Anne Eskild

Review of validation studies of the Edinburgh Postnatal Depression Scale.

Objective:  To review validation studies of the Edinburgh Postnatal Depression Scale (EPDS).

Depression in postpartum and non-postpartum women: prevalence and risk factors

Objective:  The aim of the study was to assess the prevalence of depression in postpartum women as compared with non‐postpartum women, and to identify risk factors of depression in both groups.

The Edinburgh Postnatal Depression Scale: validation in a Norwegian community sample.

This study was undertaken to validate a Norwegian translation of the Edinburgh Postnatal Depression Scale (EPDS). The EPDS was validated against the DSM-IV criteria for major depression, derived from the PRIME-MD, in an interview study of 56 women selected from a community-based questionnaire study of 310 women 6 weeks postpartum. A score of > or =10 on the EPDS scale identified all women with major depression, giving a sensitivity of 100% (95% confidence interval; 72%-100%) and a specificity of 87% (95% confidence interval; 77%-95%). The EPDS scores were strongly correlated with the Montgomery-Asberg Depression Rating Scale in the subsample of women interviewed (n=56) and with the Hopkins Symptom Check List (SCL-25) scores in the questionnaire study (n=310). Our results with regard to the sensitivity and specificity estimates are comparable with prior validation studies; however, the confidence intervals around the estimates are wide. Nevertheless, this study confirms that the EPDS is a valid clinical screening instrument for detecting postpartum depression.

Maternal Serum Levels of 25-Hydroxy-Vitamin D During Pregnancy and Risk of Type 1 Diabetes in the Offspring

Previous studies indicate reduced risk of type 1 diabetes after intake of vitamin D supplements during pregnancy or early childhood. We aimed to test whether lower maternal serum concentrations of 25-hydroxy-vitamin D (25-OH D) during pregnancy were associated with an increased risk of childhood-onset type 1 diabetes. In this case-control study nested within a cohort of 29,072 women in Norway, 25-OH D levels were measured using a radioimmunoassay on samples from late pregnancy in 109 women delivering a child who developed type 1 diabetes before 15 years of age (case subjects) and from 219 control women. Dividing the levels of maternal 25-OH D into quartiles, there was a trend toward a higher risk of type 1 diabetes with lower levels of vitamin D during pregnancy. The odds of type 1 diabetes was more than twofold higher for the offspring of women with the lowest levels of 25-OH D compared with the offspring of those with levels above the upper quartile. Given future replication in independent cohorts, our findings provide support for the initiation of a randomized intervention trial to prevent type 1 diabetes in children by enhancing maternal 25-OH D status during pregnancy.

Body mass, diabetes and smoking, and endometrial cancer risk: a follow-up study

We examined the relationship of body mass index (BMI), diabetes and smoking to endometrial cancer risk in a cohort of 36 761 Norwegian women during 15.7 years of follow-up. In multivariable analyses of 222 incident cases of endometrial cancer, identified by linkage to the Norwegian Cancer Registry, there was a strong increase in risk with increasing BMI (P-trend <0.001). Compared to the reference (BMI 20–24 kg m−2), the adjusted relative risk (RR) was 0.53 (95% confidence interval (CI): 0.19–1.47) for BMI<20 kg m−2, 4.28 (95% CI: 2.58–7.09) for BMI of 35–39 kg m−2 and 6.36 (95% CI: 3.08–13.16) for BMI⩾40 kg m−2. Women with known diabetes at baseline were at three-fold higher risk (RR 3.13, 95% CI: 1.92–5.11) than those without diabetes; women who reported current smoking at baseline were at reduced risk compared to never smokers (RR 0.55, 95% CI: 0.35–0.86). The strong linear positive association of BMI with endometrial cancer risk and a strongly increased risk among women with diabetes suggest that any increase in body mass in the female population will increase endometrial cancer incidence.

Fear of childbirth; the relation to anxiety and depression

Abstract  Objective. To study the associations of anxiety and depression with fear of childbirth. Design. A cross‐sectional questionnaire study. Setting. Prenatal public healthcare in Norway. Sample. Pregnant women (n=1642) recruited during November 2008 until April 2010. Methods. Data were collected by a postal questionnaire at pregnancy week 32. Fear of childbirth was measured by the Wijma Delivery Expectancy Questionnaire (W‐DEQ) and by a numeric rating scale. Symptoms of anxiety were measured by the Hopkins Symptom Check List (SCL‐25) and symptoms of depression by the Edinburgh Postnatal Depression Scale (EPDS). Main outcome measure. Fear of childbirth. Results. Eight per cent (137 of 1642) of the women had fear of childbirth (W‐DEQ≥85), 8.8% (145 of 1642) had anxiety (SCL‐anxiety≥18) and 8.9% (146 of 1642) had depression (EPDS≥12). More than half (56.2%) of the women with fear of childbirth did not have anxiety or depression; however, presence of anxiety or depression increased the prevalence of fear of childbirth (odds ratio 2.4, 95% confidence interval 1.1–5.2 and odds ratio 8.4, 95% confidence interval 4.8–14.7, respectively). Women with both anxiety and depression had the highest prevalence of fear of childbirth (odds ratio 11.0, 95% confidence interval 6.6–18.3). Similar associations of anxiety and depression were estimated by using the numerical rating scale for measuring fear of childbirth. Conclusions. Presence of anxiety and depression increased the prevalence of fear of childbirth; however, the majority of women with fear of childbirth had neither anxiety nor depression.

Use of Psychotropic Medications in Treating Mood Disorders during Lactation Practical Recommendations

Many new mothers who need antidepressant or mood-stabilising drug treatment may wish to breastfeed their infants, but are hesitant to do so because of possible harmful effects of the medication on the infant. This article reviews current data on drug excretion into breast milk and the effects on the breast-fed child, and provides recommendations for the use of the different psychotropic drugs in lactating women.Relevant literature was identified through systematic searches of MEDLINE, EMBASE and the Science Citation Index Expanded (ISI) from 1966 to February 2005. The present knowledge is based on the accumulation of case studies. No randomised controlled trials in breast-fed infants have been performed and there is a lack of long-term follow-up studies.Use of SSRIs and TCAs (except doxepin) is compatible with breastfeeding. However, if treatment with an SSRI is started in the postpartum period, fluoxetine and citalopram may not be drugs of first choice. With regard to other antidepressants, such as venlafaxine, trazodone, mirtazapine, reboxetine, moclobemide and other MAOIs, very little knowledge exists. Breastfeeding should be avoided while using lithium. Carbamazepine and sodium valproate (valproic acid) are generally better tolerated by the breast-fed infant than lithium. Data on lamotrigine are still sparse. Knowledge is also scarce on the novel antipsychotics and thus recommendations in lactating women cannot be made for these agents. It is unwise to expose infants unnecessarily to drugs that may have severe adverse effects. As such, clozapine should probably be avoided because of the risk of agranulocytosis.Our knowledge of the impact of drug exposure through breast milk is still limited. Infant drug exposure is, however, generally higher during pregnancy through placental passage than through breast milk. Despite the low dosage transfered to the infant through breast milk, premature infants and infants with neonatal diseases or inherited disturbances in metabolism may be vulnerable to such exposure.

Placental Weight Relative to Birth Weight and Long-term Cardiovascular Mortality: Findings From a Cohort of 31,307 Men and Women

Birth weight is inversely associated with risk of adult cardiovascular disease, and evidence exists that fetal adaptation to challenges in the intrauterine environment may adversely affect long-term cardiovascular health. The placenta is in a key position to mediate such effects because adequate placental function is necessary for delivery of nutrients, oxygen, and hormones to the fetus. This prospective population study based on data from the hospital birth charts of 31,307 Norwegian men and women born between 1934 and 1959 assessed whether placental weight relative to birth weight was associated with risk of death from cardiovascular disease in adulthood. During 45 years of follow-up, 382 people died from cardiovascular disease (median age, 51.3 years). Results showed that the placenta-to-birth-weight ratio was positively associated with cardiovascular disease mortality; the sex- and cohort-adjusted hazard ratio for the highest versus the lowest third was 1.38 (95% confidence interval: 1.07, 1.77). The authors concluded that a disproportionately large placenta relative to birth weight was associated with increased risk of cardiovascular disease death. This finding suggests that placental function is important in the association of intrauterine factors with cardiovascular disease later in life.

Depression during pregnancy and after delivery: a repeated measurement study.

The aim of this study was to examine the risk of depression in the postpartum period (first four months after delivery) as compared to the remaining postnatal year and the pregnancy period.All postpartum women from two municipalities in Norway were included in a questionnaire study of mental health (n = 416). Over 50% of the women (n = 259) answered an identical questionnaire at an additional time either before or after the postpartum period. The level of depression was measured by the Edinburgh Postnatal Depression Scale (EPDS) and the Hopkins Symptom Check List-25 items (SCL-25).The point prevalence of depression (EPDS ≥ 10) in the first four months postpartum did not differ significantly as compared to other time periods during pregnancy and the postnatal year. This finding remained also after controlling for other risk factors of depression; high score on the life event scale, prior depression and poor partner relationship. There was a non-significant trend of lower prevalence of depression during early pregnancy and after the first eight postnatal months.In conclusion, our findings suggest that the first four months postpartum were not distinguished by higher depression prevalence as compared to other time periods during pregnancy and the first postnatal year.

Association of cerebral palsy with Apgar score in low and normal birthweight infants: population based cohort study

Objectives To assess the association of Apgar score 5 minutes after birth with cerebral palsy in both normal weight and low birthweight children, and also the association with the cerebral palsy subdiagnoses of quadriplegia, diplegia, and hemiplegia. Design Population based cohort study. Setting The Medical Birth Registry of Norway was used to identify all babies born between 1986 and 1995. These data were linked to the Norwegian Registry of Cerebral Palsy in Children born 1986-95, which was established on the basis of discharge diagnoses at all paediatric departments in Norway. Population All singletons without malformations born in Norway during 1986-95 and who survived the first year of life (n=543 064). Main outcome measure Cerebral palsy diagnosed before the age of 5 years. Results 988 children (1.8 in 1000) were diagnosed with cerebral palsy before the age of 5 years. In total, 11% (39/369) of the children with Apgar score of less than 3 at birth were diagnosed with cerebral palsy, compared with only 0.1% (162/179 515) of the children with Apgar score of 10 (odds ratio (OR) 53, 95% CI 35 to 80 after adjustment for birth weight). In children with a birth weight of 2500 g or more, those with an Apgar score of less than 4 were much more likely to have cerebral palsy than those who had an Apgar score of more than 8 (OR 125, 95% confidence interval 91 to 170). The corresponding OR in children weighing less than 1500 g was 5 (95% CI 2 to 9). Among children with Apgar score of less than 4, 10-17% in all birthweight groups developed cerebral palsy. Low Apgar score was strongly associated with each of the three subgroups of spastic cerebral palsy, although the association was strongest for quadriplegia (adjusted OR 137 for Apgar score <4 v Apgar score >8, 95% CI 77 to 244). Conclusions Low Apgar score was strongly associated with cerebral palsy. This association was high in children with normal birth weight and modest in children with low birth weight. The strength of the association differed between subgroups of spastic cerebral palsy. Given that Apgar score is a measure of vitality shortly after birth, our findings suggest that the causes of cerebral palsy are closely linked to factors that reduce infant vitality.