The interrelationship of maternal stress, endocrine factors and inflammation on gestational length

Gestational Viral Infections: Role of Host Immune System

Viral infections in pregnancy are major causes of maternal and fetal morbidity and mortality. Infections can develop in the neonate transplacentally, perinatally, or postnatally (from breast milk or other sources) and lead to different clinical manifestations, depending on the viral agent and the gestational age at exposure. Viewing the peculiar tolerogenic status which characterizes pregnancy, viruses could exploit this peculiar immunological status to spread or affect the maternal immune system, adopting several evasion strategies. In fact, both DNA and RNA virus might have a deep impact on both innate and acquired immune systems. For this reason, investigating the interaction with these pathogens and the host's immune system during pregnancy is crucial not only for the development of most effective therapies and diagnosis but mostly for prevention. In this review, we will analyze some of the most important DNA and RNA viruses related to gestational infections.

Is it Necessary to Evaluate Fear of Childbirth in Pregnant Women? A Scoping Review

OBJECTIVE

 To review concepts, definitions, and findings about fear of childbirth (FOC).

METHODS

 A bibliographic review was carried out through the main scientific databases in 2020.

RESULTS

 All 32 articles considered potentially relevant were analyzed. A recent study suggests that the global prevalence of FOC can reach up to 14%. Factors such as parity, gestational age, previous birth experience, age and nationality of the woman seem to influence FOC.

CONCLUSION

 Fear of childbirth could be related to an increased risk of adverse obstetric outcomes such as maternal request for cesarean delivery, preterm birth, prolonged labor, postpartum depression, and post-traumatic stress. These evidence highlight the importance of the discussion regarding this topic.

Pregnant Women Infected with Zika Virus Show Higher Viral Load and Immunoregulatory Cytokines Profile with CXCL10 Increase

BACKGROUND

Zika virus (ZIKV) infection during pregnancy usually shows only mild symptoms and is frequently subclinical. However, it can be vertically transmitted to the fetus, causing microcephaly and other congenital defects. During pregnancy, the immune environment modifications can alter the response to viruses in general and ZIKV in particular.

OBJECTIVE

To describe the role of pregnancy in the systemic pro- and anti-inflammatory response during symptomatic ZIKV infection.

MATERIALS AND METHODS

A multiplex assay was used to measure 25 cytokines, chemokines, and receptors in 110 serum samples from pregnant and nonpregnant women with and without ZIKV infection with and without symptoms. Samples were collected through an epidemiological surveillance system.

RESULTS

Samples from pregnant women with ZIKV infection showed a higher viral load but had similar profiles of inflammatory markers as compared with nonpregnant infected women, except for CXCL10 that was higher in infected pregnant women. Notably, the presence of ZIKV in pregnancy favored a regulatory profile by significantly increasing anti-inflammatory cytokines such as interleukin (IL)-10, receptors IL-1RA, and IL-2R, but only those pro-inflammatory cytokines such as IL-6, interferon (IFN)-α, IFN-γ and IL-17 that are essential for the antiviral response. Interestingly, there were no differences between symptomatic and weakly symptomatic ZIKV-infected groups.

CONCLUSION

Our results revealed a systemic anti-inflammatory cytokine and chemokine profile that could participate in the control of the virus. The anti-inflammatory response in pregnant women infected with ZIKA was characterized by high CXCL10, a cytokine that has been correlated with congenital malformations.

Psychological predictors of gestational outcomes in second trimester pregnant women: associations with daily uplifts

PURPOSE

We investigated whether pregnancy/birth anxiety is associated with shorter gestation while maternal chronic stress and depressive symptoms are associated with lower birth weight; we also examined whether experiencing daily uplifts prenatally may contribute to a more favorable birth outcome.

METHODS

Thirty-four healthy second trimester pregnant women responded to questions regarding their experience of pregnancy/birth anxiety, chronic stress, depressive symptoms, and daily uplifts. Information on birth outcome was obtained from medical records.

RESULTS

Maternal pregnancy/birth anxiety, depression, and stress were unrelated to birth outcomes. Daily uplifts were associated with gestational age at birth (B = 2.0, p = 0.01), neonatal weight (B = 46.9, p = 0.00), and size (B = 10.6, p = 0.01). Our results suggest that pregnancy/birth anxiety is not associated with shorter gestation as well as depression and stress seem to not predict lower birth weight.

CONCLUSION

We expand the literature by showing that experiencing daily uplifts during mid-gestation may further fetal development.

Design and Psychometric Analysis of the Stressors and Modulators of Gestational Stress Inventory (SMGSI)

Gestational stress is associated with many maternal and child complications, however, this association must be taken with care, since there are studies that find inconsistent results between stress measures and maternal complications. It is believed that the lack of convergence is due to the way in which gestational stress is evaluated.The aim of the present study was to design and validate an instrument based on a bio-psycho-social model of gestational stress. The design and validation process of the inventory was divided into four phases: (a) Construction of the items bank and content validity, (b) construct validity, (c) inventory reliability and (d) convergent and discriminant validity with psychometric instruments that have been used in other investigations to evaluate gestational stress.A valid and reliable Stressors and Modulators of Gestational Stress Inventory (SMGSI) conformed by two scales was developed: (a) Gestational stressors, which is formed by two factors, the psychological stressors and social stressors with a variance of 48.5% and 51.8% and a reliability of .79 and .67, respectively; and (b) gestational stress modulators integrated by 8 items that explain 55.2% of the variance and with a reliability of .92. In conclusion, a valid and reliable tool was obtained that measures gestational stress from a bio-psycho-social perspective. This inventory allows for the identification of allostatic and pantostatic stress, making it useful as a diagnostic tool to prevent maternal and childhood complications that are associated with chronic gestational stress.

The Association Between State-Level Racial Attitudes Assessed From Twitter Data and Adverse Birth Outcomes: Observational Study

Background

In the United States, racial disparities in birth outcomes persist and have been widening. Interpersonal and structural racism are leading explanations for the continuing racial disparities in birth outcomes, but research to confirm the role of racism and evaluate trends in the impact of racism on health outcomes has been hampered by the challenge of measuring racism. Most research on discrimination relies on self-reported experiences of discrimination, and few studies have examined racial attitudes and bias at the US national level.

Objective

This study aimed to investigate the associations between state-level Twitter-derived sentiments related to racial or ethnic minorities and birth outcomes.

Methods

We utilized Twitter’s Streaming application programming interface to collect 26,027,740 tweets from June 2015 to December 2017, containing at least one race-related term. Sentiment analysis was performed using support vector machine, a supervised machine learning model. We constructed overall indicators of sentiment toward minorities and sentiment toward race-specific groups. For each year, state-level Twitter-derived sentiment data were merged with birth data for that year. The study participants were women who had singleton births with no congenital abnormalities from 2015 to 2017 and for whom data were available on gestational age (n=9,988,030) or birth weight (n=9,985,402). The main outcomes were low birth weight (birth weight ≤2499 g) and preterm birth (gestational age <37 weeks). We estimated the incidence ratios controlling for individual-level maternal characteristics (sociodemographics, prenatal care, and health behaviors) and state-level demographics, using log binomial regression models.

Results

The accuracy for identifying negative sentiments on comparing the machine learning model to manually labeled tweets was 91%. Mothers living in states in the highest tertile for negative sentiment tweets referencing racial or ethnic minorities had greater incidences of low birth weight (8% greater, 95% CI 4%-13%) and preterm birth (8% greater, 95% CI 0%-14%) compared with mothers living in states in the lowest tertile. More negative tweets referencing minorities were associated with adverse birth outcomes in the total population, including non-Hispanic white people and racial or ethnic minorities. In stratified subgroup analyses, more negative tweets referencing specific racial or ethnic minority groups (black people, Middle Eastern people, and Muslims) were associated with poor birth outcomes for black people and minorities.

Conclusions

A negative social context related to race was associated with poor birth outcomes for racial or ethnic minorities, as well as non-Hispanic white people.

Glucocorticoid receptor sensitivity in early pregnancy in an African American cohort

PROBLEM

Disruption in homeostatic feedback loops between inflammatory mediators and the hypothalamic-pituitary-adrenal (HPA) axis is a key mechanism linking chronic stress to inflammation and adverse health outcomes, including those occurring during pregnancy. In particular, alterations in glucocorticoid sensitivity may occur as a result of chronic stress, including that due to racial discrimination, and may be implicated in the persistent adverse maternal and infant health outcomes experienced by African Americans. While there are a few large-scale studies in human pregnancy that measure both cytokines and HPA axis hormones, to our knowledge, none directly measure glucocorticoid sensitivity at the cellular level, especially in an African American population.

METHOD OF STUDY

We measured the full range of the dexamethasone (DEX) dose-response suppression of TNF-α in first-trimester blood samples from 408 African American women and estimated leukocyte cell type contribution to the production of TNF-α.

RESULTS

The mean (SD) DEX level needed to inhibit TNF-α production by 50% (ie, DEX IC50 ) was 9.8 (5.8) nmol/L. Monocytes appeared to be the main driver of Uninhibited TNF-α production, but monocyte counts explained only 14% of the variation. Monocyte counts were only weakly correlated with the DEX IC50 (r = -.11, P < .05). Moreover, there was no statistically significant correlation between the DEX IC50 and circulating pro-inflammatory (CRP, IL-6, IFN-γ) or anti-inflammatory (IL-10) mediators (P > .05).

CONCLUSION

These findings challenge some prior assumptions and position this comprehensive study of glucocorticoid sensitivity as an important anchor point in the growing recognition of interindividual variation in maternal HPA axis regulation and inflammatory responses.

Association of Maternal Eating Disorders With Pregnancy and Neonatal Outcomes

IMPORTANCE

The prevalence of eating disorders is high among women of reproductive age, yet the association of eating disorders with pregnancy complications and neonatal health has not been investigated in detail, to our knowledge.

OBJECTIVE

To investigate the relative risk of adverse pregnancy and neonatal outcomes for women with eating disorders.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study included all singleton births included in the Swedish Medical Birth Register from January 1, 2003, to December 31, 2014. A total of 7542 women with eating disorders were compared with 1 225 321 women without eating disorders. Statistical analysis was performed from January 1, 2018, to April 30, 2019. Via linkage with the national patient register, women with eating disorders were identified and compared with women free of any eating disorder. Eating disorders were further stratified into active or previous disease based on last time of diagnosis.

MAIN OUTCOMES AND MEASURES

The risk of adverse pregnancy outcomes (hyperemesis, anemia, preeclampsia, and antepartum hemorrhage), the mode of delivery (cesarean delivery, vaginal delivery, or instrumental vaginal delivery), and the neonatal outcomes (preterm birth, small and large sizes for gestational age, Apgar score <7 at 5 minutes, and microcephaly) were calculated using Poisson regression analysis to estimate risk ratios (RRs). Models were adjusted for age, parity, smoking status, and birth year.

RESULTS

There were 2769 women with anorexia nervosa (mean [SD] age, 29.4 [5.3] years), 1378 women with bulimia nervosa (mean [SD] age, 30.2 [4.9] years), and 3395 women with an eating disorder not otherwise specified (EDNOS; mean [SD] age, 28.9 [5.3] years), and they were analyzed and compared with 1 225 321 women without eating disorders (mean [SD] age, 30.3 [5.2] years). All subtypes of maternal eating disorders were associated with an approximately 2-fold increased risk of hyperemesis during pregnancy (anorexia nervosa: RR, 2.1 [95% CI, 1.8-2.5]; bulimia nervosa: RR, 2.1 [95% CI, 1.6-2.7]; EDNOS: RR, 2.6 [95% CI, 2.3-3.0]). The risk of anemia during pregnancy was doubled for women with active anorexia nervosa (RR, 2.1 [95% CI, 1.3-3.2]) or EDNOS (RR, 2.1 [95% CI, 1.5-2.8]). Maternal anorexia nervosa was associated with an increased risk of antepartum hemorrhage (RR, 1.6 [95% CI, 1.2-2.1]), which was more pronounced in active vs previous disease. Women with anorexia nervosa (RR, 0.7 [95% CI, 0.6-0.9]) and women with EDNOS (RR, 0.8 [95% CI, 0.7-1.0]) were at decreased risk of instrumental-assisted vaginal births; otherwise, there were no major differences in mode of delivery. Women with eating disorders, all subtypes, were at increased risk of a preterm birth (anorexia nervosa: RR, 1.6 [95% CI, 1.4-1.8]; bulimia nervosa: RR, 1.3 [95% CI, 1.0-1.6]; and EDNOS: RR, 1.4 [95% CI, 1.2-1.6]) and of delivering neonates with microcephaly (anorexia nervosa: RR, 1.9 [95% CI, 1.5-2.4]; bulimia nervosa: RR, 1.6 [95% CI, 1.1-2.4]; EDNOS: RR, 1.4 [95% CI, 1.2-1.9]).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that women with active or previous eating disorders, regardless of subtype, are at increased risk of adverse pregnancy and neonatal outcomes and may need increased surveillance in antenatal and delivery care.

Chronic HPA activity in mothers with preterm delivery: A pilot nested case-control study

BACKGROUND

Chronic hypothalamic-pituitary-adrenal (HPA) axis activity role in the pathogenesis of preterm birth (PTB) remains unclear due to inconsistent measures with limited ability to monitor long-term cortisol concentrations. We explored this relationship using the novel method of assessing cortisol in hair, which is a valid and reliable measure of chronic HPA axis activity.

METHODS

137 participants (40 PTB cases and 97 controls from a birth cohort of pregnant women in Peru) were interviewed and invited to provide a 9-cm hair sample from the posterior vertex position of the scalp (mean = 13 weeks gestation). Hair cortisol concentration (HCC) was determined using luminescence immunoassay and values were natural-log transformed. PTB cases were defined as women who delivered before 37 gestational weeks. Case-control differences were assessed using multivariable linear and logistic regressions.

RESULTS

Overall, combined pre-conception and first-trimester HCC was 13% lower among cases as compared with controls (p-value = 0.01). Compared with controls, maternal HCC among PTB cases were 14% (p = 0.11), 10% (p = 0.22) and 14% (p = 0.08) lower for 3-6 months pre-conception, 0-3 months pre-conception, and first trimester, respectively. After adjusting for putative confounders, a 1-unit increase in HCC was associated with 55% reduced odds of PTB (aOR = 0.45; 95% CI: 0.17-1.17). For a 1-unit increase in HCC in the scalp-intermediate and scalp-distal segments (representing HCC concentrations in 0-3 months pre-conception and first trimester), the corresponding odds for PTB were 0.53 (95% CI: 0.19-1.48) and 0.39 (95% CI: 0.13-1.13), respectively.

CONCLUSIONS

Women who deliver preterm, as compared with those who deliver at term, have lower preconception and first trimester HCC. Our findings suggest that HPA axis activation, integral to the adaptive stress-response system, may be chronically dysregulated in women at increased risk of PTB.

Risk of Adverse Obstetric Outcomes and the Abnormal Growth of Offspring in Women with a History of Thyroid Cancer

Background: It is unclear whether a history of thyroid cancer is associated with an increased risk of adverse pregnancy outcomes in subsequent pregnancies. This study aimed to evaluate the risk of adverse obstetric outcomes and the abnormal growth of offspring in women with a history of thyroid cancer. Methods: This retrospective observational study used nationwide data from between 2006 and 2014 to compare pregnancy outcomes of women with a history of thyroid cancer and those with no such history. Cases of thyroid cancer were identified using ICD-10 codes. Results: During the study period, 7232 women with a history of thyroid cancer and 2,269,051 women without a history of thyroid cancer gave birth. The risks of cesarean section, preterm birth, low birth weight, large for gestational age, preeclampsia, placental abruption, placenta previa, and stillbirth were not different between the groups. Women with a history of thyroid cancer had a statistically higher risk of postpartum hemorrhage (odds ratio [OR] = 1.23 [confidence interval (CI) 1.15-1.32], p < 0.05, corrected with the false discovery rate). Additionally, generalized estimating equations analysis showed that there was no difference in the risk of underweight (OR = 1.05 [CI 0.93-1.19]) and obese (OR = 0.94 [CI 0.84-1.05]) offspring assessed over a period of 80 months after adjusting for confounding factors. Conclusions: Women with a history of thyroid cancer have similar pregnancy outcomes and offspring growth to those with no such history.

Threatened preterm labour: Women's experiences of risk and care management: A qualitative study

BACKGROUND

Preterm birth is a major cause of neonatal death and severe morbidity, so pregnant women experiencing symptoms of threatened preterm labour may be very anxious. The risk assessment and management that follows recognition of threatened preterm labour has the potential to either increase or decrease this anxiety. The aim of this study was to explore women's experience of threatened preterm labour, risk assessment and management in order to identify potential improvements in practice.

DESIGN

One-to-one semi-structured interviews with 19 women who experienced assessment for threatened preterm labour took place between March 2015 and January 2017. A purposive sample approach was employed to ensure participants from different risk and demographic backgrounds were recruited at an inner city UK NHS hospital. Interviews were recorded and transcribed. Data was managed with NVivo software and analysed using the Framework Approach. A public and patient involvement panel contributed to the design, analysis and interpretation of the findings.

FINDINGS

Data saturation was achieved after 19 interviews. 11 women were low risk and 8 were high risk for preterm birth. All high risk women had experience of being supported by a specialist preterm team. Four main themes emerged: (i) coping with uncertainty; (ii) dealing with conflicts; (iii) aspects of care and (iv) interactions with professionals. Both low and high risk women experiencing TPTL struggle to cope with the uncertainty of this unpredictable state. The healthcare management they receive can both help and hinder their ability to cope with this extremely stressful experience. High risk women were less likely to receive conflicting advice.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Clinicians should acknowledge uncertainty, minimize conflicting information and advice, and promote continuity of care models for all women, including those attending high risk clinics and in the ward environment.

Evaluating Stress during Pregnancy: Do We Have the Right Conceptions and the Correct Tools to Assess It?

Gestational stress is believed to increase the risk of pregnancy failure and perinatal and adult morbidity and mortality in both the mother and her child or children. However, some contradictions might arise from methodological issues or even from differences in the philosophical grounds that guide the studies on gestational stress. Biased perspectives could lead us to use and/or design inadequate/incomplete panels of biochemical determinations and/or psychological instruments to diagnose it accurately during pregnancy, a psychoneuroimmune-endocrine state in which allostatic loads may be significant. Here, we review these notions and propose a model to evaluate and diagnose stress during pregnancy.

Efficacy of an internet-based cognitive behavioral stress management training in women with idiopathic preterm labor: A randomized controlled intervention study

OBJECTIVE

This randomized controlled trial aimed at evaluating the efficacy of an internet-based cognitive behavioral stress management program (IB-CBSM) for pregnant women with preterm labor (PTL) on birth outcome and stress-related psychological and biological parameters.

METHODS

93 pregnant women with PTL (gestational age 18-32) were assigned to either the IB-CBSM (n=50) or a control group (CG) based on distraction (n=43). Participants in both groups worked through six weekly modules. Birth outcome measures included gestational age, neonatal weight and length at birth and the rate of preterm birth (PTB). Questionnaires assessed psychological wellbeing and the activity of the HPA-axis was measured with the cortisol awakening reaction (CAR), both before (T1) and after the intervention (T2).

RESULTS

Birth outcome and psychological wellbeing did not differ between IB-CBSM and CG. However, psychological wellbeing was higher after both interventions (PSS: η_p²=0.455, STAIX1: η_p²=0.455, STAIX2: η_p²=0.936, PRAT: η_p²=0.465, EPDS: η_p²=0.856). Cortisol levels were stable and did not alter differently between groups from T1 to T2. Higher cortisol levels were associated with lower gestational age at birth, whereas no significant correlations were found between weight and length at birth.

CONCLUSIONS

Although there were no significant differences between the two groups and birth outcome, psychological and biological parameters, both interventions (CBSM and CG) showed equivalent effects and proved to be beneficial with regard to psychosocial distress and well-being. Further research is needed to investigate CBSM and distraction interventions for pregnant women at risk for PTB together with a non-intervention control condition.

Neonatal outcomes following exposure in utero to fallout from Chernobyl

Iodine 131 (I-131), the principal component of nuclear fallout from the Chernobyl accident, concentrates in the thyroid gland and may pose risks to fetal development. To evaluate this, neonatal outcomes following the accident in April of 1986 were investigated in a cohort of 2582 in utero-exposed individuals from northern Ukraine for whom estimates of fetal thyroid I-131 dose were available. We carried out a retrospective review of cohort members' prenatal, delivery and newborn records. The relationships of dose with neonatal anthropometrics and gestational length were modeled via linear regression with adjustment for potentially confounding variables. We found similar, statistically significant dose-dependent reductions in both head circumference (-1.0 cm/Gy, P = 0.005) and chest circumference (-0.9 cm/Gy, P = 0.023), as well as a similar but non-significant reduction in neonatal length (-0.6 cm/Gy, P = 0.169). Gestational length was significantly increased with increasing fetal dose (0.5 wks/Gy, P = 0.007). There was no significant (P > 0.1) effect of fetal dose on birth weight. The observed associations of radioiodine exposure with decreased head and chest circumference are consistent with those observed in the Japanese in utero-exposed atomic bomb survivors.

IL-6 and IL-10 levels in the umbilical cord blood of newborns with a history of crack/cocaine exposure in utero: a comparative study

INTRODUCTION

Prenatal cocaine exposure (PCE) is associated with neurobehavioral problems during childhood and adolescence. Early activation of the inflammatory response may contribute to such changes. Our aim was to compare inflammatory markers (IL-6 and IL-10) both in umbilical cord blood and in maternal peripheral blood at delivery between newborns with history of crack/cocaine exposure in utero and non-exposed newborns.

METHODS

In this cross-sectional study, 57 newborns with a history of crack/cocaine exposure in utero (EN) and 99 non-exposed newborns (NEN) were compared for IL-6 and IL-10 levels. Sociodemographic and perinatal data, maternal psychopathology, consumption of nicotine and other substances were systematically collected in cases and controls.

RESULTS

After adjusting for potential confounders, mean IL-6 was significantly higher in EN than in NEN (10,208.54, 95% confidence interval [95%CI] 1,328.54-19,088.55 vs. 2,323.03, 95%CI 1,484.64-3,161.21; p = 0.007; generalized linear model [GLM]). Mean IL-10 was also significantly higher in EN than in NEN (432.22, 95%CI 51.44-812.88 vs. 75.52, 95%CI 5.64-145.39, p = 0.014; GLM). Adjusted postpartum measures of IL-6 were significantly higher in mothers with a history of crack/cocaine use (25,160.05, 95%CI 10,958.15-39,361.99 vs. 8,902.14, 95%CI 5,774.97-12,029.32; p = 0.007; GLM), with no significant differences for IL-10. There was no correlation between maternal and neonatal cytokine levels (Spearman test, p ≥ 0.28 for all measures).

CONCLUSIONS

IL-6 and IL-10 might be early biomarkers of PCE in newborns. These findings could help to elucidate neurobiological pathways underlying neurodevelopmental changes and broaden the range of possibilities for early intervention.

Symptoms of Depression Predict Negative Birth Outcomes in African American Women: A Pilot Study

INTRODUCTION

African American women have higher rates of preterm birth and low-birth-weight infants compared with non-Hispanic white women. Symptoms of depression have also been related to these negative birth outcomes. Lower levels of social support and higher levels of avoidance coping and cortisol have been related to more symptoms of depression in pregnant women. The purpose of this pilot study was to examine the relationships among symptoms of depression, social support, avoidance coping, cortisol, and negative birth outcomes (ie, preterm birth, low-birth-weight infants) in a sample of African American women.

METHODS

This study used a prospective design. A convenience sample of 90 African American women completed questionnaires and had blood drawn in the second trimester of pregnancy. Birth data were collected from medical records.

RESULTS

Based on the Center for Epidemiological Studies-Depression (CES-D) Scale scores, 28% of women were at increased risk for clinical depression (CES-D ≥ 16). Compared to women who gave birth at term, women who had preterm birth had higher CES-D scores (11.67 and 19.0, respectively) and used avoidance coping more often (7.98 and 13.14, respectively). Compared to women with normal-birth-weight infants, women with low-birth-weight infants had higher levels of cortisol (61.75 mcg/dL and 89.72 mcg/dL, respectively). Women at increased risk for clinical depression were 16 times more likely to have preterm birth and 4 times more likely to have low-birth-weight infants. Women with plasma cortisol levels in the top 25th percentile were 7 times more likely to have low-birth-weight infants. Preeclampsia during pregnancy also predicted preterm birth and low-birth-weight infants.

DISCUSSION

Symptoms of depression in pregnancy may predict adverse birth outcomes. Interventions that have the potential to improve the mental health of pregnant women and ultimately birth outcomes need to be explored.

Global Satisfaction With Perinatal Hospital Care: Stability and Relationship to Anxiety, Depression, and Stressful Medical Events

To evaluate the stability of global maternal satisfaction with perinatal hospital care during the post-partum period and its relationship to anxiety, depression, and stressful medical events, a cohort study of 300 mothers delivering at a university hospital was performed during the first month postpartum. Satisfaction, measured on a 4-point Likert scale (0-3), declined from 2.75 +/- 0.03 (mean +/- standard error) before hospital discharge to 2.48 +/- 0.04 at 1 month postpartum (P = .000), and only 69.5% of mothers very much satisfied predischarge remained so at 1 month (P = .000). Predischarge satisfaction declined with greater medical events (adjusted odds ratio [AOR] = 0.85, 95% confidence interval [CI] = 0.74, 0.97, P < .05) and with concomitant anxiety (AOR= 0.92, CI= 0.89, 0.95, P< .001); reduced satisfaction at 1 month was associated with high anxiety (AOR = 0.97, CI = 0.95, 0.98) and depression (AOR = 0.96, CI = 0.93, 0.99) at that time. Thus, perinatal satisfaction may be time-dependent and associated with contemporaneous medical and psychological changes.

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

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

Patient satisfaction and psychological well-being after internet-based cognitive behavioral stress management (IB-CBSM) for women with preterm labor: A randomized controlled trial

OBJECTIVE AND METHODS

Despite its value for the management of psychological burden, little is known about the efficacy of and patient satisfaction with internet-based cognitive behavioral stress management (IB-CBSM) for women with preterm labor. The present study sets out to analyze stress/anxiety reduction, patient satisfaction and patient's working alliance in a group of 58 women with preterm labor participating in an online psychological stress management project. As part of the project, women were randomly assigned to online stress management or a control condition.

RESULTS

Levels of stress and anxiety decreased significantly in both conditions from pre- to post-treatment measure. Participants in IB-CBSM reported significant higher working alliance inventory (WAI) scores in the task and goal subscale (p<.001; p<.05) than women in the control condition. In Addition the IB-CBSM group showed significant correlations of the WAI subscale task and goal and the stress/anxiety outcome. Regarding patient satisfaction, women in the IB-CBSM reported significantly higher satisfaction scores (p<.001) than women in the control condition. WAI explained nearly 40% of the variance in patient satisfaction. Furthermore, WAI mediates, at least in part, the relationship between group condition and patient satisfaction.

CONCLUSION

The current analysis indicated that participants in IB-CBSM had higher WAI scores and were more satisfied with the program. In addition only the IB-CBSM group showed significant correlations of the WAI with the stress/anxiety reduction outcome. Based on these findings, it can be presumed that measures of agreement with working alliance parameters, especially task and goal components, are substantially important for more effective and satisfactory therapeutic interventions.

Bidirectional psychoneuroimmune interactions in the early postpartum period influence risk of postpartum depression

More than 500,000 U.S. women develop postpartum depression (PPD) annually. Although psychosocial risks are known, the underlying biology remains unclear. Dysregulation of the immune inflammatory response and the hypothalamic-pituitary-adrenal (HPA) axis are associated with depression in other populations. While significant research on the contribution of these systems to the development of PPD has been conducted, results have been inconclusive. This is partly because few studies have focused on whether disruption in the bidirectional and dynamic interaction between the inflammatory response and the HPA axis together influence PPD. In this study, we tested the hypothesis that disruption in the inflammatory-HPA axis bidirectional relationship would increase the risk of PPD. Plasma pro- and anti-inflammatory cytokines were measured in women during the 3rd trimester of pregnancy and on Days 7 and 14, and Months 1, 2, 3, and 6 after childbirth. Saliva was collected 5 times the day preceding blood draws for determination of cortisol area under the curve (AUC) and depressive symptoms were measured using the Edinburgh Postpartum Depression Survey (EPDS). Of the 152 women who completed the EPDS, 18% were depressed according to EDPS criteria within the 6months postpartum. Cortisol AUC was higher in symptomatic women on Day 14 (p=.017). To consider the combined effects of cytokines and cortisol on predicting symptoms of PPD, a multiple logistic regression model was developed that included predictors identified in bivariate analyses to have an effect on depressive symptoms. Results indicated that family history of depression, day 14 cortisol AUC, and the day 14 IL8/IL10 ratio were significant predictors of PPD symptoms. One unit increase each in the IL8/IL10 ratio and cortisol AUC resulted in 1.50 (p=0.06) and 2.16 (p=0.02) fold increases respectively in the development of PPD. Overall, this model correctly classified 84.2% of individuals in their respective groups. Findings suggest that variability in the complex interaction between the inflammatory response and the HPA axis influence the risk of PPD.

The association between breastfeeding, the stress response, inflammation, and postpartum depression during the postpartum period: Prospective cohort study

BACKGROUND

Research suggests that exclusive breastfeeding may have a stress-protective role in postpartum depression; however, less is known about the underlying mechanisms by which this protection may occur or whether the protective relationship holds for women who mix breast and bottle feeding.

OBJECTIVES

To examine patterns of the stress response, inflammation, and depressive symptoms among women predominantly breastfeeding or bottle feeding their infants at 6 months postpartum.

DESIGN

A part of a larger longitudinal study across 6 months postpartum investigating the psychoneuroimmunology (PNI) of postpartum depression.

SETTING

Prenatal clinics and community.

PARTICIPANTS

One hundred nineteen postpartum women who met inclusion/exclusion criteria and followed up from the prenatal period to postpartum 6 months.

METHODS

Data were collected during seven home visits occurring during the 3rd trimester (weeks 32-36) and on postpartum days 7 and 14, months 1, 2, 3, and 6. Women completed stress and depression surveys and provided blood for pro- (IL-1β, IL-6, IL-8, TNF-a, IFN-γ) and anti-inflammatory (IL-10) cytokines, and collected saliva for diurnal cortisol.

RESULTS

Self-report of predominant breastfeeding during 6 months postpartum ranged from 91.9% at day 7 to 70.6% at month 6 postpartum. There were no associations between the pattern of feeding and depressive symptoms. Biological differences, however, existed between the groups, with levels of salivary cortisol at 8 AM and 8:30 AM at month 6 higher and levels of IL-6 at month 6 lower in women who primarily breastfed compared to those who primarily bottle fed their infants after controlling for confounding variables.

CONCLUSIONS

Breastfeeding was not related to postpartum depression however differences in stress and inflammatory markers are apparent at month 6 postpartum.

[Relation Between Stress During Pregnancy and Spontaneous Preterm Birth]

BACKGROUND

Preterm birth occurs before 37 completed weeks, its causes are multifactorial and vary according to the gestational age, ethnicity and geographical context. Although several medical/social factors have been clearly identified, over 50% of cases are unknown or unclear; however, psychopathological components emerge as potentially important risk factors.

OBJECTIVE

To determine the relationship between the presence of stress during pregnancy and spontaneous preterm birth.

MATERIAL AND METHODS

Through a study of cases and controls in a level III hospital, with a sample of 360 patients during the period from March to November of 2013, where sociodemographic characteristics were collected. In addition, they were applied scales social adjustment, coping strategies and social support. Logistic regression models were developed; psychological, biological and social. Based on the significant variables in each of these generated a final one.

RESULTS

The final model was found that stress during pregnancy increases the odds of spontaneous preterm birth 1.91 times (adjusted OR=2.91; 95%CI, 1.67-5.08; P<.05). Other significant variables were: history of preterm delivery, unplanned pregnancy, no emotional support, rural residence, inadequate prenatal care and non-stable partner.

CONCLUSIONS

The findings support the hypothesis that stress during pregnancy is associated with spontaneous preterm delivery.

Perineal Injury During Childbirth Increases Risk of Postpartum Depressive Symptoms and Inflammatory Markers

INTRODUCTION

Perineal lacerations during childbirth affect more than 65% of women in the United States. Little attention has been given to the long-term biologic consequences associated with perineal lacerations or possible associations with postpartum mental health. In this article, we describe the results of a study that explored inflammatory cytokines in women who reported perineal lacerations during childbirth and the relationship with stress and depressive symptoms during the first 6 months postpartum.

METHODS

A repeated measures design was used to explore the relationship between varying degrees of perineal lacerations, inflammatory cytokines, postpartum stress, and depressive symptoms in 153 women over 6 months. Depressive symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS), and maternal stress was measured using the Perceived Stress Scale. Plasma was analyzed for proinflammatory (tumor necrosis factor alpha, interleukin 6 (IL-6), interleukin-1 beta, interferon gamma) and anti-inflammatory (interleukin 10) cytokines. Levels of cytokines were compared between women with or without varying degrees of injury.

RESULTS

A relationship was identified between symptoms of depression and a second-degree or more severe perineal laceration starting at one month postpartum (P = .04) and continuing through 3 months postpartum (P = .03). Similarly, stress symptoms were higher at 3 months postpartum (P = .02). Markers of inflammation were significantly higher among this group, with IL-6 increased at 2 weeks postpartum (P = .02) and remaining elevated through 2 months postpartum (P = .003); there were also significant differences in pro- to anti-inflammatory cytokine ratios out to 6 months postpartum. Regression analysis indicated that second-degree or more severe lacerations accounted for 5.9% of the variance in EPDS score at one month postpartum (P = .024, F = 2.865, t = 2.127), increasing substantially when the one month stress score was included as well.

DISCUSSION

This study suggests that perineal lacerations, inflammation, stress, and depressed mood are associated; however, more research is needed to elucidate the actual relationship between inflammation and mental health in women who experience such injuries.

Does magnesium sulfate delay the active phase of labor in women with premature rupture of membranes? A randomized controlled trial

OBJECTIVE

Administration of many drugs including magnesium sulfate (MS) has considerable influences on pregnancy outcomes. The present study investigates the effects of MS administration on reaching the active phase of labor in women with premature rupture of membrane (PROM) and subsequent fetal complications.

MATERIALS AND METHODS

A double blind, randomized, placebo-controlled trial was performed among primipara women referred to the PROM center in Tehran, Iran between March 2010 and August 2012. Patients were equally allocated into two groups; the intervention group who received MS (n = 46) and the control (placebo) group (n = 46). Both groups received a corticosteroid, 1g oral azithromycin (oral) and 2 g ampicillin (IV) every 6 hours for 48 hours, followed by amoxicillin (500 mg orally 3 times daily) for an additional 5 days. None of the research staff were aware of the treatment allocation of patients in order for blinding purposes.

RESULTS

Administration of MS in intervention group increases this period 2.7 times compared to the control group. In women whose gestational age was <30 weeks, MS administration increased the active phase of labor up to 77%. Administration of magnesium sulfate reduced the risk of respiratory distress syndrome significantly (p = 0 .002), without producing any adverse pregnancy outcomes.

CONCLUSION

Magnesium sulfate increases delay in reaching the active phase of labor in mothers with PROM, without producing adverse birth outcomes. (Registration ID in IRCT; IRCT2012091810876N1).

A protocol to identify non-classical risk factors for preterm births: the Brazilian Ribeirão Preto and São Luís prenatal cohort (BRISA)

Background

Preterm birth is the main cause of morbidity and mortality during the perinatal period. Classical risk factors are held responsible for only 1/3 of preterm births and no current intervention has produced an appreciable reduction of this event. It is necessary to explore new hypotheses and mechanisms of causality by using an integrated approach, collaboration among research groups and less fragmented theoretical-methodological approaches in order to detect new risk factors and to formulate more effective intervention strategies.

Methods

The study will be conducted on a convenience cohort of Brazilian pregnant women recruited at public and private prenatal health services. A total of 1500 pregnant women in São Luís, and 1500 in Ribeirão Preto, will be invited for an interview and for the collection of biological specimens from the 22nd to the 25th week of gestational age (GA). At the time of delivery they will be reinterviewed. GA will be determined using an algorithm based on two criteria: date of last menstruation (DLM) and obstetric ultrasound (OUS) performed at less than 20 weeks of GA. Illicit drug consumption during pregnancy will be determined using a self-applied questionnaire and the following instruments will be used: perceived stress scale, Beck anxiety scale, screening for depression of the Center of Epidemiological Studies (CES-D), experiences of racial discrimination, social network and social support scale of the Medical Outcomes Study and violence (Abuse Assessment Screening and violence questionnaire of the WHO). Bacterial vaginosis, urinary tract infection and periodontal disease will also be identified. Neuroendocrine, immunoinflammatory and medical intervention hypotheses will be tested. The occurrence of elective cesarean section in the absence of labor will be used as a marker of medical intervention.

Conclusion

Psychosocial, genetic and infectious mechanisms will be selected, since there are indications that they influence preterm birth (PTB). The studies will be conducted in two Brazilian cities with discrepant socioeconomic conditions. The expectation is to identify risk factors for PTB having a greater predictive power than classically studied factors. The final objective is to propose more effective interventions for the reduction of PTB, which, after being tested, might subsidize health policies.

Electronic supplementary material

The online version of this article (doi:10.1186/1742-4755-11-79) contains supplementary material, which is available to authorized users.

Pregnancy with chronic illness

OBJECTIVE

To describe the experience of pregnancy with a chronic illness.

DESIGN

Qualitative description.

SETTING

Tertiary Medical Center, Northeast United States.

PARTICIPANTS

A purposive sample of eight pregnant women with various chronic conditions.

METHODS

Telephone interviews.

RESULTS

The participants described their chronic illnesses as deviations from normality and their pregnancies brought them closer to normality. They described pregnancy as a balancing act between the fantasy of being normal and the reality of having a chronic disease. At the same time, women acknowledged the blessings and burdens of physical changes and intense vigilance. Participants also described emotional demands related to the need to be vigilant, additional physiological alternations, and information overload.

CONCLUSION

Pregnancy may alter chronic illness, increase stress, and create new health care needs for women. In turn, increased stress associated with chronic illness may alter perinatal outcomes. Pregnant women with chronic illness may benefit from interventions aimed at helping them balance the blessings and burdens associated with the symptoms of pregnancy.

Relationships among psychosocial factors, biomarkers, preeclampsia, and preterm birth in African American women: a pilot

AIM

To explore the relationships among psychosocial factors (optimism, uncertainty, social support, coping, psychological distress), biomarkers (cortisol, cytokines), preeclampsia, and preterm birth in African American women.

METHODS

Forty-nine pregnant African American women completed psychosocial questionnaires and had blood collected for biomarkers between 26 and 36 weeks of gestation. Birth outcomes were obtained from birth records.

RESULTS

Women reporting higher levels of social support had lower levels of pro-inflammatory cytokines (IL-2, IL-5, and IL-6). Surprisingly, compared with low-risk pregnant women, women diagnosed with preeclampsia reported more optimism and less avoidance, and had lower levels of cortisol and IFN-γ. Similarly, compared to women with full-term birth, women with preterm birth reported higher levels of optimism and lower levels of avoidance, and had lower levels of IL-10.

CONCLUSION

Psychosocial factors influence inflammation and pregnancy outcomes. Close assessment and monitoring of psychosocial factors may contribute to improved pregnancy outcomes.

Raman spectroscopy provides a noninvasive approach for determining biochemical composition of the pregnant cervix in vivo

The molecular changes that occur with cervical remodelling during pregnancy are not completely understood. This study reviews Raman spectroscopy, an optical technique for detecting changes in the pregnant cervix, and reports preliminary studies on cervical remodelling in mice that suggest that the technique provides advantages over other methods.

CONCLUSION

Raman spectroscopy is sensitive to biochemical changes in the pregnant cervix and has high potential as a tool for detecting premature cervical remodelling in pregnant women.

No association between antenatal common mental disorders in low-obstetric risk women and adverse birth outcomes in their offspring: results from the CDS study in Ghana and Côte D'Ivoire

Background

Evidence linking common mental disorders (CMD) in pregnant women to adverse birth outcomes is inconsistent, and studies often failed to control for pregnancy complications. This study aimed to explore the association between antenatal depression and anxiety symptoms and birth outcomes in a low-obstetric risk sample of mother/child dyads in Ghana and Côte d’Ivoire.

Methods

In 2010-2011, a prospective cohort of 1030 women in their third trimester in Ghana and Côte d’Ivoire was enrolled. Depression and anxiety were assessed in the third trimester using the Patient Health Questionnaire depression module and the 7-item Generalized Anxiety Disorder scale. 719 mother/child dyads were included in the analysis. We constructed multivariate regression models to estimate the association between CMD and low birth weight (LBW), and preterm birth (PTB) to control for potential confounders.

Results

The prevalence of depression and anxiety symptoms were 28.9% and 14.2% respectively. The mean birth weight was 3172.1g (SD 440.6) and the prevalence of LBW was 1.7%. The mean gestational age was 39.6 weeks and the proportion of PTB was 4%. Multivariate linear regression revealed no significant association between maternal depression (B=52.2, 95% CI -18.2 122.6, p=0.15) or anxiety (B=17.1, 95% CI -74.6 108.7, p=0.72) and birth weight. Yet, low socio-economic status, female sex of the child, and younger maternal age were associated with lower birth weight. Multivariate logistic regression suggested no significant association between maternal depression (OR: 2.1, 95% CI 0.8 5.6, p=0.15) or anxiety (OR: 1.8, 95% CI 0.6 5.5, p=0.29) with PTB.

Conclusions

Our data suggests that depression and/or anxiety in the 3^rd trimester of pregnancy are not independent predictors of adverse birth outcomes in low obstetric risk women. The role of pregnancy complications as confounders or effect modifiers in studies of maternal CMD and their impact on birth outcomes should be investigated.

Psychosocial stress in pregnancy and preterm birth: associations and mechanisms

AIMS

Psychosocial stress during pregnancy (PSP) is a risk factor of growing interest in the etiology of preterm birth (PTB). This literature review assesses the published evidence concerning the association between PSP and PTB, highlighting established and hypothesized physiological pathways mediating this association.

METHOD

The PubMed and Web of Science databases were searched using the keywords "psychosocial stress", "pregnancy", "pregnancy stress", "preterm", "preterm birth", "gestational age", "anxiety", and "social support". After applying the exclusion criteria, the search produced 107 articles.

RESULTS

The association of PSP with PTB varied according to the dimensions and timing of PSP. Stronger associations were generally found in early pregnancy, and most studies demonstrating positive results found moderate effect sizes, with risk ratios between 1.2 and 2.1. Subjective perception of stress and pregnancy-related anxiety appeared to be the stress measures most closely associated with PTB. Potential physiological pathways identified included behavioral, infectious, neuroinflammatory, and neuroendocrine mechanisms.

CONCLUSIONS

Future research should examine the biological pathways of these different psychosocial stress dimensions and at multiple time points across pregnancy. Culture-independent characterization of the vaginal microbiome and noninvasive monitoring of cholinergic activity represent two exciting frontiers in this research.

Immune dysregulation and glucocorticoid resistance in minority and low income pregnant women

Chronic prenatal stress contributes to poor birth outcomes for women and infants. Importantly, poor birth outcomes are most common among minority and low income women. To investigate underlying mechanisms, we tested the hypothesis that chronic stress related to minority or low income status is associated with glucocorticoid resistance as indicated by disruption in the cytokine-glucocorticoid feedback circuit. Home visits were conducted during which 3rd trimester pregnant women completed stress and depression surveys and provided blood for pro- and anti-inflammatory cytokines. Saliva was collected 5 times the preceding day for diurnal cortisol levels. For statistical analyses, women were grouped 3 ways, by race, income, and the presence or absence of either of those risk factors; this last group was labeled high or low general risk. Immune regulation was evaluated by evidence of a functioning negative feedback relationship between cytokines and cortisol. Of 96 participants, 18 were minority, 22 of low income, and 29 either minority or low income (high general risk). Pearson partial correlation identified a significant negative relationship between cortisol area under the curve (AUC) and pro- to anti-inflammatory cytokine ratios in the low general risk women (i.e., Caucasian, higher income) including IFNγ/IL10 (r=-0.73, p<0.0001), IL6/IL10 (r=-0.38, p=0.01), IL1β/IL10 (r=-0.44, p=0.004) and TNFα/IL10 (r=-0.41; p=0.005); no such correlations existed in the high general risk women (i.e., minority, low income) for (IFNγ/IL10: r=-0.25, p=0.43; IL6/IL10: r=0.12, p=0.70; IL1 β/IL10: r=0.05, p=0.87; TNFα/IL10: r=0.10; p=0.75), suggestive of glucocorticoid resistance. Cortisol levels throughout the day also were higher in minority and high general risk groups (p<0.05). Without cytokine glucocorticoid feedback, a pregnant woman's ability to regulate inflammation is limited, potentially contributing to adverse maternal and infant outcomes.

Family cohesion, acculturation, maternal cortisol, and preterm birth in Mexican-American women

Objective

To examine the potential moderating effects of family cohesion and acculturation on the physiological stress response (cortisol) as a predictor of preterm birth (PTB) in pregnant Mexican-American women.

Methods

The sample included 470 participants; 33 had preterm births. All participants were self-identified as Mexican-American. In this cross-sectional study, family cohesion was measured by a self-report questionnaire. Acculturation was measured by self-report questionnaire as well as by years in the United States and country of birth. Stress was measured by serum cortisol. All measures were obtained at 22–24 weeks gestation. Additional data including history of PTB were obtained from the health record. Data analysis was primarily conducted using logistic regression.

Results

The relationship between stress and PTB was predicted by family cohesion (estimate/ standard error [E/SE] = −2.46, P = 0.014) and acculturation (E/SE = 2.56, P = 0.011). In addition, there was an interaction between family cohesion and history of previous PTB (E/SE = −2.12, P = 0.035).

Conclusion

Results indicate that the impact of cortisol on PTB is predicted by acculturation and family cohesion such that higher levels of cortisol in conjunction with higher levels of acculturation and lower levels of family cohesion are associated with increased risk of PTB. In addition, low family cohesion in combination with a history of PTB was associated with higher levels of PTB. Assessment of family cohesion, including problem solving, adherence to family decisions, family shared space, and activity, should be included as part of prenatal assessment for risk of PTB. Subsequently, interventions that focus on improving the individual’s response to an imbalance in family functioning are needed. In addition, prenatal assessment of level of acculturation may also identify those who are at risk for PTB.

Do pregnant women with depression have a pro-inflammatory profile?

AIM

We tested the hypothesis that maternal depression is associated with a pro-inflammatory state in pregnancy.

MATERIAL AND METHODS

In this nested case-control study, pro-inflammatory cytokine levels were compared between women with depression in pregnancy (n = 100) and a computer-generated referent group of healthy women known not to be depressed (n = 100). We only included cases with a documented Diagnostic and Statistical Manual of Mental Disorders depression diagnosis in the current pregnancy. Serum samples drawn at 11-14 weeks of gestation were analyzed for levels of tumor necrosis factor-alpha and interleukin-6 using high-sensitivity immunoassays.

RESULTS

Maternal demographics were similar between the groups except for older age (34.1 vs 32.7 years, P = .05), and lower body mass index (27.3 vs 28.9 kg/m², P = 0.03) among the depressed subjects. Compared to control women, tumor necrosis factor-alpha (5.8 ± 3.4 vs 3.2 ± 2.8 pg/ml, P < 0.0001) and interleukin-6 (2.4 ± 3.8 vs 1.5 ± 1.4 pg/ml, P = 0.03) levels were higher among women with depression. The higher rate of inflammatory cytokines remained significant after controlling for potential confounders, including maternal age and body mass index.

CONCLUSION

Women with depression may have higher levels of inflammatory markers in early pregnancy. Our findings support the hypothesis that inflammation may be a mediator in the association between maternal depression and adverse perinatal outcomes.

Stressors, resources, and stress responses in pregnant African American women: a mixed-methods pilot study

This research aimed to develop an initial understanding of the stressors, stress responses, and personal resources that impact African American women during pregnancy, potentially leading to preterm birth. Guided by the ecological model, a prospective, mixed-methods, complementarity design was used with 11 pregnant women and 8 of their significant others. Our integrated analysis of quantitative and qualitative data revealed 2 types of stress responses: high stress responses (7 women) and low stress responses (4 women). Patterns of stress responses were seen in psychological stress and cervical remodeling (attenuation or cervical length). All women in the high stress responses group had high depression and/or low psychological well-being and abnormal cervical remodeling at one or both data collection times. All but 1 woman had at least 3 sources of stress (racial, neighborhood, financial, or network). In contrast, 3 of the 4 women in the low stress responses group had only 2 sources of stress (racial, neighborhood, financial, or network) and 1 had none; these women also reported higher perceived support. The findings demonstrate the importance of periodically assessing stress in African American women during pregnancy, particularly related to their support network as well as the positive supports they receive.

Risk factors for preterm birth and small-for-gestational-age births among Canadian women

BACKGROUND

Preterm births (PTB) and small-for-gestational-age (SGA) births are distinct but related pregnancy outcomes, with differing aetiologies and short and long-term morbidities. Few studies have compared a broad array of predictors among these two outcomes. The purpose of this study was to compare risk factors for PTB and SGA births using a national sample of Canadian women.

METHODS

We analysed data from the Canadian Maternity Experiences Survey (n = 6421). Mothers were ≥ 15 years of age, gave birth to a singleton infant and were living with their infant at the time of the interview (between 5 and 14 months post-partum). Backward stepwise multivariable logistic regression models were constructed for each outcome.

RESULTS

Risk profiles for the two outcomes had both differences and similarities. Risk factors specific to PTB were education less than high school, having a previous medical condition, developing a new medical condition or health problem during pregnancy, being a primigravida, or being a multigravida with a previous PTB or a previous miscarriage or abortion. Risk factors unique to SGA were low pre-pregnancy body mass index (<18 kg/m(2) ), smoking during pregnancy and being a recent immigrant. Risk factors for both outcomes included low weight gain during pregnancy (<9.1 kg), short stature (<155 cm) and reporting life as 'very stressful' in the year prior to birth of the baby.

CONCLUSION

A greater understanding of the risk factors related to PTB and SGA may help to reduce the prevalence of these conditions and the associated risk of infant mortality and morbidity.

The Psychoneuroimmunology of Stress in Pregnancy

The rate of preterm birth in the United States remains high. In up to 40% of cases of preterm birth, the mothers are healthy women who have no clear risk factors. Accordingly, research has begun to explore the effect of prenatal stress on the risk of preterm birth and shortened gestational age at birth. There is increasing evidence that psychosocial stress throughout gestation increases the risk of preterm birth through changes in maternal endocrine, immune, and inflammatory activity during pregnancy. In this article, I describe foundational and current research examining the effects and biological mechanisms of prenatal stress in preterm birth and shortened gestational age at birth. I emphasize psychoneuroimmunology-focused studies showing that prenatal stress alters inflammatory and endocrine markers during gestation and that these changes are associated with preterm birth and shortened gestational age at birth.

Maternal depression and Epstein-Barr virus reactivation in early pregnancy

OBJECTIVE

Recent evidence suggests a link between Epstein-Barr virus reactivation and chronic stress due to decreased cellular immune responses. Maternal depression complicates 10% to 20% of pregnancies and is accompanied by stress. We sought to estimate the association of Epstein-Barr virus reactivation with depression in pregnancy.

METHODS

In this cohort study, prevalence of Epstein-Barr virus reactivation was compared between 100 pregnant women with depression before pregnancy and a computer-generated referent group of 100 healthy women not known to be depressed. We included only those women with documented Diagnostic and Statistical Manual of Mental Disorders depression diagnoses in the current pregnancy. Serum samples were analyzed for presence of Epstein-Barr virus viral capsid antigen, nuclear antigen, and early antigen antibodies. Epstein-Barr virus reactivation was defined by presence of viral capsid antigen or nuclear antigen immunoglobulin (Ig) G, along with early antigen IgG, viral capsid antigen IgM, or both early antigen IgG and viral capsid antigen IgM.

RESULTS

Maternal demographics were similar between the groups except for older age (34.1 compared with 32.7 years, P=.05), and lower body mass index (27.3 compared with 28.9, P=.03) among the depressed individuals. Ninety-five percent of the women were seropositive for Epstein-Barr virus. Women with depression were more likely to have Epstein-Barr virus reactivation (48% compared with 30%, P=.01) when compared with referent participants. Epstein-Barr virus reactivation remained associated with maternal depression (adjusted odds ratio 1.97, 95% confidence interval 1.10-3.77, P=.03) after controlling for potential confounders.

CONCLUSION

Women with depression have higher prevalence of Epstein-Barr virus reactivation, possibly due to increased stress.

LEVEL OF EVIDENCE

II.

The occurrence of preterm delivery is linked to pregnancy-specific distress and elevated inflammatory markers across gestation

There is mounting evidence that stress during pregnancy can have detrimental effects on gestation and birth. Existing studies indicate that prenatal stress may increase levels of circulating inflammatory markers that are associated with prematurity and pregnancy complications, suggesting that stress-related changes in the cytokine milieu may increase the risk of poor pregnancy outcome. Previous studies, however, have not clearly connected stress during pregnancy to changes in inflammatory mediators and, in turn, to clinically-relevant outcomes such as premature delivery. The present study sought to directly connect prenatal stress and changes in inflammatory markers to preterm delivery and gestational age at birth (GAB). A sample of 173 women was recruited during the first trimester of pregnancy and followed through delivery. Overall stress, pregnancy-specific distress, and inflammatory markers were assessed early and later in pregnancy, and the predictive value of these measures for preterm birth and GAB was determined. There were significant differences in pregnancy-specific distress, IL-6, and TNF-α between women who delivered prematurely versus those who delivered at term, and elevated levels of pregnancy-specific distress, IL-6, and TNF-α were predictive of shortened GAB overall. Importantly, in many cases, the effects of overall stress and pregnancy-specific distress on GAB were mediated by levels of circulating inflammatory markers. Collectively, these data provide strong evidence that prenatal stress experiences can affect the timing of parturition via alterations in circulating inflammatory mediators, and underscore the need for ongoing research aimed at further understanding the mechanisms and effects of prenatal stress on maternal and infant health.

Antenatal psychobiological predictors of psychological response to childbirth

BACKGROUND

Several psychological and obstetric predictors of a negative childbirth experience and traumatic response to delivery have been identified. However, the influence of antepartum physiological stress parameters has not been elucidated.

OBJECTIVE

The study includes an exploratory analysis of the associations of fear of delivery, antenatal basal and reactive activity of the hypothalamic-pituitary-adrenal axis, and obstetric outcomes, with childbirth experience and posttraumatic avoidance in the postpartum period.

DESIGN

This was a prospective study with two antenatal measurements and a final assessment during the first week postpartum. An experimental condition with a standardized stressor (Trier Social Stress Test) was included in the design to study psychobiological stress response as a predictor of traumatic birth and posttraumatic avoidance.

RESULTS

Linear regression analyses show independent associations of fear of delivery and more pronounced antenatal cortisol awakening response with a more negative childbirth experience. Fear of delivery was mediated by state anxiety after stress exposure, which, together with cortisol awakening response, explained 16% of the variance in the outcome of a more negative childbirth experience. Finally, antenatal fear of delivery and a negative childbirth experience both predicted higher avoidance scores during the first week postpartum.

CONCLUSIONS

The associations found in this study can improve identification during pregnancy of women at risk for negative psychological response to childbirth. For these women, the provision of supportive care during pregnancy should be evaluated.

Specialised antenatal clinics for women with a pregnancy at high risk of preterm birth (excluding multiple pregnancy) to improve maternal and infant outcomes

BACKGROUND

Amongst the risk factors for preterm birth, previous preterm delivery is a strong predictor. Specialised clinics for women with a history of spontaneous preterm delivery have been advocated as a way of improving outcomes for women and their infants.

OBJECTIVES

To assess using the best available evidence, the value of specialised antenatal clinics for women with a pregnancy at high risk of preterm delivery when compared with 'standard' antenatal clinics.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2011).

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials (including cluster-randomised trials) examining specialised compared with standard antenatal clinic care for women with a singleton pregnancy considered at high risk of preterm labour.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

We included three trials with 3400 women, all carried out in the USA. All focused on specialised clinics for women at high risk of preterm birth. Gestational age at delivery, preterm delivery, or both were primary outcomes in all studies. The interventions in the three trials differed.Overall there was very little data on our prespecified outcomes. For most outcomes a single study provided data, hence there was not the statistical power to detect any possible differences between groups. There was no clear evidence that specialised antenatal clinics reduce the number of preterm births.

AUTHORS' CONCLUSIONS

Specialised antenatal clinics are now an accepted part of care in many settings, and carrying out further randomised trials may not be possible. Any future research in this area should include psychological outcomes and should focus on which aspects of service provision are preferred by women. Such research could underpin further service development in this area.

Maternal corticotropin-releasing hormone and the use of selective serotonin reuptake inhibitors independently predict the occurrence of preterm birth

INTRODUCTION

Studies support the premise that chronic maternal stress may trigger a premature sequence of physiologic events ending in preterm birth (PTB). Furthermore, chronic stress is highly correlated with depression and anxiety, which also are associated with PTB. However, some studies report that medication status rather than depression and/or anxiety may reflect the risk for PTB. Although the purpose of this small, preliminary study was to evaluate the association between chronic maternal stress and PTB, this report focuses on the unexpected finding of the association between maternal use of selective serotonin reuptake inhibitors (SSRIs) and PTB.

METHODS

A prospective cohort study of 100 pregnant women included measures of contributors to chronic maternal stress and corticotropin-releasing hormone (CRH). Demographic and behavioral data included smoking, substance use, and use of medications for depression and anxiety.

RESULTS

Pregnant women who used SSRIs to treat depression and/or anxiety were nearly 12 times more likely to give birth before term when compared with women who did not use these medications. Women with CRH levels in the fourth quartile were 6 times more likely to give birth before term when compared with women whose CRH levels were in the lower 3 quartiles. No associations were found between SSRI use and CRH levels.

DISCUSSION

Associations between PTB and maternal use of SSRIs are not understood. It is important not to alter current approaches to the treatment of depression and anxiety without thorough discussion with women regarding the potential benefits and harms of various treatment options.

Development and Psychometric Testing of the Rural Pregnancy Experience Scale (RPES)

Rural pregnant woman who lack local access to maternity care due to their remote living circumstances may experience stress and anxiety related to pregnancy and parturition. The Rural Pregnancy Experience Scale (RPES) was designed to assess the unique worry and concerns reflective of the stress and anxiety of rural pregnant women related to pregnancy and parturition. The items of the scale were designed based on the results of a qualitative study of the experiences of pregnant rural women, thereby building a priori content validity into the measure. The relevancy content validity index (CVI) for this instrument was 1.0 and the clarity CVI was .91, as rated by maternity care specialists. A field test of the RPES with 187 pregnant rural women from British Columbia indicated that it had two factors: financial worries and worries/concerns about maternity care services, which were consistent with the conceptual base of the tool. Cronbach’s alpha for the total RPES was .91; for the financial worries subscale and the worries/concerns about maternity care services subscale, alpha were .89 and .88, respectively. Construct validity was supported by significant correlations between the total scores of the RPES and the Depression Anxiety Stress Scales (DASS [r =.39, p < .01]), and subscale scores on the RPES were significantly correlated and converged with the depression, anxiety, and stress subscales of the DASS supporting convergent validity (correlations ranged between .20; p < .05 and .43; p < .01). Construct validity was also supported by findings that the level of access and availability of maternity care services were significantly associated with RPES scores. It was concluded that the RPES is a reliable and valid measure of worries and concerns reflective of rural pregnant women’s stress and anxiety related to pregnancy and parturition.

A intervenção de enfermagem : relaxamento e seus efeitos no sistema imunológico de puérperas

OBJETIVOS: Avaliar os efeitos da técnica de relaxamento nos níveis de Imunoglobulina A (IgA) salivar em puérperas e a relação com as variáveis: idade, grau de instrução, estado civil, tipo de parto e paridade. MÉTODOS: Estudo experimental randomizado realizado em uma maternidade do Espírito Santo (Brasil). A amostra constituiu-se de 60 puérperas. O grupo experimental composto por 30 puérpuras seguiu a técnica de relaxamento proposta por Benson. As variáveis foram coletadas por meio de formulário específico e o nível de IgA salivar por imunoturbidimetria em dois momentos: até 24 horas pós-parto e 7 dias depois. RESULTADOS: Verificou-se aumento significativo dos níveis de IgA no grupo experimental (p= 0,01) após a prática do relaxamento e ausência de relação entre as variáveis de controle e a IgA. CONCLUSÃO: O relaxamento pode ajudar a aumentar a resistência imunológica de puérperas.

Religion, spirituality, social support, and perceived stress in pregnant and postpartum Hispanic women

OBJECTIVE

To examine the association between religion/spirituality and perceived stress in prenatal and postpartum Hispanic women.

DESIGN

Cross-sectional survey.

SETTING

An urban, publicly funded hospital in California.

PARTICIPANTS

Two hundred and forty-eight pregnant and postpartum Hispanic women between age 18 and 45 years.

METHOD

Patients presenting for prenatal or postpartum care or for the first infant visit were recruited to participate in the current study. PARTICIPANTS completed surveys consisting of questions about demographic characteristics, religiosity, spirituality, social support, and stress.

RESULTS

Most participants were unmarried, low-income women with low educational attainment. Ninety percent of women reported a religious affiliation, with more than one half (57.4%) listing their religious affiliation as "Catholic." Overall religiousness/spirituality was significantly associated with increased negative experiences of stress in women who selected English language instruments (Spearman's r=.341, p=.007); there was no such relationship in women who selected Spanish language instruments. Social support and greater relationship quality with a significant other were significantly associated with reduced perceived stress in Spanish reading and English reading women.

CONCLUSIONS

In this sample of pregnant and postpartum Latinas, religiousness/spirituality was not associated with reduced perceived stress and was in fact associated with increased perceived stress among women who selected English-language surveys. Additional research is needed to investigate this association. On the other hand, the current study reinforces the importance of social support and relationship quality for pregnant and postpartum women.

Prenatal life events stress: implications for preterm birth and infant birthweight

OBJECTIVE

The objective of the study was to evaluate the effects of maternal exposure to severe life events during different stage of gestation on preterm birth and infant birthweight.

STUDY DESIGN

A sample of 1800 women who delivered after 32 weeks' gestation were assessed with questionnaires that measured stressful life events during different stages of pregnancy. Demographic characteristics and birth outcomes were collected through the interviews and medical charts.

RESULTS

There was an increased risk of preterm birth among women with higher levels of life events stress during the first trimester (adjusted risk ratio, 2.40; 95% confidence interval, 1.13-5.09) and second trimester (adjusted risk ratio, 2.86; 95% confidence interval, 1.26-6.47). Each unit increase of perceived life events stress during first trimester was associated with a 99.09 g decrease in infant birthweight.

CONCLUSION

Prenatal severe life events, especially in the first trimester, may play an important role in increasing the risk of preterm birth and low birthweight.