Obstetrical, pregnancy and socio-economic predictors for new-onset severe postpartum psychiatric disorders in primiparous women

Abstract

Background Childbirth is a potent trigger for the onset of psychiatric illness in women including postpartum depression (PPD) and postpartum psychosis (PP). Medical complications occurring during pregnancy and/or childbirth have been linked to postpartum psychiatric illness and sociodemographic factors. We evaluated if pregnancy and obstetrical predictors have similar effects on different types of postpartum psychiatric disorders. Method A population-based cohort study using Danish registers was conducted in 392 458 primiparous women with a singleton delivery between 1995 and 2012 and no previous psychiatric history. The main outcome was first-onset postpartum psychiatric episodes. Incidence rate ratios (IRRs) were calculated for any psychiatric contact in four quarters for the first year postpartum. Results PPD and postpartum acute stress reactions were associated with pregnancy and obstetrical complications. For PPD, hyperemesis gravidarum [IRR 2.69, 95% confidence interval (CI) 1.93–3.73], gestational hypertension (IRR 1.84, 95% CI 1.33–2.55), pre-eclampsia (IRR 1.45, 95% CI 1.14–1.84) and Cesarean section (C-section) (IRR 1.32, 95% CI 1.13–1.53) were associated with increased risk. For postpartum acute stress, hyperemesis gravidarum (IRR 1.93, 95% CI 1.38–2.71), preterm birth (IRR 1.51, 95% CI 1.30–1.75), gestational diabetes (IRR 1.42, 95% CI 1.03–1.97) and C-section (IRR 1.36, 95% CI 1.20–1.55) were associated with increased risk. In contrast, risk of PP was not associated with pregnancy or obstetrical complications. Conclusions Pregnancy and obstetrical complications can increase the risk for PPD and acute stress reactions but not PP. Identification of postpartum women requiring secondary care is needed to develop targeted approaches for screening and treatment. Future work should focus on understanding the contributions of psychological stressors and underlying biology on the development of postpartum psychiatric illness.

Depression precedes, but does not follow, gestational diabetes

“…This confirms our interpretation of the existing literature, which, though obfuscated by variation in methods and study populations, overall is more supportive of a forward causation, such that pre‐existing depression predisposes women to develop GDM, rather than the reverse. This is in line with the majority of relevant studies which also found no association of GDM with the later development of perinatal depression . In those studies where GDM was reported to precede depression , excessive maternal weight gain and Caesarean delivery may have been important mediating factors.…”

“…In those studies where GDM was reported to precede depression , excessive maternal weight gain and Caesarean delivery may have been important mediating factors. Only a single study that we reviewed found an association between GDM and PPD that was robust to adjustments , and one other found such an association but was unable to conduct the relevant adjustments .…”

“…Conversely, the available studies examining GDM as a risk factor for postpartum depression have yielded more variable results. A number of studies have either not found an association , or else found that when a relationship is present, it is explained by adjustment for medical comorbidities . One previous case–control study of 81 matched pairs did reveal a strong association between GDM and PPD that was robust to adjustment for confounders .…”

The association between gestational diabetes mellitus and postpartum depressive symptomatology: A prospective cohort study

“…Despite the above findings being in line with our observations, five other studies have found no associations between GDM and PPD/PPDS (Huang et al, 2015;Kim et al, 2005;Liu and Tronick, 2013;Meltzer-Brody et al, 2017;Miller et al, 2016). However, it is notable that the only one of these five studies to specify the diagnostic criteria for GDM used the two-step method recommended by the American Diabetes Association (Huang et al, 2015).…”

“…Thus, it remains uncertain whether it is possible to compare the longitudinal US study (Huang et al, 2015) with our study, considering the noticeable difference in the criteria used to diagnose GDM. However, one of the five studies with no observed association between GDM and PPD/PPDS found an association between GDM and the postpartum acute stress reaction (Meltzer-Brody et al, 2017). Moreover, one cross-sectional study examined the relationship between GDM and PPDS in two ethnically different populations: an association was observed among Qatari women, while no such association was observable among other Arab women (Burgut et al, 2013).…”