Maternal prenatal stress and its effects on primary pregnancy outcomes in twin pregnancies.

Objective: To assess the prevalence and degrees of maternal prenatal stress among twin-pregnant women and to investigate the impact of prenatal stress on primary pregnancy outcomes.Methods: The Chongqing Longitudinal Twin Study (LoTiS) began in December 2015 in China. Participants of LoTiS who met the inclusion criteria were recruited into this study and completed a stress rating scale (PSRS) in both early and late pregnancy. Maternal prenatal stress was examined in subgroups. Correlations between maternal prenatal stress and primary pregnancy outcomes were analyzed by multivariate logistic regression.Results: A total of 215 eligible twin pregnancies from LoTiS were recruited into this study. The overall mean scores of prenatal stress were 43.41 ± 19.84 and 51.33 ± 20.43 in early and late pregnancy, respectively. The first prenatal stressor was regarding concern about the pregnancy and childbirth safety. Subgroup analyses revealed prenatal stress in late pregnancy that differed based on different pregravid BMIs and education levels. Correlation analysis suggested that the risk of preterm premature rupture of membranes increases 1.8% per unit of stress scale in late pregnancy (OR = 1.018, 95% CI 1.001-1.025).Conclusions: Prenatal stress in twin pregnancies increases with the progression of pregnancy. Higher stress in late pregnancy is associated with a higher risk of premature rupture of membranes; therefore, interventions might be essential for improving pregnancy outcomes.

The complex impact of five years of stress related to life-threatening events on pregnancy outcomes: a preliminary retrospective study.

OBJECTIVE: To study the impact of chronic, life-threatening stressors in the form of daily missile attacks, for five consecutive years, on pregnancy outcomes. METHOD: Charts of deliveries from two neighboring towns in the south of Israel, covering the years 2000 and 2003-2008, were reviewed retrospectively. One city had been exposed to missile attacks, while the other was not. For each year, 100 charts were chosen at random. RESULTS: Significant association was found between exposure to stress and frequency of pregnancy complications (P=0.047) and premature membrane rupture (P=0.029). A more detailed analysis, based on dividing the stressful years into three distinct periods: early (2003-2004), intermediate (2005-2006) and late (2007-2008), revealed that preterm deliveries were significantly more frequent (P=0.044) during the intermediate period, as was premature membrane rupture during the late period (P=0.014). CONCLUSION: Exposure to chronic life-threatening stress resulted in more pregnancy complications and in particular more premature membrane ruptures. The impact was most significant during the middle period of the 5-year-exposure to the stressor. Hence it seems that factors of duration and habituation may play a role in the impact of chronic, life-threatening stressors on pregnancy.

Fathers with PTSD and depression in pregnancies complicated by preterm preeclampsia or PPROM.

PURPOSE: To assess prevalence and risk factors for posttraumatic stress disorder (PTSD) and depression in fathers after early preeclampsia (PE) or preterm premature rupture of membranes (PPROM). METHODS: Partners of patients hospitalized for PE or PPROM and partners of healthy controls completed PTSD (PSS-SR) and depression (BDI-II) questionnaires during pregnancy (t 1) and 6 weeks postpartum (t 2). 85 of the 187 eligible men participated (51 partners of patients, 34 partners of control) at t 1, and 66 men participated both time points. RESULTS: No significant differences were found between partners of patients and partners of controls in symptoms of PTSD and depression (t 1: p = 0.28 for PTSD and p = 0.34 for depression; t 2: p = 0.08 for PTSD and p = 0.31 for depression). For partners of patients, correlation between PTSD and depression sum-scores was 0.48 (p < 0.001) at t 1 and 0.86 (p < 0.001) at t 2. Within-couple correlation was low and not significant during pregnancy, but strong at postpartum (PSS-SR: r = 0.62, p < 0.001; BDI-II: r = 0.59, p < 0.001). Higher paternal age was associated with more symptoms of PTSD and depression postpartum in partners of patients. Symptoms of PTSD and depression during pregnancy predicted the occurrence of PTSD symptoms following childbirth in partners of patients. CONCLUSIONS: Symptoms of PTSD and depression occurred at a similar rate in partners of women with PE or PPROM and partners of healthy pregnant controls. Symptoms of PTSD and depression during pregnancy predicted the occurrence of PTSD symptoms following childbirth. Increased paternal age predicted more symptoms of PTSD and depression postpartum. At 6 weeks postpartum, a strong association was found between men and women in symptoms of PTSD and depression.

Posttraumatic stress disorder following preeclampsia and PPROM: a prospective study with 15 months follow-up.

OBJECTIVE: A prospective longitudinal evaluation of the prevalence of and risk factors for posttraumatic stress disorder (PTSD) in women with preeclampsia (PE) or preterm premature rupture of membranes (PPROM) compared to uncomplicated pregnancies. METHODS: Participating women completed PTSD and depression questionnaires during pregnancy, 6 weeks, and 15 months postpartum. Data regarding psychiatric history and indices of obstetric care were collected from patient charts. RESULTS: We included 57 PE, 53 PPROM, and 65 healthy pregnant women, of whom 137 also participated in the 15-month follow-up (PE 70%, PPROM 48%, and controls 95%; P < .001). At 6 weeks postpartum, the prevalence of PTSD, but not depression, following childbirth was significantly higher in patients than in controls (14% vs 3%; P = .023). A history of depression, depressive symptoms during pregnancy, and infant death were significantly associated with symptoms of postpartum PTSD. The maternal condition seems to be of less decisive value, as there was no difference between the prevalence of PTSD after PE and PPROM (11% vs 17%; P = .324). At 15 months postpartum, 11% of women with PE had PTSD, some of which did not have PTSD 6 weeks postpartum. The low response rate in the PPROM group at 15 months postpartum does not allow for definite conclusions. CONCLUSION: Pregnancies complicated by PE or PPROM are associated with PTSD in a substantial number of women. Especially women with proven vulnerability for psychological problems are at risk of developing PTSD postpartum, as are women whose children died in the perinatal period.

Stress pathways to spontaneous preterm birth: the role of stressors, psychological distress, and stress hormones.

The authors investigated a large number of stressors and measures of psychological distress in a multicenter, prospective cohort study of spontaneous preterm birth among 5,337 Montreal (Canada)-area women who delivered from October 1999 to April 2004. In addition, a nested case-control analysis (207 cases, 444 controls) was used to explore potential biologic pathways by analyzing maternal plasma corticotrophin-releasing hormone (CRH), placental histopathology, and (in a subset) maternal hair cortisol. Among the large number of stress and distress measures studied, only pregnancy-related anxiety was consistently and independently associated with spontaneous preterm birth (for values above the median, adjusted odds ratio = 1.8 (95% confidence interval: 1.3, 2.4)), with a dose-response relation across quartiles. The maternal plasma CRH concentration was significantly higher in cases than in controls in crude analyses but not after adjustment (for concentrations above the median, adjusted odds ratio = 1.1 (95% confidence interval: 0.8, 1.6)). In the subgroup (n = 117) of participants with a sufficient maternal hair sample, hair cortisol was positively associated with gestational age. Neither maternal plasma CRH, hair cortisol, nor placental histopathologic features of infection/inflammation, infarction, or maternal vasculopathy were significantly associated with pregnancy-related anxiety or any other stress or distress measure. The biologic pathways underlying stress-induced preterm birth remain poorly understood.

Serial factitious disorder and Munchausen by proxy in pregnancy.

Factitious disorder, including Munchausen syndrome, is seldom documented among pregnant patients but can have powerful consequences. We report on a 44-year-old woman who, over a period of two decades, self-induced labour and delivery in five consecutive pregnancies. She precipitated labour by rupturing her own amniotic sac with a fingernail or cervical manipulation, or misappropriating and self-administering prostaglandin suppositories from the hospital unit on which she worked as a nurse. Preterm deliveries resulted in fetal demise in one case and in neonatal intensive care treatment for two of the offspring. One of the surviving children has cerebral palsy attributable to the mother's factitious illness behaviour, which raises the spectre of Munchausen by proxy maltreatment. The patient sought attention and care through the ruses, which have never been uncovered by her obstetric and gynaecologic caregivers. Indeed, she underwent an unnecessary hysterectomy because of the illusion of heavy menstrual bleeding. Most recently, the patient has been engaging in surreptitious autophlebotomy to force blood transfusions.

Evidence-based case management in a high-risk pregnancy: a case study.

This article examines the case management needs of a pregnant woman confined to bed after preterm premature rupture of membranes. Through the period when she is confined to bed, interventions and outcomes are determined on the basis of evidence-based guidelines. By examining this case study, it is anticipated that best practices can be determined for women in similar situations.

Maternal role transition experiences of women hospitalized with PROM: a phenomenological study.

This study investigated the subjective experiences of the maternal role transition during the first two weeks of hospitalization for premature rupture of the amniotic membranes (PROM). Thirteen pregnant couples participated in the study by completing interviews. Average gestation of the expectant mothers was 27 weeks and the women were already experiencing fetal movement during the first two weeks of hospitalization for PROM. Lincoln and Cuba's trustworthiness criteria were employed to evaluate methodological rigor. Colaizzi's phenomenological approach was used to analyze the structure of the experience. Four themes emerged: pending loss, concern about the safety of the fetus, identification of maternal roles, and the process of maternal role-making. The results provide a scientific basis for empowering nurses to assist with maternal role transition in high-risk pregnancies in a more sensitive and effective manner.

Clinical, psychosocial, and economic effects of antenatal day care for three medical complications of pregnancy: a randomised controlled trial of 395 women.

BACKGROUND: Day care is increasingly being used for complications of pregnancy, but there is little published evidence on its efficacy. We assessed the clinical, psychosocial, and economic effects of day care for three pregnancy complications in a randomised trial of day care versus standard care on an antenatal ward. METHODS: 395 women were randomly assigned day (263) or ward (132) care in a ratio of two to one, stratified for major diagnostic categories (non-proteinuric hypertension, proteinuric hypertension, and preterm premature rupture of membranes). The research hypothesis was that for these disorders, as an alternative to admission, antenatal day care will reduce specified interventions and investigations, result in no differences in clinical outcome, lead to greater satisfaction and psychological wellbeing, and be more cost-effective. Data were collected through case-note review, self-report questionnaires (response rates 81.0% or higher) and via the hospital's financial system. Analysis was by intention to treat. FINDINGS: All participants were included in the analyses. There were no differences between the groups in antenatal tests or investigations or intrapartum interventions. The total duration of antenatal care episodes was shorter in the day-care group than in the ward group (median 17 [IQR 5-9] vs 57 [35-123] h; p=0.001). Overall stay was also significantly shorter in the day-care group (mean 7.22 [SE 0.31] vs 8.53 [0.44]; p=0.014). The median number of care episodes was three (range one to 14) in the day-care group and two (one to nine) in the ward group (p=0.01). There were no statistically or clinically significant differences in maternal or perinatal outcomes. The day-care group reported greater satisfaction, with no evidence of unintended psychosocial sequelae. There was no significant difference in either average cost per patient or average cost per day of care. INTERPRETATION: Since clinical outcomes and costs are similar, adoption by maternity services of a policy providing specified women with the choice between admission and day-unit care seems appropriate.

Dysphoria among high-risk pregnant hospitalized women on bed rest: a longitudinal study.

BACKGROUND: While approximately 700,000 women experience pregnancy complications and are treated with bed rest in the hospital each year, little is known about negative affect in these women. OBJECTIVES: The study purpose was to describe dysphoria, a composite of symptoms of negative affect across the antepartum and postpartum and to identify the relationship between dysphoria and the length of pre-admission home bed rest, hospital bed rest, and maternal and fetal/neonatal indices of risk. METHODS: The convenience sample for this longitudinal repeated measures study consisted of 63 high-risk pregnant women admitted on antepartum bed rest to one of three university-affiliated hospitals. Women were included if they were diagnosed with (a) preterm labor, (b) premature rupture of membranes, (c) incompetent cervix, (d) placenta previa, (e) placental abruption or multiple gestation, and (f) did not have a psychiatric disorder. The Multiple Affect Adjective Checklist-Revised (MAACL-R) was used to assess dysphoria. Obstetric risk status was assessed by both the Hobel and Creasy Risk Assessment tools. RESULTS: Dysphoria was highest upon hospital admission and decreased significantly across time (F (5) = 23.58, p <.001). Positive Affect-Sensation Seeking significantly increased across time (F (5) = 53.16, p <.001). Dysphoria scores were significantly greater for those with highest Hobel obstetric risk scores (F (1, 60) = 4.53, p =.037). Antepartum dysphoria was not correlated with gestational age upon hospital admission, length of bed rest, or Creasy risk status. However, gestational age at birth was significantly correlated with postpartum dysphoria. DISCUSSION: The stimulus for antepartum dysphoria is unclear. However, postpartum dysphoria appears to be related to indicators of the infant's state of health at birth.

Women's evaluations of induction of labor versus expectant management for prelabor rupture of the membranes at term. TermPROM Study Group.

BACKGROUND: Induction of labor has become common practice in many Western countries, but few studies have assessed women's views. METHODS: A randomized, controlled trial was conducted at 72 hospitals in six countries. Five thousand forty-one women meeting eligibility criteria, with no contraindications for induction of labor or expectant management, were randomly assigned to four groups: induction with intravenous oxytocin, induction with vaginal prostaglandin E2 gel, or expectant management followed by induction with either oxytocin or with prostaglandin E2 gel if complications developed. The three main outcome measures were evaluations of the treatment received, perceived control during childbirth, and evaluations of the experience of trial participation. RESULTS: Questionnaires were completed by 81.9 percent of the sample. No significant differences occurred between the two induction groups. Compared with the expectant management groups, induced women were less likely to report there was nothing they liked about their treatment and less likely to report that the treatment caused additional worry. No between-group differences occurred in experienced control during childbirth. Women in the induction groups were more likely to be willing to participate in the study again and to feel reassured. CONCLUSIONS: Women's preferences should be considered when making decisions about their method of management when membranes rupture before labor. Obtaining participants' views is both feasible and worthwhile when evaluating forms of medical care.

The psychiatrist in an obstetric/gynaecology hospital: establishing a consultation-liaison service.

The establishment and first six months of a psychiatric consultation-liaison service to an Australian obstetric and gynaecology hospital is described. Referrals, diagnoses and follow-up of patients are discussed, with case reports used to illustrate the types of patients seen. Evaluation of the findings and possible future directions for the service are discussed.