Psychopharmacotherapy in Pregnancy and Breastfeeding

Psychiatric Treatment in Pregnancy: A Narrative Review

Pregnancy, childbirth and the puerperium are a series of transformations and huge changes in a woman's life, which may also be accompanied by various mental problems. Very often, women experiencing mental disorders during this period and their doctors face a decision on safety of treatment. The purpose of the following review was to assess the safety of treatment during pregnancy. Internet scientific database PubMed was searched. There are groups of psychiatric medications contraindicated during pregnancy such as valproates as well as relatively safe ones such as selective serotonin reuptake inhibitors (SSRIs) or antipsychotics. However, in every clinical situation, a decision should be made with caution, based on individual characteristics of patient, severity of disorder and clinical picture.

Immunological evaluation of herbal extracts commonly used for treatment of mental diseases during pregnancy

Nonpsychotic mental diseases (NMDs) affect approximately 15% of pregnant women in the US. Herbal preparations are perceived a safe alternative to placenta-crossing antidepressants or benzodiazepines in the treatment of nonpsychotic mental diseases. But are these drugs really safe for mother and foetus? This question is of great relevance to physicians and patients. Therefore, this study investigates the influence of St. John's wort, valerian, hops, lavender, and California poppy and their compounds hyperforin and hypericin, protopine, valerenic acid, and valtrate, as well as linalool, on immune modulating effects in vitro. For this purpose a variety of methods was applied to assess the effects on viability and function of human primary lymphocytes. Viability was assessed via spectrometric assessment, flow cytometric detection of cell death markers and comet assay for possible genotoxicity. Functional assessment was conducted via flow cytometric assessment of proliferation, cell cycle and immunophenotyping. For California poppy, lavender, hops, and the compounds protopine and linalool, and valerenic acid, no effect was found on the viability, proliferation, and function of primary human lymphocytes. However, St. John's wort and valerian inhibited the proliferation of primary human lymphocytes. Hyperforin, hypericin, and valtrate inhibited viability, induced apoptosis, and inhibited cell division. Calculated maximum concentration of compounds in the body fluid, as well as calculated concentrations based on pharmacokinetic data from the literature, were low and supported that the observed effects in vitro would probably have no relevance on patients. In-silico analyses comparing the structure of studied substances with the structure of relevant control substances and known immunosuppressants revealed structural similarities of hyperforin and valerenic acid to the glucocorticoids. Valtrate showed structural similarities to the T cells signaling modulating drugs.

Positive intervention effect of mobile health application based on mindfulness and social support theory on postpartum depression symptoms of puerperae

OBJECTIVE

This study investigated the effects of mobile health application designed based on mindfulness and social support theory on parenting self-efficacy and postpartum depression symptoms of puerperae.

METHODS

We recruited 130 puerperae from a hospital in China and randomized them to an App use group (n = 65) and a waiting control group (n = 65). The App group underwent an 8-week app use intervention while the control group underwent no intervention. We measured four main variables (mindfulness, perceived social support, maternal parental self-efficacy and postpartum depressive symptoms) before and after the App use intervention.

RESULTS

In the App group, perceived social support, maternal parental self-efficacy were significantly higher and postpartum depressive symptoms was significantly lower. In the control group, there were no significant differences in any of the four variables between the pre-test and post-test.

CONCLUSIONS

Our findings indicated that the mobile health application may help to improve perceived social support, maternal self-efficacy and reduce postpartum depressive symptoms. The finding of the mobile health application's effect extends our understanding of integrative effects of mindfulness and perceived social support on reduction of postpartum depressive symptoms and suggests clinical potentials in the treatment of postpartum depressive symptoms.

Risk factors for postpartum depression in women undergoing elective cesarean section: A prospective cohort study

Background

Postpartum depression (PPD) has adverse effects on maternal and child health. Cesarean section (CS) is suggested to be associated with PPD, but no study has examined the risk factors for PPD in women who underwent CS. Therefore, this study aimed to investigate this association.

Methods

A prospective observational study was conducted between December 2020 and September 2021. In total, 590 women who underwent elective CS participated in this study. Data were collected using a questionnaire through a face-to-face interview at three time points: 32nd week of gestation, 2 days postpartum, and 6 weeks postpartum. PPD was defined by an Edinburgh Postnatal Depression Scale (EPDS) score of ≥ 11 at 6 weeks postpartum. Multivariate logistic regression analysis was performed to identify the risk factors for PPD.

Results

Among the 590 women, 25.4% had PPD (142/590). After adjustment for the confounding factors, high antenatal self-rating anxiety scale score (OR = 1.10, 95% CI = 1.04–1.16), PPD symptoms (EPDS ≥ 11) at 2 days postpartum (OR = 6.17, 95% CI = 1.35–28.31), and pain at 6 weeks postpartum (OR = 2.14, 95% CI = 1.24–3.69) were independently associated with PPD.

Conclusion

Prenatal anxiety, PPD symptoms occurring at an early postoperative stage, and pain at 6 weeks postpartum may be associated with an increased risk of PPD among women who undergo CS.

The silent burden: a landscape analysis of common perinatal mental disorders in low- and middle-income countries

Background

Mental health has long fallen behind physical health in attention, funding, and action—especially in low- and middle-income countries (LMICs). It has been conspicuously absent from global reproductive, maternal, newborn, child, and adolescent health (MNCAH) programming, despite increasing awareness of the intergenerational impact of common perinatal mental disorders (CPMDs). However, the universal health coverage (UHC) movement and COVID-19 have brought mental health to the forefront, and the MNCAH community is looking to understand how to provide women effective, sustainable care at scale. To address this, MOMENTUM Country and Global Leadership (MCGL) commissioned a landscape analysis in December 2020 to assess the state of CPMDs and identify what is being done to address the burden in LMICs.

Methods

The landscape analysis (LA) used a multitiered approach. First, reviewers chose a scoping review methodology to search literature in PubMed, Google Scholar, PsychInfo, and Scopus. Titles and abstracts were reviewed before a multidisciplinary team conducted data extraction and analysis on relevant articles. Second, 44 key informant interviews and two focus group discussions were conducted with mental health, MNCAH, humanitarian, nutrition, gender-based violence (GBV), advocacy, and implementation research experts. Finally, reviewers completed a document analysis of relevant mental health policies from 19 countries.

Results

The LA identified risk factors for CPMDs, maternal mental health interventions and implementation strategies, and remaining knowledge gaps. Risk factors included social determinants, such as economic or gender inequality, and individual experiences, such as stillbirth. Core components identified in successful perinatal mental health (PMH) interventions at community level included stepped care, detailed context assessments, task-sharing models, and talk therapy; at health facility level, they included pre-service training on mental health, trained and supervised providers, referral and assessment processes, mental health support for providers, provision of respectful care, and linkages with GBV services. Yet, significant gaps remain in understanding how to address CPMDs.

Conclusion

These findings illuminate an urgent need to provide CPMD prevention and care to women in LMICs. The time is long overdue to take perinatal mental health seriously. Efforts should strive to generate better evidence while implementing successful approaches to help millions of women “suffering in silence.”

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04589-z.

Pregnancy-related claustrophobia

A 35-year-old primigravida presented with significant anxiety symptoms at 26 weeks' gestation. Symptoms were preceded by a nightmare about her upcoming labour. She developed repetitive intrusive thoughts of being trapped emotionally and physically in her pregnancy. Her symptoms were suggestive of new-onset claustrophobia associated with pregnancy, which has not been previously reported on. Her symptoms ameliorated with a combination of cognitive-behavioural therapy and pharmacotherapy (sertraline and low dose quetiapine). The later stages of pregnancy were associated with minimal symptoms and the resolution of her subjective 'entrapment'. A subsequent pregnancy resulted in similar although less severe symptomatology. No postpartum anxiety symptoms were demonstrated on both occasions. Anxiety symptoms can adversely impact both the mother and fetus, and thus correct identification and management of pregnancy-related claustrophobia improved symptomatology and functioning and allowed for earlier detection and reduced symptomatology in a subsequent pregnancy.

Prevalence and associated psychological risk factors of postpartum depression: a cross-sectional study

This cross-sectional study aimed to evaluate the prevalence of postpartum depression and the associated risk factors in a sample of Italian women at three months after delivery. Eighty women were screened by completing the Edinburgh Postnatal Depression Scale (EPDS). Women with a score ≥10 were evaluated as positive and other variables were detected through the administration of the Postpartum Depression Predictors Inventory.The prevalence of postpartum depression in the sample was 11.25% (EPDS score >10). A statistically significant relationship was found between the predisposition to postnatal depression and various risk factors such as prenatal depression, stressful life experiences marital problems. Furthermore, strong emotional and instrumental support from the partner and a good economic status can represent protective factors. It is essential to promote an integrated approach to postpartum affective disorders in which psychosocial risk factors are taken into account, and adequate screening programs are implemented.Impact StatementWhat is already known on this subject? Pregnancy can cause emotional stress for women with consequent development, in some cases, of mood disorders such as postpartum depression.What do the results of this study add? According to this study, women suffering from postpartum depression showed a significant tendency to anxiety and depression, low perceived support from the partner, and low socio-economic status.What are the implications of these findings for clinical practice and/or further research? It would be desirable to promote an integrated approach to postpartum affective disorders in which psychosocial risk factors are taken into account and adequate screening programs are implemented.

Development of the Uncertainty Scale for Women Hospitalized With High-Risk Pregnancies in South Korea

The purpose of the study was to develop the Uncertainty Scale for Women Hospitalized with High-Risk Pregnancies (USWHHP) and to evaluate its validity and reliability. The USWHHP was developed through four steps: generation of the initial items, evaluation of content validity, preliminary survey, and evaluation of validity and reliability in a sample survey. The final USWHHP scale includes 27 items in seven subdomains, which are scored using a 5-point Likert scale. The total possible score ranges from 27 to 135, and a higher score indicates a greater level of uncertainty. The USWHHP had a Cronbach's alpha coefficient of 0.93. The USWHHP is an easy-to-apply questionnaire specifically designed to measure uncertainty levels of women hospitalized with high-risk pregnancies.

Traditional plant use during lactation and postpartum recovery: Infant development and maternal health roles

ETHNOPHARMACOLOGICAL RELEVANCE

Evidence of phytochemical roles in infant development and maternal recovery offers insights into beneficial functions of traditional plant use during lactation and the postpartum period. Ethnopharmacological research has relevance to global priorities on maternal and child health, to understanding origins and determinants of human self-medication, and for reconciling traditional postpartum practices and mainstream healthcare.

AIM OF THE STUDY

Present emerging evidence, within evolutionary and socio-cultural contexts, on the role of maternal consumption on transfer of phytochemicals into breast milk with impacts on maternal and child health, and on infant development. Establish current state of knowledge and an ethnopharmacological research agenda that is attentive to cross-cultural and regional differences in postpartum plant use.

MATERIALS AND METHODS

An extensive literature review using Medline, Scopus, and Web of Science focused on traditional and contemporary use and socio-cultural context, as well as physiological, pharmacological, toxicological, and behavioral activities of plants used medicinally by women during postpartum recovery and lactation.

RESULTS

The most widely reported postpartum plants show antimicrobial, anti-inflammatory, immunological, and neurophysiological activities, with low toxicity. Phytochemicals transfer from maternal consumption into breast milk in physiological concentrations, while animal studies demonstrate immunomodulation and other actions of medicinal plants during lactation. Reporting on the use and diverse traditional knowledge of women about plants during the postpartum period is obscured by the marginal place of obstetric issues and by gender biases in ethnobotanical research. In many contemporary contexts use is prejudiced by precautionary risk warnings in health literature and practice that confound lactation with pregnancy.

CONCLUSIONS

Although systematic investigation of postpartum plant use is lacking, known pharmacological activities support potential benefits on infant development and maternal health with immediate and long-term consequences in relation to allergic, inflammatory, autoimmune, and other diseases. An ethnopharmacological agenda focused on the perinatal period requires directed methodologies and a regional approach in relation to culturally-specific knowledge and practices, traditional plant use, and local health needs. Testing the hypothesis that phytochemicals transferred from medicinal plants into breast milk impact the human immune system and other aspects of infant development requires extended analysis of phytochemicals in human milk and infant lumen and plasma, as well as effects on gastrointestinal and milk microbiome.

Frequency of menstrual abnormalities and their associated neuroimaging findings in women with focal refractory epilepsy

Patients with refractory epilepsy can suffer from psychological and physical problems. Epilepsy can also be associated with menstruation abnormalities in women. In this paper, we aim to survey women with focal refractory epilepsy who also suffer from menstrual abnormalities. This cross-sectional study was performed in 2018 in Tertiary Epilepsy Center in Kashani Hospital, Isfahan, Iran and Milad hospital, Isfahan, Iran. A total number of 381 patients diagnosed with refractory epilepsy joined the study based on an inclusion and exclusion criteria. Clinical characteristics of epilepsy, menstrual issues and brain MRI findings were assessed. Among 381 women with refractory epilepsy, 250 had refractory focal epilepsy (65.61%), and the others (34.39%) had generalized refractory epilepsy. 132 patients out of 381 had menstrual abnormalities (34.65%). Among 132 women with coexisting refractory epilepsy and menstrual abnormalities, 86 (65.15%) were diagnosed with refractory focal epilepsy, and 46 (34.86%) had generalized refractory epilepsy (p value = 0.041). Oligomenorrhea-hypomenorrhea was the most common type of menstrual abnormality in women with refractory epilepsy seen in 83 (62.87%) (p value = 0.039). The most common brain MRI pathology in women with refractory focal epilepsy was mesial temporal sclerosis (MTS) (39.20%, p = 0.00). We report that almost one-third of women with refractory epilepsy suffer from menstrual disorders, and the most common disorder was Oligomenorrhea-hypomenorrhea, and the most common brain pathology was MTS. It has also been a hypothesis that reproductive dysfunctions are connected to temporal lobe malfunctions, and more specific studies are required in this issue.

Factors Influencing Uptake of Breastfeeding: The Role of Early Promotion in the Maternity Hospital

Background: This study aimed to explore the prevalence of breastfeeding at birth points in Sicily and the relevance of the factors influencing the adoption of exclusive breastfeeding during hospitalization linked to childbirth. Methods: A survey was conducted to monitor the prevalence of breastfeeding in seven out of nine facilities providing maternity services in the province of Catania (Sicily, Southern Italy) in the years 2016–2018. An online questionnaire was administered using an electronic tablet by the midwife to the mother after discharge. Results: Women who had a higher educational qualification breastfed in a greater proportion (59.6%; odds ratio OR 0.60 for abandoning breastfeeding). Having had a caesarean section moderately impaired breastfeeding uptake, with an almost double chance of declining exclusive breastfeeding (OR = 1.74). Starting breastfeeding within 1 h from delivery showed a significant facilitating effect (OR = 0.58). Rooming-in had a strong facilitating effect on exclusive breastfeeding. A breastfeeding advocacy program was shown to protect from abandoning breastfeeding. Conclusions: It is important to offer in all hospitals the possibility and support for breastfeeding in the first moments after childbirth to increase the number of those who will then continue with exclusive breastfeeding.

Perinatal treatment of parents with the broad-spectrum antibiotic enrofloxacin aggravates contact sensitivity in adult offspring mice

BACKGROUND

Antibiotics, while eliminating pathogens, also partially deplete commensal bacteria. Antibiotic-induced dysbiosis may contribute to the observed rise in "immune-mediated" diseases, including autoimmunity and allergy. The aim of this study is to investigate the impact of perinatal antibiotic treatment on T cell-mediated immune response in adult mice.

METHODS

Oral treatment with broad-spectrum antibiotic enrofloxacin during gestation and breastfeeding or breastfeeding or gestation alone was used to evaluate whether antibiotic exposure early in life could modulate contact sensitivity (CS) in adult mice.

RESULTS

Here, we demonstrated that enrofloxacin treatment during gestation and breastfeeding, but not during pregnancy or breastfeeding alone, aggravated CS reaction in adult mice measured by ear swelling. These data correlate with increased myeloperoxidase (MPO) activity in the ear extracts and elevated production of IL-6 and IL-17A by auricular lymph node cells (ELNC) and was not influenced by food consumption and body weight. In each dosing regimen, enrofloxacin treatment reduced the relative abundance of Enterococcus spp. but did not influence the relative abundances of Lactobacillus, Clostridium cluster XIVa, XIVab, I, Bacteroidetes, and segmented filamentous bacteria (SFB). However, prolonged enrofloxacin-treatment during both gestation and breastfeeding decreased the relative abundance of Clostridium cluster IV.

CONCLUSION

These data show that long-term perinatal enrofloxacin treatment induces intestinal dysbiosis, characterized by decreased levels of anti-inflammatory Clostridium cluster IV, and alters T cell-dependent immune responses, enhancing CS reaction in adult mice.

Psychometric properties of the Turkish version of the Pregnancy Sexual Response Inventory

PURPOSE

The purpose of this study was to adapt the Pregnancy Sexual Response Inventory (PSRI) into Turkish and to determine the psychometric properties for pregnant women.

METHODS

A total of 139 pregnant women were included in the study. The psychometric features of the questionnaire were analyzed in terms of internal consistency, test-retest reliability, content and criterion validity. The Turkish version of the PSRI and the Female Sexual Function Index (FSFI) was completed by the pregnant women. Criterion validity was tested by measuring the correlations between the total and subscale scores of the PSRI and the FSFI.

RESULTS

The test-retest reliability of the Turkish PSRI was found to be moderate to very strong (ICC = 0.57-0.96, p < 0.001). The internal consistency [Cronbach's alpha (α) coefficient] was found to be 0.65-0.70 before pregnancy and 0.73-0.80 during pregnancy. The criterion validity of the PSRI was supported by moderate to strong correlations between the subscales of the FSFI (desire, arousal, orgasm, satisfaction, pain) and the subscales of the PSRI-during pregnancy (r = 0.59, r = 0.45, r = 0.64, r = 0.53, r = 0.41, p < 0.001, respectively). The total score of the PSRI was significantly correlated with the total score of the FSFI (r = 0.71, p < 0.001).

CONCLUSION

The results of this study showed that the Turkish version of the PSRI has valid and reliable properties for assessing sexuality and sexual response during pregnancy.

Gestational diabetes mellitus: Prevention, diagnosis and treatment. A fresh look to a busy corner

BACKGROUND

Gestational diabetes mellitus (GDM) is a common pregnancy complication characterized by hyperglycaemia with onset or first recognition during pregnancy. Risk factors include family history of diabetes, previous GDM, genetic predisposition for GDM/type 2 diabetes, insulin resistance conditions such as overweight, obesity and ethnicity. Women with GDM are at high risk for fetal macrosomia, small for gestational age, neonatal hypoglycaemia, operative delivery and caesarean delivery. The aim of this narrative review is to summarize the most recent findings of diagnosis and treatment of GDM in order to underline the importance to promote adequate prevention of this disease, especially through lifestyle interventions such as diet and physical activity.

METHODS

The research was conducted using the following electronic databases, MEDLINE, EMBASE, Web of Science, Scopus, ClinicalTrial.gov, OVID and Cochrane Library, including all published randomized and non-randomized studies as well as narrative and systematic reviews.

RESULTS

The lack of universally accepted criteria makes the definition of diagnosis and prognosis of this condition difficult. Early diagnosis and glucose blood level control may improve maternal and fetal short and long-term outcomes. Treatment strategies include nutritional interventions and exercise. Medical treatment can be necessary if these strategies are not effective. Moreover, novel non-pharmacologic agents such as myo-inositol seem to be effective and safe both in the prevention and the treatment of GDM.

CONCLUSIONS

It is important to promote adequate prevention of GDM. Further studies are needed in order to better define the most appropriate strategies for the clinical management of women affected by GDM.

Mediating effect of resilience during pregnancy on the association between maternal trait anger and postnatal depression

OBJECTIVE

The association between anger and postnatal depression has been reported in previous studies. However, whether this association is mediated by resilience is unknown. Resilience is a dynamic process of individuals' positive adaptation to stress and adversity. This study investigated the mediating effect of resilience during pregnancy on the association between trait anger during pregnancy and postnatal depression at one-month.

METHODS

A longitudinal study from the third trimester to one-month postnatal using online self-report questionnaires was conducted in two maternity clinics in Tokyo. Trait anger and resilience during pregnancy and postnatal depression at one-month were measured by the State-Trait Anger Expression Inventory, resilience test, and the Edinburgh Postnatal Depression Scale. To test the hypothesis, Structural Equation Modeling was used.

RESULTS

Data of 531 participants were analyzed. The final Structural Equation Modeling model demonstrated that resilience during pregnancy had a partial mediating effect on the association between trait anger during pregnancy and postnatal depression at one-month. Trait anger was significantly associated with resilience during pregnancy (β = -0.28) and postnatal depression (β = 0.24). Resilience during pregnancy was significantly associated with postnatal depression (β = -0.20).

CONCLUSIONS

This study demonstrated that resilience during pregnancy had a partial mediating effect on the association between trait anger during pregnancy and postnatal depression at one-month. The findings highlight the importance of identifying pregnant women with high trait anger and providing interventions to enhance their resilience to decrease the risk of postnatal depression.

Iron Deficiency Anemia in Pregnancy: Novel Approaches for an Old Problem

Iron needs increase exponentially during pregnancy to meet the increased demands of the fetoplacental unit, to expand maternal erythrocyte mass, and to compensate for iron loss at delivery. In more than 80% of countries in the world, the prevalence of anemia in pregnancy is > 20% and could be considered a major public health problem. The global prevalence of anemia in pregnancy is estimated to be approximately 41.8%. Undiagnosed and untreated iron deficiency anemia (IDA) can have a great impact on maternal and fetal health. Indeed, chronic iron deficiency can affect the general wellbeing of the mother and leads to fatigue and reduced working capacity. Given the significant adverse impact on maternal-fetal outcomes, early recognition and treatment of this clinical condition is fundamental. Therefore, the laboratory assays are recommended from the first trimester to evaluate the iron status. Oral iron supplementation is the first line of treatment in cases of mild anemia. However, considering the numerous gastrointestinal side effects that often lead to poor compliance, other therapeutic strategies should be evaluated. This review aims to provide an overview of the current evidence about the management of IDA in pregnancy and available treatment options.

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.

Analysis of the Impact of the Confinement Resulting from COVID-19 on the Lifestyle and Psychological Wellbeing of Spanish Pregnant Women: An Internet-Based Cross-Sectional Survey

(1) Background: This study aimed to analyze the impact of the confinement due to the COVID-19 pandemics on the eating, exercise, and quality-of-life habits of pregnant women. (2) Methods: This was an internet-based cross-sectional survey which collected information about adherence to the Mediterranean diet, physical exercise, health-related quality of life (HRQoL), and perceived obstacles (in terms of exercise, preparation for delivery, and medical appointments) of pregnant women before and after the confinement. The survey was conducted in 18–31 May 2020. (3) Results: A total of 90 pregnant women participated in this study. There was a significant decrease in the levels of physical activity (p < 0.01) as well as in HRQoL (p < 0.005). The number of hours spent sitting increased by 50% (p < 0.001), 52.2% were unable to attend delivery preparation sessions because these had been cancelled. However, there were no significant differences in the eating pattern of these women (p = 0.672). Conclusions: These results suggest the need to implement specific online programs to promote exercise and reduce stress, thus improving the HRQoL in this population, should similar confinements need to occur again for any reason in the future.

Effects of a Brief Electronic Mindfulness-Based Intervention on Relieving Prenatal Depression and Anxiety in Hospitalized High-Risk Pregnant Women: Exploratory Pilot Study

Background

Peripartum depression and anxiety disorders are highly prevalent and are correlated with adverse maternal and neonatal outcomes. Antenatal care in Germany does not yet include structured screening and effective low-threshold treatment options for women facing peripartum depression and anxiety disorders. Mindfulness-based interventions (MBIs) are increasingly becoming a focus of interest for the management of such patients. Studies have shown a decrease in pregnancy-related stress and anxiety in expectant mothers following mindfulness programs.

Objective

The aim of this study was to explore the clinical effectiveness of a 1-week electronic course of mindfulness on prenatal depression and anxiety in hospitalized, high-risk pregnant women. We hypothesized that participating in a 1-week electronic MBI (eMBI) could alleviate symptoms of depression and anxiety during the hospital stay.

Methods

A prospective pilot study with an explorative study design was conducted from January to May 2019 in a sample of 68 women hospitalized due to high-risk pregnancies. After enrolling into the study, the participants were given access to an eMBI app on how to deal with stress, anxiety, and symptoms of depression. Psychometric parameters were assessed via electronic questionnaires comprising the Edinburgh Postnatal Depression Scale (EPDS), State-Trait Anxiety Inventory (STAI-S), and abridged version of the Pregnancy-Related Anxiety Questionnaire (PRAQ-R).

Results

We observed a high prevalence of peripartum depression and anxiety among hospitalized high-risk pregnant women: 39% (26/67) of the study participants in the first assessment and 41% (16/39) of the participants in the second assessment achieved EPDS scores above the cutoff value for minor/major depression. The number of participants with anxiety levels above the cutoff value (66% [45/68] of the participants in the first assessment and 67% [26/39] of the participants in the second assessment) was significantly more than that of the participants with anxiety levels below the cutoff value, as measured with the STAI-S. After completing the 1-week electronic course on mindfulness, the participants showed a significant reduction in the mean state anxiety levels (P<.03). Regarding pregnancy-related anxiety, participants who completed more than 50% of the 1-week course showed lower scores in PRAQ-R in the second assessment (P<.05). No significant changes in the EPDS scores were found after completing the intervention.

Conclusions

Peripartum anxiety and depression represent a relevant health issue in hospitalized pregnant patients. Short-term eMBIs could have the potential to reduce anxiety levels and pregnancy-related anxiety. However, we observed that compliance to eMBI seems to be related to lower symptoms of pregnancy-related stress among high-risk patients. eMBIs represent accessible mental health resources at reduced costs and can be adapted for hospitalized patients during pregnancy.

Potential Cultivation of Lactobacillus pentosus from Human Breastmilk with Rapid Monitoring through the Spectrophotometer Method

The present study focused on the development of a new method to determine the lag phase of Lactobacillus in breast milk which was attained during the 1st, 3rd, and 6th month (M1, M3, and M6). The colonies’ phylogenetic analysis, derived from the 16S rRNA gene sequences, was evaluated with genus Lactobacillus pentosus and achieved a similarity value of 99%. Raman spectroscopy in optical densities of 600 nm (OD600) were used for six consecutive days to observe the changes of the cell growth rate. The values of OD600 were well fitted with the regression model. From this work, M1 was found to be the longest lag phase in 18 h, and it was 17% to 27% longer compared to M3 and M6, respectively. However, the samples of M3 and M6 showed the shortest duration in reaching 0.5 of OD600 nm (16 h) which was enhanced by 80% and 96% compared to M1, respectively. These studies will be of significance when applied in determining the bacteria growth curve and in assessing the growth behavior for the strain in human breast milk.

Maternal mental health and reproductive outcomes: a scoping review of the current literature

PURPOSE

Current data show that maternal mental conditions affect about 10% of pregnant women worldwide. Assessing timing and patterns of mental health illness, therefore, is critical to ensure the wellbeing of the mother, the new-born and the whole family. The aim of this review is to summarize the latest evidence linking maternal mental disorders and adverse reproductive outcomes.

METHODS

Following the PRISMA guidelines for systematic reviews, a literature search was conducted to ascertain the possible impact of mental health conditions on reproductive outcomes before and during pregnancy. The comprehensive strategy included cohort studies, randomised controlled trials and literature reviews on women with Primary Maternal Mental Illness (PMMI) and Secondary Maternal Mental Illness (SMMI) considering periconceptional, obstetric and foetal-neonatal outcomes. PubMed, WoS, CINAHL and Google scholar were used for the search. Cross-referencing in bibliographies of the selected papers ensured wider study capture.

RESULTS

Evidence linking depressive disorders and infertility among PMMI is weak. Given this, women with prior mental conditions experience additional distress when undergoing fertility treatments. Primary mental disorders may also increase the risk of miscarriage and other pregnancy complications (e.g., gestational diabetes). For SMMI, there is more robust evidence correlating Preterm Birth (PTB) and Low Birth Weight (LBW) with common mental disorders which develop during pregnancy.

CONCLUSION

Prevention and management of maternal mental health diseases and minor mental conditions within the first 1000 days' timeframe, should have a place in the holistic approach to women going through reproductive decisions, infertility treatment and pregnancy.

Religiosity among women undergoing pregnancy termination for medical reasons: the experiences and views of Polish women

OBJECTIVES

The study aimed to determine the influence of religious and moral beliefs on contraceptive use, assisted reproduction and pregnancy termination in Polish women requesting a termination of pregnancy for medical reasons.

METHODS

Between 1 June 2014 and 31 May 2016, women deemed eligible for a termination of pregnancy for medical reasons at a Polish tertiary care centre received an anonymous questionnaire comprising 65 items. A total of 150 completed questionnaires were collected.

RESULTS

Of the respondents, 95% described themselves as Catholics, including 60% practising Catholics. The study revealed a discrepancy between respondents' beliefs and the teachings of the Catholic Church: an overwhelming majority of respondents used contraception, and 79% were in favour of in vitro fertilisation and believed the treatment should be refunded by the state. Interestingly, 66% of the respondents who attended confession did not perceive abortion as sinful.

CONCLUSION

The study detected a considerable discrepancy between declared religiosity and individual interpretations of the commandments and teachings of the Catholic Church. Despite stating they were Catholics, most women did not perceive abortion as sinful and did not follow the teachings of the Catholic Church regarding the sacraments for deceased children.

Attitudes and Opinions of Young Gynecologists on Pregnancy Termination: Results of a Cross-Sectional Survey in Poland

Background: This paper aims to explore the attitudes and opinions of a group of Polish young gynecologists toward pregnancy termination. Method: An anonymous questionnaire was completed by physicians who participated in obligatory trainee courses held in 2019 in Warsaw. Results: The study group included 71 physicians with an average age of 29 years (SD 3.05). A considerable number of the physicians accepted terminations for medical reasons up to the end of pregnancy, especially in cases of lethal defects (46%) and a serious disease in the mother (34%). Only 6% of the group of gynecologists not performing terminations claimed that the procedure was contrary to their conscience, and 62% of them stated that such procedures were not performed at their hospital. Terminations would be performed by 90% of the respondents in cases of lethal defects of the fetus and by 80% if severe irreversible fetal defects were diagnosed. Conclusions: The main problem associated with the inaccessibility of pregnancy termination in Poland is not linked to individuals, meaning medical personnel and the possibility of invoking the conscience clause, but probably to the lack of approval for terminations granted by hospital supervisors. Adequate knowledge on pregnancy termination procedures, fetal defects, and diseases in the mother translated into the changes of opinions on pregnancy terminations.

Breastfeeding in Hospitals: Factors Influencing Maternal Choice in Italy

Monitoring the prevalence of breastfeeding is one of the actions provided for in Italian National Health System. This study aims to observe the prevalence of breastfeeding in a representative set of birthing hospitals in the province of Catania, in Sicily, Italy, to assess the factors influencing women in their decisions to breastfeed during hospitalization after delivery. We conducted an observational study on 3813 questionnaires administered to mothers of newborns during their hospital stay from the years 2016 to 2018 in eight hospitals of various types. The average maternal age was 31.3 years ± 5.8. Sixty-nine percent of women did not attend a prenatal course. From childbirth to discharge, the percentage of women who breastfed was 88%, of whom 45% did exclusive breastfeeding. Only 35% of women who had a caesarean section adopted exclusive breastfeeding. In our experience, rooming-in was not associated with an increase in breastfeeding. We observed that both attendance to prenatal courses and the mother's education level played a minor role in influencing the mother's decision in breastfeeding A fairly high percentage of exclusive breastfeeding, 75%, was attained just in one hospital, where dedicated staff was deployed to encourage breastfeeding. The lowest percentage (12%) of exclusive breastfeeding was observed in a large private accredited health facility. Hospital presence of professionals trained in human lactation is a smart investment for society.

Pregnancy exposure to venlafaxine-Therapeutic drug monitoring in maternal blood, amniotic fluid and umbilical cord blood and obstetrical outcomes

BACKGROUND

For treatment with psychotropic drugs during pregnancy, extended therapeutic drug monitoring is recommended for individual therapy adjustment. We measured venlafaxine (VEN), O-desmethylvenlafaxine (ODV) and active moiety, AM (sum of VEN+ODV) concentrations in maternal serum, amniotic fluid and umbilical cord blood.

METHODS

Concentrations of VEN, ODVEN and AM were measured in nine mother-infant pairs at time of delivery; in five cases, amniotic fluid samples were available. Concentrations are reported as median values, first (Q1) and third (Q3) quartiles and ranges. Penetration ratio was calculated by dividing concentrations of VEN, ODVEN and AM in amniotic fluid and umbilical cord blood by maternal serum concentrations.

RESULTS

Median daily dosage of venlafaxine was 75 mg (range 37.5-225 mg). There were no significant correlations between daily dose, maternal serum, umbilical cord blood and amniotic fluid concentrations. Median penetration ratio into amniotic fluid was 2.5 (range 0.56-4.48). Median penetration ratio into fetal circulation was 1.05 (range 0.62-2.08). Median concentration of AM was 223.8 ng/mL, range 33.9-338.0 ng/mL (maternal serum), 789.0 ng/mL, range 309-1052.5 ng/mL (amniotic fluid) and 291.0 ng/mL, range 21.1-448.4 ng/mL (cord blood).

DISCUSSION

VEN, ODVEN and AM concentrations in maternal serum, amniotic fluid and umbilical cord blood indicate that the fetus might have been exposed to relatively high concentrations throughout pregnancy. High concentrations in amniotic fluid indicate an increased penetration into and/or accumulation within amniotic fluid and a decreased elimination out of amniotic fluid. Findings indicate that fetal in-utero exposition to venlafaxine is higher compared to other antidepressants.

The effect of counseling with a skills training approach on maternal functioning: a randomized controlled clinical trial

Background

The role of the mother can be deeply satisfying, but it is associated with many challenges including challenges during the postpartum period that may impede the optimal development of the infant. Therefore, the aim of the present study was to investigate the effects of counseling using the Skills Training Approach (STA) on postpartum maternal functioning.

Methods

This randomized controlled trial was performed on 68 postpartum women who referred to health centers of Tabriz-Iran in 2019. Participants were assigned to one of two groups - either counseling or control through the block randomization method. The intervention group received four counseling sessions using the Skills Training Approach (STA). Before and two weeks after the completion of the intervention, the Barkin Index of Maternal Functionning (BIMF) was completed by the participants. The independent t-test and ANCOVA (Analysis of Covariance) was used to analyze the data.

Results

There was no statistically significant difference between the two groups in terms of sociodemographic characteristics and the baseline scores of the BIMF and its domains (p > 0.05). Before the intervention, the mean (SD) total score of the BIMF in the intervention group was 73.1 (8.5) and in the control group, it was 71.6 (4.8). Post-intervention, the mean (SD) of the total score of the BIMF in the intervention group was 95.8 (11.8) and in the control group, it was 70.3 (4.5). Based on the ANCOVA test and after adjusting the baseline score, the mean total score of the BIMF was significantly higher in the intervention group than in the control group (Mean Difference (MD): 22.9; 95% CI: 18.2 to 27.6; p < 0.001). The post-intervention scores of all domains of the BIMF including self-care (MD: 3.8), infant care (MD: 2.0), mother-child interaction (MD: 4.8), psychological wellbeing (MD: 8.4), social support (MD: 4.0), management (MD: 6.8), and adjustment to new motherhood (MD: 3.2) were significantly higher in the intervention group compared to the control group (P < 0.001).

Conclusion

In this study, counseling, using STA, was effective in improving maternal functioning in all of the domains. This intervention, aimed at skill-building, should be strongly considered where improved postpartum functioning is the goal.

Trial registration

IRCT20120718010324N49. Registered 18 January 2019.

Amniotic fluid concentrations of soluble endoglin and endothelial cell-specific molecule-1 in pregnancies complicated with neural tube defects

Objective To determine the concentrations of soluble endoglin (sCD105) and endothelial cell-specific molecule-1 (ESM-1) in the amniotic fluid (AF) of pregnant women, and to investigate the relationship between these concentrations and neural tube defects (NTDs). Methods AF concentrations of sCD105 and ESM-1 were measured in the study group, which included 60 pregnant women complicated with NTDs, and 64 pregnant women with unaffected healthy fetuses (control group). The AF concentrations of sCD105 and ESM-1 in both groups were measured using enzyme-linked immunosorbent assay and compared. Results There were no significant differences in terms of the mean AF concentrations of sCD105 and ESM-1 between the groups (P=0.141, P=0.084, respectively). There was a significant difference between the AF sCD105 concentrations in those with gestational age <24 weeks (n=101) and ≥24 weeks (n=23) (X̅<24=76.35±126.62 vs. X≥24=39.87±58.32, P=0.041). AF ESM-1 concentrations were found to be statistically significant in the gestational age <22 weeks (n=90) and ≥22 weeks (n=34) groups (X̅<22=135.91±19.26 vs. X̅≥22=148.56±46.85, P=0.035). A positive and low-level relation at a statistically significant level was determined between the gestational age and AF ESM-1 concentration in the study group (r=0.257; P=0.048). Conclusion AF concentrations of sCD105 and ESM-1 were not associated with the development of NTDs. Unlike studies that reported that ESM-1 concentrations decreased in maternal plasma with increased gestational age, we determined an increase that was proportionate to gestational age in AF.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSION

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

Salivary Aldosterone, Cortisol, and Their Morning to Evening Slopes in Patients with Depressive Disorder and Healthy Subjects: Acute Episode and Follow-Up 6 Months after Reaching Remission

BACKGROUND/OBJECTIVE

Cortisol is thought to be involved in the pathophysiology of affective disorders. Less attention has been given to other neuroendocrine factors. The aim of the present study was to test the hypothesis that adrenocortical steroids aldosterone and cortisol show different dynamic changes in the course of clinical depression with the assumption that aldosterone is a state marker of depression.

METHODS

A total of 78 adult subjects (39 patients with depressive disorder and 39 healthy controls) participated in a prospective non-interventional clinical study. Patients were investigated at the time of an acute episode and 6 months after reaching remission. The clinical and personal characteristics, and morning and evening salivary concentrations of aldosterone and cortisol were evaluated.

RESULTS

Patients with an acute depressive episode exhibited higher evening aldosterone and lower morning cortisol concentrations compared to healthy subjects. In these patients, both hormone concentrations showed flatter morning to evening slopes. Salivary aldosterone, but not cortisol concentrations, were lower in patients 6 months after reaching remission compared to those in the acute state. Similarly, 6 months of remission resulted in a steeper morning to evening slope of salivary aldosterone compared to the acute state. The cortisol rhythm remained dysregulated. A significant negative correlation between trait anxiety scores and morning cortisol concentrations in patients at 6 months of clinical remission was observed.

CONCLUSION

Diurnal changes in salivary aldosterone concentrations appear to be a state marker, whilst those of cortisol a trait marker of depression.

Hepatitis C Virus Infection in Children and Pregnant Women: An Updated Review of the Literature on Screening and Treatments

Objective  The aim of the paper is to review the current information relating to the diagnosis and treatment of hepatitis C virus (HCV) infection in pregnant women and children, particularly those infected by mother-to-child transmission. Study Design  A review of published literature was performed to identify relevant articles published between January 2015 and March 2019 on: HCV infection in pregnant woman, mother-to child-transmission of HCV and HCV infection in pediatrics. The results of the evaluation of the different studies were summarized in two sections describing separately the screening and effective treatments in pregnant women and children. Results  The rate of mother-to-child transmission of HCV is approximately 5%. HCV infection is strongly associated with cholestasis and preterm birth. Prenatal diagnosis of hepatitis C virus has a dual benefit for mother and child. Perinatally infected children develop cirrhosis in earlier age than those who acquire HCV as adolescents. Pregnant women with cirrhosis have a higher risk of poor maternal and neonatal outcomes than those without cirrhosis. Conclusion  To improve public health, universal screening of pregnant women for HCV infection should be performed. Early identification of women and children with HCV infection is important to enable them to be included in assessment and/or treatment programs.

Validation of the Iranian version of the childbirth experience questionnaire 2.0

BACKGROUND

Assessing women's childbirth experiences is a crucial indicator in maternity services because negative childbirth experiences are associated with maternal mortalities and morbidities. Due to the high caesarean birth rate in Iran, measuring childbirth experience is a top priority, however, there is no standard tool to measure this key indicator in Iran. The aim of present study is to adapt the "Childbirth Experience Questionnaire 2.0" to the Iranian context and determine its psychometric characteristics.

METHODS

Childbirth Experience Questionnaire 2.0 was translated into Farsi. A total of 500 primiparous women, at 4 to 16 weeks postpartum, were randomly selected from 54 healthcare centres in Tabriz. Internal consistency and reliability was calculated using the Cronbach's Coefficient alpha and Intraclass Correlation Coefficient, respectively. Construct validity was assessed using exploratory and confirmatory factor analysis and discriminant validity using the known-group method and the Mann-Whitney U-test.

RESULTS

The internal consistency and reliability for the total tool were high (Cronbach's alpha = 0.93; Intraclass Correlation Coefficient = 0.97). Explanatory factor analysis demonstrated the adequacy of the sampling (Kaiser-Meyer-Olkin = 0.923) and significant factorable sphericity (p < 0.001). Confirmation factor analysis demonstrated acceptable values of fitness (RMSEA = 0.07, SRMSEA = 0.06, TLI = 0.97, CFI > 0.91, x 2/ df = 4.23). Discriminatory validity of the tool was confirmed where the CEQ score and its subdomains were significantly higher in women who reported having control over their childbirth than women who did not.

CONCLUSION

The Farsi version of the Childbirth Experience Questionnaire 2.0 tool is a valid and reliable tool and can be used to measure the childbirth experience in Iranian women.

Personality traits of volunteer females of normal vaginal delivery or cesarean section based on HEXACO's personality model: a comparison study

BACKGROUND

Child birth is one of the most important events in a mother's life. Different factors influence whether a child is delivered by cesarean or normal vaginal delivery. Despite the complications of cesarean, demand for this type of delivery is increasing. The purpose of this study was to examine the influence of personal traits on the choice of the delivery method based on HEXACO personality model.

METHODS

Two hundred and ten pregnant women in some health centers in Tehran volunteered to participate in this research. To identify their personality dimensions, the pregnant women first filled out HEXACO personality forms. Then, the received data were analyzed through multivariate analysis of variance using a software package called SPSS-23.

RESULTS

104 women selected cesarean and 106 other women preferred normal vaginal delivery. The results of the multivariate analysis of variance showed that there is a significant difference between the two groups of women for six personality factors in HEXACO (P = 0.001). The linear combination of personality characteristics of pregnant women has a significant effect on the choice of delivery method (P < 0.05).

CONCLUSIONS

Personality differences of pregnant women can be considered in psychological interventions and antenatal counseling to overcome psychological resistance to vaginal delivery and increase its choice.

Evaluation of the relationship between sexual functions and depressive symptoms among pregnant patients during the second trimester

PURPOSE

Pregnancy is a process during which anatomical, physiological, and emotional changes occur. During this process, the sex lives of couples can be affected. Possible depressive symptoms and female sexual dysfunction can affect the relationship between partners, pregnancy-delivery process, and as a result, the newborn. The objective in the present study was to evaluate the relationship of female sexuality during pregnancy with sociodemographic parameters and depressive symptoms.

METHODS

150 pregnant women during the second trimester of their pregnancy and age-matched 150 healthy volunteers were included in the study. Sociodemographic data were recorded. "Female Sexual Function Index" (FSFI) was used to evaluate sexual functions and "Beck Depression Inventory" (BDI) was used to evaluate depressive symptoms. The data were analysed using SPSS 23 statistical software. The results were interpreted with "Independent Samples t Test", Spearman's Rho correlation coefficient, Mann-Whitney U analysis and Chi-square test, and a p value of < 0.05 was considered statistically significant.

RESULTS

It was detected that FSFI score of the pregnant group was lower compared to that of the non-pregnant group (16.953 ± 8.24; p = 0.000). There was no difference between the groups in terms of BDI scores (p = 0.100). There was no relationship between the FSFI score and the BDI score in the pregnant group (r = - 0.087; p = 0.144).

CONCLUSION

It was found that female sexual dysfunction occurs in pregnant women, depressive symptoms remained unchanged when compared to non-pregnant women and sexual functions remain unaffected.

Non-pharmacological management of gestational diabetes: The role of myo-inositol

Gestational diabetes mellitus (GDM) is the most common metabolic disorder occurring in pregnancy. GDM plays an important role in the current diabetes epidemic: exposure to a high glycemic environment during the early stages of development increases the risk of the fetus to develop type two diabetes mellitus (T2DM) in adult life. Various cardiometabolic risk factors are linked to GDM. A thorough knowledge of the risk factors and genes involved in the development of GDM, along with an understanding of the underlying pathophysiological mechanisms are crucial to properly identify patients at risk of developing this condition. There is growing evidence showing that myo-inositol, combined with an appropriate therapeutic regimen for GDM, can provide additional benefits to the patient. The aim of this review is to analyze the role of inositol isomers - especially myo-inositol (MYO-INS) - in the treatment of patients with GDM.

Efficacy of Low-Dose Paroxetine for the Treatment of Hot Flushes in Surgical and Physiological Postmenopausal Women: Systematic Review and Meta-Analysis of Randomized Trials

Background and Objectives: Hot flushes and sleep disturbances are the most common vasomotor symptoms (VMS) reported by postmenopausal women. Hormonal treatment is to date referred to as the gold standard approach but not suitable for all the patients. Alternative treatments are needed in case of a contraindication to menopausal hormone therapy (MHT), adverse side effects, and poor compliance. Paroxetine salt is the only nonhormonal medication approved by the US Food and Drug Administration for the management of VMS. Nonetheless, few trials with low consensus are available about this topic. In this review, we aimed to evaluate the efficacy of low-dose paroxetine therapy in the treatment of vasomotor hot flushes and night sleep disturbances in postmenopausal women. Materials and Methods: We performed an electronic search from the beginning of all databases to July 2019. All results were then limited to a randomized trial. Restrictions for language or geographic location were not utilized. Inclusion criteria were randomized clinical trials of physiological or surgical postmenopausal women experiencing hot flushes and sleep disturbances who were randomized to either low-dose paroxetine or placebo (i.e., formulations without active ingredients). The primary outcome evaluated was the mean weekly reduction of hot flushes. Results: Five randomized clinical trials, including 1482 postmenopausal women, were analyzed. Significant heterogeneity (I² = 90%) between studies was noted. Hot flushes episodes were significantly reduced in the treatment arm compared to placebo (mean difference (MD) −7.97 [−10.51, −5.92] episodes/week). Results on the improvement on sleep were limited by being reported in only two studies; however, no significant reduction of night-time awakenings was observed (MD, −0.40 awakenings/night [−1.38, 0.58 CI]). Conclusions: Low-dose paroxetine is an effective treatment for vasomotor menopause symptoms, including hot flushes.

Fluorescence lateral flow competitive protein binding assay for the assessment of serum folate concentrations

Folate is a micronutrient required for the production of new cells, making it a key factor in early fetal development and ensuring normal growth and maintenance of health. The increase in consumption of folate due to increased periconceptional supplementation and fortification of grains in many countries has led to a decrease in occurrence of folate deficiency and a class of birth defects called neural tube defects. However, an opportunity remains to further improve folate status of populations in areas with limited access to fortified foods and supplementation. Screening of women of reproductive age and other vulnerable populations for folate status would increase our understanding of the magnitude of the burden of folate deficiency and inform monitoring of public health programs. Current gold standard methods for folate assessment are time-intensive and require cold chain, sophisticated laboratory infrastructure, and highly-trained personnel. Our lateral flow assay is low-cost, easy to use, and allows a user to assess folate insufficiency at the point of care in less than 40 minutes. We evaluated the sensitivity and specificity of our assay in 24 human serum samples, including 8 samples with folate concentrations less than 10.0 nmol/L and 14 samples less than 13.4 nmol/L using the Immulite 2000 commercial assay as a reference standard. The sensitivity and specificity were found to be 93% (95% CI: 54.7-100.0) and 91% (95% CI: 80.0-100.0), respectively, when using our test to determine folate insufficiency based on a cutoff of 13.4 nmol/L. Our point-of-care diagnostic test for folate concentrations could inform screening and public health programs in at-risk populations.

A practical guide to the use of psychotropic medications during pregnancy and lactation

The use of psychotropic medications during the perinatal period is often met with fear and discomfort on the part of both clinicians and patients. There is a great deal of misinformation about the risks of medication use during pregnancy and lactation. The risk of untreated or undertreated mental illness during this time is an important consideration when making treatment recommendations. This paper serves as a practical guide for clinicians who may be treating patients with psychotropic medication during the perinatal period. A heuristic tool for making treatment decisions will be introduced, and coverage of specific psychiatric disorders and medication classes will be provided.

Men and women respond differently to antipsychotic drugs

BACKGROUND

Because women are often perceived as having better outcomes than men in psychotic illnesses such as schizophrenia - women are less often in hospital, have a lower suicide rate, are less often involved with the law, enjoy better relationships with family and friends - the question arises as to whether or not this apparent advantage is attributable to a gender difference in antipsychotic response.

OBJECTIVE

The aim of this paper is to critically review the quantitative and qualitative literature on gender difference in antipsychotic response sourced mainly from medical databases of the last ten years.

FINDINGS

There are theoretical reasons why women's effective doses of antipsychotics might need to be lower than guidelines recommend for men, especially as regards olanzapine and clozapine, but, because there are so many variables that impinge on antipsychotic response, it is difficult to provide definitive guidance. What is evident is that some antipsychotic side effects, weight gain for instance, are more worrisome for women than for men. It is also evident that, after menopause, women need an increase in their antipsychotic dose; other reproductive stages in women's lives require special prescribing considerations as well.

CONCLUSION

There is a science, and an art, to prescribing antipsychotics, which needs to take gender into account. This article is part of the issue entitled 'Special Issue on Antipsychotics'.

Cesarean Section or Natural Childbirth? Cesarean Birth May Damage Your Health

The increasing popularity of Cesarean birth has become a social concern in many countries. This paper reviews the literature on the effects of Cesarean section on children's psychological health. The results show that Cesarean birth may have adverse effects on children's sensory perception, sensory integration ability, neuropsychiatric development, and the infant-mother relationship. However, there remain deficiencies in extant research methods, research content, subject groupings, and interpretation of research results. Future research should improve research methods, broaden the research content, and refine the grouping of children born by Cesarean section. The exploration of neural mechanisms is also needed, as well as research directed toward suggesting effective interventions to reduce unnecessary Cesarean sections.

Epidemiology of mental disorders during pregnancy and link to birth outcome: a large-scale retrospective observational database study including 38,000 pregnancies

PURPOSE

To investigate the real-life epidemiology of mental disorders during pregnancy and their impact on birth outcome in an unselected low-risk population in Germany.

METHODS

Claims data of the Techniker Krankenkasse (TK) were analyzed as part of a retrospective observational study over a one-year period from 01/2008 to 12/2008 including 38,174 pregnant women. ICD-10 codes were clustered into four diagnostic groups: depression, anxiety disorders, somatoform/dissociative disorders and acute stress reactions. The relationship between mental disorders, birth mode and infant weight was tested using chi-squared tests and multivariate logistic regression. Main outcome measures included the prevalence of mental disorders during pregnancy, performed cesarean sections and infants born underweight.

RESULTS

N = 16,639 cases with at least one diagnosis from the four mental disorder diagnostic groups were identified: 9.3% cases of depression, 16.9% cases with an anxiety disorder, 24.2% cases with a somatoform/dissociative disorder, and 11.7% cases of acute stress reactions. Women diagnosed with a mental disorder were more likely to deliver their child by cesarean section ([depression: OR =1.26 (95% CI 1.14-1.39); anxiety: OR 1.11 (95% CI 1.02-1.19); somatoform disorders: OR 1.12 (95% CI 1.05-1.20); acute stress reactions: OR 1.17 (95% CI 1.07-1.28)]. Furthermore, infants of women diagnosed with an ICD-10 code for depression during pregnancy were more likely to be underweight and/or delivered preterm [OR =1.34 (95% CI 1.06-1.69)].

CONCLUSIONS

We observed substantially high prevalence rates of mental disorders during pregnancy which urgently warrant more awareness for validated screening and adequate treatment options.

Recommendations for the use of ECT in pregnancy: literature review and proposed clinical protocol

Psychiatric disorders are common in pregnancy, affecting 15-29% of pregnant women. Untreated depression has negative health consequences for mother and fetus. Electroconvulsive therapy (ECT) is an effective option for the treatment of severe depression, high suicide risk, catatonia, medication-resistant illness, psychotic agitation, severe physical decline, and other life-threatening conditions. To our knowledge, however, there is no literature that consolidates all the evidence on maternal and fetal risks associated with untreated depression, medications, and ECT then translating it into one cohesive protocol that could serve as a management guide and a source of reassurance to health-care providers involved in such practice. Hoping to facilitate ECT access to perinatal patients, the authors combined their multidisciplinary clinical experience (in perinatal psychiatry, neuropsychiatry and neuromodulation, and anesthesiology) at three different centers in the USA (Brigham and Women's Hospital/Harvard Medical School, The University of Chicago, and Brown University) with a careful and critical literature review and propose guidelines for the administration of ECT in pregnancy. A comprehensive review of the relevant literature regarding both ECT and psychotropic medications in pregnancy was performed, including meta-analyses of randomized controlled trials published in general medicine, anesthesiology, psychiatry, and obstetrics journals and guidelines. The indication and appropriateness of ECT in pregnancy must be carefully weighed against the risks of untreated maternal illness and those of alternative treatment options. The safety of ECT in pregnancy has been documented over the last 50 years. The adverse effects in pregnancy are similar to the risks of ECT in any individual. The most common risk to the mother is premature contractions and preterm labor, which occur infrequently and are not clearly caused by ECT. The rates of miscarriages were not significantly different from that of the general population. There have been no associations of ECT with congenital anomalies, either morphologic or behavioral, and no neurocognitive disturbances in the child. ECT is a reasonably safe and effective treatment alternative for management of many psychiatric disorders in pregnant patients. The authors provide recommendations for treatment modifications in pregnancy-based physiologic changes that occur during that period and consolidate them into a protocol that can assist clinicians in improving access and safety of ECT for pregnant patients.

Threatened miscarriage and depressive and anxiety symptoms among women and partners in early pregnancy

BACKGROUND

Antenatal depression has been associated with poor maternal and fetal outcomes, and threatened miscarriage is often seen clinically to impact adversely on maternal wellbeing, notwithstanding the limited research evidence. Our study aims to examine the link between threatened miscarriage and antenatal depression and anxiety in an Asian obstetric population.

METHODS

We recruited 121 women and 68 partners facing threatened miscarriage, and 241 women and 180 partners experiencing uncomplicated pregnancies from a tertiary maternity hospital in Singapore. All participants completed a Patient Information Questionnaire and the Edinburgh Postnatal Depression Scale (EPDS).

RESULTS

The proportion of women with major depressive and anxiety symptomatology was significantly higher among women facing threatened miscarriage compared to those with stable pregnancies (depressive: 33.1% vs. 17.0%, p = 0.008; anxiety: 48.8% vs. 23.7%, p < 0.0001). Amongst their partners, there was a non-significant trend towards a similar finding (depressive: 10.3% vs. 7.2%, p = 0.439; anxiety: 23.5% vs. 18.9%, p = 0.478). Threatened miscarriage remained significantly associated with major depressive symptomatology after adjusting for potential confounders among women (OR 2.70; 95% CI 1.55, 4.71; p < 0.0001) but not among their partners (OR 1.47; 95% CI 0.56, 3.87; p = 0.430).

LIMITATIONS

This study is limited by its cross-sectional design and relatively small sample size for male partners.

CONCLUSION

Antenatal depressive and anxiety symptomatology affects one in four women in their first trimester, with even higher prevalence among women facing threatened miscarriage. Targeted depression and anxiety screening that includes women facing threatened miscarriages may facilitate early and efficient detection and management of mental health problems among pregnant women.

The practice of experimental studies in psychopharmacology: Top 10 tips from one centre's experience

OBJECTIVE

Recent efforts to optimise translation of basic research findings to successful clinical trials have led to a sharper focus on experimental medicine translational studies. This is coupled with a movement towards greater methodological integrity and openness. Although this can be achieved through preregistration and detailed reporting of study methodology, the reality of study application can often be lost.

METHODS

In practice, challenges in study application can often lead to diminished scientific robustness, even in well-designed studies. A detailed description of experiences is essential for learning and subsequent improvement. To this end, the authors undertook a description of the experience of a specialised psychopharmacology experimental study centre.

RESULTS

This centre's experiences reveal that even supposedly routine study elements, such as screening parameters, peri-drug administration, and peri-discharge procedures, can pose significant practical obstacles to the achievement of minimal protocol deviation. Ultimately, these factors impact on academic standards such as enhanced data reliability; but they have additional implications for participant clinical safety and well-being, for instance in relation to adverse event and incidental finding recording.

CONCLUSIONS

The facilitation of a scientific culture that is more transparent even at the operational level will hopefully augment translational process and probability of success.

Use of Nimesulide During Early Pregnancy and the Risk of Congenital Malformations: A Population-Based Study from Italy

INTRODUCTION

Nimesulide is the most prescribed non-steroidal anti-inflammatory drug in Italy, and it is currently marketed in about 50 countries worldwide. The association between the use of nimesulide in early pregnancy and the risk of birth defects was investigated in a large cohort of pregnant women from Italy.

METHODS

Data were from the healthcare utilization databases of the Italian region of Lombardy. The cohort of 353,081 newborns occurring in Lombardy during the period 2005-2010 was investigated. Exposure to nimesulide during the first trimester of pregnancy, and congenital malformations detected at presentation and within 90 days after birth (outcome), were investigated. Exposure-outcome association was measured by the ratio between the prevalence of congenital malformations among users and non-users of nimesulide. Propensity score stratification was used to control for potential confounders, including maternal medical comorbidities, concomitant medications and sociodemographic characteristics.

RESULTS

The 627 (0.18%) women who filled prescriptions for nimesulide in the first trimester of pregnancy had a 2.6-fold risk of having children with congenital urinary tract anomalies compared to those who did not (adjusted prevalence ratio 2.6; 95% CI 1.2-5.7). Weaker and non-significant evidence for congenital malformations as a whole was found (adjusted prevalence ratio 1.2, 95% CI 0.9-1.6).

CONCLUSION

Our study suggests that the use of nimesulide in early pregnancy may result in a greater risk of having births with congenital urinary tract anomalies.

FUNDING

This study was funded by grants from the Italian Ministry of the Education, University and Research ('Fondo d'Ateneo per la Ricerca' portion, year 2015).

Is there consensus across international evidence-based guidelines for the psychotropic drug management of bipolar disorder during the perinatal period?

BACKGROUND

Clinicians treating a patient with bipolar disorder who is pregnant or breastfeeding may seek advice from bipolar management guidelines that provide recommendations for perinatal treatment. We examine the consistency of such recommendations across several evidence-based guidelines.

METHODS

A literature search in the National Guideline Clearinghouse, the Cochrane Database of Systematic Reviews, PsycInfo and PubMed was undertaken using the search terms "bipolar disorder" and "guidelines," which generated 11 sets of evidence-based guidelines published by professional organizations during the 2005-2015 period. Information relevant to management during the perinatal period was reviewed by two independent reviewers, with key themes qualitatively analysed.

RESULTS

There was a moderate level of agreement across guidelines regarding the potential teratogenic effects of lithium, sodium valproate and carbamazepine, with most highlighting caution in using these medications during the perinatal period. There was less agreement regarding the safety risks associated with lamotrigine, antipsychotics, and antidepressants, and little agreement regarding the risks and recommendations of medications during breastfeeding.

LIMITATIONS

Some differences in recommendations are likely due to varying publication dates, with recent guidelines having more up-to-date evidence available to use when formulating recommendations. Further, due to ethical issues surrounding pregnancy and infant research, the evidence used to formulate perinatal recommendations is largely based on retrospective reports and/or case studies. It is therefore unrealistic to expect such recommendations to be entirely consistent and based on rigorous evidence.

CONCLUSIONS

While there was some consistency across guidelines on key recommendations, there were also substantial inconsistencies, with the latter risking compromising clinical management.

Prenatal depression screening and antidepressant prescription: obstetrician-gynecologists' practices, opinions, and interpretation of evidence

Obstetrician-gynecologists (ob-gyns) are well-positioned to detect symptoms of perinatal depression; however, little is known about how ob-gyns respond. The purpose of this study was to evaluate ob-gyns' beliefs and practices related to prenatal depression screening and antidepressant prescription during pregnancy. A larger survey on prenatal medication was developed at the American College of Obstetricians and Gynecologists (ACOG) and distributed to a sample of 1000 Fellows. The overall response rate was 37.9% (N = 379). Two hundred eighty-eight provided care to pregnant patients and therefore, responded to questions on prenatal depression screening and antidepressant prescription. Most ob-gyns (87.8%) routinely screened patients for depression at least once during pregnancy. When symptoms of depression were reported, 52.1% "sometimes" prescribed an antidepressant medication with 22.5% doing so "usually or always". While 84.0% prescribed selective serotonin reuptake inhibitors (SSRIs) to pregnant patients, only 31.9% prescribed non-SSRIs. Ob-gyns felt comfortable prescribing SSRIs (78.1%) and counseled patients that the benefits of treating depression pharmacologically outweigh the risks (83.0%), and the use of SSRIs during pregnancy is relatively safe (87.5%). Prescribing SSRIs to pregnant patients was not significantly associated with interpretation of evidence on fetal and neonatal outcomes. Findings suggest most ob-gyns in the USA at least sometimes prescribe antidepressants in response to patient reports of depression symptoms during pregnancy. Mixed interpretations of evidence regarding the effects of SSRIs on fetal and neonatal outcomes reflect a critical need for high-quality safety data upon which to base treatment recommendations.

Spontaneous miscarriage in first trimester pregnancy is associated with altered urinary metabolite profile

Threatened miscarriage is the most common gynecological emergency, occurring in about 20% of pregnant women. Approximately one in four of these patients go on to have spontaneous miscarriage and the etiology of miscarriage still remains elusive. In a bid to identify possible biomarkers and novel treatment targets, many studies have been undertaken to elucidate the pathways that lead to a miscarriage. Luteal phase deficiency has been shown to contribute to miscarriages, and the measurement of serum progesterone as a prognostic marker and the prescription of progesterone supplementation has been proposed as possible diagnostic and treatment methods. However, luteal phase deficiency only accounts for 35% of miscarriages. In order to understand the other causes of spontaneous miscarriage and possible novel urine biomarkers for miscarriage, we looked at the changes in urinary metabolites in women with threatened miscarriage. To this end, we performed a case-control study of eighty patients who presented with threatened miscarriage between 6 and 10 weeks gestation. Urine metabolomics analyses of forty patients with spontaneous miscarriages and forty patients with ongoing pregnancies at 16 weeks gestation point to an impaired placental mitochondrial β-oxidation of fatty acids as the possible cause of spontaneous miscarriage. This study also highlighted the potential of urine metabolites as a non-invasive screening tool for the risk stratification of women presenting with threatened miscarriage.