Psychosomatic disorders in pregnancy

PURPOSE OF REVIEW: Common and important psychosomatic disorders in pregnancy reviewed here include perinatal depression, posttraumatic stress disorders, anxiety disorders, eating disorders, and postpartum psychosis. RECENT FINDINGS: Research has focused on antenatal depression as postpartum depression often has onset prior to delivery. Certain psychosocial and psychological interventions can effectively prevent postnatal depression. Although the use of selective serotonin reuptake inhibitors was associated with miscarriage, preterm delivery, and fetal death, discontinuation of antidepressants also increased the relapse rate during pregnancy. Studies also show that about 8% of mothers had eating problems during their pregnancy, which increased to 19% in the postpartum period. Postpartum psychosis is an important diagnosis related to maternal death from suicide. Personal and family history of bipolar disorders are important risk factors. SUMMARY: Recent findings highlight the importance of correct diagnosis and awareness of serious mental illness. In view of the higher rate of relapse, women should be counselled carefully regarding discontinuation of antidepressants during pregnancy. Differentiation of posttraumatic stress disorders with comorbid anxiety and depression, awareness of risk factors, and clinical features of psychosis are important in the management of psychosomatic disorders in pregnancy.     

Remission of eating disorder during pregnancy: five cases and brief clinical review

Eating disorder during pregnancy is associated with a diversity of adverse outcomes and is of potential danger to both mother and child. There is, however, a tendency for remission of the eating disorder during pregnancy with improvement of symptoms such as restrictive dieting, binging and purging, and some women actually manage to put the disease behind them. This case report describes five women with different eating disorders and focuses on the symptomatology during pregnancy and in the months postpartum. The discussion deals with the possible psychological, social and endocrinological reasons for remission and the subsequent relapse, the definition of recovery and the factors which should alert health care professionals of the at-risk pregnancies in cases of undisclosed eating disorder. Furthermore, therapeutic interventions are proposed.     

Obstetricians and maternal body weight and eating disorders during pregnancy

Intrauterine growth restriction (IUGR) is associated with maternal prepregnancy body mass index (BMI), body weight gain during pregnancy and smoking, eating and weight-losing behaviors. The aim of this pilot study was to examine the practices of obstetricians to determine whether more can be done to prevent IUGR and 'do no harm' to the body image of women during pregnancy. Obstetricians (n = 67) who reported delivering an average of 125 babies in the previous year completed a questionnaire that enquired about their antenatal practice of maternal weighing, history taking and referral of pregnant women. No doctor calculated the prepregnancy BMI. Women (90%) were weighed during some or all antenatal visits, usually by the nurse-receptionist, but one-third of the obstetricians did not refer to these body weight records. Most obstetricians asked women about their cigarette smoking and alcohol intake before pregnancy, and during pregnancy discussed supplements and nausea and vomiting. Fewer than 50% of doctors asked about depression, body weight control and disordered eating. One-third of doctors were not aware of having seen a woman with an eating disorder in the previous year. Obstetricians who asked about eating disorders were more likely to ask about depression, and obstetricians in private practice were significantly less likely to ask women about a history of depression and to refer women to a psychologist or psychiatrist Obstetricians could improve antenatal care by asking about body weight and calculating prepregnancy BMI, and investigating weight-losing behavior and psychological or psychiatric problems such as eating disorders.     

Effectiveness of a Counseling Intervention after a Traumatic Childbirth: A Randomized Controlled Trial

Abstract: Adverse childbirth experiences can evoke fear and overwhelming anxiety for some women and precipitate posttraumatic stress disorder. The objective of this study was to assess a midwife‐led brief counseling intervention for postpartum women at risk of developing psychological trauma symptoms. Method : Of 348 women screened for trauma symptoms, 103 met inclusion criteria and were randomized into an intervention (n = 50) or a control (n = 53) group. The intervention group received face‐to‐face counseling within 72 hours of birth and again via telephone at 4 to 6 weeks postpartum. Main outcome measures were posttraumatic stress symptoms, depression, self‐blame, and confidence about a future pregnancy. Results : At 3‐month follow‐up, intervention group women reported decreased trauma symptoms, low relative risk of depression, low relative risk of stress, and low feelings of self‐blame. Confidence about a future pregnancy was higher for these women than for control group women. Three intervention group women compared with 9 control group women met the diagnostic criteria for posttraumatic stress disorder at 3 months postpartum, but this result was not statistically significant. Discussion : A high prevalence of postpartum depression and trauma symptoms occurred after childbirth. Although most women improved over time, the intervention markedly affected participants’ trajectory toward recovery compared with women who did not receive counseling. Conclusions : A brief, midwife‐led counseling intervention for women who report a distressing birth experience was effective in reducing symptoms of trauma, depression, stress, and feelings of self‐blame. The intervention is within the scope of midwifery practice, caused no harm to participants, was perceived as helpful, and enhanced women's confidence about a future pregnancy.     

Eating disorders and women's health: an update

Anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified have a significant impact on the health care and childbearing outcomes of the female population. Primary care contact for gynecologic care, childbearing, or infertility can serve as a critical entry point for the initial recognition of potentially devastating disorders that may result in permanent impairment and/or chronic debilitation. This review addresses the nature and prevalence of eating disorders and the management of pregnancy complicated by an active eating disorder or a history of an eating disorder. Genetic influences and intergenerational transmission of eating disorders are discussed. Finally, the increased risk for postpartum depression among women with a current or past eating disorder is examined. Factors critical to improving pregnancy outcome and reducing the risk for exacerbation or relapse in the postpartum period are identified.     

Depression,anxiety, PTSD and comorbidity in perinatal women in Turkey: A longitudinal population-based study

Objective: (a) to assess prevalence of depression, anxiety and post-traumatic stress disorder (PTSD) and their comorbidity among women during the perinatal period (b) to examine course of those disorders from pregnancy to 6 months postpartum (c) to determine the rates of new-onset cases at 4-6 weeks and 6 months postpartum.Design: A longitudinal population-based study in which participants completed psychosocial measures of depression, anxiety and PTSD in pregnancy (n = 950), 4-6 weeks (n = 858) and 6 months (n = 829) after birth.Setting: A consecutive sample of pregnant women were recruited from three maternity hospitals in three cities of Turkey: Istanbul, Ankara and Izmir.Measures: Edinburgh Postnatal Depression Scale (EPDS), Hospital Anxiety and Depression Scale (HADS), and Posttraumatic Diagnostic Scale (PDS) were used to assess depression, anxiety and PTSD, respectively.Findings: Depression and PTSD peaked at 4-6 weeks postpartum and then fell at 6 months postpartum, whereas anxiety followed a gradually declining linear-pattern from pregnancy to 6 months postpartum. The prevalence of depression was 14.6% in pregnancy, 32.6% at 4-6 weeks and 18.5% at 6 months postpartum, respectively. The prevalence of PTSD was 5.8% in pregnancy, 11.9% at 4-6 weeks postpartum and 9.2% at 6 months postpartum. Anxiety was highest in pregnancy (29.6%) and then decreased to 24.6% 4-6 weeks after birth and to 16.2% 6 months after birth. New-onset cases were most apparent at 4-6 weeks postpartum: 24.6% for depression; 13.7% for anxiety and 8.9% for PTSD.Key conclusions: A relatively high prevalence of psychological disorders was identified during the perinatal period. Anxiety was most prevalent in pregnancy, and depression and PTSD were highest at 4-6 weeks postpartum. Depression was more common than anxiety 4-6 weeks and 6 months after birth and highly comorbid with anxiety throughout this period. New-onset cases were observed at both 4-6 weeks and 6 months postpartum.Implications: High rates of affective disorders in pregnancy and after birth highlight three main points: first, it is important to have effective perinatal screening to identify women with psychological needs; second, providing early treatment to women experiencing severe psychological problems is essential to ensure psychological well-being of those women and to prevent chronicity; and finally, psychosocial screening and interventions should be offered until at least 6 months after birth to catch new-onset cases.     

Women’s Mental Health Before,During, and After Pregnancy: A Population‐Based Controlled Cohort Study

ABSTRACT: Background: Common mental health disorders like depressive and anxiety disorders are frequent in antenatal and postpartum women. However, no agreement about the prevalence of these disorders and the course of women’s mental health during the transition to motherhood exists. This study compared women’s mental health before, during, and after pregnancy with a control group of nonpregnant women. Methods: Three hundred and twenty‐four women were assessed before, during, and after their pregnancy with the 12‐item version of the General Health Questionnaire (GHQ‐12). A control group of 324 women who did not deliver during 3 subsequent years was assessed with the GHQ‐12 at corresponding time‐points. Results: No differences in GHQ‐12 mean scores, prevalence, and incidence of common mental health disorders between the study and control groups were found. No differences in prevalence and incidence rates within each group were found. The presence of a common mental health disorder before pregnancy or in early pregnancy predicted common mental health disorders in the postpartum period. Conclusions: Common mental health disorders are frequent during pregnancy and the postpartum period, but pregnant or postpartum women are not more at risk than those who are not pregnant or who did not deliver. (BIRTH 33:4 December 2006)     

Practical advice for caring for women with eating disorders during the perinatal period

Pregnancy is a critical time for women struggling with disordered eating and weight concerns. For the majority of women with eating disorders, symptoms improve during pregnancy. Other women, particularly those with either subclinical or binge eating disorders, are at risk for an escalation of pathologic behaviors, putting both mother and fetus at risk for negative birth outcomes. Routinely screening for eating disorders will help identify those women who will most benefit from specialized care. Attention must be paid to possible harmful comorbid behaviors found in women with eating disorders, such as smoking, alcohol use, abusing laxatives or herbal supplements, and self-injurious behavior. This article reviews the mixed research findings of the impact of eating disorders upon pregnancy and identifies key times in prenatal care where nutritional counseling and specific interventions will increase the likelihood of positive pregnancy outcomes. The postpartum period is another critical time for provider intervention that may lower women's risks for eating disorder relapse, postpartum depression, and breastfeeding difficulties.     

Depression and anxiety during pregnancy and six months postpartum: a follow-up study

AIMS: To investigate the relationship between antenatal and postpartum depression and anxiety and to explore associated maternal characteristics. METHODS: From a population-based sample of 1,555 women attending two obstetric clinics in Sweden, all women with an antenatal psychiatric diagnosis (n = 220) and a random selection of healthy women (n = 500) were contacted for a second assessment three to six months postpartum. The Primary Care Evaluation of Mental Disorders was used for evaluation on both occasions. RESULTS: Fewer cases of depressive and/or anxiety disorders were prevalent postpartum compared with the second trimester screening. Depression and/or anxiety were prevalent in 16.5% of postpartal women versus 29.2% of pregnant women. There was a significant shift from a majority of subthreshold diagnoses during pregnancy to full Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) diagnoses during the postpartum period. A history of previous psychiatric disorder, living single, and obesity were significantly associated with a new-onset postpartum psychiatric disorder. The absence of a previous psychiatric disorder was significantly associated with a postpartum recovery of depression or anxiety. CONCLUSIONS: Depression and anxiety appear to be less common postpartum than during pregnancy.     

Maternal and neonatal outcome following cerebrovascular accidents during pregnancy.

OBJECTIVE: To assess the clinical characteristics of maternal and neonatal outcome among women with cerebrovascular accidents (CVA) during pregnancy. METHODS: Our computerized database was used to identify patients with CVA during pregnancy and puerperium from January 1988 to March 2004. Their medical records were identified and reviewed. RESULTS: There were 16 cases of CVA among 173,803 deliveries, giving a risk of almost one case per 10,000 pregnant women. Out of 16 patients, 14 (88%) had a stroke and the remaining two cases were diagnosed with venous thrombosis. Of those 14 cases, nine (64%) had ischemic strokes and five (36%) had hemorrhagic strokes. Ten of the CVAs occurred antepartum, two intrapartum and four postpartum. Hypertensive disorders were diagnosed in 75% (12/16) of the patients. Out of these 12 patients with hypertension, 9 (75%) suffered from preeclampsia. One woman had a history of chronic hypertension. Smoking was associated with 63% (10/16) of the cases. There were two maternal deaths, both in women who had hemorrhagic strokes, and both in the first half of the study (1994 and 1996). Nine out of 16 women (56%), were delivered within 48 hours of the CVA including 7 (78%) antepartum, and two (22%) intrapartum. Cesarean deliveries were performed in 11/16 women (69%) including 8/10 with CVAs occurring antepartum, 1/2 intrapartum and 2/4 postpartum. One case of neonatal mortality was identified in a patient who was delivered at 24 gestational weeks. CONCLUSIONS: (1) Hypertensive disorders and smoking were the most important factors associated with CVA during pregnancy. (2) Maternal mortality was high among patients with CVA during pregnancy. (3) Neonatal outcome was considered generally good in cases of CVA.     

Prior psychiatric inpatient care and risk of cesarean sections: a registry study

This study of 17,443 childbearing women, investigated the relationship between hospital admissions 5 years prior to index birth, type of mental disorders and risk factors for mode of delivery. Hospital based electronic perinatal medical records between 2001 and 2006, were linked with the Swedish National Inpatient Care Registry 1996-2006. Of all the women, 39.3% had had inpatient care prior to index birth (27.3% had had obstetric, 10.1% somatic, and 1.9% psychiatric inpatient care). Diagnoses of mental disorders at psychiatric admission (n=333) were categorized into five groups: personality/behavioral/unspecified disorder (30.9%), affective disorders and 'suicide attempt' (28.9%), neurotic/somatoform disorders (18.9%), substance use (17.1%) and schizophrenia (4.2%). Women with history of psychiatric care were more often smokers, below age 24 and single (p<0.001, respectively), had more markers of mental ill-health in pregnancy records (p≤0.001), compared to women without such previous care, and fewer were nulliparous (p<0.001). The results show that women with prior psychiatric inpatient care and those with identified mental ill-health in pregnancy records, were associated with increased adjusted risks of cesarean sections. Identifying a woman?s mental health status in pregnancy may predict and prevent emergency cesarean section.     

Rates and risk factors associated with depressive symptoms during pregnancy and with postpartum onset

Abstract

The objectives of this study were to evaluate the prevalence of depressive symptoms in the third trimester of pregnancy and at 3 months postpartum and to prospectively identify risk factors associated with elevated depressive symptoms during pregnancy and with postpartum onset. About 364 women attending antenatal clinics or at the time of their ultrasound were recruited and completed questionnaires in pregnancy and 226 returned their questionnaires at 3 months postpartum. Depressed mood was assessed by the Edinburgh Postnatal Depression Scale (EPDS; score of?≥?10). The rate of depressed mood during pregnancy was 28.3% and 16.4% at 3 months postpartum. Among women with postpartum depressed mood, 6.6% were new postpartum cases. In the present study, belonging to a non-Caucasian ethnic group, a history of emotional problems (e.g. anxiety and depression) or of sexual abuse, comorbid anxiety, higher anxiety sensitivity and having experienced stressful events were associated with elevated depressed mood during pregnancy. Four risk factors emerged as predictors of new onset elevated depressed mood at 3 months postpartum: higher depressive symptomatology during pregnancy, a history of emotional problems, lower social support during pregnancy and a delivery that was more difficult than expected. The importance of identifying women at risk of depressed mood early in pregnancy and clinical implications are discussed.     

Anorexia nervosa, bulimia, and pregnancy

Of 74 women previously treated for anorexia nervosa or bulimia, 15 had conceived 23 pregnancies when assessed at follow-up. The status of the eating disorder, course of pregnancy and delivery, infant health, and postpartum adjustment are described. Women in whom eating disorders were in remission at conception had greater maternal weight gain and babies with higher birth weights and 5-minute Apgar scores than women who conceived while they still had symptoms of restricting anorexia nervosa or bulimia. Women who had symptoms of eating disorders at conception also had continuance or worsening of these symptoms during pregnancy and the postpartum year. We recommend delay of pregnancy until the eating disorder is truly in remission.     

History of the Diagnosis of a Sexually Transmitted Disease is Linked to Normal Variation in Personality Traits

IntroductionStable individual differences in personality traits have well‐documented associations with various aspects of health. One of the health outcomes that directly depends on people's behavioral choices, and may therefore be linked to personality traits, is having a sexually transmitted disease (STD).AimThe study examines the associations between a comprehensive set of basic personality traits and past STD history in a demographically diverse sample.MethodsParticipants were 2,110 Estonians (1,175 women) between the ages of 19 and 89 (mean age 45.8 years, SD = 17.0). The five‐factor model personality traits (Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness) and their specific facets were rated by participants themselves and knowledgeable informants. Sex, age, and educational level were controlled for.Main Outcome MeasureHistory of STD diagnosis based on medical records and/or self‐report.ResultsHistory of STD diagnosis was associated with higher Neuroticism and lower Agreeableness in both self‐ and informant‐ratings. Among the specific personality facets, the strongest correlates of STD were high hostility and impulsiveness and low deliberation.ConclusionsIndividual differences in several personality traits are associated with a history of STD diagnosis. Assuming that certain personality traits may predispose people to behaviors that entail a higher risk for STD, these findings can be used for the early identification of people at greater STD risk and for developing personality‐tailored intervention programs. Mõttus R, Realo A, Allik J, Esko T, and Metspalu A. History of the diagnosis of a sexually transmitted disease is linked to normal variation in personality traits. J Sex Med 2012;9:2861–2867.     

Eating disorders and depression in hungarian women with menstrual disorders and infertility

Menstrual disorders are among the most frequent somatic computations and symptoms of eating disorders. This study was designed to assess the prevalence of eating disorders connected to menstrual disorders of a non-organic origin in women at two gynecological out-patient departments.

We performed a survey via questionnaires (ANIS: Anorexia Nervosa Inventory Scale; BCDS: Bulimic Cognitive Distortions Scale; BITE: Bulimia Investigation list, Edinburgh; EDI: Eating Disorders Inventory; BDI: Beck Depression Inventory). Among 75 women tested we found a prevalence figure of 4% for anorexia nervosa (AN) and 12% for bulimia nervosa (BN). The total prevalence of clinical and subclinical eating disorders syndromes was 44%. The prevalence of depression was 64% for all respondents, whilst severe depression accounted for 11%. This study demonstrates the (relatively) higher frequency of bulimia nervosa in Hungary, compared with other countries.     

Eating disorders and depression in Hungarian women with menstrual disorders and infertility.

Menstrual disorders are among the most frequent somatic complications and symptoms of eating disorders. This study was designed to assess the prevalence of eating disorders connected to menstrual disorders of a non-organic origin in women at two gynecological out-patient departments. We performed a survey via questionnaires (ANIS: Anorexia Nervosa Inventory Scale; BCDS: Bulimic Cognitive Distortions Scale; BITE: Bulimia Investigation Test, Edinburgh; EDI: Eating Disorders Inventory; BDI: Beck Depression Inventory). Among 75 women tested we found a prevalence figure of 4% for anorexia nervosa (AN) and 12% for bulimia nervosa (BN). The total prevalence of clinical and subclinical eating disorders syndromes was 44%. The prevalence of depression was 64% for all respondents, whilst severe depression accounted for 11%. This study demonstrates the (relatively) higher frequency of bulimia nervosa in Hungary, compared with other countries.     

Critical issues in the care of pregnant women with eating disorders and the impact on their children

Pregnancy and eating disorders is a subject that has received relatively little attention in the literature. Nevertheless, serious complications have been found in both the mother and the baby during both pregnancy and post partum period. This article alerts practitioners to the physical and psychological risks that imperil pregnant women with histories of recent eating disorders, describes the experiences of three women with eating disorders during pregnancy whose children developed eating difficulties, and suggests some guidelines for the screening and care of women with eating disorders and their babies.     

Eating Disorders and Childbearing: Concealment and Consequences

ABSTRACT: The reported incidence of eating disorders has increased markedly during the past 30 years. Numerous studies have linked a spectrum of eating disorders to serious medical complications resulting in hospitalization and death. The prevalence of such disorders occurs primarily in women of adolescent and childbearing age. This article reviews the published literature alerting the practitioner to the indicators of a condition that is seldom disclosed bythe client or detected by the caregiver. Predisposing factors, behavioral theories, and reproductive outcomes are discussed to provide clear evidence of the link between eating disorders and poor pregnancy outcome. Recommendations are offered for early recognition ofa repeatedly concealed disease and for management of eating disorders during the childbearing cycle. (BIRTH 29:3 September 2002)     

Severe Maternal Morbidity Associated with Hypertensive Disorders in Pregnancy in the United States

Objectives: This study was to report the incidence of severe maternal morbidity associated with hypertensive disorders of pregnancy in the United States. Study Design: We used data from the National Hospital Discharge Survey, a nationally representative sample of discharge records, from 1988 to 1997. The database consisted of approximately 300,000 deliveries, which represented 39 million births during the 10‐year period. Results: The overall incidence of hypertensive disorders in pregnancy was 5.9% [95% confidence interval (CI): 5.2 to 6.5%]. Eclampsia was reported at 1.0 per 1000 deliveries (95% CI: 0.8 to 1.2). The incidence of eclampsia, severe preeclampsia, and superimposed preeclampsia remained unchanged during the 10‐year period. Women with preeclampsia and eclampsia had a 3‐ to 25‐fold increased risk of severe complications, such as abruptio placentae, thrombocytopenia, disseminated intravascular coagulation, pulmonary edema, and aspiration pneumonia. More than half of women with preeclampsia and eclampsia had cesarean delivery. African American women not only had higher incidence of hypertensive disorders in pregnancy but also tended to have a greater risk for most severe complications. Preeclamptic and eclamptic women younger than 20 years or older than 35 years had substantially higher morbidity. Conclusion: Preeclampsia and eclampsia carry a high risk for severe maternal morbidity. Compared to Caucasians, African Americans have higher incidence of hypertensive disorders in pregnancy and suffer from more severe complications.     

Relationship of reproductive cycle-associated and non-reproductive cycle-associated psychological problems in women

OBJECTIVE: To determine the frequency of past psychological problems associated with the reproductive cycle in women seeking routine gynecological care. METHODS: Three hundred and sixty-eight women of menopausal age seen at a university medical center gynecology clinic were mailed a questionnaire requesting information about past mood or anxiety problems associated with specific reproductive cycle or hormone use times, such as the premenstruum, pregnancy, postpartum, perimenopause, following total hysterectomy with bilateral salpingo-oophorectomy, and during oral contraceptive or hormone replacement treatment. Chi-square analysis was done between groups categorized as with and without reproductively associated psychological problems (RAPP) and with or without non-reproductively related psychological problems (non-RAPP). Relative risk of women with RAPP having non-RAPP also was calculated. Results-One hundred thirteen women returned the questionnaire. Fifty percent of these women reported a past history of reproductive cycle-associated psychological problems (RAPP). Of these, 37% also reported psychological problems at times in their lives not associated with particular reproductive cycle (non-RAPP) times. However, of the 50% of women who reported no history of RAPP, only 14% reported non-RAPP. This was a significant difference between the groups (p = .0064). There was also a 2.7 times greater risk of women with RAPP also having non-RAPP (RR 2.7). CONCLUSIONS: Women with reproductively associated psychological problems have a greater risk of also having psychological problems at non-reproductively associated times.