Fertility after Transcatheter Arterial Embolization for Obstetric Hemorrhage: An Urban Health Care System Observational Study.

OBJECTIVE: This study aimed to investigate pregnancy rate, pregnancy outcomes, and resumption of menses after transcatheter arterial embolization (TAE) for obstetric hemorrhage (OH). STUDY DESIGN: Sixty-seven patients who underwent TAE for OH from 2006 to 2020 within an urban, multihospital health care system were identified retrospectively. Selected patients were interviewed by phone to complete a survey with a primary outcome of self-reported pregnancy in those seeking pregnancy. Secondary outcomes included pregnancy outcomes and resumption of menses. Univariate testing of association of pregnancy and miscarriage rate with embolic agent was performed using Fisher's exact test. RESULTS: Thirty-three of 50 patients (66%) meeting the inclusion criteria completed the survey on fertility, a median of 47 (range, 13-123) months after TAE for OH. Of the 13 patients who attempted pregnancy, there was a pregnancy rate of 77% and miscarriage rate of 38%. Those who delivered live newborns conceived spontaneously, carried to term, and delivered a healthy newborn via cesarean section at a weight appropriate for gestational age. Thirty (91%) patients resumed menstruation, and the majority with unchanged frequency. Most patients underwent bilateral uterine artery embolization with radial artery access (54%). The most common embolic agents used were gelfoam only (30%) and glue only (24%). There was no statistically significant association between embolic agent and pregnancy or miscarriage rate. CONCLUSION: Spontaneous pregnancy with live birth and resumption of menses can occur in a majority of patients after TAE for OH. KEY POINTS: · Most patients who attempted pregnancy after TAE for OH achieved pregnancy.. · Most patients who became pregnant conceived spontaneously and delivered healthy newborns at term.. · Most patients resumed menstruation after TAE for OH.. · There was no significant association between type of embolic and pregnancy or miscarriage rate..

Longitudinal Changes in Fecal Calprotectin Levels Among Pregnant Women With and Without Inflammatory Bowel Disease and Their Babies.

BACKGROUND & AIMS: The effect of pregnancy on inflammatory bowel disease (IBD) remains poorly understood. We aimed to monitor intestinal inflammation using fecal calprotectin (FC) in pregnant women and their babies during early life. METHODS: Pregnant women with or without IBD and their infants were prospectively enrolled. FC levels were measured at each trimester of pregnancy and in babies throughout the first 3 years of life. Repeated-measures analysis was applied to investigate changes in FC levels while adjusting for confounders. The FC levels were correlated with the bacterial abundance in both mothers and babies. RESULTS: Six hundred and fourteen fecal samples from 358 mothers (98 with IBD) and 1005 fecal samples from 289 infants (76 born to IBD mothers) were analyzed. Pregnant Patients with IBD maintained higher FC levels through pregnancy compared with controls (P = 7.5 × 10-54). FC gradually increased in controls and declined in Patients with IBD throughout pregnancy (P for interaction = 5.8 × 10-7). Babies born to mothers with IBD presented with significantly higher FC levels than those born to controls up to 3 years of age, after adjusting for sex, delivery mode, feeding behavior, and antibiotics exposure (2 weeks to 3 months of age, P = .015; 12-36 months of age, P = .00003). Subdoligranulum, Roseburia, Fusicatenibacter, and Alistipes negatively correlated, and Streptococcus, Prevotella, Escherichia-Shigella, and Bifidobacterium positively correlated with maternal FC levels at T3. Faecalibacterium, Bifidobacterium, and Alistipes showed negative correlations, and Streptococcus were positively correlated with FC levels within 3 months of birth. CONCLUSIONS: Pregnancy is associated with decreased inflammatory activity in mothers with IBD. Higher FC levels in babies born to mothers with IBD suggest subclinical inflammation in early life, the long-term consequences of which are uncertain.

Postpartum mood among universally screened high and low socioeconomic status patients during COVID-19 social restrictions in New York City.

The mental health effects of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and the Coronavirus Disease 2019 (COVID-19) pandemic on postpartum women are of increasing concern among mental health practitioners. To date, only a handful of studies have explored the emotional impact of the pandemic surrounding pregnancy and none have investigated the consequence of pandemic-related social restrictions on the postpartum mood of those living among different socioeconomic status (SES). All postpartum patients appearing to the Mount Sinai Health System for their postpartum appointment between January 2, 2020 and June 30, 2020, corresponding to before and during pandemic imposed social restrictions, were screened for mood symptomatology using the Edinburgh Postnatal Depression Scale (EPDS). Each patient's socioeconomic status (high/low) was determined by their location of clinical service. A total of 516 postpartum patients were screened. While no differences in EPDS scores were observed by SES prior to social restrictions (U = 7956.0, z = - 1.05, p = .293), a significant change in mood symptomatology was observed following COVID-19 restrictions (U = 4895.0, z = - 3.48, p < .001), with patients living in lower SES reporting significantly less depression symptomatology (U = 9209.0, z = - 4.56, p < .001). There was no change in symptomatology among patients of higher SES (U = 4045.5, z = - 1.06, p = .288). Postpartum depression, the most common complication of childbearing, is a prevalent, cross-cultural disorder with significant morbidity. The observed differences in postpartum mood between patients of different SES in the context of temporarily imposed COVID-19-related social restrictions present a unique opportunity to better understand the specific health and social support needs of postpartum patients living in urban economic poverty. Given that maternal mental illness has negative long-term developmental implications for the offspring and that poor mental health reinforces the poverty cycle, future health policy specifically directed towards supporting postpartum women living in low SES by ameliorating some of the early maternal burdens associated with balancing employment-family-childcare demands may assist in interrupting this cycle while simultaneously improving the long-term outcomes of their offspring.

Testing of Patients and Support Persons for Coronavirus Disease 2019 (COVID-19) Infection Before Scheduled Deliveries.

OBJECTIVE: To evaluate the rate of coronavirus disease 2019 (COVID-19) infection with the use of universal testing in our obstetric population presenting for scheduled deliveries, as well as the concordance or discordance rate among their support persons during the initial 2-week period of testing. Additionally, we assessed the utility of a screening tool in predicting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing results in our cohort. METHODS: This was an observational study in which all women who were scheduled for a planned delivery within the Mount Sinai Health system from April 4 to April 15, 2020, were contacted and provided with an appointment for themselves as well as their support persons to undergo COVID-19 testing 1 day before their scheduled delivery. Both the patients and the support persons were administered a standardized screen specific for COVID-19 infection by telephone interview. Those support persons who screened positive were not permitted to attend the birth. All patients and screen-negative support persons underwent SARS-CoV-2 testing. RESULTS: During the study period, 155 patients and 146 support persons underwent SARS-CoV-2 testing. The prevalence of asymptomatic COVID-19 infection was 15.5% (CI 9.8-21.2%) and 9.6% (CI 4.8-14.4%) among patients and support persons, respectively. The rate of discordance among tested pairs was 7.5%. Among patients with COVID-19 infection, 58% of their support persons also had infection; in patients without infection, fewer than 3.0% of their support persons had infection. CONCLUSION: We found that more than 15% of asymptomatic maternity patients tested positive for SARS-CoV-2 infection despite having screened negative with the use of a telephone screening tool. Additionally, 58% of their asymptomatic, screen-negative support persons also tested positive for SARS-CoV-2 infection. Alternatively, testing of the support persons of women who had tested negative for COVID-19 infection had a low yield for positive results. This has important implications for obstetric and newborn care practices as well as for health care professionals.

Knowledge of the Relationship Between Breastfeeding and Breast Cancer Risk Among Racial and Ethnic Minority Women.

Research indicates breastfeeding can reduce the risk of breast cancer in women. Black and Hispanic women are more likely to die from breast cancer than non-Hispanic white women and are least likely to breastfeed. The current study was designed to evaluate women's knowledge of the link between breastfeeding and decreased breast cancer risk among a racially diverse cohort of pregnant women. Pregnant women 18 and older (N = 89; 48.4% black; 28% Hispanic) were recruited during a prenatal visit to complete a survey. Women indicated limited understanding of the association between breastfeeding and breast cancer risk reduction; less than 40% of black and white women indicated knowledge, while 64.7% of Hispanic women were aware of the association. These findings underscore the need for interventions to educate women about the protective benefits of breastfeeding as a strategy to reduce their breast cancer incidence and mortality.

Infants born to mothers with IBD present with altered gut microbiome that transfers abnormalities of the adaptive immune system to germ-free mice.

BACKGROUND AND AIMS: Prenatal and early life bacterial colonisation is thought to play a major role in shaping the immune system. Furthermore, accumulating evidence links early life exposures to the risk of developing IBD later in life. We aimed to assess the effect of maternal IBD on the composition of the microbiome during pregnancy and on the offspring's microbiome. METHODS: We prospectively examined the diversity and taxonomy of the microbiome of pregnant women with and without IBD and their babies at multiple time points. We evaluated the role of maternal IBD diagnosis, the mode of delivery, antibiotic use and feeding behaviour on the microbiome composition during early life. To assess the effects of IBD-associated maternal and infant microbiota on the enteric immune system, we inoculated germ-free mice (GFM) with the respective stool and profiled adaptive and innate immune cell populations in the murine intestines. RESULTS: Pregnant women with IBD and their offspring presented with lower bacterial diversity and altered bacterial composition compared with control women and their babies. Maternal IBD was the main predictor of the microbiota diversity in the infant gut at 7, 14, 30, 60 and 90 days of life. Babies born to mothers with IBD demonstrated enrichment in Gammaproteobacteria and depletion in Bifidobacteria. Finally, GFM inoculated with third trimester IBD mother and 90-day infant stools showed significantly reduced microbial diversity and fewer class-switched memory B cells and regulatory T cells in the colon. CONCLUSION: Aberrant gut microbiota composition persists during pregnancy with IBD and alters the bacterial diversity and abundance in the infant stool. The dysbiotic microbiota triggered abnormal imprinting of the intestinal immune system in GFM.

The Association between Solo versus Group Obstetrical Practice Model and Delivery Outcomes.

OBJECTIVE: To determine if women under the care of obstetricians in solo practice have different delivery outcomes from women in a group practice. STUDY DESIGN: This is a retrospective cohort of live, term, singleton, vertex (LTSV) deliveries at one hospital from 2011 to 2015. We compared outcomes between women whose obstetrician was in solo practice with women in a group practice model. RESULTS: There were 18,214 LTSV deliveries by private obstetricians. Solo obstetricians were more likely to deliver at night (41.0 vs. 37.5%, p = 0.002) and less likely to induce labor (22.6 vs. 30.6%, p < 0.001). Solo obstetricians had a significantly higher rate of cesarean delivery (35.7 vs. 27.2%, adjusted odds ratio, aOR: 1.53, 95% confidence interval, CI [1.32, 1.78]), but also had a significantly lower rate of shoulder dystocia (0.4 vs. 1.4, aOR: 0.42, 95% CI [0.19, 0.89]), third or fourth degree lacerations (1.6 vs. 2.4%, aOR: 0.56, 95% CI [0.35, 0.914]), and neonatal intensive care unit admission rates (3.2 vs. 6.2%, aOR: 0.57, 95% CI [0.42, 0.77]). CONCLUSION: In a large, tertiary care hospital, solo obstetricians have similar neonatal outcomes as group obstetricians. Their higher cesarean delivery rate is balanced by fewer shoulder dystocias and third/fourth degree lacerations, indicating a more conservative approach to labor management. Patient outcomes should not be a reason to discourage a solo practice model.

Association Between Senior Obstetrician Supervision of Resident Deliveries and Mode of Delivery.

OBJECTIVE: In December 2012, the Mount Sinai Hospital implemented a program to have senior obstetricians (more than 20 years of experience) supervise residents on labor and delivery during the daytime. The objective of this study was to estimate the association of resident supervision by senior obstetricians with mode of delivery. METHODS: This was a retrospective cohort study of all resident deliveries at Mount Sinai from July 2011 to June 2015. We included all patients with live, term, singleton, vertex fetuses. We compared delivery outcomes between patients delivered before December 2012 and patients delivered December 2012 and later using logistic regression analysis to control for age, body mass index, parity, induction, and prior cesarean delivery. During the study period there were no other specific departmental initiatives to increase forceps deliveries aside from having six obstetricians with significant experience in operative deliveries supervise and teach residents on labor and delivery. RESULTS: There were 5,201 live, term, singleton, vertex deliveries under the care of residents, 1,919 (36.9%) before December 2012 and 3,282 (63.1%) December 2012 or later. The rate of forceps deliveries significantly increased from 0.6% to 2.6% (adjusted odds ratio [OR] 8.44, 95% confidence interval [CI] 3.1-23.1), and the rate of cesarean deliveries significantly decreased from 27.3% to 24.5% (adjusted OR 0.68, 95% CI 0.55-0.83). There were no statistically significant differences in the rates of third- or fourth-degree lacerations or 5-minute Apgar scores less than 7. Among nulliparous women, the forceps rate increased from 1.0% to 3.4% (adjusted OR 4.87, 95% CI 1.74-13.63) and the cesarean delivery rate decreased from 25.6% to 22.7% (adjusted OR 0.69, 95% CI 0.53-0.89). The increase in forceps deliveries and the decrease in cesarean deliveries were seen only in daytime hours (7 AM to 7 PM), that is, the shift that was covered by senior obstetricians. CONCLUSION: Having senior obstetricians supervise resident deliveries is significantly associated with an increased rate of forceps deliveries and a decreased rate of cesarean deliveries.

Epigenome-wide cross-tissue predictive modeling and comparison of cord blood and placental methylation in a birth cohort.

AIM: We compared predictive modeling approaches to estimate placental methylation using cord blood methylation. MATERIALS & METHODS: We performed locus-specific methylation prediction using both linear regression and support vector machine models with 174 matched pairs of 450k arrays. RESULTS: At most CpG sites, both approaches gave poor predictions in spite of a misleading improvement in array-wide correlation. CpG islands and gene promoters, but not enhancers, were the genomic contexts where the correlation between measured and predicted placental methylation levels achieved higher values. We provide a list of 714 sites where both models achieved an R2 ≥0.75. CONCLUSION: The present study indicates the need for caution in interpreting cross-tissue predictions. Few methylation sites can be predicted between cord blood and placenta.

Using clinical decision support as a means of implementing a universal postpartum depression screening program.

A major barrier to the diagnosis of postpartum depression (PPD) includes symptom detection. The lack of awareness and understanding of PPD among new mothers, the variability in clinical presentation, and the various diagnostic strategies can increase this further. The purpose of this study was to test the feasibility of adding clinical decision support (CDS) to the electronic health record (EHR) as a means of implementing a universal standardized PPD screening program within a large, at high risk, population. All women returning to the Mount Sinai Hospital OB/GYN Ambulatory Practice for postpartum care between 2010 and 2013 were presented with the Edinburgh Postnatal Depression Scale (EPDS) in response to a CDS "hard stop" built into the EHR. Of the 2102 women who presented for postpartum care, 2092 women (99.5 %) were screened for PPD in response to a CDS hard stop module. Screens were missing on ten records (0.5 %) secondary to refusal, language barrier, or lack of clarity in the EHR. Technology is becoming increasingly important in addressing the challenges faced by health care providers. While the identification of PPD has become the recent focus of public health concerns secondary to the significant social burden, numerous barriers to screening still exist within the clinical setting. The utility of adding CDS in the form of a hard stop, requiring clinicians to enter a standardized PPD mood assessment score to the patient EHR, offers a sufficient way to address a primary barrier to PPD symptom identification at the practitioner level.

An intervention to reduce postpartum depressive symptoms: a randomized controlled trial.

Depressive symptoms and depression are a common complication of childbirth, and a growing body of literature suggests that there are modifiable factors associated with their occurrence. We developed a behavioral educational intervention targeting these factors and successfully reduced postpartum depressive symptoms in a randomized trial among low-income black and Latina women. We now report results of 540 predominantly white, high-income mothers in a second randomized trial. Mothers in the intervention arm received a two-step intervention that prepared and educated mothers about modifiable factors associated with postpartum depressive symptoms (e.g., physical symptoms, low self-efficacy), bolstered social support, and enhanced management skills. The control arm received enhanced usual care. Participants were surveyed prior to randomization, 3 weeks, 3 months, and 6 months postpartum. Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS of 10 or greater). Prevalence of depressive symptoms postpartum was unexpectedly low precluding detection of difference in rates of depressive symptoms among intervention versus enhanced usual care posthospitalization: 3 weeks (6.0 vs. 5.6 %, p = 0.83), 3 months (5.1 vs. 6.5 %, p = 0.53), and 6 months (3.6 vs. 4.6 %, p = 0.53).

Global methylation in the placenta and umbilical cord blood from pregnancies with maternal gestational diabetes, preeclampsia, and obesity.

Emerging evidence indicates that maternal medical risk during pregnancy, such as gestational diabetes mellitus (GDM), preeclampsia, and obesity, predisposes the offspring to suboptimal development. However, the underlying biological/epigenetic mechanism in utero is still unknown. The current pilot study (N = 50) compared the levels of global methylation in the placenta and umbilical cord blood among women with and without each risk condition (GDM, preeclampsia, and obesity) and explored whether the levels of global methylation were associated with fetal/infant growth. Results show that global methylation levels in the placenta were lower in patients with gestational diabetes (P = .003) and preeclampsia (P = .05) but higher with obesity (P = .01). Suggestive negative associations were found between global methylation level in the placenta and infant body length and head circumference. While preliminary, it is possible that the placenta tissue, but not umbilical cord blood, may be epigenetically programmed by maternal GDM, preeclampsia, and obesity to carry out its own specific functions that influence fetal growth.

The Effects of Preeclampsia on Perinatal Risks and Infant Temperaments Among Mothers With Antenatal Depression.

IMPORTANCE: Preeclampsia and depression are two most prevalent disorders known to affect pregnant women and unborn infant. However, few studies have prospectively examined the adverse influence of the in-utero exposures to the two disorders on the optimal development in their offspring, including mortality, adverse birth outcomes, and infant temperament styles. OBJECTIVES: (1) To examine whether exposures to preeclampsia and antenatal depression were associated with developmental indices of offspring at birth and temperament at 3 months; and (2) To evaluate how preeclampsia and antenatal depression associated with offspring temperamental style. DESIGN: Prospective cohort study with regular assessment of mother's blood pressure at each prenatal visit: offspring were followed till 3 months. SETTING: Two prenatal clinics, New York City, USA. PARTICIPANTS: A cohort of 233 pregnant women was followed throughout pregnancy. Of those, 141 provided ratings of infant temperament at three months. EXPOSURES: Diagnostic outcome of maternal depression by clinical interviewers blind to preeclampsia status, were ascertained using the Structured Clinical Interview for DSM-IV Axis I Disorders. The development of preeclampsia, defined by the onset of hypertension (> 140/90 mm HG) after 20 weeks' gestation, accompanied by 300 mg of protein, monitored via electronic medical records. MAIN OUTCOME MEASURES: Birth outcomes were assessed via standardized ratings at delivery. Infant temperament was reported by the mother at three months, using 91-item IBQ-R (Infant Behavioral Questionnaire-Revised). RESULTS: Preeclampsia was associated with an over 5-fold increased risk for fetal/infant mortality, a 3- to 7-fold increased risk for poorer birth outcomes, and flatter affect and distress in infants. Furthermore, infants born to preeclamptic mothers with co-occurring depression displayed lower levels of smile/laughter, high-intensity pleasure seeking behavior, perceptual sensitivity, and approach behavior. CONCLUSION: Preeclampsia was associated with a few difficult temperament styles in the first three months after birth. Moreover, its negative impact was amplified by mother's antenatal depression. Our findings regarding additive risk for negative infant outcomes in babies exposed to preeclampsia and antenatal depression suggests that the development of early detection programs to identify and monitor women who are at heightened risk for these conditions can potentially have a positive influence on long-term infant neurobehavioral development.

Diversified microbiota of meconium is affected by maternal diabetes status.

OBJECTIVES: This study was aimed to assess the diversity of the meconium microbiome and determine if the bacterial community is affected by maternal diabetes status. METHODS: The first intestinal discharge (meconium) was collected from 23 newborns stratified by maternal diabetes status: 4 mothers had pre-gestational type 2 diabetes mellitus (DM) including one mother with dizygotic twins, 5 developed gestational diabetes mellitus (GDM) and 13 had no diabetes. The meconium microbiome was profiled using multi-barcode 16S rRNA sequencing followed by taxonomic assignment and diversity analysis. RESULTS: All meconium samples were not sterile and contained diversified microbiota. Compared with adult feces, the meconium showed a lower species diversity, higher sample-to-sample variation, and enrichment of Proteobacteria and reduction of Bacteroidetes. Among the meconium samples, the taxonomy analyses suggested that the overall bacterial content significantly differed by maternal diabetes status, with the microbiome of the DM group showing higher alpha-diversity than that of no-diabetes or GDM groups. No global difference was found between babies delivered vaginally versus via Cesarean-section. Regression analysis showed that the most robust predictor for the meconium microbiota composition was the maternal diabetes status that preceded pregnancy. Specifically, Bacteroidetes (phyla) and Parabacteriodes (genus) were enriched in the meconium in the DM group compared to the no-diabetes group. CONCLUSIONS: Our study provides evidence that meconium contains diversified microbiota and is not affected by the mode of delivery. It also suggests that the meconium microbiome of infants born to mothers with DM is enriched for the same bacterial taxa as those reported in the fecal microbiome of adult DM patients.

Exposure to gestational diabetes mellitus and low socioeconomic status: effects on neurocognitive development and risk of attention-deficit/hyperactivity disorder in offspring.

OBJECTIVE: To examine the independent and synergistic effects of gestational diabetes mellitus (GDM) and low socioeconomic status (SES) on neurodevelopment and attention-deficit/hyperactivity disorder (ADHD) outcomes. DESIGN: Cohort study. SETTING: Flushing, New York. PARTICIPANTS: A total of 212 preschool children as a part of the ongoing cohort study. MAIN EXPOSURES: Gestational diabetes mellitus and low SES. MAIN OUTCOME MEASURES: Primary outcomes are ADHD diagnosis based on Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria at age 6 years and several well-validated measures of neurobehavioral outcomes, cognitive functioning, ADHD symptoms, and temperament at age 4 years. Secondary outcomes are parent and teacher reports of behavioral and emotional problems at age 6 years. Neurobehavioral measures in relation to GDM and low SES were examined using generalized estimating equations and multivariate logistic regression analyses. RESULTS: Both maternal GDM and low SES were associated with an approximately 2-fold increased risk for ADHD at age 6 years. However, the risk by GDM was greater among lower SES families than among higher SES families. Children exposed to both GDM and low SES demonstrated compromised neurobehavioral functioning, including lower IQ, poorer language, and impoverished behavioral and emotional functioning. A test of additive interaction found that the risk for ADHD increased over 14-fold (P = .006) when children were exposed to both GDM and low SES. Neither children exposed to maternal GDM alone nor those exposed to low SES alone had a notable increased risk for ADHD. CONCLUSIONS: Maternal GDM and low SES, especially in combination, heighten the risk for childhood ADHD. Long-term prevention efforts should be directed at mothers with GDM to avoid suboptimal neurobehavioral development and mitigate the risk for ADHD among their offspring.

The neural processing of negative emotion postpartum: a preliminary study of amygdala function in postpartum depression.

While contemporary diagnostic nosology characterizes postpartum depression (PPD) as a specifier of a major depressive disorder (MDD), this classification continues to be questioned. Functional magnetic resonance imaging (fMRI) holds the promise of helping to characterize the neuroanatomical dysfunction associated with dysregulated emotion after childbirth. Twenty postpartum women underwent fMRI in the presence of emotionally valenced stimuli. The observation of relative amygdala non-responsivity in subjects demonstrating greater depression symptomotology stands in contrast to imaging studies of MDD and provides insight into possible phenotypic differences of PPD.

Antenatal reports of pre-pregnancy abuse is associated with symptoms of depression in the postpartum period.

The purpose of this study is to estimate characteristics predictive of postpartum mood change symptoms among urban women. Women receiving prenatal care at The Mount Sinai Hospital OB/GYN Diagnostic and Treatment Center and who delivered over one calendar year (2007; n = 884) were evaluated for psychosocial risk factors at their first prenatal visit and then subsequently for postpartum mood symptomatology (n = 510) at 6 weeks postpartum. Symptoms associated with postpartum depression (PPD) were best predicted by a pre-pregnancy history of physical or sexual abuse, a history of psychiatric problems, or psychiatric diagnosis at the time of first prenatal visit. This study provides the first large sample evidence that PPD is associated with the report of sexual or physical abuse. Screening for a history of abuse, a history of psychiatric problems, or having a psychiatric illness at the time of the first prenatal visit may be an efficient means to identify women at risk for developing PPD. Early identification of women at risk would provide an opportunity to provide a selective prevention intervention to reduce the likelihood of PPD symptomatology.

Neural dysfunction in postpartum depression: an fMRI pilot study.

INTRODUCTION: With approximately 4 million births each year in the United States, an estimated 760,000 women annually suffer from a clinically significant postpartum depressive illness. Yet even though the relationship between psychiatric disorders and the postpartum period has been documented since the time of Hippocrates, fewer than half of all these cases are recognized. OBJECTIVE: Because postpartum depression (PPD), the most common complication of childbearing, remains poorly characterized, and its etiology remains unclear, we attempted to address a critical gap in the mechanistic understanding of PPD by probing its systems-level neuropathophysiology, in the context of a specific neurobiological model of fronto-limbic-striatal function. METHODS: Using emotionally valenced word probes, with linguistic semantic specificity within an integrated functional magnetic resonance imaging (fMRI) protocol, we investigated emotional processing, behavioral regulation, and their interaction (functions of clinical relevance to PPD), in the context of fronto-limbic-striatal function. RESULTS: We observed attenuated activity in posterior orbitofrontal cortex for negative versus neutral stimuli with greater PPD symptomatology, increased amygdala activity in response to negative words in those without PPD symptomotology, and attenuated striatum activation to positive word conditions with greater PPD symptomotology. CONCLUSION: Identifying the functional neuroanatomical profile of brain systems involved in the regulation of emotion and behavior in the postpartum period will not only assist in determining whether the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition psychiatric diagnostic specifier of PPD has an associated, unique, functional neuroanatomical profile, but a neurobiological characterization in relation to asymptomatic (postpartum non-depressed) control subjects, will also increase our understanding of the affective disorder spectrum, shed additional light on the possible mechanism(s) responsible for PPD and provide a necessary foundation for the development of more targeted, biologically based diagnostic and therapeutic strategies for PPD.