Maternal hypothalamic-pituitary-adrenal axis in pregnancy and the postpartum period. Postpartum-related disorders

Increased prevalence of negative pregnancy and fetal outcomes in women with primary adrenal insufficiency. A systematic review and meta-analysis

Maternal primary adrenal insufficiency (PAI) during pregnancy, due to either Addison disease (AD) or congenital adrenal hyperplasia (CAH), is rare. Only few studies have examined the subsequent important outcomes of maternal glucocorticoid and mineralocorticoid deficiencies during pregnancy upon the fetus and the neonate. Therefore, this systematic review and meta-analysis evaluated the impact of these deficiencies, with data from PubMed/Medline, Cochrane/CENTRAL, and Google Scholar. A total of 31 studies were included for qualitative analysis and 11 for quantitative analysis. Studies examining the prevalence of spontaneous abortion, preterm birth, the occurrence of small for gestational age (SGA) neonates, as well as the neonatal birth weight were included. The systematic review revealed a substantial number of spontaneous abortions, preterm births and SGA neonates in pregnant women with PAI. The meta-analysis showed a mean spontaneous abortion prevalence of 18%, 18% and 17% in women with PAI, AD or CAH, respectively. The mean preterm birth prevalence was 11% when women with AD or CAH were analyzed together, and 13% and 9% in women with AD or CAH, respectively, when these women were analyzed separately. The mean prevalence of SGA neonates was 8% when women with AD or CAH were analyzed together, and 5% and 10% in women with AD or CAH, respectively, when these women were analyzed separately. The mean fetal birth weight was within normalcy in all women with PAI, as well as in women with AD or CAH. In conclusion the executed systematic review of 31 studies followed by a meta-analysis of 11 studies in pregnant women with PAI has shown a greater prevalence of pregnancies with negative outcome (spontaneous abortion, preterm birth) and of negative fetal outcome (SGA) in women with either AD or CAH, as compared to control pregnant women.

Rheumatoid arthritis and adverse pregnancy outcomes: a bidirectional two-sample mendelian randomization study

BACKGROUND

There is growing evidence of bidirectional associations between rheumatoid arthritis and adverse pregnancy outcomes (APOs) in observational studies, but little is known about the causal direction of these associations. Therefore, we explored the potential causal relationships between rheumatoid arthritis and APOs using a bidirectional two-sample Mendelian randomization (MR) in European and Asian populations.

METHODS

We conducted a bidirectional two-sample Mendelian randomization analysis using available summary statistics from released genome-wide association studies. Summary statistics for instrument-outcome associations were retrieved from two separate databases for rheumatoid arthritis and adverse pregnancy outcomes, respectively. The inverse-variance weighted method was used as the primary MR analysis, and cML-MA-BIC was used as the supplementary analysis. MR-Egger, MR pleiotropy residual sum and outlier (MR-PRESSO), and Cochran Q statistic method were implemented as sensitivity analyses approach to ensure the robustness of the results.

RESULTS

Our study showed that a higher risk of rheumatoid arthritis in the European population was associated with gestational hypertension (OR: 1.04, 95%CI: 1.02-1.06), pre-eclampsia (OR: 1.06, 95%CI: 1.01-1.11), fetal growth restriction (OR: 1.08, 95%CI: 1.04-1.12), preterm delivery (OR:1.04, 95%CI: 1.01-1.07). Furthermore, we found no evidence that APOs had causal effects on rheumatoid arthritis in the reverse MR analysis. No association between rheumatoid arthritis and APOs was found in East Asian population. There was no heterogeneity or horizontal pleiotropy.

CONCLUSIONS

This MR analysis provides the positive causal association from rheumatoid arthritis to gestational hypertension, pre-eclampsia, fetal growth restriction and preterm delivery genetically. It highlights the importance of more intensive prenatal care and early intervention among pregnant women with rheumatoid arthritis to prevent potential adverse obstetric outcomes.

Effects of reproductive experience on cost-benefit decision making in female rats

Many individuals undergo mating and/or other aspects of reproductive experience at some point in their lives, and pregnancy and childbirth in particular are associated with alterations in the prevalence of several psychiatric disorders. Research in rodents shows that maternal experience affects spatial learning and other aspects of hippocampal function. In contrast, there has been little work in animal models concerning how reproductive experience affects cost-benefit decision making, despite the relevance of this aspect of cognition for psychiatric disorders. To begin to address this issue, reproductively experienced (RE) and reproductively naïve (RN) female Long-Evans rats were tested across multiple tasks that assess different forms of cost-benefit decision making. In a risky decision-making task, in which rats chose between a small, safe food reward and a large food reward accompanied by variable probabilities of punishment, RE females chose the large risky reward significantly more frequently than RN females (greater risk taking). In an intertemporal choice task, in which rats chose between a small, immediate food reward and a large food reward delivered after a variable delay period, RE females chose the large reward less frequently than RN females. Together, these results show distinct effects of reproductive experience on different forms of cost-benefit decision making in female rats, and highlight reproductive status as a variable that could influence aspects of cognition relevant for psychiatric disorders.

Longitudinal Associations between Prenatal Exposure to Phthalates and Steroid Hormones in Maternal Hair Samples from the SEPAGES Cohort

We assessed phthalate-hormone associations in 382 pregnant women of the new-generation SEPAGES cohort (2014-2017, France) using improved exposure and outcome assessments. Metabolites from seven phthalate compounds and the replacement di(isononyl)cyclohexane-1,2-dicarboxylate (DINCH) were measured in within-subject pools of repeated urine samples collected at the second and third pregnancy trimesters (≈21 samples/trimester). Metabolites from five steroid hormones were measured in maternal hair samples collected at delivery, reflecting cumulative levels over the previous weeks to months. Adjusted linear regression and Bayesian weighted quantile sum (BWQS) mixture models were performed. Each doubling in third-trimester urinary mono-benzyl phthalate (MBzP) concentrations was associated with an average increase of 13.3% (95% CI: 2.65, 24.9) for ∑cortisol, 10.0% (95% CI: 0.26, 20.7) for ∑cortisone, 17.3% (95% CI: 1.67, 35.4) for 11-dehydrocorticosterone, and 16.2% (95% CI: 2.20, 32.1) for testosterone, together with a suggestive 10.5% (95% CI: -1.57, 24.1) increase in progesterone levels. Each doubling in second-trimester urinary di-isononyl phthalate (DiNP) concentrations was inversely associated with testosterone levels (-11.6%; 95% CI: -21.6, -0.31). For most hormones, a nonsignificant trend toward a positive phthalate mixture effect was observed in the third but not in the second trimester. Our study showed that exposure to some phthalate metabolites, especially MBzP, may affect adrenal and reproductive hormone levels during pregnancy.

Prenatal depression and risk of child autism-related traits among participants in the Environmental influences on Child Health Outcomes program

This study evaluated the association between prenatal depression and offspring autism-related traits. The sample comprised 33 prenatal/pediatric cohorts participating in the Environmental influences on Child Health Outcomes program who contributed information on prenatal depression and autism-related traits. Autism-related traits were assessed continuously and at the diagnostic cut-off using the Social Responsiveness Scale for children up to 12 years of age. Main analyses included 3994 parent-child pairs with prenatal depression diagnoses data; secondary analyses included 1730 parent-child pairs with depression severity data. After confounder adjustment, we observed an increase in autism-related traits among children of individuals with prenatal depression compared to those without (adjusted β = 1.31 95% CI: 0.65, 1.98). Analyses stratified by child sex documented a similar significant association among boys (aβ = 1.34 95%CI: 0.36, 2.32) and girls (aβ = 1.26 95% CI: 0.37, 2.15). Prenatal depression was also associated with increased odds of moderate to severe autism-related traits (adjusted odds ratio: 1.64, 95%CI: 1.09, 2.46), the screening threshold considered high risk of autism spectrum disorder (ASD) diagnosis. Findings highlight the importance of prenatal depression screening and preventive interventions for children of pregnant individuals with depression to support healthy development. Future research is needed to clarify whether these findings reflect overlap in genetic risk for depression and ASD-related traits or another mechanism.

Association between neutrophil-lymphocyte ratio and perinatal depressive symptoms among Chinese women

OBJECTIVE

The prevalence of depression has increased dramatically in the past few decades, and pregnant women are at high risk for depression. It is widely thought that inflammation plays a critical role in the pathogenesis of depression. Therefore, we aimed to evaluate the association between the neutrophil-lymphocyte ratio (NLR), a marker of chronic immune inflammation, and perinatal depressive symptoms.

METHODS

A cohort study involving 535 pregnant women was conducted based on a prospective birth cohort in Wuhan, China. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess antepartum depression (APD) and postpartum depression (PPD) during the second trimester of pregnancy and one month after delivery. The NLR during the second trimester was determined based on a routine blood test. The association between NLR and depressive symptoms was evaluated using logistic regression analysis and restricted cubic spline (RCS) regression.

RESULTS

We found that the prevalence of APD and PPD was 8.4% and 15.1%, respectively. NLR levels were positively associated with APD (OR = 1.52, 95% CI: 1.20--1.91). After adjusting for potential confounders, the OR (95% CI) of APD for the highest NLR quartile was 4.56 (1.58, 13.13) compared with the lowest quartile. No significant association was found between NLR and PPD. RCS regression model analysis indicated a linear correlation between NLR and APD (P for non-linearity = 0.58).

CONCLUSION

Overall, elevated mid-trimester NLR is independently associated with APD but not PPD.

High-progesterone environment preserves T cell competency by evading glucocorticoid effects on immune regulation

Progesterone (P4) and glucocorticoid (GC) play crucial roles in the immunoregulation of a mother to accept and maintain a semi-allogenic fetus. P4 concentration increases during pregnancy and becomes much higher in the placenta than in the other peripheral tissues, wherein the concentration of cortisol (COR), the most abundant GC and a strong immunosuppressor, remains uniform throughout the rest of the body. Here, we evaluated the effect of a high-P4 environment on pregnant immunity by comparing it with COR. Naïve T cell proportion increased transiently in peripheral blood of pregnant women just after delivery and decreased after one month. T cells stimulated with superantigen toxic-shock-syndrome-1 (TSST-1) in the presence of P4 stayed in the naïve state and did not increase, irrespective of the presence of COR, and reactive T cells could not survive. Treatment of T cells with P4 without T cell receptor (TCR) stimulation transiently suppressed T cell activation and proliferation, whereas the levels remain unaltered if P4 was not given before stimulation. Comparison of the engraftment and response against specific antigens using hu-PBL-NOG-hIL-4-Tg mice showed that P4-pretreated lymphocytes preserved CD62L expression and engrafted effectively in the spleen. Moreover, they produced antigen-specific antibodies, whereas COR-pretreated lymphocytes did not. These results suggest that a high-P4 environment suppresses T cell activation and induces T cell migration into lymphoid tissues, where they maintain the ability to produce anti-pathogen antibodies, whereas COR does not preserve T cell function. The mechanism may be pivotal in maintaining non-fetus-specific T cell function in pregnancy.

Stress-Related Mental Health Disorders and Inflammation in Pregnancy: The Current Landscape and the Need for Further Investigation

Many studies have focused on psychoimmunological mechanisms of risk for stress-related mental health disorders. However, significantly fewer studies have focused on understanding mechanisms of risk for stress-related disorders during pregnancy, a period characterized by dramatic changes in both the innate and adaptive immune systems. The current review summarizes and synthesizes the extant literature on the immune system during pregnancy, as well as the sparse existing evidence highlighting the associations between inflammation and mood, anxiety, and fear-related disorders in pregnancy. In general, pregnant persons demonstrate lower baseline levels of systemic inflammation, but respond strongly when presented with an immune challenge. Stress and trauma exposure may therefore result in strong inflammatory responses in pregnant persons that increases risk for adverse behavioral health outcomes. Overall, the existing literature suggests that stress, trauma exposure, and stress-related psychopathology are associated with higher levels of systemic inflammation in pregnant persons, but highlight the need for further investigation as the existing data are equivocal and vary based on which specific immune markers are impacted. Better understanding of the psychoimmunology of pregnancy is necessary to reduce burden of prenatal mental illness, increase the likelihood of a successful pregnancy, and reduce the intergenerational impacts of prenatal stress-related mental health disorders.

The Value of HPA Axis Hormones as Biomarkers for Screening and Early Diagnosis of Postpartum Depression: Updated Information About Methodology

Because of the high prevalence of postpartum depression (PPD) and the suffering involved, early diagnosis is urgent; however, current screening tools and diagnosis are inadequate. In addition to conventional methods such as the Edinburgh Postnatal Depression Scale and clinical interviews, several hormones in the hypothalamic-pituitary-adrenal (HPA) axis, such as corticotrophin-releasing hormone, adrenocorticotropic hormone, and cortisol, have been considered because of their critical roles in stress regulation in the mothers. The study designs are complicated, however, and so the effectiveness of these hormones as biomarkers for PPD is still controversial. Such inconsistency may have resulted from the variation in methodology between studies. The methodology problems in the investigation of PPD and HPA axis hormones have not been reported extensively. We therefore sought to summarize the methodological problems of studies published in the past decade, including the strengths and weaknesses of the examinations and the technological difficulties involved. Our findings suggest that (a) suitable samples and appropriate detection methods would reduce heterogeneity among trials; (b) the cutoff value of the scale test should be carefully selected for determining the performance of biomarker tests; (c) evaluation methods and criteria should be chosen with consideration of the tools feasible for use in local hospitals and population; and (d) the cost of diagnosis should be reduced. We hope that these findings provide insight for future investigations of HPA axis hormones as biomarkers for screening and early diagnosis of PPD.

Calorie restriction modulates neuro-immune system differently in young and aged rats

Aging weakens and deregulates the immune system and plays an impact on the central nervous system (CNS). A crosstalk in between the CNS-mediated immune system and the body's overall innate immunity is often found to increase and subsequently accelerate neurodegeneration and behavioural impairment during aging. Dietary calorie restriction (CR) is found to be a beneficial non-invasive anti-aging therapy as it shows rejuvenation of stress response, brain functions and behaviour during aging. The present investigation deals with the consequence of CR diet supplementation for two different duration (one and two consecutive months) on aging-related alteration of the immune response in male albino Wistar rats at the level of (a) lymphocyte viability, proliferation, cytotoxicity, and DNA fragmentation in blood, spleen, and thymus and (b) cytokines (IL-6, IL-10, and TNF-α) in blood, spleen, thymus and different brain-regions to understand the effect of CR diet on neuroimmune system. The results depict that CR diet consumption for consecutive one and two months by the aged (18 and 24 months) rats significantly attenuated the aging-related (a) decrease of blood, splenic and thymic lymphocyte viability, proliferative activity, cytotoxicity, and IL-10 level and (b) increase of (i) blood, splenic and thymic DNA fragmentation and (ii) IL-6 and TNF-α level in those tissues and also in different brain regions. Unlike older rats, in young (4 months) rats, the consumption of CR diet under similar conditions affected those above-mentioned immune parameters reversibly and adversely. This study concludes that (a) aging significantly (p < 0.01) deregulates the above-mentioned immune parameters, (b) consecutive consumption of CR diet for one and two months is (i) beneficial (p < 0.05) to the aging-related immune system [lymphocyte viability, lymphocyte proliferation, cytotoxicity, pro (IL-6 and TNF-α)- and anti (IL-10)-inflammatory cytokines], but (ii) adverse (p < 0.05) to the immune parameters of the young rats, and (c) consumption of CR diet for consecutive two months is more potent (p < 0.05) than that due to one month.

Placental CRH as a Signal of Pregnancy Adversity and Impact on Fetal Neurodevelopment

Early life is a period of considerable plasticity and vulnerability and insults during that period can disrupt the homeostatic equilibrium of the developing organism, resulting in adverse developmental programming and enhanced susceptibility to disease. Fetal exposure to prenatal stress can impede optimum brain development and deranged mother's hypothalamic-pituitary-adrenal axis (HPA axis) stress responses can alter the neurodevelopmental trajectories of the offspring. Corticotropin-releasing hormone (CRH) and glucocorticoids, regulate fetal neurogenesis and while CRH exerts neuroprotective actions, increased levels of stress hormones have been associated with fetal brain structural alterations such as reduced cortical volume, impoverishment of neuronal density in the limbic brain areas and alterations in neuronal circuitry, synaptic plasticity, neurotransmission and G-protein coupled receptor (GPCR) signalling. Emerging evidence highlight the role of epigenetic changes in fetal brain programming, as stress-induced methylation of genes encoding molecules that are implicated in HPA axis and major neurodevelopmental processes. These serve as molecular memories and have been associated with long term modifications of the offspring's stress regulatory system and increased susceptibility to psychosomatic disorders later in life. This review summarises our current understanding on the roles of CRH and other mediators of stress responses on fetal neurodevelopment.

How Stressful Is Maternity? Study about Cortisol and Dehydroepiandrosterone-Sulfate Coat and Claws Concentrations in Female Dogs from Mating to 60 Days Post-Partum

In dogs, the phase from mating to the end of weaning lasts about 120 days and encompasses many aspects that, interacting, contribute to increase the allostatic load. The coat and claws, useful for long-term change assessments, have the advantage of being collectable without invasiveness. In the present study, the Cortisol (C) and Dehydroepiandrosterone-sulfate (DHEA-S) concentration monthly changes in the coat and claws were studied in female dogs from mating to the end of weaning to assess Hypothalamic-Pituitary-Adrenal (HPA) axis activation during pregnancy and the post-partum period. The results from 15 Dobermann Pinscher female dogs showed a trend of increase of the coat C from mating to 60 days post-partum, with significant changes between mating and parturition-60 days post-partum (p < 0.01) and between the 30-day pregnancy diagnosis (PD) and 30-60 days post-partum (p < 0.05). The claws C trend showed significant increases between mating and 30-60 days post-partum (p < 0.05) and between the PD and 60 days post-partum (p < 0.01). DHEA-S in both matrices showed non-significant changes. The results suggest that maternity could play a pivotal role in the HPA axis activation, with a subsequent chronic secretion of C determining an increase in the allostatic load in the mothers. Neither maternal parity nor litter size played a significant role in the accumulation of C and DHEA-S in both matrices.

Endocrine stress response in pregnancy and 12 weeks postpartum - Exploring risk factors for postpartum depression

Pregnancy and the postpartum period are characterized by physiological alterations in cortisol and cortisone levels. In the present study, we sought to explore the risk factors for postpartum depression (PPD) and self-remitting postpartum adjustment disorder (AD) and whether cortisol/cortisone metabolism might have any bearing on them. Hair samples from 196 participants (mean age = 31.44, SD = 4.71) were collected at two time points (1-6 days after childbirth and 12 weeks postpartum) to determine the cumulative hair cortisol (HCC) and hair cortisone (HCNC) exposure in the third trimester and during the 12 weeks postpartum. Compared to the non-depressed group (ND, n = 141), more women in the AD (n = 28) and PPD (n = 27) groups had a personal or family history of depression and more stressful life events. Compared to ND and PPD, more women in the AD group had birth-related complications with their children being more often transferred to a pediatric ward. The factors associated with PPD were found to include being unmarried and having a lower household income, less support at home, more subjectively perceived stress after childbirth and lower maternal sensitivity. The natural decrease in HCC concentration from the third trimester to 12 weeks postpartum was significant only in the ND and AD groups, but not in PPD. In summary, prolonged subjectively perceived postpartum stress associated with living situations may contribute to the development of PPD while birth- and child-related complications are likely to trigger brief episodes of AD. Only in ND and AD, the pregnancy-related physiological changes in glucocorticoid levels return to the pre-pregnancy baseline after 12 weeks. Our observations point to the difference between the ND and PPD groups in glucocorticoid metabolism-related postpartum adjustment, which may be a factor in the development of PPD.

Swann-Thomsen H, Douthit N. Maternal Prenatal Cortisol and Breastfeeding Predict Infant Growth

Fetal/infant growth affects adult obesity and morbidities/mortality and has been associated with prenatal exposure to cortisol. Bidirectional relations between maternal stress and breastfeeding suggest that they interact to influence offspring growth. No models have tested this hypothesis, particularly regarding longer-term offspring outcomes. We used a subset of the IDAHO Mom Study (n = 19-95) to examine associations among maternal prenatal cortisol (cortisol awakening response (CAR) and area under the curve), and standardized weight-for-length (WLZ) and length-for-age (LAZ) z-scores from birth-18 months, and main and interactive effects of prenatal cortisol and breastfeeding on infant growth from birth-6 months. CAR was negatively associated with LAZ at birth (r = -0.247, p = 0.039) but positively associated at 13-14 months (r = 0.378, p = 0.033), suggesting infant catch-up growth with lower birth weights, likely related to elevated cortisol exposure, continues beyond early infancy. A negative correlation between breastfeeding and 10-month WLZ (r = -0.344, p = 0.037) and LAZ (r = -0.468, p = 0.005) suggests that breastfeeding assists in managing infant growth. WLZ and LAZ increased from birth to 6 months (ps < 0.01), though this was unrelated to interactions between prenatal cortisol and breastfeeding (i.e., no significant moderation), suggesting that other factors played a role, which should be further investigated. Findings add to our understanding of the predictors of infant growth.

The hypothalamic-pituitary-adrenal axis in the perinatal period: Its relationship with major depressive disorder and early life adversity

Objectives: Effects of major depressive disorder and early life adversity (ELA) on the maternal HPA axis in the perinatal period were examined.Methods: Four groups of women (n = 127) were recruited, with the perinatal groups being compared during pregnancy (Preg) and at two months postpartum (PP) - [1] Depressed during pregnancy (Depressed-Preg/PP), [2] Prior history of depression but euthymic during pregnancy (History-Preg/PP), [3] Healthy pregnant women (Control-Preg/PP), and [4] Healthy non-pregnant women (Non-pregnant Control). Serial saliva samples were collected over the course of a day and waking and evening cortisol, total cortisol output and the cortisol awakening response were examined.Results: There were no HPA axis differences among the three groups during pregnancy. A history of ELA, regardless of comorbid depression, was associated with higher evening cortisol levels during pregnancy (p = 0.015). Women in the Depressed-PP group had had higher evening cortisol levels compared to the History-PP group (p < 0.017).Conclusions: Evening cortisol measures are a potential marker for both ELA and depression, with higher levels during pregnancy being associated with ELA and higher levels postpartum being associated with antenatal depression.

The reproductive stress hypothesis

In this paper, we propose the reproductive stress hypothesis that describes the pregnant females response to reproductive events based upon the activation of the hypothalamic–pituitary–adrenal axis and sympathetic adrenomedullary system. The main components of the reproductive stress hypothesis can be summarized as follows: (1) events unique to reproduction including empathema, pregnancy, parturition and lactation cause non-specific responses in females, called active reproductive stress; (2) the fetus is a special stressor for pregnant females where endocrine hormones, including corticotropin-releasing hormones and fetal glucocorticoids secreted by the fetus and placenta, enter the maternal circulatory system, leading to another stress response referred to as passive reproductive stress and (3) response to uterine tension and intrauterine infection is the third type of stress, called fetal intrauterine stress. Appropriate reproductive stress is a crucial prerequisite in normal reproductive processes. By contrast, excessive or inappropriate reproductive stress may result in dysfunctions of the reproductive system, such as compromised immune function, leading to susceptibility to disease. The novel insights of the reproductive stress hypothesis have important implications for deciphering the pathogenesis of certain diseases in pregnant animals, including humans, which in turn may be applied to preventing and treating their occurrence.

Early and current life adversity: Past and present influences on maternal diurnal cortisol rhythms during pregnancy

Stress during pregnancy affects maternal health and well-being, as well as the health and well-being of the next generation, in part through the hypothalamic-pituitary-adrenal (HPA) axis. Although most studies have focused solely on proximal experiences (i.e., during the pregnancy) as sources of prenatal stress, there has been a recent surge in studies that examine maternal early life adversity as a source of stress system dysregulation during pregnancy. The current study of 178 pregnant women examined the association of economic and life stress experienced during two time periods (i.e., childhood and pregnancy) with maternal HPA axis activity during the third trimester of pregnancy. Findings indicated that a current annual income of less than $15,000 and greater childhood disadvantage were associated with a flatter diurnal cortisol slope. Childhood maltreatment, particularly sexual abuse, was associated with a higher cortisol awakening response (CAR), even when controlling for recent adversity. We found some evidence that past adversity moderates the relationship between current adversity and diurnal cortisol, specifically for economic adversity and waking cortisol. Overall, our findings indicate that early life stressors play an important and underappreciated role in shaping stress biology during pregnancy.

Maternal chronic stress correlates with serum levels of cortisol, glucose and C-peptide in the fetus, and maternal non chronic stress with fetal growth

INTRODUCTION

During pregnancy, maternal stressors cause changes in both maternal and fetal HPA axes. We therefore investigated the impact of maternal non chronic and chronic stress on fetal glucose metabolism and growth, and serum levels of cortisol in the fetus.

MATERIALS AND METHODS

Normal weight pregnant women (n = 192; mean ± SD 27.9 ± 4.2 years old, and; 26.9 ± 2.4 kg/m²) were assessed during the 2nd and 3rd trimester with anthropometry, fetal ultrasound, blood samples for serum CRH, cortisol and IL6, and STAI trait and state stress questionnaires. We measured serum cortisol, insulin and c-peptide, and plasma glucose from cord blood. Neonates underwent anthropometry at the 3rd post-delivery day.

RESULTS

In both 2nd and 3rd trimesters, women with STAI trait scores ≥40 had significantly greater levels of fasting serum CRH and cortisol than those with STAI trait scores<40. 2nd trimester: STAI trait scores correlated positively with cord blood glucose and c-peptide. Maternal serum CRH correlated negatively with U/S fetal biparietal head diameter, while serum cortisol correlated positively with abdominal circumference. Maternal serum IL6, CRH and cortisol all correlated positively with birth waist circumference. 3rd trimester: Women with STAI state scores ≥40 had fetuses with larger U/S abdominal and smaller head circumferences compared to those of women with STAI scores <40. Women with STAI trait scores ≥40 had greater levels of cord blood cortisol, glucose, and c-peptide compared to women with STAI scores <40. STAI state scores ≥40 correlated positively with maternal CRH and U/S fetal abdominal circumference, and negatively with fetal head circumference and biparietal diameter. STAI trait scores correlated positively with cord blood c-peptide, glucose, insulin and cortisol. Maternal serum levels of CRH correlated positively with U/S fetal abdominal circumference and cord blood cortisol, and negatively with fetal head circumference and biparietal head diameter. Maternal serum levels of both CRH and cortisol correlated positively with cord blood c-peptide, glucose, and insulin. STAI trait was the best positive predictor of cord blood cortisol, glucose and c-peptide, whilst STAI state was the best positive and negative predictor, respectively of fetal abdominal circumference and fetal head circumference or biparietal diameter.

CONCLUSIONS

Increased maternal chronic stress (reflected by the STAI trait score) associates with increased fetal cortisol, glucose, c-peptide secretion and thus, insulin resistance. Maternal non chronic stress (STAI state) in the 3rd trimester associates with changes in fetal growth pattern, including increased and decreased measurements of fetal abdominal and head growth respectively.

Postpartum changes in affect-related behavior and VTA dopamine neuron activity in rats

The onset of motherhood is accompanied by alterations in emotional and affective behaviors. Many new mothers experience transient and mild depressive symptoms that typically resolve spontaneously (i.e. postpartum blues) but increase the risk for postpartum depression (PPD). There is little data regarding the neural adaptations occurring in response to parturition and shortly after birth that may be associated with these affective changes. Although the dopamine (DA) system is involved in affect, maternal motivation and PPD, little is known about postpartum DA function. We compared affective behavior in virgin and postpartum adult female rats at early and late time points. In vivo extracellular recordings of VTA DA neurons were performed to evaluate 3 parameters: number of active DA neurons (i.e. population activity), firing rate, and firing pattern. Compared with virgins, postpartum rats exhibited increased anxiety-like behavior in the elevated plus maze at 1-day postpartum; reduced social motivation at 1- and 3-days postpartum, reduced anxiety-like behavior in the novelty suppressed feeding test throughout the first week postpartum and increased forced swim test immobility at 1-day postpartum. 1- and 3-day postpartum females exhibited attenuated VTA population activity without changes in firing rate or pattern. None of these effects were observed in late postpartum females when compared with virgins. These data suggest that parturition induces time-dependent changes in a subset of affect-related behaviors and DA function during the postpartum period in rodents, with early postpartum females exhibiting depression-related phenotypes (i.e. low social motivation, higher immobility, blunted DA activity).

Developmental Timing Determines the Protective Effect of Maternal Electroacupuncture on Perinatal Nicotine Exposure-Induced Offspring Lung Phenotype

Introduction. Environmental exposure of the developing offspring to cigarette smoke or nicotine is an important predisposing factor for many chronic respiratory conditions, such as asthma, emphysema, pulmonary fibrosis, and so forth, in the exposed offspring. Studies showed that electroacupuncture (EA) applied to maternal "Zusanli" (ST36) acupoints during pregnancy and lactation protects against perinatal nicotine exposure- (PNE-) induced lung damage. However, the most effective time period, that is, prenatal vs. postnatal, to attain this effect has not been determined.

OBJECTIVE

To determine the most effective developmental timing of EA's protective effect against PNE-induced lung phenotype in the exposed offspring.

METHODS

Pregnant rats were given (1) saline ("S" group); (2) nicotine ("N" group); (3) nicotine + EA, exclusively prenatally ("Pre-EA" group); (4) nicotine + EA, exclusively postnatally ("Post-EA," group); and (5) nicotine + EA, administered both prenatally and postnatally ("Pre- and Post-EA" group). Nicotine was injected once daily (1 mg/kg, 100 μl) and EA was administered to bilateral ST36 acupoints once daily during the specified time-periods. At the end of the experimental periods, key hypothalamic pituitary adrenal (HPA) axis markers in pups and dams, and lung function, morphometry, and the central molecular markers of lung development in the offspring were determined.

RESULTS

After nicotine exposure, alveolar mean linear intercept (MLI) increased, but mean alveolar number (MAN) decreased and lung PPARγ level decreased, but glucocorticoid receptor (GR) and serum corticosterone (Cort) levels increased, in line with the known PNE-induced lung phenotype. In the nicotine exposed group, maternal hypothalamic corticotropin releasing hormone (CRH) level decreased, but pituitary adrenocorticotropic hormone (ACTH) and serum Cort levels increased. In the "Pre- and Post-EA" groups, PNE-induced alterations in lung morphometry, lung development markers, and HPA axis were blocked. In the "Pre-EA" group, PNE-induced changes in lung morphometry, GR, and maternal HPA axis improved; lung PPARγ level decreased, but glucocorticoid receptor (GR) and serum corticosterone (Cort) levels increased, in line with the known PNE-induced lung phenotype. In the nicotine exposed group, maternal hypothalamic corticotropin releasing hormone (CRH) level decreased, but pituitary adrenocorticotropic hormone (ACTH) and serum Cort levels increased. In the "Pre- and Post-EA" groups, PNE-induced alterations in lung morphometry, lung development markers, and HPA axis were blocked. In the "Pre-EA" group, PNE-induced changes in lung morphometry, GR, and maternal HPA axis improved; lung PPAR.

CONCLUSIONS

Maternal EA applied to ST36 acupoints during both pre- and postnatal periods preserves offspring lung structure and function despite perinatal exposure to nicotine. EA applied during the "prenatal period" affords only limited benefits, whereas EA applied during the "postnatal period" is ineffective, suggesting that the EA's effects in modulating PNE-induced lung phenotype are limited to specific time-periods during lung development.

Allopregnanolone-based treatments for postpartum depression: Why/how do they work?

Recent FDA approval of an allopregnanolone-based treatment specifically for postpartum depression, brexanolone, now commercially called Zulresso®, is an exciting development for patients and families impacted by postpartum depression and allows us to start asking questions about why and how this compound is so effective. Allopregnanolone is a neuroactive steroid, or neurosteroid, which can be synthesized from steroid hormone precursors, such as progesterone, or synthesized de novo from cholesterol. Neurosteroids are positive allosteric modulators at GABA_A receptors (GABA_ARs), a property which is thought to mediate the therapeutic effects of these compounds. However, the durability of effect of brexanolone in clinical trials questions the mechanism of action mediating the remarkable antidepressant effects, leading us to ask why and how does this drug work. Asking why this drug is effective may provide insight into the underlying neurobiology of postpartum depression. Exploring how this drug works will potentially elucidate a novel antidepressant mechanism of action and may provide useful information for next generation drug development. In this review, we examine the clinical and preclinical evidence supporting a role for allopregnanolone in the underlying neurobiology of postpartum depression as well as foundational evidence supporting the therapeutic effects of allopregnanolone for treatment of postpartum depression.

Biological and psychosocial predictors of anxiety worsening in the postpartum period: A longitudinal study

BACKGROUND

As many as 20% of women will experience an anxiety disorder during the perinatal period. Women with pre-existing anxiety disorders are at increased risk of worsening during this time, yet little is known about its predictors.

STUDY AIM

To investigate the psychosocial and biological risk factors for anxiety worsening in the postpartum in women with pre-existing anxiety disorders.

METHODS

Thirty-five (n = 35) pregnant women with pre-existing DSM-5 anxiety disorders were enrolled in this prospective study investigating the psychosocial (e.g., childhood trauma, intolerance of uncertainty, depression) and biological risk factors (e.g. C-reactive protein, interleukin-6, tumor necrosis factor-α) for anxiety worsening in the postpartum period. Anxiety worsening was defined as an increase of ≥50% or greater on Hamilton Anxiety Rating Scale scores from the third trimester of pregnancy (32.94 ± 3.35 weeks) to six weeks postpartum.

RESULTS

Intolerance of uncertainty, depressive symptom severity, and obsessive-compulsive disorder symptoms present in pregnancy were significant predictors of anxiety worsening in the postpartum.

LIMITATIONS

Sample heterogeneity and limited sample size may affect study generalizability.

CONCLUSIONS

To our knowledge, this is the first longitudinal study to investigate psychosocial and biological risk factors for anxiety worsening in the postpartum in women with pre-existing anxiety disorders. Continued research investigating these risk factors is needed to elucidate whether they differ from women experiencing new-onset anxiety disorders in the perinatal period, and those in non-puerperal groups. Identifying these risk factors can guide the development of screening measures for early and accurate symptom detection. This can lead to the implementation of appropriate interventions aimed at decreasing the risk of perinatal anxiety worsening.

Mom doesn't care: When increased brain CRF system activity leads to maternal neglect in rodents

Mothers are the primary caregivers in mammals, ensuring their offspring's survival. This strongly depends on the adequate expression of maternal behavior, which is the result of a concerted action of "pro-maternal" versus "anti-maternal" neuromodulators such as the oxytocin and corticotropin-releasing factor (CRF) systems, respectively. When essential peripartum adaptations fail, the CRF system has negative physiological, emotional and behavioral consequences for both mother and offspring often resulting in maternal neglect. Here, we provide an elaborate and unprecedented review on the implications of the CRF system in the maternal brain. Studies in rodents have advanced our understanding of the specific roles of brain regions such as the limbic bed nucleus of the stria terminalis, medial preoptic area and lateral septum even in a CRF receptor subtype-specific manner. Furthermore, we discuss potential interactions of the CRF system with other neurotransmitters like oxytocin and noradrenaline, and present valuable translational aspects of the recent research.

At the forefront of psychoneuroimmunology in pregnancy: Implications for racial disparities in birth outcomes: PART 2: Biological mechanisms

As reviewed in Part 1 of this two part review, 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) and remarkable racial disparities in shortened gestation are observed among African Americans as compared to Whites. Biomechanisms linking stressor exposures with birth outcomes are increasingly being explicated. The current paper reviews the mechanistic role of maternal biological functioning in the link between behavioral exposures and birth outcomes. These include the inter-related roles of neuroendocrine function, inflammatory regulation, biological aging, and the microbiome. An integrative approach which addresses both behavioral and biological factors within the same study, carefully considers the role of race/ethnicity, and rigorously defines birth outcomes (e.g., spontaneous versus medically-indicated and inclusive of early term birth) is needed to move research in this field toward better mechanistic understanding and clinical application.

Neuroactive Steroids and GABAergic Involvement in the Neuroendocrine Dysfunction Associated With Major Depressive Disorder and Postpartum Depression

Stress and previous adverse life events are well-established risk factors for depression. Further, neuroendocrine disruptions are associated with both major depressive disorder (MDD) and postpartum depression (PPD). However, the mechanisms whereby stress contributes to the underlying neurobiology of depression remains poorly understood. The hypothalamic-pituitary-adrenal (HPA) axis, which mediates the body's neuroendocrine response to stress, is tightly controlled by GABAergic signaling and there is accumulating evidence that GABAergic dysfunction contributes to the impact of stress on depression. GABAergic signaling plays a critical role in the neurobiological effects of stress, not only by tightly controlling the activity of the HPA axis, but also mediating stress effects in stress-related brain regions. Deficits in neuroactive steroids and neurosteroids, some of which are positive allosteric modulators of GABA_A receptors (GABA_ARs), such as allopregnanolone and THDOC, have also been implicated in MDD and PPD, further supporting a role for GABAergic signaling in depression. Alterations in neurosteroid levels and GABAergic signaling are implicated as potential contributing factors to neuroendocrine dysfunction and vulnerability to MDD and PPD. Further, potential novel treatment strategies targeting these proposed underlying neurobiological mechanisms are discussed. The evidence summarized in the current review supports the notion that MDD and PPD are stress-related psychiatric disorders involving neurosteroids and GABAergic dysfunction.

Cumulative cortisol exposure in the third trimester correlates with postpartum mothers' neural response to emotional interference

Prolonged stress affects the central nervous system, rendering individuals vulnerable to a wide range of mental health disorders. 76 healthy postpartum mothers were studied by means of functional magnetic resonance imaging within 6 days of childbirth. The subjects were required to perform the emotional Stroop task involving happy and anxious word-face combinations. Hair samples were collected to determine cumulative hair cortisol concentration (HCC) in the third trimester. HCC was found to be negatively correlated with the recruitment of the dorsal anterior cingulate cortex (ACC) and the midcingulate cortex (MCC). In response to the emotional interference of only anxious target faces, a negative correlation was seen between HCC and the bilateral orbitofrontal cortex, extending to the rostral ACC and the MCC. Women with lower HCC recruited brain areas relevant to emotional cognitive control, indicating that lower HCC helps preserve conflict monitoring and resolution capacities and thus benefits mental health in pregnancy.

Associations of maternal oestradiol, cortisol, and TGF-β1 plasma concentrations with thyroid autoantibodies during pregnancy and postpartum

BACKGROUND

Thyroid physiology and autoimmunity are altered in pregnancy. While oestradiol, cortisol, and TGF-β1 are implicated in these phenomena outside pregnancy, their associations with thyroid autoantibodies during pregnancy and postpartum are not thoroughly examined. This study aimed to unravel their eventual associations during pregnancy and postpartum in the same cohort of 93 pregnant women studied prospectively from 2015 to 2017.

METHODS

Blood samples were drawn at the 24th and the 36th gestational week and at the 1st postpartum week for measurements of thyroid hormones, TSH, anti-TPO, anti-Tg, oestradiol, cortisol, and TGF-β1.

RESULTS

Serum anti-TPO was greater (P < 0.05) at the 1st postpartum than at the 24th and 36th gestational weeks. At the 36th gestational week, cortisol was greater (P < 0.05) and TGF-β1 lower (P < 0.05) than at the 24th gestational and the 1st postpartum weeks. At the 1st postpartum week, cortisol correlated negatively with anti-Tg (r = -0.419) (P < 0.05). ΔTGF-β1 was the best negative and Δoestradiol the best positive predictor of the 1st postpartum week anti-TPO (P < 0.05, b = -0.509; P < 0.05, b = 0.459 respectively).

CONCLUSIONS

At postpartum, increased TGF-β1 is related to a less pronounced anti-TPO increase as compared to the 3rd trimester, suggesting an immunosuppressive role for TGF-β1. During pregnancy and postpartum, oestradiol, cortisol, and TGF-β1 are associated with suppression of thyroid autoantibodies.

Oral administration of tea saponins to relive oxidative stress and immune suppression in chickens

The present study was designed to evaluate the effects of tea saponins on oxidative stress induced by cyclophosphamide in chickens. One hundred twenty chickens were randomly divided into 5 groups. Groups 3 to 4 received intramuscular injection of cyclophosphamide to induce oxidative stress and immunosuppression. After that, groups 2 and 4 were orally administered tea saponins in drinking water for 7 d. Then, groups 1 to 4 were immunized with a live, bivalent vaccine of Newcastle disease virus and infectious bronchitis virus. Blood samples were collected for analysis of oxidative parameters and specific antibody titers, and splenocytes were prepared for lymphocyte proliferative assay. The results showed that administration of tea saponins significantly increased total antioxidant capacity, total superoxide dismutase, catalase, glutathione peroxidase, glutathione, ascorbic acid, and α-tocopherol, and decreased malondialdehyde and protein carbonyl. Enhanced immune responses, such as lymphocyte proliferation induced by concanavalin A and lipopolysaccharides, and serum Newcastle disease virus- and infectious bronchitis virus-specific antibodies were also observed in chickens injected with or without cyclophosphamide. In addition, no side effects were found in chickens throughout the study. Therefore, tea saponins may be a potential agent to improve imunosuppression induced by oxidative stress in chickens.

The plasma protein binding of the endogenous glucocorticosteroids is of vital importance for the concentrations in hair and saliva

BACKGROUND

The endogenous glucocorticosteroid cortisol (F) and its metabolite cortisone (E) are known to be involved in stress adaption and anti-inflammatory and immune regulatory effects. The ratios of F to E in the matrices serum, hair and saliva are different. The shift of this ratio by the enzyme activity of 11β-hydroxysteroid-dehydrogenase, which inactivates cortisol, was often discussed. The aim of our study was to calculate the contribution of the plasma protein binding (PPB) to this shift. The PPB of F is known to be 96% of the total F-Concentration in serum. The PPB of E was not analyzed in previous studies.

METHODS

Our study was designed to evaluate the correlation of corticosteroid concentrations in serum (total and free), hair and saliva. The samples were self-collected by the author (A.K.) monthly over a pregnancy cycle (1st samples before pregnancy, 8 samples during pregnancy and 5 samples postpartum). Serum protein binding was calculated from the determination of the total hormone concentrations of F and E (protein bound and unbound) and the free hormone concentrations in serum. The samples were processed by ether extraction and ultrafiltration. Hair samples were extracted with methanol and purified by solid-phase extraction. Saliva samples were collected using Salivette^® collection system. The concentrations of F and E were measured by liquid chromatography-mass spectrometry with LODs for free serum, total serum, hair and saliva of F: 0.11ng/mL, 2.13ng/mL, 1.6pg/mg, 0.08ng/mL and E: 0.12ng/mL, 0.54ng/mL, 2.1pg/mg, 0.09ng/mL, respectively.

RESULTS AND DISCUSSION

The serum concentrations (free and total) of both glucocorticosteroids rise up continuously during the time of pregnancy and decrease after delivery. The free and total serum concentrations were well correlated. No change was detected for the intensity of PPB of F. In contrast, the PPB of E decreases from 86.3% to 80.7% during pregnancy. The concentration ratios of F to E change from 3:1 in total serum to 1:1 in free serum. For hair samples, an increase of F and E in proximal segments was confirmed with the highest concentration 6.5weeks postpartum. Independently, corticosteroid concentrations in corresponding hair segments were found to be reduced with increasing distance from the root; an average decline of F and E by half in 5 and 6months was estimated, respectively. The counter effect of the mechanisms incorporation and wash-out is clearly visible. For saliva samples a good correlation with free, non-protein bound serum concentration was detected.

In pregnancy increased maternal STAI trait stress score shows decreased insulin sensitivity and increased stress hormones

INTRODUCTION

Chronic or acute stressors influence maternal and fetal Hypothalamus-Pituitary-Adrenal Axes (HPA) during pregnancy. In this study, the effect of maternal stress into maternal insulin sensitivity was investigated during pregnancy.

MATERIALS AND METHODS

Eighty-two pregnant women [aged 27.1±2.5 (mean±SD) yrs; BMI=25±2.2kg/m²] had at the 2^nd and 3^rd trimesters anthropometry, fasting blood samples (cortisol, Corticotropin Releasing Hormone (CRH), active amylin, Interleukin (IL6)), Oral Glucose Tolerance Test (OGTT) for glucose and insulin, state-trait anxiety inventory (STAI) trait and state questionnaires (for stress assessment).

RESULTS

Maternal cortisol, CRH and STAI state score increased significantly from 2^nd to 3^rd trimester. At these trimesters women with STAI trait scores ≥40 had greater serum cortisol and CRH concentrations and lower insulin sensitivity index (ISI) values than those with scores <40 while STAI trait score predicted negatively ISI. At the 2^nd trimester maternal CRH concentrations correlated positively with maternal STAI state, Homeostatic Model Assessment Insulin Resistance (HOMAR), 1^st and 2^nd phase insulin secretion and negatively with ISI. STAI trait correlated negatively with ISI. STAI state correlated positively with maternal systolic blood pressure and HOMAR. At the 3^rd trimester STAI trait correlated negatively and positively with ISI and STAI state, respectively, while STAI state correlated positively with HOMAR. In women with STAI state scores ≥40, these scores correlated positively with maternal CRH.

CONCLUSIONS

In normal pregnant women, enhanced long-term stress is associated with decreased insulin sensitivity. Both long- and short- term stress are associated with enhanced maternal HPA axis and increased placental CRH secretion.

Fetal and maternal metabolic responses to exercise during pregnancy

Pregnancy is characterized by physiological, endocrine and metabolic adaptations creating a pseudo-diabetogenic state of progressive insulin resistance. These adaptations occur to sustain continuous fetal requirements for nutrients and oxygen. Insulin resistance develops at the level of the skeletal muscle, and maternal exercise, especially activity involving large muscle groups improve glucose tolerance and insulin sensitivity. We discuss the maternal hormonal and metabolic changes associated with a normal pregnancy, the metabolic dysregulation that may occur leading to gestational diabetes mellitus (GDM), and the consequences to mother and fetus. We will then examine the acute and chronic (training) responses to exercise in the non-pregnant state and relate these alterations to maternal exercise in a low-risk pregnancy, how exercise can be used to regulate glucose tolerance in women at risk for or diagnosed with GDM. Lastly, we present key exercise guidelines to help maintain maternal glucose regulation and suggest future research directions.

Puberty and perimenopause: reproductive transitions and their implications for women's health

This scoping review synthesizes existing research on two major transitions in females' lives: puberty and perimenopause. These two periods of vast physiological change demarcate the beginning and the end of the reproductive life cycle and are associated with major neuroendocrine reorganization across two key systems, the hypothalamic-pituitary-gonadal (HPG) axis the hypothalamus-pituitary-adrenal (HPA) axis. Despite growing evidence suggesting that the timing and experience of puberty and perimenopause are related to various physical and mental health outcomes (e.g., mood disorders, metabolism, cardiovascular health, autoimmune conditions, and cancer), these two processes are rarely examined together. In this paper, we bridge these disparate literatures to highlight similarities, isolate inconsistencies, and identify important areas for future research in women's health.

Developmental origins of flatter cortisol rhythms: socioeconomic status and adult cortisol activity

OBJECTIVE

Low socioeconomic status (SES) is associated with increased psychosocial stress among low-income persons, which could contribute to differences in activity of the HPA axis (assessed by diurnal cortisol profiles). The current article investigates associations of SES from different developmental stages with cortisol profiles.

METHODS

Using data from a large, socioeconomically diverse birth cohort (N = 1,490) in Cebu, Philippines, the current study compares the relative and joint contributions of SES from five developmental periods, between the prenatal/birth period and early adulthood, to adult cortisol, and examines the effects of chronic exposure to low SES.

RESULTS

Chronically low SES from infancy through early adulthood predicts the highest bedtime cortisol levels, lowest cortisol awakening responses (CARs), lowest total cortisol levels across the day (area under curve or AUC), and the flattest cortisol rhythms between wake up and bedtime, a profile associated with poorer health. Results indicate that cumulative economic strain (between the prenatal period and early adulthood) predicts flatter cortisol rhythms more consistently than SES from any particular period.

CONCLUSION

Interventions focusing on the psychosocial stressors associated with economic deprivation during any period from infancy to adulthood may be helpful, but targeting interventions across multiple periods may have the greatest impact. Interventions aimed at improving economic conditions between infancy and early adulthood may have implications for long-term changes in HPA axis functioning.

The effects of childhood sexual abuse on cortisol trajectories in pregnancy are moderated by current family functioning

The goal of this study was to understand the roles of maternal history of childhood sexual abuse (CSA) and current family functioning on the cortisol awakening response (CAR) in pregnancy. Participants were 185 pregnant women (ages 18-40) who completed items from the Adverse Childhood Experiences scale to measure child maltreatment history and the Family Assessment Device to measure current family functioning. Participants provided saliva samples at wake-up and 30min after wake-up at 25, 29, and 35 weeks gestation to measure CAR. A moderation effect was found such that participants with more severe CSA histories and poorer perceived family functioning had increasing CAR in pregnancy compared to participants with less severe CSA histories and better family functioning. These findings highlight the importance of considering stress in both childhood and current environments in predicting maternal cortisol in pregnancy.

Evaluation of the association between placental corticotrophin-releasing hormone and postpartum depressive symptoms

OBJECTIVE

Postpartum depression (PPD) represents a significant threat to maternal-child health. Although PPD is common, with an estimated prevalence of 10% to 15%, critical questions concerning its etiology remain unanswered. Existing studies seem to provide conflicting evidence regarding the relation between placental corticotrophin-releasing hormone (pCRH) and the development of PPD. The purpose of the present investigation was to determine whether maternal prepartum hypothalamic-pituitary-adrenal and placental dysregulation, in particular elevated midgestational pCRH, represent markers of risk for the development of PPD symptoms.

METHODS

One hundred seventy adult women with singleton, term pregnancies were recruited during the first trimester and participated in study visits at 15, 19, 25, 31, and 36+ weeks' gestation and at 3 and 6 months postpartum. At each prenatal visit, blood samples were obtained and assayed to determine maternal cortisol, adrenocorticotropic hormone, and pCRH concentrations. Depressive symptoms were assessed at all visits.

RESULTS

Depressive symptoms at 3 months postpartum were associated with elevated midgestational pCRH (partial r = 0.26; p < .01) and also accelerated trajectories of pCRH (B values ranged from 6.9 to 8.3, p < .05). Placental CRH was not predictive of PPD symptoms at 6 months postpartum. Furthermore, prepartum cortisol and corticotrophin profiles were not associated with PPD symptoms.

CONCLUSIONS

The current prospective study provides results that reconcile both the positive and negative findings in the existing literature and identifies elevated pCRH as a marker of risk for the development of PPD symptoms.

Adverse pregnancy outcomes and risk of subsequent rheumatoid arthritis

OBJECTIVE

Pregnancy and reproductive outcomes have been associated with altered risk of some autoimmune diseases, including rheumatoid arthritis (RA). We sought to determine whether prior pregnancy resulting in a low birth weight (LBW) infant or preterm birth is associated with a risk of subsequent RA in the mother.

METHODS

We conducted an analysis of RA risk in parous women from a population-based prospective study of newly diagnosed cases of RA and age-matched healthy controls. The primary outcome measure was disease status (RA versus control), with exposures of prior preterm birth and prior delivery of an infant with LBW (≤2,500 gm), very low birth weight (VLBW; ≤1,500 gm), or extremely low birth weight (ELBW; ≤1,000 gm). A preplanned analysis including only rheumatoid factor (RF)-positive RA cases was also conducted.

RESULTS

A total of 202 RA cases and 1,102 controls were analyzed. Prior delivery of an infant with ELBW was associated with RA in the mother (relative risk [RR] 3.7 [95% confidence interval (95% CI) 1.0-13.2]). Prior VLBW (RR 4.0 [95% CI 1.3-11.4]) and ELBW (RR 5.5 [95% CI 1.4-22.5]) infants were associated with RF-positive RA. Prior LBW deliveries and preterm births were more common among RA cases than controls, but the differences were not statistically significant.

CONCLUSION

Compared to those with uncomplicated pregnancies, women with a prior VLBW or ELBW delivery had a higher risk of RA, particularly RF-positive RA. This association may reflect common risk factors for pregnancy complications and RA. Alternatively, complicated pregnancy itself may confer risk of subsequent RA.

Prenatal stress and risk of behavioral morbidity from age 2 to 14 years: the influence of the number, type, and timing of stressful life events

The maternal experience of stressful events during pregnancy has been associated with a number of adverse consequences for behavioral development in offspring, but the measurement and interpretation of prenatal stress varies among reported studies. The Raine Study recruited 2900 pregnancies and recorded life stress events experienced by 18 and 34 weeks' gestation along with numerous sociodemographic data. The mother's exposure to life stress events was further documented when the children were followed-up in conjunction with behavioral assessments at ages 2, 5, 8, 10, and 14 years using the Child Behavior Checklist. The maternal experience of multiple stressful events during pregnancy was associated with subsequent behavioral problems for offspring. Independent (e.g., death of a relative, job loss) and dependent stress events (e.g., financial problems, marital problems) were both significantly associated with a greater incidence of mental health morbidity between age 2 and 14 years. Exposure to stressful events in the first 18 weeks of pregnancy showed similar associations with subsequent total and externalizing morbidity to events reported at 34 weeks of gestation. These results were independent of postnatal stress exposure. Improved support for women with chronic stress exposure during pregnancy may improve the mental health of their offspring in later life.

"Anatomy of an Illness": control from a caregiver's perspective

Caregivers of loved ones with chronic illnesses experience an uncontrollable challenge with potentially negative behavioral and medical consequences. Extensive research has demonstrated immune and endocrine regulation can be significantly disrupted by negative behavioral factors based on both animal models and human studies. However, fewer studies have focused on how psychosocial interventions might reverse the negative consequences of stressors such as caregiving. The distress of caring for individuals with cancer has only recently begun to receive attention. These interventions addressing caregiver distress are rare overall and caregivers of patients receiving hematopoietic stem cell transplants (HSCT) have received even less attention. HSCT caregivers report feelings of loss of control. Animal studies suggest that control over aversive events can mitigate the negative consequences of stressors. Caregivers of allogeneic HSCT patients for blood cancers must be available 24/7 for three months or longer following stem cell infusion to closely monitor the recipients' health and well-being. Does establishing a greater sense of control have positive impacts on caregivers? A randomized control trial of a cognitive behavioral stress management intervention for allogeneic HSCT caregivers is briefly described. A model of caregiver mental health which may potentially impact the patient's quality of life is proposed. These relationships exist in a complex system that includes genetic influences, sex, social environment, and prior experience. This system fits well within recent formulations of a "complexity science" approach to health and well-being.

New insights into the role of perinatal HPA-axis dysregulation in postpartum depression

Postpartum depression affects 10-20% of women following birth and exerts persisting adverse consequences on both mother and child. An incomplete understanding of its etiology constitutes a barrier to early identification and treatment. It is likely that prenatal hormone trajectories represent both markers of risk and also causal factors in the development of postpartum depression. During pregnancy the maternal hypothalamic-pituitary-adrenal axis undergoes dramatic alterations, due in large part, to the introduction of the placenta, a transient endocrine organ of fetal origin. We suggest that prenatal placental and hypothalamic-pituitary-adrenal axis dysregulation is predictive of risk for postpartum depression. In this model the positive feedback loop involving the systems regulating the products of the HPA axis results in higher prenatal levels of cortisol and placental corticotropin-releasing hormone. Greater elevations in placental corticotropin-releasing hormone are related to a disturbance in the sensitivity of the anterior pituitary to cortisol and also perhaps to decreased central corticotropin-releasing hormone secretion. Secondary or tertiary adrenal insufficiencies of a more extreme nature, which emerge during the prenatal period, may be predictive of an extended or more pronounced postpartum hypothalamic-pituitary-adrenal refractory period, which in turn represents a risk factor for development of postpartum depression. In addition to reviewing the relevant existing literature, new data are presented in support of this model which link elevated placental corticotropin-releasing hormone with low levels of ACTH at 3-months postpartum. Future research will further elucidate the role of hypothalamic-pituitary-adrenal axis dysregulation in postpartum depression and also whether prenatal placental and hypothalamic-pituitary-adrenal profiles might prove useful in the early identification of mothers at risk for postpartum mood dysregulation.

Alterations in physiology and anatomy during pregnancy

Pregnant women undergo profound anatomical and physiological changes so that they can cope with the increased physical and metabolic demands of their pregnancies. The cardiovascular, respiratory, haematological, renal, gastrointestinal and endocrine systems all undergo important physiological alterations and adaptations needed to allow development of the fetus and to allow the mother and fetus to survive the demands of childbirth. Such alterations in anatomy and physiology may cause difficulties in interpreting signs, symptoms, and biochemical investigations, making the clinical assessment of a pregnant woman inevitably confusing but challenging. Understanding these changes is important for every practicing obstetrician, as the pathological deviations from the normal physiological alterations may not be clear-cut until an adverse outcome has resulted. Only with a sound knowledge of the physiology and anatomy changes can the care of an obstetric parturient be safely optimized for a better maternal and fetal outcome.

Physiological reactivity to psychological stress in human pregnancy: current knowledge and future directions

Cardiovascular and neuroendocrine reactivity to acute stress are important predictors of health outcomes in non-pregnant populations. Greater magnitude and duration of physiological responses have been associated with increased risk of hypertensive disorders and diabetes, greater susceptibility to infectious illnesses, suppression of cell-mediated immunity as well as risk for depression and anxiety disorders. Stress reactivity during pregnancy has unique implications for maternal health, birth outcomes, and fetal development. However, as compared to the larger literature, our understanding of the predictors and consequences of exaggerated stress reactivity in pregnancy is limited. This paper reviews the current state of this literature with an emphasis on gaps in knowledge and future directions.

Reproductive rate, not dominance status, affects fecal glucocorticoid levels in breeding female meerkats

Glucocorticoid hormones (GCs) have been studied intensively to understand the associations between physiological stress and reproductive skew in animal societies. However, we have little appreciation of the range of either natural levels within and among individuals, or the associations among dominance status, reproductive rate and GCs levels during breeding. To address these shortcomings, we examined variation in fecal glucocorticoid metabolites (fGC) during breeding periods in free-ranging female meerkats (Suricata suricatta) over 11 years. The vast majority of variation in fGC levels was found within breeding events by the same female (~87%), with the remaining variation arising among breeding events and among females. Concentrations of fGC generally tripled as pregnancy progressed. However, females with a high reproductive rate, defined as those conceiving within a month following parturition (mean = 9 days postpartum), showed significant reductions in fGC in the final 2 weeks before parturition. Despite these reductions, females with a high reproductive rate had higher fGC levels at conception of the following litter than those breeding at a low rate. After controlling for the higher reproductive rate of dominants, we found no association between levels of fGC and either age or dominance status. Our results suggest that one should be cautious about interpreting associations between dominance status, reproductive skew and GCs levels, without knowledge of the natural variation in GCs levels within and among females.

Both oxytocin and vasopressin are mediators of maternal care and aggression in rodents: from central release to sites of action

In the mammalian peripartum period, the activity of both the brain oxytocin and vasopressin system is elevated as part of the physiological adaptations occurring in the mother. This is reflected by increased expression and intracerebral release of oxytocin and vasopressin, as well as increased neuropeptide receptor expression and binding. In this review we discuss the functional role of the brain oxytocin and vasopressin system in the context of maternal behavior, specifically maternal care and maternal aggression in rodents. In order to enable the identification of significant and peptide-specific contributions to the display of maternal behavior, various complementary animal models of maternal care and/or maternal aggression were studied, including rats selectively bred for differences in anxiety-related behavior (HAB and LAB dams), monitoring of local neuropeptide release during ongoing maternal behavior, and local pharmacological or genetic manipulations of the neuropeptide systems. The medial preoptic area was identified as a major site for oxytocin- and vasopressin-mediated maternal care. Furthermore, both oxytocin and vasopressin release and receptor activation in the central amygdala and the bed nucleus of the stria terminalis play an important role for maternal aggression. This article is part of a Special Issue entitled Oxytocin, Vasopressin, and Social Behavior.

Changes in the maternal hypothalamic-pituitary-adrenal axis during the early puerperium may be related to the postpartum 'blues'

Most women experience time-limited and specific mood changes in the days after birth known as the maternity blues (Blues). The maternal hypothalamic-pituitary-adrenal (HPA) axis undergoes gradual changes during pregnancy because of an increasing production of placental corticotrophin-releasing hormone (CRH). The abrupt withdrawal of placental CRH at birth results in a re-equilibration of the maternal HPA axis in the days post-delivery. These changes may be involved in the aetiology of the Blues given the central role of the HPA axis in the aetiology of mood disorders in general, and in perinatal depression in particular. We aimed to test the novel hypothesis that the experience of the Blues may be related to increased secretion of hypothalamic adrenocorticotrophic hormone (ACTH) secretagogue peptides, after the reduction in negative-feedback inhibition on the maternal hypothalamus caused by withdrawal of placental CRH. We therefore examined hormonal changes in the HPA axis in the days after delivery in relation to daily mood changes: our specific prediction was that mood changes would parallel ACTH levels, reflecting increased hypothalamic peptide secretion. Blood concentrations of CRH, ACTH, cortisol, progesterone and oestriol were measured in 70 healthy women during the third trimester of pregnancy, and on days 1-6 post-delivery. Blues scores were evaluated during the postpartum days. Oestriol, progesterone and CRH levels fell rapidly from pregnancy up to day 6, whereas cortisol levels fell modestly. ACTH concentrations declined from pregnancy to day 3 post-delivery and thereafter increased up to day 6. Blues scores increased, peaking on day 5, and were positively correlated with ACTH; and negatively correlated with oestriol levels during the postpartum days, and with the reduction in CRH concentrations from pregnancy. These findings give indirect support to the hypothesis that the 'reactivation' of hypothalamic ACTH secretagogue peptides may be involved in the aetiology of the Blues.

OPRM1 gene variation influences hypothalamic-pituitary-adrenal axis function in response to a variety of stressors in rhesus macaques

The endogenous opioid system is involved in modulating a number of behavioral and physiological systems, including the hypothalamic-pituitary-adrenal (HPA) axis. In humans, a functional variant in the OPRM1 gene (OPRM1 A118G) is associated with a number of outcomes, including attenuated HPA axis responses to stress. A nonsynonymous variant (OPRM1 C77G) in the rhesus macaque has been shown to have similar effects in vivo to the human variant. The current study investigated whether OPRM1 C77G influences HPA axis response to stress in rhesus macaques. We analyzed plasma adrenocorticotropic hormone (ACTH) and cortisol levels measured in response to three different stressors: (1) maternal separation in infant subjects at 6 months of age, (2) acute ethanol administration in adolescent subjects at 4 years of age, and (3) postpartum HPA axis function in adult rhesus macaque females. For the maternal separation paradigm, ACTH and cortisol levels were determined at baseline as well as peak levels during each of 4 consecutive separation episodes. For the acute ethanol administration paradigm, hormone levels were determined at baseline and again at 5 min, 10 min, and 60 min following the ethanol infusion. For postpartum sampling, hormone levels were determined at postpartum days 7, 14, 21, 30, 60, 90, 120, and 150. Infants carrying the 77G allele exhibited lower levels of cortisol across all 4 separation episodes. Furthermore, adolescents carrying the 77G allele exhibited lower cortisol levels at 5 and 10 min following acute ethanol administration. Adult females with prior reproductive experience and who carry the 77G allele exhibited lower cortisol levels across the postpartum period. No significant genotype effects were found for ACTH, although there were some trends for lower ACTH levels in 77G allele carriers. These data are consistent with human studies that have demonstrated attenuated cortisol responses to stress among carriers of the OPRM1 118G allele, lending further support to the argument that the rhesus and human allelic variants are functionally similar. Our results also suggest that OPRM1 variation may influence coping style, as well as alcohol-induced and postpartum levels of HPA axis activity and, as such, may modify vulnerability to alcohol use disorders and postpartum depression.