Maternal mental disorders and pregnancy outcomes: a clinical study in a Japanese population

Schizophrenia pregnancies should be given greater health priority in the global health agenda: results from a large-scale meta-analysis of 43,611 deliveries of women with schizophrenia and 40,948,272 controls

Women with schizophrenia and their newborns are at risk of adverse pregnancy, delivery, neonatal and child outcomes. However, robust and informative epidemiological estimates are lacking to guide health policies to prioritise and organise perinatal services. For the first time, we carried out a systematic review and meta-analysis to synthesise the accumulating evidence on pregnancy, delivery, neonatal complications, and infant mortality among women with schizophrenia and their newborns (N = 43,611) vs. controls (N = 40,948,272) between 1999 and 2021 (26 population-based studies from 11 high-income countries) using random effects. Women with schizophrenia had higher odds (OR) of gestational diabetes (2.35, 95% CI: [1.57-3.52]), gestational hypertension, pre-eclampsia/eclampsia (OR 1.55, 95% CI: [1.02-2.36]; 1.85, 95% CI: [1.52-2.25]), antepartum and postpartum haemorrhage (OR 2.28, 95% CI: [1.58-3.29]; 1.14, 95% CI: [1.04-1.24]), placenta abruption, threatened preterm labour, and premature rupture of membrane (OR 2.20, 95% CI: [2.02-2.39]; 2.91, 95% CI: [1.57-5.40]; 1.29, 95% CI: [1.06-1.58]), c-section (OR 1.33, 95% CI: [1.22-1.45]), foetal distress (OR 1.80, 95% CI: [1.43-2.26]), preterm and very preterm delivery (OR 1.79, 95% CI: [1.62-1.98]; 2.31, 95% CI: [1.78-2.98]), small for gestational age and low birth weight (OR 1.63, 95% CI: [1.48-1.80]; 1.75, 95% CI: [1.46-2.11]), congenital malformations (OR 1.86, 95% CI: [1.71-2.03]), and stillbirths (OR 2.06, 95% CI: [1.83-2.31]). Their newborns had higher odds of neonatal death (OR 1.41, 95% CI: [1.03-1.94]), post-neonatal death (OR 2.87, 95% CI: [2.11-3.89]) and infant mortality (OR 2.33, 95% CI: [1.81-3.01]). This large-scale meta-analysis confirms that schizophrenia is associated with a substantially increased risk of very preterm delivery, stillbirth, and infant mortality, and metabolic risk in mothers. No population-based study has been carried out in low- and middle-income countries in which health problems of women with schizophrenia are probably more pronounced. More research is needed to better understand the complex needs of women with schizophrenia and their newborns, determine how care delivery could be optimised, and define best practices. Study registration: PROSPERO CRD42020197446.

Identifying Drugs Inducing Prematurity by Mining Claims Data with High-Dimensional Confounder Score Strategies

BACKGROUND

Pregnant women are largely exposed to medications. However, knowledge is lacking about their effects on pregnancy and the fetus.

OBJECTIVE

This study sought to evaluate the potential of high-dimensional propensity scores and high-dimensional disease risk scores for automated signal detection in pregnant women from medico-administrative databases in the context of drug-induced prematurity.

METHODS

We used healthcare claims and hospitalization discharges of a 1/97th representative sample of the French population. We tested the association between prematurity and drug exposure during the trimester before delivery, for all drugs prescribed to at least five pregnancies. We compared different strategies (1) for building the two scores, including two machine-learning methods and (2) to account for these scores in the final logistic regression models: adjustment, weighting, and matching. We also proposed a new signal detection criterion derived from these scores: the p value relative decrease. Evaluation was performed by assessing the relevance of the signals using a literature review and clinical expertise.

RESULTS

Screening 400 drugs from a cohort of 57,407 pregnancies, we observed that choosing between the two machine-learning methods had little impact on the generated signals. Score adjustment performed better than weighting and matching. Using the p value relative decrease efficiently filtered out spurious signals while maintaining a number of relevant signals similar to score adjustment. Most of the relevant signals belonged to the psychotropic class with benzodiazepines, antidepressants, and antipsychotics.

CONCLUSIONS

Mining complex healthcare databases with statistical methods from the high-dimensional inference field may improve signal detection in pregnant women.

Schizophrenia and motherhood

The primary aim of this study was to analyze the impact of schizophrenic disorders on pregnancy outcomes. The secondary aim was to briefly analyze the potential role of antipsychotic treatment on influencing pregnancy outcomes in expectant mothers with schizophrenia. We searched the MEDLINE, PsycINFO, and Science.gov databases for articles published in English from January 1980 to January 2019. We used the following search terms: 'schizophrenia', 'motherhood', 'pregnancy/foetal/neonatal outcomes', and 'birth defects'. The reference lists of retrieved articles were also consulted to find additional pertinent studies missed in the electronic search and/or those published before 1980. Data were extracted from articles that provided primary data on the impact of maternal schizophrenia spectrum disorders on obstetrical and perinatal outcomes. After excluding duplicates, 35 articles were identified. Systematic reviews were searched on the same databases to briefly assess the effects of antipsychotics on pregnancy outcomes. The reviewed studies showed several limitations. They were published during a time range from the early 1970s to 2019. During this period, there were significant changes in the diagnostic criteria for schizophrenia. Moreover, such studies showed no homogeneity in the investigation of potential confounders. Most importantly, no research has differentiated the effects of maternal illness on pregnancy, fetal, and neonatal outcomes from those associated with antipsychotic treatments. Thus, it is not surprising that such studies show conflicting results. Despite such limitations, in managing pregnant women with schizophrenia clinicians should consider an integrated approach that includes: antipsychotic treatment, psychological treatment, optimal dietary approaches for prevention of excessive weight gain and gestational diabetes, meticulous gynecologic and obstetric surveillance, and social and occupational support.

Association of antepartum suicidal ideation during the third trimester with infant birth weight and gestational age at delivery

Antepartum suicidal behaviors are a leading cause of maternal injury and death. Previous research has not investigated associations between antepartum suicidal ideation and perinatal complications. Our study objective was to evaluate the relationship of antepartum suicidal ideation with low infant birthweight, small for gestational age, and preterm birth. A cohort study was conducted among 1,108 women receiving prenatal care in Peru. Suicidal ideation was measured using the Patient Health Questionnaire-9 during pregnancy. Birth outcomes were extracted from medical records. Linear regressions and multivariable logistic regressions were used to estimate were used to investigate associations between suicidal ideation and pregnancy outcomes. The prevalence of suicidal ideation was 8.7%, preterm delivery was 5.7%, low birthweight was 4.4%, and small for gestational age was 3.4%. In an adjusted model, infant birthweight was 94.2 grams lower for mothers with antepartum suicidal ideation (95% CI: -183.0, -5.5, p = 0.037) compared with those without suicidal ideation. After adjusting for confounders including depression, participants with suicidal ideation had a nearly four-fold increased odds of delivering a small for gestational age infant (OR: 3.73; 95% CI: 1.59-8.74). These findings suggest suicidal ideation during pregnancy is associated with adverse perinatal outcomes, especially low infant birthweight.

Adverse Effects in the Pharmacologic Management of Bipolar Disorder During Pregnancy

Management of bipolar disorder during pregnancy often involves medications with potential adverse effects, including risks to the mother and fetus. Although some specifics are known, many medications continue to have incompletely characterized reproductive safety profiles. Women with bipolar disorder who are planning pregnancy face challenging decisions about their treatment; careful risk-benefit discussions are necessary. With the goal of further informing these discussions, this article reviews the data currently available regarding medication safety in the management of bipolar disorder during pregnancy, with specific attention to lithium, valproic acid, lamotrigine, carbamazepine, and antipsychotic medications.

Maternal psychiatric disorders and risk of preterm birth

PURPOSE

To study the effect of maternal psychiatric disorders (depression, anxiety disorder, bipolar disease, schizophrenia, unspecified psychiatric disorder, and comorbid conditions) and odds of preterm birth.

METHODS

The Consortium on Safe Labor (2002-2008), an observational cohort with 12 centers from across the United States included 223,394 singleton pregnancies with clinical data obtained from electronic medical records and maternal diagnoses of psychiatric disorders from maternal discharge summaries. Length of gestation was based on the best clinical estimate and categorized as birth less than 39, less than 37, less than 34, and less than 28 weeks' gestation. The adjusted odds ratios (ORs) with 95% confidence intervals of birth were estimated by logistic regression with generalized estimating equations.

RESULTS

Any maternal psychiatric disorder was associated with odds of birth less than 39 weeks' gestation (odds ratio [OR] = 1.32, 95% confidence interval = 1.28-1.37), less than 37 weeks' gestation (OR = 1.45, 1.38-1.52), less than 34 weeks' gestation (OR = 1.47, 1.35-1.59), and less than 28 weeks' gestation (OR = 1.57, 1.36-1.82). Specifically, odds of birth less than 37 weeks' gestation were associated with maternal depression (OR = 1.31, 1.23-1.40), anxiety disorder (OR = 1.68, 1.41-2.01), depression with anxiety disorder (OR = 2.31, 1.93-2.78), bipolar disease (OR = 1.54, 1.22-1.94), bipolar disease with depression and/or anxiety disorder (OR = 1.70, 1.30-2.22), and unspecified psychiatric disorder (OR = 1.52, 1.41-1.64).

CONCLUSIONS

Maternal psychiatric disorders, especially comorbid psychiatric conditions, were associated with increased likelihood of preterm birth.

Clinical, Ethical, and Socioeconomic Considerations for Prescription Drug Use During Pregnancy in Women Suffering From Chronic Diseases

The increasing proportion of women conceiving later in life, associated with the higher probability of contracting a chronic disease, highlights an increasing need to understand the impact of drug use for chronic diseases pre- and postpartum. In this study, the authors report the results of systematic reviews of drug use during pregnancy by focusing on pregnant women with a chronic disease, specifically, epilepsy, rheumatoid arthritis (RA), or schizophrenia. The authors studied the clinical impact of drug use in these chronic diseases on the mother and fetus, as well as the ethical issues and socioeconomic impact of drug use during pregnancy for women with these conditions. The results indicate that treatment discontinuation in epilepsy and schizophrenia can lead to serious adverse effects, whereas pregnancy can have an ameliorating effect on RA symptoms. Delivery and neonatal complications were associated with the use of older generation drugs across the 3 diseases. Newer generation drugs were deemed safer but more expensive. Ethical considerations for physicians and patients involved mainly the potential risks of drug use for the fetus. In conclusion, treatment guidelines need to be developed in the future; additionally, better insight into the economics of pregnancy for women with chronic diseases will improve value for money in obstetric care.

Pregnancy Outcomes Following In Utero Exposure to Second-Generation Antipsychotics: A Systematic Review and Meta-Analysis

Second-generation antipsychotics (SGAs) are increasingly used for a variety of mental illnesses; however, the data regarding the safety of these medications during pregnancy are inconclusive and contradictory. We examined the risk of adverse pregnancy outcomes associated with in utero exposure to SGAs by conducting a systematic review and meta-analysis. We searched the databases EMBASE and MEDLINE from January 1990 to December 2014. Eligible studies had to report pregnant women who took SGAs during pregnancy (first trimester exposure if analyzing congenital malformations), follow a healthy comparison group in a similar manner, and report data on pregnancy outcomes. There was no restriction on language, sample size, or publication date. The primary outcome analyzed was major congenital malformations, and secondary outcomes included miscarriages, stillbirths, preterm births, small or large for gestational age neonates, and differences in gestational ages and birth weights. A total of 12 studies met our inclusion criteria, totalling 1782 cases and 1,322,749 controls. The use of SGA during the first trimester of pregnancy was associated with a significant increased risk for major congenital malformations (odds ratio, 2.03; 95% confidence interval, 1.41-2.93); however, no specific pattern of malformations was found. An increased risk was also found for preterm births (odds ratio, 1.85; 95% CI, 1.20-2.86). The use of SGA during pregnancy was not found to be associated with an increased risk for secondary outcomes analyzed. The absence of a specific pattern of malformations makes it difficult to identify an explicit risk posed by SGAs, and therefore, further studies sufficiently controlling for confounding factors are needed to validate these findings.

Maternal psychiatric disease and epigenetic evidence suggest a common biology for poor fetal growth

BACKGROUND

We sought to identify and characterize predictors of poor fetal growth among variables extracted from perinatal medical records to gain insight into potential etiologic mechanisms. In this process we reevaluated a previously observed association between poor fetal growth and maternal psychiatric disease.

METHODS

We evaluated 449 deliveries of >36 weeks gestation that occurred between 9/2008 and 9/2010 at the Women and Infants Hospital in Providence Rhode Island. This study group was oversampled for Small-for-Gestational-Age (SGA) infants and excluded Large-for-Gestational-Age (LGA) infants. We assessed the associations between recorded clinical variables and impaired fetal growth: SGA or Intrauterine Growth Restriction (IUGR) diagnosis. After validating the previously observed association between maternal psychiatric disease and impaired fetal growth we addressed weaknesses in the prior studies by explicitly considering antidepressant use and the timing of symptoms with respect to pregnancy. We then evaluated DNA methylation levels at 27 candidate loci in placenta from a subset of these deliveries (n = 197) to examine if epigenetic variation could provide insight into the mechanisms that cause this co-morbidity.

RESULTS

Infants of mothers with prenatal psychiatric disease (Depression, Anxiety, OCD/Panic) had increased odds of poor fetal growth (ORadjusted = 3.36, 95%CI: 1.38-8.14). This relationship was similar among those who were treated with antidepressants (ORadjusted = 3.69, 95%CI: 1.31-10.45) and among those who were not (ORadjusted = 3.19, 95%CI: 1.30-7.83). Among those with a history of psychiatric disease but no active disease in pregnancy the ORadjusted was 0.45 (95%CI: 0.09-2.35). A locus near the transcription start site of the leptin receptor (cg21655790) had methylation levels that were decreased in the presence of: 1) SGA/IUGR, and 2) active but not resolved psychiatric disease (among mothers not on antidepressants).

CONCLUSIONS

These results validate and further characterize the association between maternal psychiatric disease and poor fetal growth. Because the association appears to depend on active psychiatric disease, this suggests a transient and potentially modifiable pathophysiology. The molecular findings in this study suggest that altered leptin signaling may be involved in the biological mechanisms that link prenatal maternal psychiatric symptoms and poor fetal growth.

Risk of Fetal Death after Treatment with Antipsychotic Medications during Pregnancy

Background

Antipsychotic medications are increasingly used during pregnancy. Nevertheless, fetal risks are still not fully studied. It is currently unclear whether the antipsychotic treatment might induce a higher risk of fetal death. We aimed to determine if use of antipsychotic medication during pregnancy is associated with an increased risk of spontaneous abortion or stillbirth.

Methods

In a historical cohort study, we identified all clinically recognized pregnancies registered in the nationwide Danish registries from 1997 to 2008 (N = 1,005,319). Exposure was defined as any prescription of antipsychotic medications redeemed by the pregnant women during the exposure window, and recorded in the Danish National Prescription Register. Outcome was defined as any spontaneous abortion or stillbirth recorded in the Danish National Hospital Register and the Danish Medical Birth Register respectively.

Results

Women exposed to antipsychotic medications during pregnancy had a 34% higher risk of spontaneous abortion (adjusted relative risk = 1.34; 95% confidence interval = 1.22; 1.46) compared to unexposed women, but a similar risk compared to women exposed prior to (but not during) pregnancy (adjusted relative risk = 1.04; 95% confidence interval = 0.93; 1.17). The risk of spontaneous abortion was not increased in exposed pregnancies when compared to unexposed pregnancies in the same women (adjusted hazard ratio = 1.11; 95% CI = 0.94; 1.31). A twofold higher risk of stillbirth was found in women exposed to antipsychotic medications compared with unexposed women (relative risk = 2.27; 95% confidence interval = 1.45; 3.55) and compared with women exposed only prior to pregnancy (relative risk = 2.06; 95% confidence interval = 1.01; 4.19).

Conclusions

The increased risk of spontaneous abortion found in women treated with antipsychotic medications during pregnancy is most likely due to confounding factors. The risk of stillbirth was twofold higher in pregnancies exposed to antipsychotic medication during pregnancy. Treatment with antipsychotic medications during pregnancy requires careful consideration.

Pregnancy outcomes following maternal exposure to second-generation antipsychotics given with other psychotropic drugs: a cohort study

OBJECTIVES

Second-generation antipsychotics (SGAs), in conjunction with other psychotropic medications, are increasingly used to treat psychiatric disorders in pregnancy. The few available studies investigating the reproductive safety of SGAs did not reach conclusive results, and none have compared monotherapy with polytherapy involving other psychotropic medications.

DESIGN

Descriptive cohort study using a prospectively collected database.

SETTING

Motherisk Program, The Hospital for Sick Children, Toronto, Canada.

PARTICIPANTS

133 women exposed to SGAs and other psychotropic drugs and 133 matched healthy controls were assessed and analysed. Outcomes of mother-child pairs exposed to SGAs in monotherapy (N=37) were compared with those exposed to SGAs with other psychotropic medications (in polytherapy; N=96).

MAIN OUTCOME MEASURES

Maternal, pregnancy, delivery and neonatal outcomes.

RESULTS

72% of exposed women received SGAs in polytherapy, and 101 women took their medications throughout pregnancy. These women had significantly higher pre-pregnancy weight, experienced more associated comorbidities and instrumental deliveries, and delivered a greater proportion of large for gestational age neonates. There were no differences in maternal weight gain in pregnancy between the exposed and comparison groups and between the monotherapy-exposed and polytherapy-exposed subgroups. The exposed neonates were more likely to be born premature, were admitted more often to the neonatal intensive care unit, presented with poor neonatal adaptation signs and had higher rates of congenital malformations. All the aforementioned neonatal outcomes were found mainly in the polytherapy subgroup.

CONCLUSIONS

The use of SGAs in polytherapy was prevalent in the assessed cohort and was associated with adverse pregnancy outcomes for both the mother and the child. In utero exposure to SGA monotherapy appears to be associated with less risk to the fetus. Future research should focus on polytherapy in pregnancy in order to define its reproductive safety and to separate the effects of medication exposure, underlying psychopathology and associated comorbidities.