Maternal psychosocial adversity during pregnancy is associated with length of gestation and offspring size at birth: evidence from a population-based cohort study

Stress and anxiety during pregnancy and length of gestation: a federated study using data from five Canadian and European birth cohorts

While its etiology is not fully elucidated, preterm birth represents a major public health concern as it is the leading cause of child mortality and morbidity. Stress is one of the most common perinatal conditions and may increase the risk of preterm birth. In this paper we aimed to investigate the association of maternal perceived stress and anxiety with length of gestation. We used harmonized data from five birth cohorts from Canada, France, and Norway. A total of 5297 pregnancies of singletons were included in the analysis of perceived stress and gestational duration, and 55,775 pregnancies for anxiety. Federated analyses were performed through the DataSHIELD platform using Cox regression models within intervals of gestational age. The models were fit for each cohort separately, and the cohort-specific results were combined using random effects study-level meta-analysis. Moderate and high levels of perceived stress during pregnancy were associated with a shorter length of gestation in the very/moderately preterm interval [moderate: hazard ratio (HR) 1.92 (95%CI 0.83, 4.48); high: 2.04 (95%CI 0.77, 5.37)], albeit not statistically significant. No association was found for the other intervals. Anxiety was associated with gestational duration in the very/moderately preterm interval [1.66 (95%CI 1.32, 2.08)], and in the early term interval [1.15 (95%CI 1.08, 1.23)]. Our findings suggest that perceived stress and anxiety are associated with an increased risk of earlier birth, but only in the earliest gestational ages. We also found an association in the early term period for anxiety, but the result was only driven by the largest cohort, which collected information the latest in pregnancy. This raised a potential issue of reverse causality as anxiety later in pregnancy could be due to concerns about early signs of a possible preterm birth.

Influence of maternal psychological distress during COVID-19 pandemic on placental morphometry and texture

The Coronavirus Disease 2019 (COVID-19) pandemic has been accompanied by increased prenatal maternal distress (PMD). PMD is associated with adverse pregnancy outcomes which may be mediated by the placenta. However, the potential impact of the pandemic on in vivo placental development remains unknown. To examine the impact of the pandemic and PMD on in vivo structural placental development using advanced magnetic resonance imaging (MRI), acquired anatomic images of the placenta from 63 pregnant women without known COVID-19 exposure during the pandemic and 165 pre-pandemic controls. Measures of placental morphometry and texture were extracted. PMD was determined from validated questionnaires. Generalized estimating equations were utilized to compare differences in PMD placental features between COVID-era and pre-pandemic cohorts. Maternal stress and depression scores were significantly higher in the pandemic cohort. Placental volume, thickness, gray level kurtosis, skewness and run length non-uniformity were increased in the pandemic cohort, while placental elongation, mean gray level and long run emphasis were decreased. PMD was a mediator of the association between pandemic status and placental features. Altered in vivo placental structure during the pandemic suggests an underappreciated link between disturbances in maternal environment and perturbed placental development. The long-term impact on offspring is currently under investigation.

Maternal stress during pregnancy and gestational duration: A cohort study from the Danish National Birth Cohort

BACKGROUND

Preterm birth is one of the most important contributors to neonatal mortality and morbidity. Experiencing stress during pregnancy may increase the risk of adverse birth outcomes, including preterm birth. This association has been observed in previous studies, but differences in measures used limit comparability.

OBJECTIVE

The objective of the study was to investigate the association between two measures of maternal stress during pregnancy, life stress and emotional distress, and gestation duration.

METHODS

Women recruited in the Danish National Birth Cohort from 1996 to 2002, who provided information on their stress level during pregnancy and expecting a singleton baby, were included in the study. We assessed the associations between the level of life stress and emotional distress in quartiles, both collected at 31 weeks of pregnancy on average, and the rate of giving birth using Cox regression within intervals of the gestational period.

RESULTS

A total of 80,991 pregnancies were included. Women reporting moderate or high levels of life stress vs no stress had a higher rate of giving birth earlier within all intervals of gestational age (e.g. high level: 27-33 weeks: hazard ratio (HR) 1.38, 95% confidence interval (CI) 1.04, 1.84; 34-36 weeks: 1.10, 95% CI 0.97, 1.25; 37-38 weeks: 1.21, 95% CI 1.15, 1.28). These associations between life stress and preterm birth were mainly driven by pregnancy worries. For emotional distress, a high level of distress was associated with shorter length of gestation in the preterm (27-33 weeks: 1.38, 95% CI 1.02, 1.86; 34-36 weeks: 1.05, 95% CI 0.91, 1.19) and early term (1.11, 95% CI 1.04, 1.17) intervals.

CONCLUSIONS

Emotional distress and life stress were shown to be associated with gestational age at birth, with pregnancy-related stress being the single stressor driving the association. This suggests that reverse causality may, at least in parts, explain the earlier findings of stress as a risk factor for preterm birth.

Adverse Pregnancy Outcomes Following the Assassination of John F. Kennedy in 1963

INTRODUCTION

Women exposed to stressful events during pregnancy are thought to be at increased risk of adverse birth outcomes. However, studies investigating stressful events are often unable to control for important confounders, such as behavioral and genetic characteristics, or to isolate the impact of the stressor from other secondary effects. We used a discordant-sibling design, which provides stronger inferences about causality, to examine whether a widespread stressor with limited impact on day-to-day life (John F. Kennedy assassination) resulted in an increased risk of adverse birth outcomes.

METHODS

Data were obtained from the Collaborative Perinatal Project, a prospective, multi-site cohort study conducted in the US from 1959 to 1965. Our analysis was restricted to singleton live births ≥24 weeks born before the assassination (n = 24,406) or in utero at the time (n = 5833). We also evaluated associations within siblings discordant for exposure (n = 1144). We used survival analysis to evaluate associations between exposure and preterm birth and marginal models to evaluate associations with birthweight and placental pathology.

RESULTS

First trimester exposure was associated with preterm birth (hazard ratio (HR): 1.17; 95% CI: 1.05, 1.31). In the discordant-sibling model, the point estimate was similar (HR: 1.22; 95% CI: 0.36, 4.06). Third trimester exposure was associated with increased odds of fetal acute inflammation in the placenta (odds ratio (OR): 1.34, 95% CI: 1.05, 1.71).

CONCLUSIONS FOR PRACTICE

First trimester exposure to an acute stressor was associated with preterm birth. We did not observe increased odds of placental pathology with first trimester exposure; however, stress may increase preterm birth risk through chronic placental inflammation, which was not evaluated in this sample.

The impact of maternal stress on offspring birth weight and the mediating effect of dietary patterns: the Shanghai Maternal-Child Pairs Cohort study

BACKGROUND

Maternal stress and nutrition during pregnancy are two of the most commonly studied factors in the context of fetal development. However, few investigators have considered the combined effects of stress and diet in pregnant women and their offspring.

AIMS

To determine the impact of maternal stress on offspring birth weight, and the potential mediating role of maternal dietary patterns.

METHODS

A total of 3542 pregnant women and their singleton live births were recruited from Shanghai Maternal-Child Pairs Cohort (Shanghai MCPC). Maternal stress was assessed using the Life Event Scale for Pregnant Women (LESPW) in early and late pregnancy. Food frequency questionnaire (FFQ) was performed to evaluate maternal diet in late pregnancy. Multiple linear regression was conducted to estimate the associations between maternal stress and child birth weight. Logistic regression was performed to calculate the association between maternal stress and small for gestational age (SGA)/large for gestational age (LGA). The bootstrap method was used to investigate the mediating effects of maternal dietary patterns.

RESULTS

Maternal subjective events stress (β = 0.367) and total stress (β = 0.079) in early pregnancy, and positive objective life events stress (β = 0.275) in late pregnancy, were positively associated with birth weight. Maternal dietary pattern of "high-fat and sugar" mediated the associations between subjective events stress and total stress during early pregnancy and birth weight. An increased risk for LGA was observed among women exposed to relatively higher stress during early pregnancy (OR, 1.416; 95% CI, 1.035-1.937). No statistically significant associations were found between maternal stress during late pregnancy and child birth weight or SGA/LGA.

CONCLUSIONS

Maternal life events stress during early pregnancy significantly increases neonatal birth weight and risk for LGA, which may mediate by a "high-fat and sugar" dietary pattern.

LIMITATIONS

The lack of biological markers limits the explanation of the mechanism. The assessment of diet used food intake frequency to evaluate dietary characteristics, which may miss information of energy intake.

Variations in Relationships Between Perceived Stress and Birth Outcomes by Immigration Status

INTRODUCTION

Past research shows that stress during pregnancy predicts adverse birth outcomes. These patterns might differ based on immigration status. Our objective was to analyze differences in relationships between perceived stress during pregnancy and birth outcomes by immigration status.

METHODS

We recruited 81 pregnant women in Canada for a prospective longitudinal study of stress during pregnancy and infant development. Participants completed the Perceived Stress Questionnaire at 16-18, 24-26 and 32-34 weeks of pregnancy. Birth records were available for 73 women, including 24 non-immigrants, 18 long-term immigrants (≥ 5 years), and 31 recent immigrants (< 5 years). We used General Linear Models to test relationships between perceived stress and birthweight, birthweight for gestational age Z-scores, and gestational age, and differences based on immigration status.

RESULTS

Controlling for sociodemographic covariates, we observed interactive relationships between immigration status and perceived stress with birthweight at 16-18 (p = 0.032, partial η² = 0.11) and 24-26 weeks pregnancy (p = 0.012, partial η² = 0.15). Results were similar for birthweight for gestational age Z-scores at 16-18 weeks (p = 0.016, partial η² = 0.13) and 24-26 weeks pregnancy (p = 0.013, partial η² = 0.14). Perceived stress predicted smaller birthweight measurements among long-term immigrants. No relation was found between perceived stress, immigration status and gestational age.

DISCUSSION

Risk of adverse health outcomes, including birth outcomes, tends to increase with duration of residence among immigrants. Stress during pregnancy might represent one risk factor for adverse birth outcomes among long-term immigrant women. Promoting psychosocial health screening and care among immigrant women, and assuring continued care with acculturation, might improve both maternal and infant health outcomes.

Effects of maternal stress and nutrient restriction during gestation on offspring neuroanatomy in humans

Cognitive and mental health are major determinants of quality of life, allowing integration into society at all ages. Human epidemiological and animal studies indicate that in addition to genetic factors and lifestyle, prenatal environmental influences may program neuropsychiatric disorders in later life. While several human studies have examined the effects of prenatal stress and nutrient restriction on brain function and mental health in later life, potentially mediating effects of prenatal stress and nutrient restriction on offspring neuroanatomy in humans have been studied only in recent years. Based on neuroimaging and anatomical data, we comprehensively review the studies in this emerging field. We relate prenatal environmental influences to neuroanatomical abnormalities in the offspring, measured in utero and throughout life. We also assess the relationship between neuroanatomical abnormalities and cognitive and mental disorders. Timing- and gender-specific effects are considered, if reported. Our review provides evidence for adverse effects of an unfavorable prenatal environment on structural brain development that may contribute to the risk for cognitive, behavioral and mental health problems throughout life.

Association between prenatal exposure to a 1-month period of repeated rocket attacks and neuropsychiatric outcomes up through age 9: a retrospective cohort study

Exposure to gestational stress is implicated in increased risk for neuropsychiatric disorders in offspring. We assessed association between prenatal exposure to a 1-month period of repeated rocket attacks during the 2006 Second Lebanon War in Northern Israel and emergence of childhood neuropsychiatric disorders from birth through 9 years of age. Children born to women who were pregnant during the war (N = 6999) were identified and compared to children in the same district born a year later (N = 7054), whose mothers were not exposed to rocket attacks during pregnancy. Multivariable regression models assessed risk for attention deficit hyperactivity disorder, autism, epilepsy, depression and/or anxiety, or any of these disorders (composite outcome) in offspring. Models controlled for multiple confounders including parents' demographics, parity, maternal use of psychotropic medications during pregnancy, post-partum depression and parental psychiatric history. Results show that exposed and comparison groups did not differ with respect to demographics, parity or psychiatric history. Exposed and comparison groups were similar with regard to gestational age and weight at birth. Multivariable models did not demonstrate an association between exposure to rocket attacks during pregnancy and neuropsychiatric outcomes by age 9. No interactions were found between exposure and gestational trimester at exposure or child's sex. Our findings suggest that in utero exposure to isolated, 1-month repeated rocket attacks on a civilian population was not associated with major neuropsychiatric outcomes in children by age 9. Future studies should evaluate whether this exposure is associated with psychiatric and/or other health-related outcomes later in life.

In-utero stress and mode of conception: impact on regulation of imprinted genes, fetal development and future health

BACKGROUND

Genomic imprinting is an epigenetic gene regulatory mechanism; disruption of this process during early embryonic development can have major consequences on both fetal and placental development. The periconceptional period and intrauterine life are crucial for determining long-term susceptibility to diseases. Treatments and procedures in assisted reproductive technologies (ART) and adverse in-utero environments may modify the methylation levels of genomic imprinting regions, including insulin-like growth factor 2 (IGF2)/H19, mesoderm-specific transcript (MEST), and paternally expressed gene 10 (PEG10), affecting the development of the fetus. ART, maternal psychological stress, and gestational exposures to chemicals are common stressors suspected to alter global epigenetic patterns including imprinted genes.

OBJECTIVE AND RATIONALE

Our objective is to highlight the effect of conception mode and maternal psychological stress on fetal development. Specifically, we monitor fetal programming, regulation of imprinted genes, fetal growth, and long-term disease risk, using the imprinted genes IGF2/H19, MEST, and PEG10 as examples. The possible role of environmental chemicals in genomic imprinting is also discussed.

SEARCH METHODS

A PubMed search of articles published mostly from 2005 to 2019 was conducted using search terms IGF2/H19, MEST, PEG10, imprinted genes, DNA methylation, gene expression, and imprinting disorders (IDs). Studies focusing on maternal prenatal stress, psychological well-being, environmental chemicals, ART, and placental/fetal development were evaluated and included in this review.

OUTCOMES

IGF2/H19, MEST, and PEG10 imprinted genes have a broad developmental effect on fetal growth and birth weight variation. Their disruption is linked to pregnancy complications, metabolic disorders, cognitive impairment, and cancer. Adverse early environment has a major impact on the developing fetus, affecting mostly growth, the structure, and subsequent function of the hypothalamic-pituitary-adrenal axis and neurodevelopment. Extensive evidence suggests that the gestational environment has an impact on epigenetic patterns including imprinting, which can lead to adverse long-term outcomes in the offspring. Environmental stressors such as maternal prenatal psychological stress have been found to associate with altered DNA methylation patterns in placenta and to affect fetal development. Studies conducted during the past decades have suggested that ART pregnancies are at a higher risk for a number of complications such as birth defects and IDs. ART procedures involve multiple steps that are conducted during critical windows for imprinting establishment and maintenance, necessitating long-term evaluation of children conceived through ART. Exposure to environmental chemicals can affect placental imprinting and fetal growth both in humans and in experimental animals. Therefore, their role in imprinting should be better elucidated, considering the ubiquitous exposure to these chemicals.

WIDER IMPLICATIONS

Dysregulation of imprinted genes is a plausible mechanism linking stressors such as maternal psychological stress, conception using ART, and chemical exposures with fetal growth. It is expected that a greater understanding of the role of imprinted genes and their regulation in fetal development will provide insights for clinical prevention and management of growth and IDs. In a broader context, evidence connecting impaired imprinted gene function to common diseases such as cancer is increasing. This implies early regulation of imprinting may enable control of long-term human health, reducing the burden of disease in the population in years to come.

The complex Impact of Five Years of Stress Related to Life-Threatening Events on Pregnancy Outcomes: A Preliminary Retrospective Study

Objective:

To study the impact of chronic, life-threatening stressors in the form of daily missile attacks, for five consecutive years, on pregnancy outcomes.

Method:

Charts of deliveries from two neighboring towns in the south of Israel, covering the years 2000 and 2003–2008, were reviewed retrospectively. One city had been exposed to missile attacks, while the other was not. For each year, 100 charts were chosen at random.

Results:

Significant association was found between exposure to stress and frequency of pregnancy complications (P = 0.047) and premature membrane rupture (P = 0.029). A more detailed analysis, based on dividing the stressful years into three distinct periods: early (2003–2004), intermediate (2005–2006) and late (2007–2008), revealed that preterm deliveries were significantly more frequent (P = 0.044) during the intermediate period, as was premature membrane rupture during the late period (P = 0.014).

Conclusion:

Exposure to chronic life-threatening stress resulted in more pregnancy complications and in particular more premature membrane ruptures. The impact was most significant during the middle period of the 5-year-exposure to the stressor. Hence it seems that factors of duration and habituation may play a role in the impact of chronic, life-threatening stressors on pregnancy.

"Five-year changes in population newborn health associated with new preventive services in targeted risk-group pregnancies"

Backgrounds

In 2009, the prevention service “Familieambulatoriet” (FA) was established in three pilot hospital areas offering psychosocial support and health monitoring to parents in high risk regarding mental health and substance use, for the purpose of preventing child mental health and developmental problems through preschool years. This study selected new-born health as a preliminary endpoint for evaluation of population effects in three pilot areas, utilizing national statistics for birth cohorts from 2005 to 2013. The aim of the study is to evaluate changes in population new born health incidences associated with the establishment of new supportive and preventive FA-services at three pilot sites from 2009 in contrast to previous years and the remaining country. This quasi-experimental design evaluated changes in populations with new services available not those receiving the services, and controlled for national historical changes, variation between hospital districts, and random variation across the years before or years after the pilot services were introduced. Our hypothesis was to expect reduced frequencies of preterm births, SGA births, low APGAR scores, pediatric transfer, and new born abstinence symptoms in the pilot areas.

Methods

The baseline was established through 4 years preceding 2009, contrasting changes at pilot sites the following 4 years 2009–2013 using the remaining hospital area populations in Norway 2005–2008 and 2009–2013 as contrasts.

Results

Related to the introduction of FA services, we found three significant improvements in new born health using mixed effects logistic regression. 1) In the population rate of babies born prematurely with small for gestational age (SGA), using the 10th percentile criteria as the definition; odds ratio (OR) = 0.73 (95% Cl: 0.60 to 0.88). 2) A similar reduction using the 2.5th percentile criteria, although with wider confidence limits; OR = 0.73 (95% Cl: 0.54 to 0.99). 3) A decrease in the frequency of low APGAR scores (0–6) 5 min. after birth; OR = 0.80 (95% Cl: 0.68 to 0.95). Thus, the FA-areas remained significantly lowered on SGA rates or Low APGAR rates across the years after FA establishment, despite considerable variation, in contrast to the baseline years and to the remaining country. No significant effect was found for the outcomes frequency of premature births (unrelated to SGA), SGA among full-term babies, child abstinence symptoms or pediatric transfer of the baby. False negative findings may result from low-rate outcomes or studying the population rather than users.

Conclusions

Population rates suggest that introducing FA services offering support and monitoring in high-risk families may contribute to improving aspects of new born infant health. Intervention components and strategies should be studied more closely using individual data.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4392-7) contains supplementary material, which is available to authorized users.

Associations of Internal-Migration Status with Maternal Exposure to Stress, Lead, and Selenium Deficiency Among Pregnant Women in Shanghai, China

Internal migration and urbanization are occurring on a global scale. Although the risk of exposure to stress/lead/low selenium is assumed to be high among migrant pregnant women, population-based evidence is limited. This study aims to explore the association of internal-migration status with maternal exposure to lead, low selenium, and stress among pregnant women. A total of 1931 pregnant women were investigated in 2010. The internal-migration status was grouped based on their hukou (registered residence) and length-of-residency in Shanghai. Maternal blood lead and serum selenium concentrations were assessed. Life event stress and emotional stress were evaluated using "Event-Stress-Scale-for-Pregnant-Women" and "Symptom-Checklist-90-R-Scale" (SCL-90-R), respectively. Logistic regression and general linear models were used to evaluate associations between migration status and lead/stress/low selenium exposure. Compared with the local (with Shanghai hukou and length-of-residency ≥ 5 years), new migrants (without Shanghai hukou and length-of-residency < 2 years) had lower social-economic-status (SES), higher lead, life event and emotional stress, and lower selenium levels. After adjusting for SES, new migrants had higher risks of emotional stress (for interpersonal sensitivity of SCL-90-R, OR = 2.10, 95% CI 1.22-3.64) and low selenium [lg(selenium): beta = - 0.08, 95% CI - 0.11, - 0.05], but no significant risks for life event stress and high lead. Compared with the local, migrant pregnant women in big cities may have emotional stress and low selenium independent of SES, and high lead and life event stress dependent on SES.

Ambulatory Blood Pressure Trajectory and Perceived Stress in Relation to Birth Outcomes in Healthy Pregnant Adolescents

OBJECTIVE

An early decline in resting blood pressure (BP), followed by an upward climb, is well documented and indicative of a healthy pregnancy course. Although BP is considered both an effector of stress and a clinically meaningful measurement in pregnancy, little is known about its trajectory in association with birth outcomes compared with other stress effectors. The current prospective longitudinal study examined BP trajectory and perceived stress in association with birth outcomes (gestational age (GA) at birth and birth weight (BW) percentile corrected for GA) in pregnant adolescents, a group at risk for stress-associated poor birth outcomes.

METHODS

Healthy pregnant nulliparous adolescents (n = 139) were followed from early pregnancy through birth. At three time points (13-16, 24-27, and 34-37 gestational weeks ±1 week), the Perceived Stress Scale was collected along with 24-hour ambulatory BP (systolic and diastolic) and electronic diary reporting of posture. GA at birth and BW were abstracted from medical records.

RESULTS

After adjustment for posture and pre-pregnancy body mass index, hierarchical mixed-model linear regression showed the expected early decline (B = -0.18, p = .023) and then increase (B = 0.01, p < .001) of diastolic BP approximating a U-shape; however, systolic BP displayed only an increase (B = 0.01, p = .010). In addition, the models indicated a stronger systolic and diastolic BP U-shape for early GA at birth and lower BW percentile and an inverted U-shape for late GA at birth and higher BW percentile. No effects of perceived stress were observed.

CONCLUSIONS

These results replicate the pregnancy BP trajectory from previous studies of adults and indicate that the degree to which the trajectory emerges in adolescence may be associated with variation in birth outcomes, with a moderate U-shape indicating the healthiest outcomes.

At the forefront of psychoneuroimmunology in pregnancy: Implications for racial disparities in birth outcomes PART 1: Behavioral risks factors

Birth prior to full term is a substantial public health issue. In the US, ˜400,000 babies per year are born preterm (<37 weeks), while>1 million are early term (37-38^6/7 weeks). Birth prior to full term confers risk both immediate and long term, including neonatal intensive care, decrements in school performance, and increased mortality risk from infancy through young adulthood. Risk for low birth weight and preterm birth are 1.5-2 times greater among African Americans versus Whites. Psychosocial stress related to being a member of a discriminated racial minority group contributes substantially to these racial disparities. Providing promising targets for intervention, depressed mood, anxiety, and poor sleep are each linked with exposure to chronic stress, including racial discrimination. A rigorous transdisciplinary approach addressing these gaps holds great promise for clinical impact in addressing racial disparities as well as ameliorating effects of stress on perinatal health more broadly. As will be reviewed in a companion paper, the mechanistic roles of physiological sequelae to stress - including neuroendocrine, inflammatory regulation, biological aging, and the microbiome - also require delineation.

A Matched Case-Control Study on the Association Between Colds, Depressive Symptoms during Pregnancy and Congenital Heart Disease in Northwestern China

The purpose of this study was to explore the association between colds, depressive symptoms during pregnancy and offspring congenital heart disease (CHD). A 1:2 matching case-control study was conducted in Northwest China. Information was gathered by a structured questionnaire and was reviewed by investigators on the spot. Multivariate logistic regressions and nonlinear mixed effect model were performed. 614 cases and 1228 controls were available in this study. After adjusting for potential confounders, the colds during the entire pregnancy were associated with increased risk of offspring CHD (OR = 1.44(1.12-1.85)). Similarly, there was a higher depression score in CHD group than the control group (OR = 1.89(1.48-2.41)). In addition, the women with both colds and higher depression scores had a higher risk of offspring CHD (OR = 2.72(1.87-3.93)) than their counterparts with only colds (OR = 1.48(1.04-2.09)) or with only higher depression scores (OR = 1.94(1.37-2.74)). The combined effects were significant in the multiplication model (OR = 2.04(1.47-2.83)) but not in the additive model (S = 1.40(0.70-2.81), AP = 0.19(-0.15-0.53) and RERI = 0.55(-0.54-1.64)). In conclusion, the colds and depressive symptoms during pregnancy were found associated with increased risk of offspring CHD and we found for the first time that there existed a statistically multiplying interaction effect of colds and depression on increasing risk of offspring CHD.

Stressful Newborn Memories: Pre-Conceptual, In Utero, and Postnatal Events

Early-life stressful experiences are critical for plasticity and development, shaping adult neuroendocrine response and future health. Stress response is mediated by the autonomous nervous system and the hypothalamic-pituitary-adrenal (HPA) axis while various environmental stimuli are encoded via epigenetic marks. The stress response system maintains homeostasis by regulating adaptation to the environmental changes. Pre-conceptual and in utero stressors form the fetal epigenetic profile together with the individual genetic profile, providing the background for individual stress response, vulnerability, or resilience. Postnatal and adult stressful experiences may act as the definitive switch. This review addresses the issue of how preconceptual in utero and postnatal events, together with individual differences, shape future stress responses. Putative markers of early-life adverse effects such as prematurity and low birth weight are emphasized, and the epigenetic, mitochondrial, and genomic architecture regulation of such events are discussed.

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Is the risk of low birth weight or preterm labor greater when maternal stress is experienced during pregnancy? A systematic review and meta-analysis of cohort studies

Antenatal stress is linked to fetal risks that increase the chances of neonatal complications and reduction of child cognitive ability. Therefore, we aimed to evaluate if maternal stress affects fetal, neonatal or child development. The following databases were searched: MEDLINE (1966 to May 2016), Embase (1980 to May 2016), LILACS (1982 to May 2016) and CENTRAL (1972 to May 2016). Observational studies published in English and Portuguese were included whether there was any relationship between fetal and neonatal outcome, such as birth weight, preterm labor, child development with pregnant women that were subjected to any stress type during at least one month of follow-up. Two independent reviewers screened eligible articles, extracted data and assessed the risk of bias. Thus, 8 cohort studies with about 8,271 pregnant women and 1,081,151 children proved eligible. Results suggested a significant association between antenatal stress exposure and increasing rates of low birth weight (Odds ratio (OR) 1.68 [95% Confidential Interval (CI) 1.19, 2.38]). However, there was no statistically significance difference between non-exposed and exposed groups related to preterm labor (OR 1.98 [95% CI 0.91 to 4.31]; I2 = 68%, p = 0.04). Although, results were inconsistent with primary analysis suggesting a significant association between antenatal stress exposure and the occurrence of higher rates of preterm birth (OR 1.42 [95% CI 1.05 to 1.91]; I2 = 68%, p = 0.04) in the sensitivity analysis. Furthermore, the current review has suggested that stress perceived during antenatal negatively influences fetal life and child development. Yet, further studies are necessary with adequate sample size and longer follow-up time to confirm our findings.

Effects of earthquake on perinatal outcomes: A Chilean register-based study

Background

Natural disasters increase the level population stress, including pregnant women, who can experience prenatal maternal stress, affecting the fetus and triggering perinatal complications, such as low birth weight, smaller head circumference, etc. However, little is known about effects of earthquake on perinatal outcomes.

Objective

To evaluate the effect of earthquake occurred on February 27, 2010 and perinatal outcomes of Chilean pregnant women, and to examine these effects by timing of exposure during pregnancy and newborn gender.

Methods

A register-based study was performed using data collected from women who had a vaginal delivery in a large private health center in Santiago, Chile, during 2009 and 2010. The study population was categorized according to exposure to earthquake and timing during gestation. Primary perinatal outcomes were gestational age at birth, birth weight, length and head circumference. Analyses adjusted for gender, gestational age at exposure, parity, maternal age and income.

Results

A total of 1,966 eligible vaginal deliveries occurred during 2009 and 2,110 in 2010. Birth weight was not affected by the trimester of exposure; however, length, head circumference and gestational age at birth were significantly different according to trimester of exposure and gender of newborn. In multivariable analysis, newborns were shorter by 2 mm, 5 mm and 4.5 mm, if they were exposed during their first, second and third trimester, respectively. Furthermore, newborns had a smaller head circumference by 1.2 mm and 1.5 mm if they were exposed during first and second trimester of gestation.

Conclusion

In this cohort, exposure to the February 2010 earthquake resulted in earlier delivery and reduced length and head circumference in the offspring. This association varied according to trimester of exposure and fetal gender. Health workers should include exposed to high levels of stress associated with natural disasters when assessing pregnancy risk factors.

Zika Virus as a Possible Risk Factor for Autism Spectrum Disorder: Neuroimmunological Aspects

The recent outbreak of the Zika virus (ZIKV) and the discovery that perinatal Zika exposure can lead to the Congenital Zika Syndrome has promoted a call for prevention measures. Due to the increased number of babies born with microcephaly, structural brain abnormalities, and neurological alterations in regions affected by ZIKV, investigations were carried out in order to better understand this process. The maternal immune system directly influences the fetal central nervous system, and complications during pregnancy have been associated with neurodevelopmental disorders. Autism spectrum disorder (ASD), a neurodevelopmental disorder commonly manifested in the first years of life, is a disease with multifactorial etiology and is manifested typically by social and communication impairments, as well as stereotyped behaviors. Brain abnormalities, including both anatomically and functionally, can be observed in this disorder, suggesting delays in neuronal maturation and altered brain connectivity. It is known that some viral congenital infections, such as rubella, and cytomegalovirus can interfere with brain development, being associated with brain calcification, microcephaly, and ASD. Here, we reviewed a range of studies evaluating the aspects concerning brain development, immunological status during pregnancy, and neuroimmunomodulation in congenital viral infections, and we discuss if the fetal brain infection caused by ZIKV could predispose to ASD. Finally, we suggest a mechanism encompassing neurological and immunological pathways that could play a role in the development of ASD in infants after ZIKV infection in pregnancy.

Gestation-related psychosocial factors in women from Medellin, Colombia

INTRODUCTION

Perinatal stress and the impact generated by adverse conditions could affect fetal development negatively with long term and short term manifestations and could increase the risk of maternal depression.

OBJECTIVE

To determine the psychosocial risk factors present in women with high-obstetric risk and hospitalized in a high complexity institution.

METHODS

A cross-sectional study that included 112 pregnant or immediate postpartum women, who were evaluated using a scale designed by the researchers and the Edinburgh Postnatal Depression Scale.

RESULTS

Median age was 24 (RIC 9) years; 39.3% of the women were pregnant, and 65.9% had a gestational age of more than 28 weeks. The main reason for hospitalization was threat of preterm delivery in 39.2%. 52.4% planned the pregnancy and 22.3% had depressive symptoms compatible with depression. Suicidal ideas and suicide attempts were more prevalent in the first trimester (7.2% and 3.6%).

DISCUSSION

The high prevalence of depressive symptoms in the population studied coincides with what was reported in similar studies in Latin America. The fact that pregnancy does not protect against suicide was confirmed.

CONCLUSIONS

Psychosocial screening is recommended in every pregnant woman and women in immediate postpartum to detect symptoms and risk factors for depression.

Dietary change mediates relationships between stress during pregnancy and infant head circumference measures: the QF2011 study

Prenatal maternal stress can adversely affect birth outcomes, likely reflecting effects of maternal stress hormones on fetal development. Maternal stress might also induce behavioural changes, such as dietary change, that might influence fetal development. Few studies have documented relationships between stress and dietary change in pregnancy. We analysed stress and dietary change among 222 pregnant women exposed to the 2011 Queensland Floods. We assessed women's objective hardship, subjective distress and cognitive appraisal of the disaster; changes in their diets and their associations with infants' gestational age, weight, length and head circumference at birth, head circumference to birth length ratio (HC/BL) and ponderal index. Greater objective hardship was correlated with more negative dietary change, skipped meals and skipped multivitamins. There were no direct effects of stress or dietary change on birth outcomes. However, we observed an interactive effect of dietary change and exposure timing on head circumference for gestational age (HC for GA) (p = 0.010) and a similar trend for HC/BL (p = 0.064). HC for GA and HC/BL were larger among children whose mothers experienced negative changes to their diet in early pregnancy compared with later pregnancy, consistent with a 'head-sparing' response with early gestation exposure. Further analyses indicated that dietary change mediates the relationship between objective hardship because of the floods and these outcomes. This is the first report of relationships among an independent stressor, dietary change and birth outcomes. It highlights another possible mechanism in the relationship between prenatal maternal stress and child development that could guide future research and interventions.

Mechanism of deoxynivalenol effects on the reproductive system and fetus malformation: Current status and future challenges

Deoxynivalenol (DON) is a toxic fungal secondary metabolite produced by molds of the Fusarium genus, and it is known to cause a spectrum of diseases both in humans and animals, such as emesis, diarrhea, anorexia, immunotoxicity, hematological disorders, impairment of maternal reproduction, and fetal development. The recently revealed teratogenic potential of DON has received much attention. In various animal models, it has been shown that DON led to skeletal deformities of the fetus. However, the underlying mechanisms are not yet fully understood, and toxicological data are also scarce. Several animal research studies highlight the potential link between morphological abnormalities and changes of autophagy in the reproductive system. Because autophagy is involved in fetal development, maintenance of placental function, and bone remodeling, this mechanism has become a high priority for future research. The general aim of the present review is to deliver a comprehensive overview of the current state of knowledge of DON-induced reproductive toxicity in different animal models and to provide some prospective ideas for further research. The focus of the current review is to summarize toxic and negative effects of DON exposure on the reproductive system and the potential underlying molecular mechanisms in various animal models.

Effect of Vocalization of the Holy Quran With and Without Translation on Pregnancy Outcomes: A Randomized Clinical Trial

Background

During recent decades, research in Iran in the area of the Quran and medical science has been seriously engaged in. With respect to the tendency toward spirituality and alternative medicine, we tried to find other aspects of the influence of the Quran.

Objectives

This study aimed to determine the effect of vocalizations of the Holy Quran with and without translation on the consequences of pregnancy (the prevalence of preterm delivery, caesarean delivery, and neonatal anthropometric indices) in women admitted to health care centers in Urmia, Iran.

Materials and Methods

This was a three-armed parallel-group randomized clinical trial in which 168 pregnant women (25-28 weeks) in their first and second pregnancies were divided into three groups of 56 (Holy Quran with translation, Holy Quran without translation, and control group) by randomized blocking. The intervention was implemented once a week for three weeks in the health center, and on other days of the week, the participants listened at home to a CD they were given. The intervention and the control groups all received routine pregnancy care once a week. These mothers were tracked during their labor. Outcomes including gestational age at delivery, delivery type, and neonatal anthropometric indices were recorded based on the mother’s records.

Results

There was no statistically significant difference between the groups in terms of demographic and obstetric characteristics before the intervention. In comparison with the control group, the probability of preterm delivery was lower in the Holy Quran with translation group (odds ratio: 0.3, CI 95%: 0.1-1.2) and in the Holy Quran without translation group (0.6, 0.2-1.9) as compared to the control group. However, this difference was not statistically significant. Similarly, the probability of caesarean delivery was lower in the Holy Quran with translation group (0.6, 0.3-1.4) and the Holy Quran without translation group (0.5, 0.2-1.2) as compared to the control group. Based on one-way ANOVA, there was no statistically significant difference between the study groups regarding the infants’ anthropometric indices.

Conclusions

Based on the results of this study, despite the lower prevalence of preterm labor and caesarean section in the intervention groups as compared to the control group, no statistically significant effect was seen. This was apparently due to the small sample size.

Advanced maternal age increases the risk of very preterm birth, irrespective of parity: a population-based register study

OBJECTIVE

To investigate whether advanced maternal age is associated with preterm birth, irrespective of parity.

DESIGN

Population-based registry study.

SETTING

Swedish Medical Birth Register.

POPULATION

First, second, and third live singleton births to women aged 20 years or older in Sweden, from 1990 to 2011 (n = 2 009 068).

METHODS

Logistic regression analysis was used in each parity group to estimate risks of very and moderately preterm births to women at 20-24, 25-29, 30-34, 35-39, and 40 years or older, using 25-29 years as the reference group. Odds ratios (ORs) were adjusted for year of birth, education, country of birth, smoking, body mass index, and history of preterm birth. Age-related risks of spontaneous and medically indicated preterm births were also investigated.

MAIN OUTCOME MEASURES

Very preterm (22-31 weeks of gestation) and moderately preterm (32-36 weeks) births.

RESULTS

Risks of very preterm birth increased with maternal age, irrespective of parity: adjusted ORs in first, second, and third births ranged from 1.18 to 1.28 at 30-34 years, from 1.59 to 1.70 at 35-39 years, and from 1.97 to 2.40 at ≥40 years. In moderately preterm births, age-related associations were weaker, but were statistically significant from 35-39 years in all parity groups. Advanced maternal age increased the risks of both spontaneous and medically indicated preterm births.

CONCLUSIONS

Advanced maternal age is associated with an increased risk of preterm birth, irrespective of parity, especially very preterm birth. Women aged 35 years and older, expecting their first, second, or third births, should be regarded as a risk group for very preterm birth.

TWEETABLE ABSTRACT

Women aged 35 years and older should be regarded as a risk group for very preterm birth, irrespective of parity.

Maternal adversities during pregnancy and cord blood oxytocin receptor (OXTR) DNA methylation

The aim of this study was to investigate whether maternal adversities and cortisol levels during pregnancy predict cord blood DNA methylation of the oxytocin receptor (OXTR). We collected cord blood of 39 babies born to mothers participating in a cross-sectional study (N = 100) conducted in Basel, Switzerland (2007-10). Mothers completed the Inventory of Life Events (second trimester: T2), the Edinburgh Postnatal Depression Scale (EPDS, third trimester: T3), the Trier Inventory of Chronic Stress (TICS-K, 1-3 weeks postpartum) and provided saliva samples (T2, T3) for maternal cortisol profiles, as computed by the area under the curve with respect to ground (AUCg) or increase (AUCi) for the cortisol awakening response (CAR) and for diurnal cortisol profiles (DAY). OXTR DNA methylation was quantified using Sequenom EpiTYPER. The number of stressful life events (P = 0.032), EPDS score (P = 0.007) and cortisol AUCgs at T2 (CAR: P = 0.020; DAY: P = 0.024) were negatively associated with OXTR DNA methylation. Our findings suggest that distinct prenatal adversities predict decreased DNA methylation in a gene that is relevant for childbirth, maternal behavior and wellbeing of mother and offspring. If a reduced OXTR methylation increases OXTR expression, our findings could suggest an epigenetic adaptation to an adverse early environment.

The effects of maternal anxiety during pregnancy on IGF2/H19 methylation in cord blood

Compelling evidence suggests that maternal mental health in pregnancy can influence fetal development. The imprinted genes, insulin-like growth factor 2 (IGF2) and H19, are involved in fetal growth and each is regulated by DNA methylation. This study aimed to determine the association between maternal mental well-being during pregnancy and differentially methylated regions (DMRs) of IGF2 (DMR0) and the IGF2/H19 imprinting control region (ICR) in newborn offspring. Maternal depression, anxiety and perceived stress were assessed at 28 weeks of pregnancy in the Barwon Infant Study (n=576). DNA methylation was measured in purified cord blood mononuclear cells using the Sequenom MassArray Platform. Maternal anxiety was associated with a decrease in average ICR methylation (Δ=-2.23%; 95% CI=-3.68 to -0.77%), and across all six of the individual CpG units in anxious compared with non-anxious groups. Birth weight and sex modified the association between prenatal anxiety and infant methylation. When stratified into lower (⩽3530 g) and higher (>3530 g) birth weight groups using the median birth weight, there was a stronger association between anxiety and ICR methylation in the lower birth weight group (Δ=-3.89%; 95% CI=-6.06 to -1.72%), with no association in the higher birth weight group. When stratified by infant sex, there was a stronger association in female infants (Δ=-3.70%; 95% CI=-5.90 to -1.51%) and no association in males. All the linear regression models were adjusted for maternal age, smoking and folate intake. These findings show that maternal anxiety in pregnancy is associated with decreased IGF2/H19 ICR DNA methylation in progeny at birth, particularly in female, low birth weight neonates. ICR methylation may help link poor maternal mental health and adverse birth outcomes, but further investigation is needed.

Prenatal screening for psychosocial risks in a high risk-population in Peru using the KINDEX interview

BACKGROUND

Prenatal stress and other prenatal risk factors (e.g. intimate partner violence) have a negative impact on mother's health, fetal development as well as enduring adverse effects on the neuro-cognitive, behavioral and physical health of the child. Mothers of low socio-economic status and especially those living in crime-ridden areas are even more exposed to a host of risk factors. Societies of extreme violence, poverty and inequalities, often present difficulties to provide adequate mental health care to the most needed populations. The KINDEX, a brief standardized instrument that assesses 11 different risk factors was used by midwives to identify pregnant women at-risk, in a suburban area with one of the highest levels of domestic violence in Lima. The instrument was designed to be used by medical staff to identify high-risk child-bearing women and, based on the results, to refer them to the adequate psychological or social support providers. The aim of this study is to assess the feasibility of psychosocial screening using the KINDEX in a Latin American Country for the first time, and to explore the relationship of the KINDEX with thee major risk areas, maternal psychopathology, perceived stress and traumatic experiences.

METHODS

The study was conducted in cooperation with the gynecological department of a general hospital in a suburban area of Lima. Nine midwives conducted interviews using the KINDEX of ninety-five pregnant women attending the gynecological unit of the hospital. From these, forty pregnant women were re-interviewed by a clinical psychologist using established instruments in order to assess the feasibility of the prenatal assessment in public health settings and the relationship of the KINDEX with maternal perceived stress, psychopathology symptoms and trauma load during pregnancy.

RESULTS

We found high rates of risk factors in the examined pregnant women comparable with those found in the general population. Significant correlations were found between the KINDEX sum score and the three risks areas, stress, psychopathology and trauma load as assessed in the Clinical Expert interviews. The different risks assessed by the KINDEX are related to higher levels of stress, psychopathology and trauma load, depending on the risk.

CONCLUSIONS

The relationship between past adverse experience and current stressors with perceived maternal stress, psychopathology symptoms and traumatic experiences confirm the importance of prenatal assessment for psychosocial risks. The use of KINDEX by midwives providing obstetrical care to pregnant women in urban Peru is feasible and can be used to identify high-risk women and refer them to the adequate mental health or social services for necessary attention and support. Early interventions are essential to mitigating the adverse effects of maternal stress, trauma and psychopathology on the fetus and child.

Maternal Stress in Gestation: Birth Outcomes and Stress-Related Hormone Response of the Neonates

BACKGROUND

Relatively few studies have been made on neurobehavioral outcomes of prenatal maternal stress during the newborn period, and little research has focused on umbilical cord stress hormones including cortisol, adrenocorticotropic hormone (ACTH), norepinephrine, and epinephrine. Our objective was to investigate the effects of prenatal maternal life stressors on neonatal birth outcomes, neurobehavioral development, and stress-related hormones levels.

METHODS

Participants were 142 mothers and their infants; 71 were selected as the prenatal life stressor exposed group and 71 as the control group matched on maternal age, gestational week, delivery type, socioeconomic and education status, and newborns' sex. Maternal life stressors during pregnancy were determined using the Life Events Scale for Pregnant Women. Neonatal neurobehavioral development was assessed with the Neonatal Behavioral Neurological Assessment. Umbilical cord plasma stress-related hormones, including ACTH, cortisol, norepinephrine, and epinephrine were measured using an enzyme-linked immunosorbent assay.

RESULTS

In the prenatal life stressors exposed group, newborns had significantly lower birth weight, smaller head circumference (p < 0.01, p < 0.01, respectively). Scores of Neonatal Behavioral Neurological Assessment were significantly reduced (p < 0.001). Cord plasma ACTH, norepinephrine, and epinephrine levels were significantly increased (p < 0.001), but cortisol levels were reduced (p < 0.001).

CONCLUSION

Prenatal maternal stress may negatively affect fetal birth outcomes, neurobehavioral development and affect neonates' cord plasma ACTH, cortisol, norepinephrine, and epinephrine.

Relation between maternal antenatal anxiety and infants' weight depends on infants' sex: A longitudinal study from late gestation to 1-month post birth

OBJECTIVE

To test for gender-differences in the relation between mothers' antenatal anxiety and infants' body weight during gestation, at birth, and at 1-month of age.

METHODS

Two hundred and twelve randomly-recruited women were divided into two groups: Controls (n=105) and Anxious Group (n=107) based on a standard cut-off of the Beck Anxiety Inventory. Outcome measures were Fetal Weight derived from biometrics obtained from an ultrasound scan in the 3rd trimester and infants' weight at birth and at 1-month of age, both obtained from medical records.

RESULTS

Multivariate analyses showed main effects of Gender on infants' birth weight (P=.001) and on infants' weight at 1-month of age (P=.004), but no main effects of Anxiety Group at any time-point. Gender x Anxiety Group interactions at all three time points (Fetal weight: P=.05; Birth weight: P=.03; 1-month of age: P=.10) reflected gender differences (males>females) among infants in the anxious group, but not among controls. Distinct trends regarding same sex comparisons across groups (Control vs. Anxiety) were in line with predictions (male controls<male anxious; female controls>females anxious). Controlling for Postpartum Anxiety and Antenatal and Postpartum Depression in the models did not affect primary results.

CONCLUSION

Gender differences in fetal and birth weight were more substantial among infants of anxious mothers than among controls due to the seemingly accelerated growth of "anxious" males and the diminution of weight among "anxious" females.

Obstetric care providers are able to assess psychosocial risks, identify and refer high-risk pregnant women: validation of a short assessment tool - the KINDEX Greek version

Background

Prenatal assessment for psychosocial risk factors and prevention and intervention is scarce and, in most cases, nonexistent in obstetrical care. In this study we aimed to evaluate if the KINDEX, a short instrument developed in Germany, is a useful tool in the hands of non-trained medical staff, in order to identify and refer women in psychosocial risk to the adequate mental health and social services. We also examined the criterion-related concurrent validity of the tool through a validation interview carried out by an expert clinical psychologist. Our final objective was to achieve the cultural adaptation of the KINDEX Greek Version and to offer a valid tool for the psychosocial risk assessment to the obstetric care providers.

Methods

Two obstetricians and five midwives carried out 93 KINDEX interviews (duration 20 minutes) with pregnant women to assess psychosocial risk factors present during pregnancy. Afterwards they referred women who they identified having two or more psychosocial risk factors to the mental health attention unit of the hospital. During the validation procedure an expert clinical psychologist carried out diagnostic interviews with a randomized subsample of 50 pregnant women based on established diagnostic instruments for stress and psychopathology, like the PSS-14, ESI, PDS, HSCL-25.

Results

Significant correlations between the results obtained through the assessment using the KINDEX and the risk areas of stress, psychopathology and trauma load assessed in the validation interview demonstrate the criterion-related concurrent validity of the KINDEX. The referral accuracy of the medical staff is confirmed through comparisons between pregnant women who have and have not been referred to the mental health attention unit.

Conclusions

Prenatal screenings for psychosocial risks like the KINDEX are feasible in public health settings in Greece. In addition, validity was confirmed in high correlations between the KINDEX results and the results of the validation interviews. The KINDEX Greek version can be considered a valid tool, which can be used by non-trained medical staff providing obstetrical care to identify high-risk women and refer them to adequate mental health and social services. These kind of assessments are indispensable for the promotion of a healthy family environment and child development.

Development of children born to mothers with mental health problems: subcortical volumes and cognitive performance at 4½ years

In a prospective longitudinal study, we investigated the outcomes of children born to mothers clinically referred for mental health problems during pregnancy (risk group, n = 17) relative to a control group (n = 31). Child cognitive functioning, and for subgroups (n = 10 + 17), brain morphometry as derived from Magnetic resonance imaging (MRI), was measured at 4½ years. Cognitive data included abstract visuospatial reasoning/problem solving and verbal scores. Subcortical regions of interest included the amygdala, accumbens area, hippocampus, caudate and putamen, chosen because their development seems potentially sensitive to an adverse intrauterine milieu and environmental experiences, and also due to their implication in cognitive and emotional processes. The risk group exhibited poorer abstract reasoning scores than the control group. No differences were found for verbal scores. MRI revealed smaller putamen volume in children in the risk group. Irrespective of group, putamen volume was positively related to visuospatial reasoning performance. Our results suggest that maternal psychopathology may be associated with child putamen development, nonverbal reasoning and problem solving skills.

Moderate antenatal anxiety symptoms and birth outcomes of boys and girls

Women's antenatal anxiety, especially if paired with significant life stressors or comorbid physical or mental health disorders, can predict adverse birth outcomes, defined in terms of birth weight, gestational age at birth and obstetric complications. Here, we tested for an impact of moderate anxiety symptoms on these outcomes because many women experience these kinds of symptoms during pregnancy, and even subtle differences in birth outcomes can have significant effects on children's development. We also tested for moderation of anxiety effects by infant gender. The sample comprised 219 women with anxiety symptoms ranging from none to moderate levels on the Beck Anxiety Inventory. Multivariate models estimated main effects of Group (no/minimal versus moderate symptoms) and interactions between Group and infant Gender. Results indicate that moderate anxiety predicted more obstetric complications, particularly among mothers of daughters. Results also demonstrate a Group × Gender interaction on BW, indicating that sons of anxious mothers weighed more than sons of controls; whereas, daughters of anxious mothers weighed less than daughters of controls. These findings show that moderate anxiety symptoms may affect some birth outcomes, and differently for males and females.

Cumulative psychosocial stress, coping resources, and preterm birth

Preterm birth constitutes a significant international public health issue, with implications for child and family well-being. High levels of psychosocial stress and negative affect before and during pregnancy are contributing factors to shortened gestation and preterm birth. We developed a cumulative psychosocial stress variable and examined its association with early delivery controlling for known preterm birth risk factors and confounding environmental variables. We further examined this association among subgroups of women with different levels of coping resources. Utilizing the All Our Babies (AOB) study, an ongoing prospective pregnancy cohort study in Alberta, Canada (n = 3,021), multinomial logistic regression was adopted to examine the independent effect of cumulative psychosocial stress and preterm birth subgroups compared to term births. Stratified analyses according to categories of perceived social support and optimism were undertaken to examine differential effects among subgroups of women. Cumulative psychosocial stress was a statistically significant risk factor for late preterm birth (OR = 1.73; 95 % CI = 1.07, 2.81), but not for early preterm birth (OR = 2.44; 95 % CI = 0.95, 6.32), controlling for income, history of preterm birth, pregnancy complications, reproductive history, and smoking in pregnancy. Stratified analyses showed that cumulative psychosocial stress was a significant risk factor for preterm birth at <37 weeks gestation for women with low levels of social support (OR = 2.09; 95 % CI = 1.07, 4.07) or optimism (OR = 1.87; 95 % CI = 1.04, 3.37). Our analyses suggest that early vulnerability combined with current anxiety symptoms in pregnancy confers risk for preterm birth. Coping resources may mitigate the effect of cumulative psychosocial stress on the risk for early delivery.

Measuring stress before and during pregnancy: a review of population-based studies of obstetric outcomes

Mounting evidence from clinic and convenience samples suggests that stress is an important predictor of adverse obstetric outcomes. Using a proposed theoretical framework, this review identified and synthesized the population-based literature on the measurement of stress prior to and during pregnancy in relation to obstetric outcomes. Population-based, peer-reviewed empirical articles that examined stress prior to or during pregnancy in relation to obstetric outcomes were identified in the PubMed and PsycInfo databases. Articles were evaluated to determine the domain(s) of stress (environmental, psychological, and/or biological), period(s) of stress (preconception and/or pregnancy), and strength of the association between stress and obstetric outcomes. Thirteen studies were evaluated. The identified studies were all conducted in developed countries. The majority of studies examined stress only during pregnancy (n = 10); three examined stress during both the preconception and pregnancy periods (n = 3). Most studies examined the environmental domain (e.g. life events) only (n = 9), two studies examined the psychological domain only, and two studies examined both. No study incorporated a biological measure of stress. Environmental stressors before and during pregnancy were associated with worse obstetric outcomes, although some conflicting findings exist. Few population-based studies have examined stress before or during pregnancy in relation to obstetric outcomes. Although considerable variation exists in the measurement of stress across studies, environmental stress increased the risk for poor obstetric outcomes. Additional work using a lifecourse approach is needed to fill the existing gaps in the literature and to develop a more comprehensive understanding of the mechanisms by which stress impacts obstetric outcomes.

Ramadan fasting and newborn's birth weight in pregnant Muslim women in The Netherlands

Many Muslim women worldwide are pregnant during Ramadan and adhere to Ramadan fasting during pregnancy. In the present study, we determined whether maternal adherence to Ramadan fasting during pregnancy has an impact on the birth weight of the newborn, and whether the effects differed according to trimester in which Ramadan fasting took place. A prospective cohort study was conducted in 130 pregnant Muslim women who attended antenatal care in Amsterdam and Zaanstad, The Netherlands. Data on adherence to Ramadan fasting during pregnancy and demographics were self-reported by pregnant women, and the outcome of the newborn was retrieved from medical records after delivery. The results showed that half of all the women adhered to Ramadan fasting. With strict adherence to Ramadan fasting in pregnancy, the birth weight of newborns tended to be lower than that of newborns of non-fasting mothers, although this was not statistically significant ( - 198 g, 95 % CI - 447, 51, P= 0·12). Children of mothers who fasted in the first trimester of pregnancy were lighter at birth than those whose mothers had not fasted ( - 272 g, 95 % CI - 547, 3, P= 0·05). There were no differences in birth weight between children whose mothers had or had not fasted if Ramadan fasting had taken place later in pregnancy. Ramadan fasting during early pregnancy may lead to lower birth weight of newborns. These findings call for further confirmation in larger studies that should also investigate potential implications for perinatal and long-term morbidity and mortality.

Maternal stress, preterm birth, and DNA methylation at imprint regulatory sequences in humans

In infants exposed to maternal stress in utero, phenotypic plasticity through epigenetic events may mechanistically explain increased risk of preterm birth (PTB), which confers increased risk for neurodevelopmental disorders, cardiovascular disease, and cancers in adulthood. We examined associations between prenatal maternal stress and PTB, evaluating the role of DNA methylation at imprint regulatory regions. We enrolled women from prenatal clinics in Durham, NC. Stress was measured in 537 women at 12 weeks of gestation using the Perceived Stress Scale. DNA methylation at differentially methylated regions (DMRs) associated with H19, IGF2, MEG3, MEST, SGCE/PEG10, PEG3, NNAT, and PLAGL1 was measured from peripheral and cord blood using bisulfite pyrosequencing in a sub-sample of 79 mother–infant pairs. We examined associations between PTB and stress and evaluated differences in DNA methylation at each DMR by stress. Maternal stress was not associated with PTB (OR = 0.98; 95% CI, 0.40–2.40; P = 0.96), after adjustment for maternal body mass index (BMI), income, and raised blood pressure. However, elevated stress was associated with higher infant DNA methylation at the MEST DMR (2.8% difference, P < 0.01) after adjusting for PTB. Maternal stress may be associated with epigenetic changes at MEST, a gene relevant to maternal care and obesity. Reduced prenatal stress may support the epigenomic profile of a healthy infant.

Antenatal maternal emotional distress and duration of pregnancy

Objective(s)

We sought to prospectively study the association between antenatal emotional distress and gestational length at birth as well as preterm birth.

Study Design

We followed up 40,077 primiparous women in the Norwegian Mother and Child Cohort Study. Emotional distress was reported in a short form of the Hopkins Symptom Checklist-25 (SCL-5) at 17 and 30 weeks of gestation. Gestational length at birth, obtained from the Medical Birth Registry of Norway, was used as continuous (gestational length in days) and categorized (early preterm (22–31 weeks) and late preterm (32–36 weeks) versus term birth (≥37 weeks)) outcome, using linear and logistic regression analysis, respectively. Births were divided into spontaneous and provider-initiated.

Results

Of all women, 7.4% reported emotional distress at 17 weeks, 6.0% at 30 weeks and 5.1% had a preterm birth. All measurements of emotional distress at 30 weeks were significantly associated with a reduction of gestational length, in days, for provider-initiated births at term. Emotional distress at 30 weeks showed a reduced duration of pregnancy at birth of 2.40 days for provider-initiated births at term. An increase in emotional distress from 17 to 30 weeks was associated with a reduction of gestational length at birth of 2.13 days for provider-initiated births at term. Sustained high emotional distress was associated with a reduction of gestational length at birth of 2.82 days for provider-initiated births. Emotional distress did not increase the risk of either early or late preterm birth.

Conclusion

Emotional distress at 30 weeks, an increase in emotional distress from 17 to 30 weeks and sustained high levels of emotional distress were associated with a reduction in gestational length in days for provider-initiated term birth. We found no significant association between emotional distress and the risk of preterm birth.

Gestational age-dependent risk factors for preterm birth: associations with maternal education and age early in gestation

OBJECTIVES

Preterm birth (PTB) before 37 weeks can occur over a wide range of gestational ages, but few studies have assessed if associations between risk factors and PTB vary over the duration of gestation. We sought to evaluate if associations between two major risk factors (maternal education and age) and PTB depend on gestational age at delivery.

STUDY DESIGN

We estimated hazard ratios of PTB for education and age in a time-to-event analysis using a retrospective cohort of 223,756 live singleton births from the province of Québec, Canada for the years 2001-2005. Differences in hazards of maternal education and age with PTB were assessed over gestational age in a Cox proportional hazards model using linear and nonlinear time interaction terms, adjusting for maternal characteristics.

RESULTS

Associations of PTB with lower (vs. higher) education and older (vs. younger) age strengthened progressively at earlier gestational ages, such that the risk of PTB for maternal education and age was not constant over the course of gestation.

CONCLUSIONS

Associations of PTB with risk factors such as maternal low education and older age may be stronger early in gestation. Models that capture the time-dependent nature of PTB may be useful when the goal is to assess associations at low gestational ages, and to avoid masked or biased associations early in gestation.

Risk of spontaneous preterm birth in relation to maternal experience of serious life events during pregnancy

Background

The purpose of this study was to examine the risk of preterm birth (PTB) in relation to serious life events experienced during pregnancy in Peruvian women.

Methods

This case-control study included 479 PTB cases and 480 term controls. In-person interviews asked information regarding sociodemographics, medical and reproductive histories, and serious life events experienced during pregnancy. Multivariate logistic regression procedures were used to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

Results

Compared with women who did not experience a serious life event during pregnancy, those who experienced the following life events had a more than two-fold increased odds of PTB: death of first-degree relative (adjusted OR 2.10; 95% CI 1.38–3.20), divorce or separation (adjusted OR 2.09; 95% CI 1.10–4.00), financial troubles (adjusted OR 2.70; 95% CI 1.85–3.94), or serious fight with partner (adjusted OR 2.40; 95% CI 1.78–3.17). Women who experienced any serious life events during pregnancy had higher odds (adjusted OR 2.29; 95% CI 1.65–3.18) of suffering spontaneous preterm labor and preterm premature rupture of membranes (adjusted OR 2.19; 95% CI 1.56–3.08), compared with women who did not experience any such events. Associations of similar directions and extent were observed for severity of PTB (ie, very, moderate, or late PTB). The magnitude of the associations increased as increased frequency of serious life events (P_trend <0.001).

Conclusion

Experiencing serious life events during pregnancy was associated with increased odds of PTB among Peruvian women. Interventions aimed at assisting women experiencing serious life events may reduce the risk of PTB. Future studies should include objective measures of stress and stress response to understand better the biological underpinnings of these associations.

Improving ambulatory saliva-sampling compliance in pregnant women: a randomized controlled study

Objective

Noncompliance with scheduled ambulatory saliva sampling is common and has been associated with biased cortisol estimates in nonpregnant subjects. This study is the first to investigate in pregnant women strategies to improve ambulatory saliva-sampling compliance, and the association between sampling noncompliance and saliva cortisol estimates.

Methods

We instructed 64 pregnant women to collect eight scheduled saliva samples on two consecutive days each. Objective compliance with scheduled sampling times was assessed with a Medication Event Monitoring System and self-reported compliance with a paper-and-pencil diary. In a randomized controlled study, we estimated whether a disclosure intervention (informing women about objective compliance monitoring) and a reminder intervention (use of acoustical reminders) improved compliance. A mixed model analysis was used to estimate associations between women's objective compliance and their diurnal cortisol profiles, and between deviation from scheduled sampling and the cortisol concentration measured in the related sample.

Results

Self-reported compliance with a saliva-sampling protocol was 91%, and objective compliance was 70%. The disclosure intervention was associated with improved objective compliance (informed: 81%, noninformed: 60%), F(1,60)  = 17.64, p<0.001, but not the reminder intervention (reminders: 68%, without reminders: 72%), F(1,60)  = 0.78, p = 0.379. Furthermore, a woman's increased objective compliance was associated with a higher diurnal cortisol profile, F(2,64) = 8.22, p<0.001. Altered cortisol levels were observed in less objective compliant samples, F(1,705) = 7.38, p = 0.007, with delayed sampling associated with lower cortisol levels.

Conclusions

The results suggest that in pregnant women, objective noncompliance with scheduled ambulatory saliva sampling is common and is associated with biased cortisol estimates. To improve sampling compliance, results suggest informing women about objective compliance monitoring but discourage use of acoustical reminders.

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.

Interaction of child disability and stressful life events in predicting maternal psychological health. Results of an area-based study of very preterm infants at two years corrected age

This study aimed at exploring the relationship between severe neuromotor and/or sensory disability in very preterm infants assessed at 2 years corrected age and their mothers' psychological health. Data on 581 Italian singletons born at 22-31 weeks of gestation in five Italian regions and their mothers were analyzed. Maternal psychological distress was measured through the General Health Questionnaire short version (GHQ-12). The prevalence of any maternal distress (GHQ scores ≥ 2) and of clinical distress (scores ≥ 5) were 31.3% and 8.1% respectively. At multivariable analysis, we found a statistically significant association between child's disability and mothers' GHQ scoring ≥ 5 (OR 3.45, 95% CI 1.07-11.15). Also lower maternal education appeared to increase the likelihood of psychological distress (OR 1.38, 95% CI 1.14-1.66). The impact of child disability was weaker in women who had experienced additional stressful life events since delivery, pointing to the existence of a "ceiling" effect. Maternal psychological assessment and support should be included in follow-up programs targeting very preterm infants.

Ambulatory assessments of psychological and peripheral stress-markers predict birth outcomes in teen pregnancy

OBJECTIVE

Pregnant adolescents have high rates of poor birth outcomes, but the causes are unclear. We present a prospective, longitudinal study of pregnant adolescents assessing associations between maternal psychobiological stress indices and offspring gestational age at birth and birthweight.

METHOD

Healthy nulliparous pregnant adolescents were recruited (n=205) and followed during pregnancy. Ambulatory assessments over 24h of perceived psychological stress (collected every 30 min) and salivary cortisol (6 samples) and a summary questionnaire, the Perceived Stress Scale, were collected at three time points (13-16, 24-27, and 34-37 gestational weeks). Corticotropin-releasing hormone, C-reactive protein, and interleukin 6 were assayed from blood taken at the latter 2 sessions. A final sample of 119 participants was selected for analyses.

RESULTS

The ambulatory assessment of perceived psychological stress was positively correlated with the Perceived Stress Scale (r=.20, p=.03) but neither was associated with any of the biological assays (all ps>.20). Based on backward selection regression models that included all stress variables and relevant covariates, the ambulatory assessments of perceived psychological stress and cortisol - though not the Perceived Stress Scale - were negatively associated with gestational age at birth (F(4, 107)=3.38, p=.01) while cortisol was negatively related to birthweight (F(5, 107)=14.83, p<.0001).

CONCLUSIONS

Targeted interventions to reduce psychological and biological indicators of heightened stress during pregnancy may have positive public health benefits for the offspring given the associations of shortened gestation and lower birthweight with risk for poor mental and physical health outcomes.