Marci Adams

Antenatal depressive symptoms increase the likelihood of preterm birth.

OBJECTIVE We evaluated the relationship between antenatal depressive symptoms and preterm birth. STUDY DESIGN Patients completed the Edinburgh Postnatal Depression Scale between 24-28 weeks of gestation. A score ≥ 12 (or thoughts of self-harm) indicated an at-risk woman. Symptomatic women were compared to risk-negative patients for relevant demography, historical variables, and pregnancy outcome. RESULTS After screening 14,175 women we found a screen positive rate of 9.1% (n = 1298). At-risk women had a significant increase in preterm birth at <37, <34, <32, and <28 weeks of gestation. Multivariable analysis adjusting for maternal age, race/ethnicity, prior preterm delivery, and insurance status revealed a persistent association between antenatal depressive symptoms and preterm birth (adjusted odds ratio, 1.3; 95% confidence interval, 1.09-1.35), which was also observed after multiple gestations were excluded from the analysis (odds ratio, 1.7; 95% confidence interval, 1.38-1.99). CONCLUSION In this large cohort of prenatally screened women, those with depressive symptoms had an increased likelihood of preterm birth.

Suicide risk among perinatal women who report thoughts of self-harm on depression screens.

OBJECTIVE: To estimate the incidence and clinical significance of suicidal ideation revealed during perinatal depression screening and estimate the associated suicide risk. METHODS: Retrospective cohort study of women completing the Edinburgh Postnatal Depression Scale at 24–28 weeks of gestation and 6 weeks postpartum through a suburban integrated health system with approximately 5,000 annual deliveries on two hospital campuses. Suicidal ideation on the Edinburgh Postnatal Depression Scale and prediction of suicide risk were examined through multivariable modeling and qualitative analysis of clinical assessments. RESULTS: Among 22,118 Edinburgh Postnatal Depression Scale questionnaires studied, suicidal ideation was reported on 842 (3.8%, 95% confidence interval [CI] 3.5–4.1%) and was positively associated with younger maternal age (antepartum mean age 30.9 compared with 31.9 years, P=.001), unpartnered relationship status (antepartum 29.5% compared with 16.5%, P<.001 and postpartum 25.0% compared with 17.5%, P<.01), non-Caucasian race (antepartum 62.1% compared with 43.8%, P<.001 and postpartum 62.4% compared with 45.2%, P<.001), non-English language (antepartum 11.0% compared with 6.6%, P<.001 and postpartum 12.4% compared with 7.7%, P<.01), public insurance (antepartum 19.9% compared with 12.5%, P<.001 and postpartum 18.2% compared with 14.2%, P<.001), and preexisting psychiatric diagnosis (antepartum 8.4% compared with 4.2%, P<.001 and postpartum 12.0% compared with 5.8%, P<.001). Multivariable antepartum and postpartum models retained relationship status, language, relationship status by language interaction, and race; the postpartum model also found planned cesarean delivery negatively associated with suicidal ideation risk (odds ratio [OR] 0.56, 95% CI 0.36–0.87) and severe vaginal laceration positively associated with suicidal ideation risk (OR 2.1, 95% CI 1.00–4.40). A qualitative study of 574 women reporting suicidal ideation indicated that 330 (57.5%, 95% CI 53.5–61.5%) experienced some degree of suicidal thought. Six patients (1.1%, 95% CI 0.2–1.9%) demonstrated active suicidal ideation with plan, intent, and access to means. Within this highest risk group, three patients reported a suicide attempt within the perinatal period. CONCLUSION: Among perinatal women screened for depression, 3.8% reported suicidal ideation, but only 1.1% of this subgroup was at high risk for suicide. These findings support the need for systematic evaluation of those who report suicidal ideation to identify the small subset requiring urgent evaluation and care. LEVEL OF EVIDENCE: II

Association of Fetal Abdominal-Head Circumference Size Difference With Shoulder Dystocia: A Multicenter Study

Objective This study aims to determine if shoulder dystocia is associated with a difference in the fetal abdominal (AC) to head circumference (HC) of 50 mm or more noted on antenatal ultrasound. Study Design A multicenter matched case–control study was performed comparing women who had shoulder dystocia to controls who did not. Women with vaginal births of live born nonanomalous singletons ≥ 36 weeks of gestation with an antenatal ultrasound within 4 weeks of delivery were included. Controls were matched for gestational age, route of delivery, and diabetes status. Results We identified 181 matched pairs. Only 5% of the fetuses had an AC to HC of ≥ 50 mm. The proportion of AC to HC difference of ≥ 50 mm was significantly higher in shoulder dystocia cases (8%) than controls (1%, p = 0.002). With multivariate regression, the three significant factors associated with shoulder dystocia were AC to HC ≥ 50 mm (odds ratio [OR], 7.3; confidence interval [CI], 1.6–33.3; p = 0.010), femur length (OR, 1.1; CI, 1.0–1.2; p = 0.002), and induced labor (OR, 1.8; CI, 1.1–3.1; p = 0.027). Conclusion A prenatal ultrasound finding of a difference in AC to HC of ≥ 50 mm while uncommon is associated with shoulder dystocia.

Clinical correlates of maternal suicidal ideation detected by perinatal depression screening.

INTRODUCTION: Suicide is a leading cause of maternal mortality in the developed world, accounting for 10% of maternal deaths. We examined the relationship between suicidal ideation during pregnancy and after delivery in a large cohort of consecutively screened women to identify maternal demographic characteristics and obstetric outcomes that correlate with this vulnerable state of mind. METHODS: The Edinburgh Postnatal Depression Scale was completed at 24–28 weeks of gestation and at 6 weeks postpartum. Edinburgh Postnatal Depression Scale item 10 queries for suicidal ideation. Multivariable analyses determined predictors of suicidal ideation separately for during pregnancy and after delivery timeframes. RESULTS: A total of 22,118 patients completed the Edinburgh Postnatal Depression Scale (2003–2011) with 842 women endorsing suicidal ideation. A during pregnancy language by marital status interaction emerged (P<.05) with English-speaking, partnered patients less likely to report suicidal ideation (odds ratio [OR] 0.75) compared with non-English-speaking, partnered women with increased suicidal ideation risk (OR 1.55). Asians were also more likely to reveal suicidal ideation during pregnancy (OR 1.64, P<.001). Planned cesarean delivery reduced suicidal ideation after delivery risk compared with vaginal delivery (OR 0.56, P<.01), whereas perineal laceration increased suicidal ideation reporting (OR 2.10, P<.05). Asian women also endorsed suicidal ideation after delivery more often than other ethnic groups (OR 1.63, P<.01). CONCLUSIONS: When asked, women commonly report suicidal thoughts during and after pregnancy. Non-English-speaking, partnered patients manifest higher suicidal ideation endorsement as do Asian women. Perineal laceration increases suicidal ideation risk, whereas planned cesarean delivery has the opposite effect. Because 1% of women with suicidal ideation are estimated to attempt suicide, knowledge of these risk profiles and identification of vulnerable patients through screening may help to avert some instances of maternal mortality.

Association of Hypertension and β -Blocker Use with Depression during Pregnancy

Objective: To evaluate the association between hypertension and β-blocker (BB) use and antepartum depression risk. Patients and Methods: We conducted a retrospective cohort study of women who delivered within our integrated health system between 2009 and 2015, and completed an Edinburgh Postnatal Depression Scale (EPDS) during pregnancy. Increased depression risk was defined as EPDS score ≥ 10, or an affirmative answer to question ten, endorsing self-harm. Antepartum hypertension was determined by blood pressure measurements and provider ICD-9 codes. Regression analyses examined the independent associations of BB use and hypertension on antepartum depression risk. Results: Of 9192 deliveries during the study time frame, 5% were hypertensive. Within the hypertensive group, 103 (22%) used a single agent BB (BB Group), 325 (68%) required no antihypertensive medication (No-Med Group), and 48 (10%) used a non-BB single agent or multi-agent therapy (All-Other Group). After adjusting for covariates, compared to normotensive pregnancies, antepartum hypertension was significantly associated with both EPDS score ≥ 10 (adjusted odds ratio [aOR] 1.61, 95% confidence interval [CI] 1.17 - 2.21) and endorsement of self-harm (aOR 1.76, 95% CI 1.05 - 2.95). In further analyses of depression risk in hypertensive pregnancies, there was no difference between the BB Group and No-Med Group (EPDS score ≥ 10, aOR 1.22, 95% CI 0.56 - 2.63; self-harm, aOR 0.84, 95% CI 0.32 - 2.21), or between the All-Other Group and No-Med Group (EPDS ≥ 10, aOR 1.42, 95% CI 0.57 - 3.54; self-harm, aOR 1.04, 95% CI 0.29 - 3.74). Conclusion: Women with antepartum hypertension have increased risk for depression and thoughts of self-harm. β-Blocker use is not associated with further increased risk.

Persistence of Depression and Suicide Risk Within and Across Pregnancies [7I]

INTRODUCTION: Little is known about how perinatal depression risk, including suicidal ideation, changes within and across pregnancies. METHODS: 62,080 Edinburgh Postnatal Depression Scales (EPDS) were administered. We studied a subset of 6,836 representing 1,709 women screened during gestation and postpartum in two successive pregnancies, totaling four screens per patient. “At-risk” EPDS (12 or more, or positive suicidal ideation-SI) were examined by multivariable logistic regression to model predictors of depression risk/SI adjusting for labor/delivery/infant variables, determined by Akaike information criterion and likelihood ratios. RESULTS: First pregnancy antepartum at-risk EPDS predicted risk in both the corresponding postpartum (aOR=4.2; 95% CI 1.2–15.0, P<.05) and the next pregnancys antepartum (aOR=4.8; 95% CI 1.7–13.5, P<.01). Second pregnancy antepartum at-risk EPDS also predicted subsequent postpartum at-risk EPDS (aOR=18.6; 95% CI 8.1–42.8, P<.0001). Similarly, first pregnancy antepartum SI predicted both the index postpartum SI (aOR=9.5; 95% CI 2.4–38.6. P<.01) and subsequent antepartum SI (aOR=9.9; 95% CI 3.1–31.6, P=.0001). Second pregnancy antepartum SI strongly predicted the corresponding postpartum SI (aOR=29.9; 95% CI 8.1–110.1, P<.0001). The mean inter-pregnancy interval was 2.6 years (range 0.5–8.8). CONCLUSION: Antepartum depression risk and suicidal ideation are strongly correlated with postpartum risk as well as persistent risk in a subsequent pregnancy. Although phone-based mental health assessment and acuity-based treatment of symptomatic women was provided to all at-risk women in this series, the chronicity of depressive risk and SI suggests that more effective and durable therapeutic interventions may be required for these women.

Preconception Detection of Undiagnosed or Poorly Controlled Diabetes by the Electronic Medical Record

INTRODUCTION: Poor preconception glucose control markedly increases adverse pregnancy outcome. We wished to determine whether undiagnosed diabetes or suboptimal glucose levels in nonpregnant women could be reliably identified using data from an integrated health systems electronic medical record. METHODS: An automated case-finding algorithm was applied to an electronic medical record-derived data warehouse to rapidly screen all nonobstetric outpatient visits for women of childbearing age by simultaneously analyzing multiple discrete data fields to determine both reproductive status and glycemic condition. Patients with hemoglobin A1C 6% or greater or serum glucose 200 mg/dL or greater were considered to have “provisional” diabetes. Detailed chart review of all algorithm-identified patients was used to confirm diagnoses. RESULTS: Of 107,339 female patient encounters screened between August 2010 and February 2012, 29,691 women were at risk for pregnancy and 373 met our criteria for provisional diabetes. Restricting cases to those with hemoglobin A1C 7% or greater, glucose greater than 200 mg/dL, or both yielded 241 of 373 (65%); 105 of these had hemoglobin A1C 8.0% or greater. The algorithm was effective across a spectrum of outpatient encounter types, including diagnostic visits (47%), medical and surgical consultations (32%), and emergency department evaluations (14%). Diabetes was entered as a discrete electronic medical record diagnosis in only 194 of 241 (80%) instances. Thus, the algorithm identified women not previously documented as being diabetic. CONCLUSION: Automated analysis of outpatient electronic medical record encounters identified 241 patients with undiagnosed or poorly controlled diabetes over 19 months. Such patients could potentially be offered diagnostic confirmation, treatment, and contraceptive counseling to optimize pregnancy timing. This screening strategy presents an opportunity to improve preconception glucose control and pregnancy outcome.