHRs). The PDO is publicly available through the National Center for Biomedical Ontology (NCBO) BioPortal ( https://bioportal.bioontology.org/ontologies/PARTUMDO ) which will enable other informaticists to utilize the PDO to study PPD in other populations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The association of asthma, atopic dermatitis, and allergic rhinitis with peripartum mental disorders

BACKGROUND

Atopic diseases are characterized by dysregulated inflammatory response, which may incur the onset of peripartum mental disorders, but the impact remains unknown. This study examined whether and to what extent the history of atopic diseases is associated with newly onset peripartum mental disorders.

METHODS

Using population-based registries, we identified all primiparous women who gave birth to live singletons in Denmark during 1978-2016 (n = 937,422). The exposure was hospital contact due to the three major types of atopic diseases-asthma, atopic dermatitis, and allergic rhinitis-before conception. The primary outcome was any hospital contact for mental disorder during pregnancy and 1-year postpartum, which was further classified into affective disorders, neurotic, stress-related and somatoform disorders, and substance abuse. The follow-up started from the date of conception and ended at the date of the first diagnosis of mental disorders, 1-year postpartum, death, emigration, or December 31, 2016, whichever came first. Cox regression was used, adjusted for calendar year, age at childbirth, education, residence, and Charlson comorbidity index.

RESULTS

A total of 24,016 (2.6%) women received diagnosis of at least one of the three atopic diseases before conception (asthma, 1.7%; atopic dermatitis, 0.6%; and allergic rhinitis, 0.8%). Exposure to asthma, atopic dermatitis, or allergic rhinitis was associated with a 37% increased overall risk of peripartum mental disorders (hazard ratio [HR], 1.37; 95% confidence interval [CI], 1.27-1.49). Higher risks were observed among women with more frequent hospital contacts for atopic disease (HR, 1.80; 95% CI, 1.37-2.35; ≥5 times), and with recent hospital contacts for atopic disease (HR, 1.74; 95% CI, 1.48-2.06; within 2 years before conception). Specific associations were observed between asthma and neurotic, stress-related and somatoform disorders (HR, 1.40; 95% CI, 1.21-1.62), and between atopic dermatitis and substance abuse (HR, 1.62; 95% CI, 1.12-2.34).

CONCLUSIONS

History of asthma, atopic dermatitis, and allergic rhinitis before conception was associated with increased risks of peripartum mental disorders. Women who have atopic diseases before pregnancy may benefit from systematic mental health monitoring.

The role of the immune system in postpartum psychosis

Postpartum psychosis is the most severe psychiatric disorder associated with childbirth. The risk is particularly high for women with a history of bipolar disorder or schizoaffective disorder, or those who have suffered a previous episode of postpartum psychosis. However, the aetiology of the illness remains unclear. Pregnancy and the early postpartum are times of significant immunological change. Furthermore, alterations to the immune system have been implicated in the onset and course of various psychopathologies, both related and unrelated to childbirth. Emerging evidence, from studies on immune related disorders, immune cells and inflammatory markers, suggests that the immune system might also be involved in the pathophysiology of postpartum psychosis. Furthermore, recent research has also begun to explore the potential mechanisms underlying immune dysfunction in postpartum psychosis (e.g., disturbances in the Treg-CCN3 protein-(re)myelination axis). Nevertheless, more research is required to understand whether immune dysfunction is a cause or consequence of postpartum psychosis and to clarify the exact mechanisms involved. The aim of this short review is to present the current findings on immune system dysregulation in postpartum psychosis, discuss possible mechanisms underlying the association, highlight potential challenges and confounders and provide suggestions for future research.

Natural vs. programmed cycles for frozen embryo transfer: study protocol for an investigator-initiated, randomized, controlled, multicenter clinical trial

Background

Randomized trials of assisted reproductive technology (ART) have been designed for outcomes of clinical pregnancy or live birth and have not been powered for obstetric outcomes such as preeclampsia, critical for maternal and fetal health. ART increasingly involves frozen embryo transfer (FET). Although there are advantages of FET, multiple studies have shown that risk of preeclampsia is increased with FET compared with fresh embryo transfer, and the reason for this difference is not clear. NatPro will compare the proportion of preeclampsia between two commonly used protocols for FET,modified natural and programmed cycle.

Methods

In this two-arm, parallel-group, multi-center randomized trial, NatPro will randomize 788 women to either modified natural or programmed FET and follow them for up to three FET cycles. Primary outcome will be the proportion of preeclampsia in women with a viable pregnancy assigned to a modified natural cycle FET (corpus luteum present) protocol compared to the proportion of preeclampsia in pregnant women assigned to a programmed FET (corpus luteum absent) protocol. Secondary outcomes will compare the proportion of live births and the proportion of preeclampsia with severe features between the protocols.

Conclusion

This study has a potential significant impact on millions of women who pursue ART to build their families. NatPro is designed to provide clinically relevant guidance to inform patients and clinicians regarding maternal risk with programmed and modified natural cycle FET protocols. This study will also provide accurate point estimates regarding the likelihood of live birth with programmed and modified natural cycle FET.

Trial registration

ClinicalTrials.govNCT04551807. Registered on September 16, 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05637-3.

Acute psychiatric illness and drug addiction during pregnancy and the puerperium

Pregnancy and the puerperium do not protect against acute psychiatric illness. During puerperium, the chance of acute psychiatric illness, such as a psychotic episode or relapse of bipolar disorder, is greatly increased. Suicide is a leading cause of maternal death. Both psychiatric disease and ongoing drug addiction impact not only the pregnant woman's somatic and mental health but also impact short-term and long-term health of the child. Indeed, prompt recognition and expeditious treatment of acute psychiatric illness during pregnancy and the puerperium optimize health outcomes for two patients. Pregnancy and puerperium represent a stage of life of great physiologic adaptations, as well as emotional and social changes. This conjunction of changes in somatic, emotional health and social health may mitigate the occurrence, clinical presentation, and clinical course of acute psychiatric illness and call for a multidisciplinary approach, taking into account both the medical and social domains. This chapter describes acute psychiatric illnesses during pregnancy and the puerperium and illicit substance abuse, from a clinical perspective, while also describing general principles of diagnosis and clinical management during this stage of life, which is an important window of opportunity for both the pregnant woman and the child.

Postpartum Psychosis after Traumatic Cesarean Delivery

An emergency cesarean delivery can be a traumatic childbirth experience for a woman and a risk factor for postpartum psychosis, especially in a patient with a history of bipolar disorder. This article describes the case of a pregnant woman with an unknown history of bipolar disorder who developed an acute psychotic reaction during the procedure of an emergency caesarian section and switched to mania. The purpose of this case study is for perinatal health care professionals to identify suspicious symptoms and promptly refer to psychiatric services so as to ensure the mother's and the newborn's safety. This case study highlights the importance of assessing women with bipolar disorder or a previous psychotic episode for the risk of psychiatric complications in pregnancy and after childbirth. Midwifery education on perinatal mental health is crucial for the detection of suspicious symptoms and early referral to a specialist.

Artificial intelligence: A rapid case for advancement in the personalization of Gynaecology/Obstetric and Mental Health care

To evaluate and holistically treat the mental health sequelae and potential psychiatric comorbidities associated with obstetric and gynaecological conditions, it is important to optimize patient care, ensure efficient use of limited resources and improve health-economic models. Artificial intelligence applications could assist in achieving the above. The World Health Organization and global healthcare systems have already recognized the use of artificial intelligence technologies to address 'system gaps' and automate some of the more cumbersome tasks to optimize clinical services and reduce health inequalities. Currently, both mental health and obstetric and gynaecological services independently use artificial intelligence applications. Thus, suitable solutions are shared between mental health and obstetric and gynaecological clinical practices, independent of one another. Although, to address complexities with some patients who may have often interchanging sequelae with mental health and obstetric and gynaecological illnesses, 'holistically' developed artificial intelligence applications could be useful. Therefore, we present a rapid review to understand the currently available artificial intelligence applications and research into multi-morbid conditions, including clinical trial-based validations. Most artificial intelligence applications are intrinsically data-driven tools, and their validation in healthcare can be challenging as they require large-scale clinical trials. Furthermore, most artificial intelligence applications use rate-limiting mock data sets, which restrict their applicability to a clinical population. Some researchers may fail to recognize the randomness in the data generating processes in clinical care from a statistical perspective with a potentially minimal representation of a population, limiting their applicability within a real-world setting. However, novel, innovative trial designs could pave the way to generate better data sets that are generalizable to the entire global population. A collaboration between artificial intelligence and statistical models could be developed and deployed with algorithmic and domain interpretability to achieve this. In addition, acquiring big data sets is vital to ensure these artificial intelligence applications provide the highest accuracy within a real-world setting, especially when used as part of a clinical diagnosis or treatment.

Is There an Association Between Oxytocin Levels in Plasma and Pregnant Women's Mental Health?

BACKGROUND: Mood and anxiety disorders are prevalent in women during peripartum. AIMS: Purpose of the present article was to study the relationship between oxytocin (OT) plasma levels and affective symptoms in women during the third trimester of pregnancy. METHODS: Thirty-four pregnant women (13 with an affective disorder, 9 with preeclampsia, and 12 controls) were evaluated through the Edinburgh Postnatal Depression Scale (EPDS), the State/Trait Anxiety Inventory Form Y (STAI-Y), and the Prenatal Attachment Inventory (PAI). A blood sample was collected from all participants, and OT plasma levels have been compared between diagnostic groups. The total sample has been divided into two groups, according to OT median plasma levels, and compared using (a) χ² tests for qualitative variables and (b) a multivariate analysis of covariance for quantitative ones. RESULTS: No statistically significant difference was found among the diagnostic groups in terms of OT plasma levels (F = 0.49, p = .62). Women with lower OT plasma levels, independent from the presence of preeclampsia or an affective disorder, showed worse EPDS and STAI-S total scores than individuals with higher hormone levels (F = 5.93, p = .02 and F = 7.57, p = .01, respectively). CONCLUSIONS: OT may play a role in the etiology of anxious/depressive symptoms during perinatal period independent from a medical or psychiatric diagnosis. This result has a clear effect on the quality of the relationship of patients with mental health professionals, including nurses, and higher levels of this hormone, in the light of its anxiolytic and antidepressive effect, may make easier medical and nursing procedures.

Preeclampsia and the longitudinal risk of hospitalization for depression at 28 years

PURPOSE

The association between pregnancy characteristics and risk of depression in women is poorly understood. We investigated the relationship between preeclampsia and risk of hospitalization for depression over three decades.

METHODS

We carried out a longitudinal cohort study of 1,210,963 women who delivered an infant in any hospital in Quebec, Canada, between 1989 and 2016. The exposure was preeclampsia at the first or in subsequent pregnancies, including preeclampsia onset time (early < 34 weeks vs. late ≥ 34 weeks of gestation) and severity (mild, severe, superimposed). The outcome was hospitalization for depression any time after pregnancy. We used Cox proportional hazards regression models adjusted for maternal characteristics to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association of preeclampsia with depression hospitalization.

RESULTS

Women with preeclampsia had a higher incidence of hospitalization for depression compared with no preeclampsia (1.43 vs. 1.14 per 1000 person-years). Preeclampsia was associated with 1.16 times the risk of depression hospitalization after 28 years of follow-up (95% CI 1.09-1.23). Associations were present for mild (HR 1.15, 95% CI 1.07-1.24), severe (HR 1.16, 95% CI 1.04-1.29) and late onset preeclampsia (HR 1.17, 95% CI 1.10-1.25). Risks were more pronounced after the first year postpartum.

CONCLUSION

Preeclampsia appears to be associated with the risk of depression hospitalization several decades after pregnancy. Clinicians who care for women with mental health disorders should be aware that a history of preeclampsia increases the risk of severe depression.

Phenomenology, Epidemiology and Aetiology of Postpartum Psychosis: A Review

Postpartum psychoses are a severe form of postnatal mood disorders, affecting 1–2 in every 1000 deliveries. These episodes typically present as acute mania or depression with psychosis within the first few weeks of childbirth, which, as life-threatening psychiatric emergencies, can have a significant adverse impact on the mother, baby and wider family. The nosological status of postpartum psychosis remains contentious; however, evidence indicates most episodes to be manifestations of bipolar disorder and a vulnerability to a puerperal trigger. While childbirth appears to be a potent trigger of severe mood disorders, the precise mechanisms by which postpartum psychosis occurs are poorly understood. This review examines the current evidence with respect to potential aetiology and childbirth-related triggers of postpartum psychosis. Findings to date have implicated neurobiological factors, such as hormones, immunological dysregulation, circadian rhythm disruption and genetics, to be important in the pathogenesis of this disorder. Prediction models, informed by prospective cohort studies of high-risk women, are required to identify those at greatest risk of postpartum psychosis.

A new molecular risk pathway for postpartum mood disorders: clues from steroid sulfatase-deficient individuals

Postpartum mood disorders develop shortly after childbirth in a significant proportion of women. These conditions are associated with a range of symptoms including abnormally high or low mood, irritability, cognitive disorganisation, disrupted sleep, hallucinations/delusions, and occasionally suicidal or infanticidal ideation; if not treated promptly, they can substantially impact upon the mother's health, mother-infant bonding, and family dynamics. The biological precipitants of such disorders remain unclear, although large changes in maternal immune and hormonal physiology following childbirth are likely to play a role. Pharmacological therapies for postpartum mood disorders can be effective, but may be associated with side effects, concerns relating to breastfeeding, and teratogenicity risks when used prophylactically. Furthermore, most of the drugs that are used to treat postpartum mood disorders are the same ones that are used to treat mood episodes during non-postpartum periods. A better understanding of the biological factors predisposing to postpartum mood disorders would allow for rational drug development, and the identification of predictive biomarkers to ensure that 'at risk' mothers receive earlier and more effective clinical management. We describe new findings relating to the role of the enzyme steroid sulfatase in maternal postpartum behavioural processes, and discuss how these point to a novel molecular risk pathway underlying postpartum mood disorders. Specifically, we suggest that aberrant steroid hormone-dependent regulation of neuronal calcium influx via extracellular matrix proteins and membrane receptors involved in responding to the cell's microenvironment might be important. Testing of this hypothesis might identify novel therapeutic targets and predictive biomarkers.

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

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

T-cell defects and postpartum depression

BACKGROUND

Most studies of immune dysregulation in perinatal mood and anxiety disorders have focused on peripheral cytokines, but literature from non-perinatal mood disorders also implicates T-cell defects. We sought to characterize proportions of T-cell subtypes in women with postpartum depression.

MATERIALS AND METHODS

We enrolled 21 women with postpartum depression (PPD), 39 healthy postpartum controls, and 114 healthy non-postpartum women. Blood was collected in sodium-heparin EDTA tubes and was analyzed using flow cytometry. We conducted statistical tests including linear regression analysis that were aimed at determining differences in proportions of T cell populations among groups.

RESULTS

Mean counts of T-cells (all CD3+ T cells), T-helper cells, (CD3+CD4+ T cells), and T-cytotoxic cells (CD3+CD8+ T cells) were significantly increased in healthy postpartum women compared to healthy non-postpartum controls (p < 0.001, p = 0.007, and p = 0.002, respectively), but not in women with PPD. The increases in healthy postpartum women were driven by increases in T_H1 cells and T regulatory cells, increases that were nonexistent or attenuated in women with postpartum depression. Mean counts of CD4+ T-helper memory cells were also increased in healthy postpartum women (p = 0.009), but slightly decreased in women with PPD (p = 0.066), when compared to healthy non-postpartum controls.

CONCLUSIONS

Our study confirms that the postpartum period in healthy women is a time of enhanced T cell activity. Women with postpartum depression failed to show physiological enhanced T-cell activity postpartum, and future research is needed to elucidate etiological mechanisms and consequences.

Postpartum psychosis in peripartum cardiomyopathy: a case report

BACKGROUND

This case report highlights the rare occurrence of postpartum psychosis in the setting of peripartum cardiomyopathy, which can have rare presentations like arrhythmias and pulmonary edema; and the challenges one should anticipate while managing these conditions together. Caution is advised whenever antipsychotic drugs are to be administered to a patient with a cardiac condition as these drugs potentially increase the risk of arrhythmias and sudden death.

CASE PRESENTATION

A 35 year old grand multiparous woman who was 1 week into puerperium was admitted with severe difficulty in breathing at rest, chest congestion and pain. She also had easy fatigability, orthopnea, paroxysmal nocturnal dyspnea, edema, tachycardia, tachypnea, irregularly irregular heart rate with a pulse deficit, elevated jugular venous pressure, cardiomegaly, hepatomegaly and pulmonary crepitations. On the sixth day while improving on standard drugs for heart failure, she developed bizarre behavior and confusion. She also had auditory, visual and olfactory hallucinations; violence to the baby and the husband; and refusal to feed and take medication. There was no altered sensorium and the vital signs were normal. She was diagnosed with puerperal psychosis during the management of peripartum cardiomyopathy.

CONCLUSION

In the rare occurrence of puerperal psychosis in the course of management of peripartum cardiomyopathy one must be acutely aware of the risk of sudden cardiac death occasioned by use of antipsychotics, either directly or due to arrhythmias. Continuous electrocardiogram (ECG) monitoring or use of alternative management modalities is thus highly advised.

Neurobiology of maternal mental illness

This chapter provides an overview of current research discoveries beginning to uncover the neurobiology of maternal mental illness. Results are described according to standard diagnostic categories (specifically, perinatal depression, perinatal anxiety and OCD, postpartum psychosis and bipolar disorder, and trauma and posttraumatic stress disorder), yet we aim to put this approach in context with the introduction of a classification model for psychiatric research, the research domain criteria, gaining traction in basic and clinical translational fields. We first review a new area of study, the neuroplasticity of the pregnant and postpartum brain, as work here has relevance for understanding the pathophysiology of mental disorders and may provide clues to changes in brain functioning that are related to compromised parenting in the context of postpartum depression. We next provide background information on neuroendocrine and immune changes during pregnancy and, to a lesser extent, the postpartum period, as alterations in these systems are significantly implicated in underlying neurobiology of mental illness for peripartum women. Our discussion of the major mental illnesses for pregnant and postpartum women includes neuroendocrine changes, neuroinflammation, and neurotransmitter alterations, as well as circuit dysfunction. Overall, remarkable progress has been made in identifying variations in neurobiology (and related systems) involved in maternal mental illness; yet, it is clear that, as classified with standard diagnostic systems, these are heterogeneous disorders and there is individual variability in the alterations in neurobiology for the same illness.

An Analysis of Cellular Communication Network Factor Proteins as Candidate Mediators of Postpartum Psychosis Risk

Postpartum (or puerperal) psychosis (PP) is a severe psychiatric condition associated with hallucinations, delusions, cognitive disorganization, and mood problems, which affects approximately 1-2 out of every 1,000 mothers shortly after childbirth. While the risk factors for, and co-morbidities of, PP are relatively well-defined, currently, the pathophysiology underlying the disorder is very poorly-specified. Here, I argue, on the basis of multiple lines of new evidence, that altered expression of the Cellular Communication Network (CCN) factor proteins (and of the heterodimerizing CCN2 and CCN3 proteins in particular), may be associated with, and possibly causal for, increased PP risk. Future preclinical and clinical studies should aim to test this hypothesis as empirical support for it would provide much-needed clues regarding the biological substrates of PP, and could point to predictive biomarkers for the condition.

Inflammatory bowel disease and new-onset psychiatric disorders in pregnancy and post partum: a population-based cohort study

OBJECTIVE

Patients with inflammatory bowel disease (IBD) have an elevated risk of mental illness. We determined the incidence and correlates of new-onset mental illness associated with IBD during pregnancy and post partum.

DESIGN

This cohort study using population-based health administrative data included all women with a singleton live birth in Ontario, Canada (2002-2014). The incidence of new-onset mental illness from conception to 1-year post partum was compared between 3721 women with and 798 908 without IBD, generating adjusted HRs (aHR). Logistic regression was used to identify correlates of new-onset mental illness in the IBD group.

RESULTS

About 22.7% of women with IBD had new-onset mental illness versus 20.4% without, corresponding to incidence rates of 150.2 and 132.8 per 1000 patient-years (aHR 1.12, 95% CI 1.05 to 1.20), or one extra case of new-onset mental illness per 43 pregnant women with IBD. The risk was elevated in the post partum (aHR 1.20, 95% CI 1.09 to 1.31), but not during pregnancy, and for Crohn's disease (aHR 1.12, 95% CI 1.02 to 1.23), but not ulcerative colitis. The risk was specifically elevated for a new-onset mood or anxiety disorder (aHR 1.14, 95% CI 1.04 to 1.26) and alcohol or substance use disorders (aHR 2.73, 95% CI 1.42 to 5.26). Predictors of a mental illness diagnosis were maternal age, delivery year, medical comorbidity, number of prenatal visits, family physician obstetrical care and infant mortality.

CONCLUSION

Women with IBD were at an increased risk of new-onset psychiatric diagnosis in the postpartum period, but not during pregnancy. Providers should look to increase opportunities for prevention, early identification and treatment accordingly.

Puerperal Psychosis: A brief review and unusual case report

This is a brief review of puerperal (post-partum) psychosis and contains a case report of Donkin Psychosis, an unusual form which is associated with pre-eclampsia, from Queen Elizabeth Central Hospital in Blantyre, Malawi. It includes considerations for treatment of Donkin Psychosis, in particular. It is the first reported case of Donkin Psychosis from Africa, to our knowledge.

[Inflammatory Biomarkers and Postpartum Depression: A Systematic Review of Literature]

OBJECTIVE

Postpartum Depression (PPD) affects over 15% new mothers. Its etiology is multifactorial and still partly unknown. Some hypotheses suggest a link with inflammation. This review aims to explore the existence of inflammatory biomarkers associated with PPD. The possibility of potential adjunct treatments, linked with these biomarkers, will be discussed.

METHOD

The systematic review of literature was performed using in PubMed, PsycInfo and Embase, and 25 articles were included. Various biomarkers were identified. The most often studied are C-reactive protein (CRP), interleukins 6 and 10, tumor necrosis factor-alpha and interferon-gamma.

RESULTS

Although few results appear as significant during the various testing times, the dosage of some inflammation biomarkers, including CRP, at the very end of pregnancy or immediately after delivery could predict PPD. Interactions between inflammation and the corticotropic axis could explain PPD onset. Epigenetic mechanisms could lead to pro-inflammatory state. Several therapeutics provide interest due to their anti-inflammatory property.

CONCLUSIONS

Further studies are needed to assess these biomarkers value as predictive factors of PPD and to consider adjunct treatments to antidepressants. If this value is confirmed, the inflammatory marker dosage, in particular CRP, could help to provide early screening of women at risk of PPD, parallel of the clinical evaluation. A zinc supplementation could then be offered.

Maternal psychological distress after severe pregnancy hypertension was associated with increased child behavioural problems at the age of 12

AIM

We examined the association between early maternal psychological distress after severe hypertensive disorders of pregnancy (HDP) and behavioural issues in their 12-year-old offspring.

METHODS

This secondary analyses of a prospective mother-child birth cohort focused on 95 women with severe HDP and their singleton offspring. The mothers were recruited during pregnancy from 2000 to 2003 in Amsterdam, the Netherlands. Maternal distress at child term age and three months post-term was measured using the Symptom Checklist-90. The Child Behaviour Checklist for six years to 18 years was used to quantify social and attention problems in their offspring at 12 years of age. Perinatal and neonatal risk factors were also analysed.

RESULTS

The children were born at a mean age of just under 32 weeks and 90% weighed below the 10th percentile. High psychological distress (score ≥133) affected 45% of the mothers at term age and 44% three months post-term. Child social problems were significantly associated with maternal distress at three months and were highest in cases of high maternal distress in combination with major neonatal morbidity. Child attention problems were associated with maternal anxiety at three months post-term.

CONCLUSION

Early maternal psychological distress after severe maternal HDP was associated with childhood behavioural issues at the age of 12.

Depression, Antidepressants and Hypertensive Disorders of Pregnancy: A Systematic Review

Background:

Hypertensive disorders of pregnancy including gestational hypertension, preeclampsia and eclampsia are conditions that cause significant perinatal and maternal morbidity and mortality. </P><P> Objective: This is a systematic review of the current evidence examining the relationship between both depression and antidepressants on pregnancy-related hypertensive conditions. </P><P> Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, six databases were searched for articles published between January 1990 and December 2017 (PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, MEDLINE and ClinicalTrials. gov). Randomized control trials, cohort studies and case-control studies were included in this review. Studies that measured the following exposures were included: Antidepressant exposure or diagnosis of depression. Studies that measured the following outcomes were included: Gestational hypertension, preeclampsia or eclampsia. A combination of keywords, as well as Medical Subject Headings (MeSH) index terms, was used for three general categories: antidepressants, depression and hypertensive disorders of pregnancy. A total of 743 studies were identified and 711 were excluded based on relevance to the research question. Twenty studies were included in the final systematic review. </P><P> Results: Of the twenty relevant studies, ten specifically examined the relationship between depression and hypertension in pregnancy. Only two of these did not find a significant association. Of the ten studies that concentrated on antidepressant medications, all except one found an association with hypertension in pregnancy to varying degrees. </P><P> Conclusion: Review of the literature suggests a possible association between depression and antihypertensive medications with pregnancy-related hypertension, but further studies are needed.</P>

Maternal bereavement shortly before or during pregnancy and risk of postpartum psychotic illness: a population-based study from Denmark and Sweden

Purpose: Postpartum psychosis is a rare but severe complication following childbirth, with unknown etiology. This study investigated whether the death of a close family member — a source of severe stress — the year before or during pregnancy was associated with an increased risk of psychotic illness in the postpartum period among women without and with a history of psychiatric disorder.

Methods: We studied live births in Denmark during 1978–2008 and births in Sweden during 1973–2006 (n=5,246,978). Information on death of women’s relatives and partners and sociodemographic, health-, and pregnancy-related factors was obtained through linkage with nationwide registries.

Results: The death of a close relative the year before or during pregnancy was not associated with psychotic illness during the first 90 days postpartum among women without (adjusted HR 1.02, 95% CI 0.76–1.37) or with a history of psychiatric disorder (HR 0.96, 95% CI 0.74–1.25). Similarly, there was no association between bereavement and risk of postpartum psychosis according to the timing of the loss (the year before or during pregnancy), the relative’s cause of death (natural or unnatural), or the woman’s relationship to the deceased (parent/sibling or partner/older child).

Conclusions: Death of a close relative, one of the most severe sources of stress, before or during pregnancy was not associated with postpartum psychosis. Therefore, these data do not support the hypothesis that severely stressful life events, such as bereavement around the time of pregnancy, are associated with postpartum psychosis.

Cytokine alterations in first-onset postpartum psychosis-clues for underlying immune dysregulation

BACKGROUND

Emerging evidence suggests a possible role for immune system dysregulation in the pathogenesis of postpartum psychosis (PP) but the evidence is limited. The current study sought to determine the serum cytokines/ chemokine changes associated with first-onset PP.

METHODS

Women with first onset PP were recruited as cases and the cytokines/ chemokine changes were compared against healthy postpartum (HP) and healthy non-postpartum (HNP) women.There were 20 subjects in each of the three groups. Levels of serum cytokines and Monocyte Chemoattractant Protein-1 (MCP-1) were estimated with a cytometric beadarray assay.

RESULTS

HP group showed significantly elevated levels of interleukin (IL)-6 as compared to HNP group. Whereas, the first onset PP group showed significantly elevated levels of both IL-6 and IL-8 as compared to HNP group.

CONCLUSION

Postpartum period appears to be a state of altered immune functioning considering the elevated level of IL-6 in both HP and PP group. Additionally, IL-8 appears to play a role in the manifestation of PP. Our study highlights the immune alterations associated with first-onset PP.

Toward a framework for best practices and research guidelines for perinatal depression research

This review article highlights the current state of perinatal depression (PND) research including established standards of care and innovative research in progress. PND can have a significant adverse impact on mother, child, and family; however, to date, wide-scale identification, prevention, and treatment have been limited. PND is heterogenous in presentation with likely multifactorial etiologies for each woman. Challenges in PND research are discussed including a need for universal tools, standardized measures, benchmarks, and best practices. Current examples are reviewed that highlight approaches to novel treatment paradigms and interventions. This includes reviewing epidemiologic studies in PND research, examining the biological underpinnings of PND, and discussing examples from this field and other fields currently developing translational research that spans from bench to bedside. Current and future challenges and opportunities in developing best practices for the treatment of PND are outlined. We also discuss the use of the NIMH Research Domain Criteria approach for PND research and provide recommendations for future directions in PND research collaboration. In conclusion, greater precision in perinatal psychiatry can be possible in the future with the development of guidelines and best practices that build on current work and apply innovative and collaborative approaches of scientists, providers, patients, community members, and government officials.

Recognizing and Managing Postpartum Psychosis: A Clinical Guide for Obstetric Providers

Postpartum psychosis is a psychiatric emergency that affects 1 to 2 per 1000 women. Key clinical features include mood fluctuation, abnormal thoughts or behaviors, and confusion. Women with a history of bipolar disorder are at heightened risk, as are first-time mothers; current research on the causes focuses on biological triggers, such as immune dysregulation. Women with postpartum psychosis require inpatient hospitalization and should be treated with lithium, antipsychotics, and benzodiazepines.

Inflaming sex differences in mood disorders

Men and women often experience different symptoms or rates of occurrence for a variety of mood disorders. Many of the symptoms of mood disorders overlap with autoimmune disorders, which also have a higher prevalence in women. There is a growing interest in exploring the immune system to provide biomarkers for diagnosis of mood disorders, along with new targets for developing treatments. This review examines known sex differences in the immune system and their relationship to mood disorders. We focus on immune alterations associated with unipolar depression, bipolar depression, and anxiety disorders. We describe work from both basic and clinical research examining potential immune mechanisms thought to contribute to stress susceptibility and associated mood disorders. We propose that sex and age are important, intertwined factors that need to be included in future experimental designs if we are going to harness the power of the immune system to develop a new wave of treatments for mood disorders.

Electronic Algorithm Is Superior to Hospital Discharge Codes for Diagnoses of Hypertensive Disorders of Pregnancy in Historical Cohorts

OBJECTIVES

To develop and validate criteria for the retrospective diagnoses of hypertensive disorders of pregnancy that would be amenable to the development of an electronic algorithm, and to compare the accuracy of diagnoses based on both the algorithm and diagnostic codes with the gold standard, of physician-made diagnoses based on a detailed review of medical records using accepted clinical criteria.

PATIENTS AND METHODS

An algorithm for hypertensive disorders of pregnancy was developed by first defining a set of criteria for retrospective diagnoses, which included relevant clinical variables and diagnosis of hypertension that required blood pressure elevations in greater than 50% of readings ("the 50% rule"). The algorithm was validated using the Rochester Epidemiology Project (Rochester, Minnesota). A stratified random sample of pregnancies and deliveries between January 1, 1976, and December 31, 1982, with the algorithm-based diagnoses was generated for review and physician-made diagnoses (normotensive, gestational hypertension, and preeclampsia), which served as the gold standard; the targeted cohort size for analysis was 25 per diagnosis category according to the gold standard. Agreements between (1) algorithm-based diagnoses and (2) diagnostic codes and the gold standard were analyzed.

RESULTS

Sensitivities of the algorithm for 25 normotensive pregnancies, 25 with gestational hypertension, and 25 with preeclampsia were 100%, 88%, and 100%, respectively, and specificities were 94%, 100%, and 100%, respectively. Diagnostic code sensitivities were 96% for normotensive pregnancies, 32% for gestational hypertension, and 96% for preeclampsia, and specificities were 78%, 96%, and 88%, respectively.

CONCLUSION

The electronic diagnostic algorithm was highly sensitive and specific in identifying and classifying hypertensive disorders of pregnancy and was superior to diagnostic codes.

Do Defective Immune System-Mediated Myelination Processes Increase Postpartum Psychosis Risk?

Postpartum (or puerperal) psychosis (PP) is a rare, severe psychiatric disorder that affects women shortly after childbirth; risk is particularly high in individuals with a history of bipolar disorder or PP, but the underlying pathophysiology remains poorly understood. Emerging evidence suggests that immune system (dys)function plays an important role in disorder onset. On the basis of new findings from clinical and animal model studies, we hypothesise that the abundance and/or activity of regulatory T cells, and the efficacy of consequent (re)myelination processes in the brain mediated by CCN proteins, is perturbed in PP; this pathway may be modulated by risk and protective/treatment factors for the disorder, and identifying abnormalities within it could signpost novel predictive biomarkers and therapeutic targets.