Momentary stress, cortisol, and gestational length among pregnant victims of childhood maltreatment: a pilot study

Stress before conception and during pregnancy and maternal cortisol during pregnancy: A scoping review

BACKGROUND

Stress before conception and during pregnancy is associated with less favorable maternal and child health. Alterations in prenatal cortisol levels may serve as a central biological pathway linking stress to adverse maternal and child health. Research examining associations between maternal stress from childhood through pregnancy and prenatal cortisol has not been comprehensively reviewed.

METHOD

The current scoping review of 48 papers synthesizes studies reporting on associations between stress before conception and during pregnancy with maternal cortisol in pregnancy. Eligible studies measured childhood, the proximal preconception period, pregnancy, or lifetime stress based on stress exposures or appraisals and measured cortisol in saliva or hair during pregnancy.

RESULTS

Higher maternal childhood stress was associated with higher cortisol awakening responses and alterations in typical pregnancy-specific changes in diurnal cortisol patterns across studies. In contrast, most studies of preconception and prenatal stress reported null associations with cortisol and those reporting significant effects were inconsistent in direction. A few studies found that the associations between stress and cortisol during pregnancy varied as a function of several moderators including social support and environmental pollution.

CONCLUSIONS

Although many studies have evaluated effects of maternal stress on prenatal cortisol, this scoping review is the first to synthesize existing literature on this topic. The association between stress before conception and during pregnancy and prenatal cortisol may depend on the developmental timing of stress and several moderators. Maternal childhood stress was more consistently associated with prenatal cortisol than proximal preconception or pregnancy stress. We discuss methodological and analytic factors that may contribute to mixed findings.

The associations between childhood maltreatment and pregnancy complications: A systematic review and meta-analysis

INTRODUCTION

Childhood maltreatment is associated with pregnancy complications. This study aimed to systematically review and quantitatively synthesize the strength of the associations between maternal histories of childhood maltreatment and the risk of preterm delivery, low birth weight, and gestational diabetes.

METHODS

Subject Headings and keywords for childhood maltreatment and the pregnancy outcomes were searched in MEDLINE (Ovid; 1946-Present), PsycINFO (Ovid; 1806-Present), and Web of Science Core Collection. Original studies or dissertations that reported quantitative associations between childhood maltreatment and any of the pregnancy outcomes of interest were included. Two independent reviewers selected the pertinent studies, assessed the risk of bias, and extracted data. Pooled effect sizes were calculated for the three outcomes.

RESULTS

Twenty-eight studies were reviewed and 22 were meta-analysed. Maternal childhood maltreatment was associated with preterm birth (OR = 1.27 95% CI: 1.06-1.52, p = 0.001), low birth weight (OR = 1.42 95% CI: 1.10-1.83, p = 0.001), and gestational diabetes (RR = 1.37 95% CI: 1.02-1.83, p = 0.030), however high levels of heterogeneity were found. Findings were insignificant for studies examining gestational age and birth weight as continuous variables.

DISCUSSION

Findings confirm that under certain conditions, childhood maltreatment is associated with pregnancy outcomes. Future research should prioritize mediation and moderation models to clarify the mechanisms underlying these relationships. Trauma-informed care is needed to tailor the appropriate care for expecting mothers.

Integrative Review of Early Life Adversity and Cortisol Regulation in Pregnancy

OBJECTIVE

To synthesize published findings on the relationship between early life adversity and hypothalamic-pituitary-adrenal axis cortisol parameters in pregnant women.

DATA SOURCES

We searched PubMed, CINAHL, and PsycINFO databases using variants and combinations of the keywords early life adversity, pregnancy, hypothalamic-pituitary-adrenal axis, and cortisol.

STUDY SELECTION

We selected articles that included pregnant participants, included measures of cortisol and early life adversity, were published in English in a peer-reviewed journal, and were of sufficient methodologic quality. Date of publication was unrestricted through May 2020.

DATA EXTRACTION

Twenty-five articles met the inclusion criteria and were evaluated for quality and risk of bias. Sources of cortisol included saliva, hair, plasma, and amniotic fluid.

DATA SYNTHESIS

We categorized findings according to four physiologically distinct cortisol output parameters: diurnal (daily pattern), phasic (in response to an acute stressor), tonic (baseline level), and pregnancy-related change. Preliminary evidence suggests that early adversity may be associated with elevated cortisol awakening response (diurnal) and blunted response to acute stressors (phasic), irrespective of other psychosocial symptoms or current stress. For women with high levels of current stress or psychological symptoms, early adversity was associated with higher baseline (tonic) cortisol levels.

CONCLUSION

Early life adversity in women is linked with alterations in cortisol regulation that are apparent during pregnancy. Researchers should examine how variations in each cortisol parameter differentially predict pregnancy health risk behaviors, maternal mental health, and neonatal health outcomes.

The social ecology of childhood and early life adversity

An increasing prevalence of early childhood adversity has reached epidemic proportions, creating a public health crisis. Rather than focusing only on adverse childhood experiences (ACEs) as the main lens for understanding early childhood experiences, detailed assessments of a child's social ecology are required to assess "early life adversity." These should also include the role of positive experiences, social relationships, and resilience-promoting factors. Comprehensive assessments of a child's physical and social ecology not only require parent/caregiver surveys and clinical observations, but also include measurements of the child's physiology using biomarkers. We identify cortisol as a stress biomarker and posit that hair cortisol concentrations represent a summative and chronological record of children's exposure to adverse experiences and other contextual stressors. Future research should use a social-ecological approach to investigate the robust interactions among adverse conditions, protective factors, genetic and epigenetic influences, environmental exposures, and social policy, within the context of a child's developmental stages. These contribute to their physical health, psychiatric conditions, cognitive/executive, social, and psychological functions, lifestyle choices, and socioeconomic outcomes. Such studies must inform preventive measures, therapeutic interventions, advocacy efforts, social policy changes, and public awareness campaigns to address early life adversities and their enduring effects on human potential. IMPACT: Current research does not support the practice of using ACEs as the main lens for understanding early childhood experiences. The social ecology of early childhood provides a contextual framework for evaluating the long-term health consequences of early life adversity. Comprehensive assessments reinforced with physiological measures and/or selected biomarkers, such as hair cortisol concentrations to assess early life stress, may provide critical insights into the relationships between early adversity, stress axis regulation, and subsequent health outcomes.

Climate change is a major stressor causing poor pregnancy outcomes and child development

The climate crisis is the existential threat of our times and for generations to come. This is no longer a threat but a reality affecting us, our children, and the generations that follow. Pregnant mothers, their fetuses, and their children are among those at greatest risk in every population and every jurisdiction. A timely consideration is the health of racialized groups who are particularly vulnerable owing to the confluence of several risk factors that are compounded by climate change. Included among these are Indigenous communities that are the most directly threatened by climate change. This review discusses the main health challenges faced by mothers, fathers, and their children during the climate crisis, focusing on mental health as a causal factor. Exploration of this topic includes the role of prenatal maternal and paternal stresses, allostatic load, and the effect of degradation of the environment and ecosystems on individuals. These will be examined in relation to adverse pregnancy outcomes and altered developmental trajectories of children. The climate crisis is a health threat multiplier that amplifies the health inequities of the most at-risk populations and individuals. It accelerates the increase in allostatic load of those at risk. The path of tragedy begins with an accumulating allostatic load that overwhelms both individual and socio-ecological resilience. This can lead to worse mental health including depression and anxiety and, in the case of pregnant women and their children, more adverse pregnancy outcomes and impaired developmental trajectories for their newborn children. We argue that there is an urgent need to develop new (or re-discover or re-purpose existing) tools that will predict communities and individuals who are experiencing the highest levels of climate-related hazards and intervene to reduce stress and increase resilience in pre-conceptual women and men, pregnant and post-partum women, and their young children.

Maternal History of Adverse Childhood Experiences and Ambulatory Blood Pressure in Pregnancy

OBJECTIVE

This study aimed to study the association between maternal history of childhood adversity and blood pressure in pregnancy.

METHODS

A total of 127 pregnant women completed measures of adverse childhood experiences (ACE) and prenatal stress between June 2015 and April 2019. At 11 weeks' gestation (range, 6-17 weeks), we measured 24-hour ambulatory blood pressure. All women were considered to be at risk for pregnancy complications due to elevated body mass index and self-reporting snoring in pregnancy.

RESULTS

Women were, on average, 30 years old (range, 19-40 years), and average (standard deviation) body mass index in this sample was 34 (7) kg/m (range, 27-55 kg/m). Higher ACE scores were associated with higher nighttime blood pressure (systolic blood pressure: β = 0.23, p = .013; diastolic blood pressure: β = 0.22, p = .028). There were no significant associations between the ACE score and daytime blood pressure. Women with four or more ACEs were more likely to display nocturnal blood pressure nondipping (odds ratio = 3.97, 95% confidence interval = 1.38-11.40). Associations between ACE and nocturnal blood pressure remained significant after adjusting for symptoms of prenatal stress.

CONCLUSIONS

Results indicate that experiences of childhood adversity are associated with elevated nocturnal blood pressure and loss of a typical decline in blood pressure between day and night.

Early life adversity and depressive symptoms predict cortisol in pregnancy

Evidence suggests that exposure to early life adversity (ELA) programs the hypothalamic-pituitary-adrenal (HPA) axis to influence responses to later adversity and predisposes women to depression. However, few studies have examined whether ELA moderates the HPA cortisol response to adulthood adversity and depressive symptoms in pregnant women. The aims of this study were to determine (a) whether ELA, adulthood adversity, and depressive symptoms differentially predict patterns of cortisol and (b) whether ELA moderates the relationship of adulthood adversity or depressive symptoms to cortisol. This was a descriptive, cross-sectional study of pregnant women (N = 58, mean = 26.5 weeks gestation). Participants completed the Stress and Adversity Inventory and Edinburgh Depression Scale and collected salivary cortisol five times per day for 3 days to assess cortisol awakening response (CAR), diurnal cortisol slope, and cortisol area under the curve (AUC). ELA predicted a larger CAR, while depressive symptoms predicted a blunted CAR and higher cortisol AUC. Adulthood adversity predicted a blunted CAR and steeper diurnal slope, but only in women with high ELA. ELA also moderated the effect of depressive symptoms on diurnal slope. Early adversity and depressive symptoms appear to have significant effects on the HPA axis during pregnancy, with early adversity also moderating effects of depressive symptoms and adulthood adversity on cortisol regulation. Early adversity may be an important factor in identifying unique HPA phenotypes and risk for HPA axis dysregulation in pregnancy.

Prenatal two-hit stress affects maternal and offspring pregnancy outcomes and uterine gene expression in rats: match or mismatch?

Maternal stress and inflammation excesses can lead to adverse pregnancy outcomes and offspring development. We evaluated whether distinct prenatal stressors affect pregnancy, maternal and offspring outcomes, and uterine gene expression differently when combined than either alone. Long-Evans dams were exposed to psychological or/and (two-hit) immune stress (interleukin-1 beta [IL-1β]), on gestational days 12-18 and 17-delivery, respectively. Gestational length, maternal weight gain, glycaemia and corticosterone levels, offspring weight, and gender effects were recorded. Maternal and offspring uteri were collected at weaning and on postnatal day 160 correspondingly. Uterine expression of genes involved in local progesterone metabolism, neuroendocrine and immune systems were analyzed using quantitative real-time polymerase chain reaction. Maternal two-hit stress increased gestational length variation and the occurrence of adverse pregnancy outcomes while reducing gestational weight gain. Pup weight was negatively affected by prenatal stressors in a gender-specific way. In dams, IL-1β upregulated gene expression of neuroendocrine (Crh, Crhr1) and cytokine genes (Il1b, Il1rn, Il6, and Il10). Conversely, transcriptional patterns in offspring uteri were more variable with gene-specific up- or downregulation by each stressor separately, while exposure to both extensively reduced the expression of neuroendocrine (Hsd11b1), cytokine (Il1a, Il1rn, Il6), and IL-1 receptor genes. In conclusion, maternal stress affects physiological and molecular processes in dams and their offspring; two hits have different effects than single stressors. Outcomes appear generation-, gender-, and stressor-specific. Dampening of offspring uterine gene expression after exposure to multiple stressors could fit within the match/mismatch hypothesis of perinatal programming, with offspring preparing for a stressful life.

Childhood maltreatment and inflammation among pregnant women with gestational diabetes mellitus: A pilot study

BACKGROUND

Women with childhood maltreatment histories are at increased risk for adverse birth outcomes. Mechanisms explaining this link are poorly understood. Past research is limited by sampling pregnant women at low risk for adverse maternal and neonatal outcomes.

METHODS

This pilot study was a secondary data analysis of 24 women with gestational diabetes mellitus; 17% of the sample also reported a maltreatment history. Women provided a blood sample to measure inflammatory cytokines and insulin resistance, and saliva samples to measure diurnal cortisol. Birth outcomes for past and current pregnancies were recorded.

RESULTS

Histories of maltreatment were associated with elevated interleukin-15 and a marginally greater incidence of preterm delivery in current and past pregnancies.

CONCLUSIONS

This pilot study was the first to demonstrate an association between childhood maltreatment history and inflammatory cytokine levels in pregnant women diagnosed with gestational diabetes mellitus.