Depression disrupts daily life and affects thoughts, feelings, behavior, and relationships that have a significant impact on mental, emotional, social, professional, and physical well-being. Women are twice as likely as men to have depression. Clinical depression is common among reproductive age women 25-45 and the leading cause of disability in women in the U.S. This can account for $30-50 billion in lost productivity or medical costs.
Perinatal depression refers to depression that occurs during pregnancy and postpartum up to one year after delivery. 14%-23% of women experience depression during pregnancy and 5%-25% of women will have postpartum depression. It is essential that perinatal depression be treated as it can lead to sporadic prenatal care, inadequate nutrition, poor fetal growth, preterm delivery, preeclampsia, low birth weight, self-medication with tobacco, alcohol, or drugs, increased risk of postpartum depression, inability to care for self or child, lack of mother-infant bonding, and in extreme cases may lead to suicide or infanticide. Studies have shown that untreated maternal depression negatively affects an infant’s cognitive, neurologic, and motor skill development and can also impact older children’s mental health and behavior.
Symptoms of depression include:
Treatment options for depression in pregnancy include:
As many as 1 in 4 pregnant women may suffer from depression, and about 1 in 8 receives treatment with antidepressants. If a pregnant woman was previously on antidepressants then it is not advisable to stop abruptly as she may experience nausea, vomiting, fatigue, anxiety, and irritability. Additionally, a 2006 study in Journal of American Medical Association (JAMA) found that 68% of women who discontinued their antidepressants in pregnancy experienced a relapse of their depression.
Many antidepressants and drugs have been used for many years without any obvious signs of serious risk to the baby. There are some potential concerns, side effects, and risks associated with the anti-depressant medications. However, studies have had small sample sizes, conflicting data, and lack of consistency with findings.
MAOIs are not typically recommended as they can limit fetal growth and aggravate maternal high blood pressure. There appears to be a small potential risk of fetal malformation with antidepressants, but not higher than the average overall risk of malformations in the general pregnancy population which is 1-3%. Previously, there were concerns for limb defects with TCAs, but these results have not been reproduced in future studies. TCAs are considered safe, but blood levels may need to be monitored during treatment. SSRIs may be associated with low birth weight, preterm birth, and miscarriage. Of all the SSRIs, Paxil is a category D and not recommended in pregnancy due to initial studies showing possible cardiac defects of the fetus when taken in the first trimester of pregnancy. 15-30% of babies whose mothers took SSRIs late in pregnancy may experience withdrawal symptoms with irritability, jittery behavior, weak crying, hypoglycemia, seizures, temperature instability, and tachypnea. These symptoms typically resolve within two weeks. The remaining SSRIs are considered safe, but there have been some inconsistent findings of cardiac septal defects (“holes in the heart”) which typically occur in less than 1% of babies and resolve spontaneously without treatment, omphaloceles, and neural tube defects. There have been no studies showing any neurobehavioral , IQ, or language problems. There has inconsistently been an increased relative risk of persistent pulmonary hypertension of the newborn (PPHN).
PPHN is a condition which causes an elevation in the pressure of the pulmonary artery causing a patent ductus arteriosis and right to left shunting of blood through the heart which results in hypoxia (lack of oxygen) to the baby and results in respiratory distress. Most cases are treatable and 10% of cases can be fatal. Risk factors for PPHN can include meconium aspiration, maternal obesity, smoking, diabetes, or maternal use of non-steroidal anti-inflammatory drugs (NSAIDs). It can normally occur in 1-2/1000 infants. Based upon 6 studies from the past 15 years, for those pregnant women taking SSRI medication there can be no association to a 6-fold increased risk of PPHN. Most recently a study published in British Medical Journal (BMJ) on January 12, 2012 reveals that SSRI treatment in pregnancy may double the risk of PPHN as their findings from 1.6 million infants revealed an incidence of 3/1000 rather than the normal 1.2/1000. Although, the risk may be two-fold in this study, it is still clearly extremely low.
The FDA recently made a safety announcement regarding SSRI and PPHN on December 14, 2011:
FDA has reviewed the additional new study results and has concluded that, given
the conflicting results from different studies, it is premature to reach any conclusion
about a possible link between SSRI use in pregnancy and PPHN . . . At this time, FDA advises health care professionals not to alter their current clinical practice of treating depression
The FDA had not evaluated the recent BMJ study which was published a few weeks later. However, it is unlikely the findings would have changed their recommendation as it was another conflicting result.
This poses the question as to whether it is worse to have depression during pregnancy or take medication for it? As outlined at the beginning of this discussion, untreated depression in pregnancy can lead to multiple maternal, obstetrical, and neonatal problems. As for the antidepressant options, no drug is 100% safe, but most are considered safe and effective for treatment and may be necessary depending upon the severity of maternal depression. Additionally, in some cases the duration of treatment can be targeted to not start until after embryogenesis is complete at 8-10 weeks and discontinued in the third trimester before delivery to reduce risks of withdrawal and PPHN. However, if there is severe maternal depression this would not be advisable as it increases the risk of postpartum depression.
Postpartum blues encompasses mood symptoms such as crying, anxiety, trouble sleeping, feeling sad or doubt, and being overwhelmed that may occur immediately postpartum, but subside within two weeks without treatment. 70-80% of women will have some “baby blues”. Postpartum depression is depression and anxiety symptoms that occur anytime postpartum up to 1 year after delivery and interfere with daily functioning. The condition may occur from an imbalance or adjustment of hormones, body changes, lack of sleep, feeling overwhelmed as a mother, lack of support or socialization, loss of freedom/identity, genetic predisposition, and breastfeeding problems. The same treatment options can be used during the postpartum period and most antidepressants are considered safe during breastfeeding. Antidepressant exposure through the breast milk is significantly less than transplacental exposure and is not associated with significant risks to full-term and healthy infants.
The risks and benefits of taking an antidepressant during pregnancy must be weighed carefully. Ultimately, it is best to treat each patient individually, case by case to determine the best course of action and treatment. Whenever possible, multidisciplinary management involving the obstetrician, mental health clinician, primary care provider, and pediatrician is helpful to facilitate and coordinate care. It is essential that we screen and treat perinatal depression and stabilize maternal mental health for the overall well-being of mom and baby.
By Monique Fox, MD
Don’t Forget To Do Your Monthly And Yearly Clinical Breast Exam
In Addition to Your Yearly Mammogram
So many of my patients casually mention to me that they do not do their monthly breast exam because they get a yearly mammogram and think that they are covered. While yearly screening with mammography is the only test shown to decrease mortality, the combination of a yearly screening mammogram , monthly self breast exam and yearly clinical breast exam is the best combination for early detection of cancer.
Breast Cancer Detection
Clinical Breast Exam
Breast Awareness and Breast Self-Exam
Commonly Accepted Recommendations For Early Breast Cancer Detection
*Remember: No one knows your body like you do, and you have the best chance of spotting changes early on!
Dr. Monique Fox is a breast radiologist at The Trio Breast Center at Parker Adventist Hospital. For more information visit parkerhospital.org/mammogram.
By Vandna Jerath, MD
Vandna Jerath, MD
Dr. Jerath will be discussing this topic live on Denver Channel 7News on June 14, 2011 at 6:30am.
Premenstrual Syndrome (PMS) is defined by the American College of Obstetricians and Gynecologists (ACOG) as “the cyclic occurrence of symptoms that are of sufficient severity to interfere with some aspects of life and that appear with consistent and predictable relationship to the menses.” Typically, PMS is a syndrome with physical, emotional and/or psychological manifestations. Symptoms occur after ovulation and are most significant 5-7 days before the menses and subside within 4 days after the onset of menses.
PMS can affect women of any reproductive age, but is most common between age 25-45. 75 - 85% of women will have at least one symptom or some form of PMS. Many women will find their symptoms tolerable, but 20-30% will have clinically significant PMS with moderate to severe symptoms that have an adverse affect on their life. 3-5% of women will have debilitating PMS with a disruption of daily, social, and work activities and a significant impairment of their lifestyle. These women have a severe variant known as PMDD – Premenstrual Dysphoric Disorder.
Risk factors and the cause of PMS or PMDD are still unknown and research continues, but symptoms are thought to occur due to an imbalance or alteration of cyclic physiologic hormones and brain chemicals known as neurotransmitters, particularly an insufficient amount of serotonin.
Symptoms include an affective or mood component and/or a somatic or physical component:
PMS can mimic several medical conditions including hypothyroidism, irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia, migraines, and depression/mood disorders. The best way to diagnose PMS is to keep a comprehensive menstrual diary outlining symptoms for 2-3 cycles. If symptoms typically occur after ovulation, before menses, and resolve after menses, they are consistent with PMS. A variety of menstrual diaries can be found on the internet or most smart phones will have a useful app for charting.
There is no “cure” for PMS, but there are multiple options to reduce PMS symptoms. Treatment regimens include lifestyle modifications, alternative therapies, and medications:
PMS is definitely a woman’s monthly madness and many women live in silent suffering. But, with proper recognition, communication, and understanding between the patient and doctor, there are many options that can improve quality of life.
THINGS TO DO:
THINGS TO AVOID:
By Vandna Jerath, MD
Dr. Jerath will be interviewed live on Denver Channel 7News regarding this topic on October 5, 2010 at 6:30am.
Although the hype may have calmed down about the pandemic 2009 H1N1 flu , both 2009 H1N1 flu and the seasonal flu remain important concerns in pregnancy. The U.S. Public Health Emergency determination for 2009 H1N1 influenza expired on June 23, 2010 and the World Health Organization (WHO ) formally declared an end to the 2009 H1N1 influenza global pandemic on August 10, 2010. The Centers for Disease Control and Prevention (CDC ) feel that the 2009 H1N1 virus will continue to circulate as part of seasonal influenza and have an impact on pregnant women.
Influenza, known as the flu is a respiratory illness with seasonal epidemics typically from October through April with a peak in the U.S. in January. The flu accounts for numerous complications, hospitalizations, and deaths each year. In the U.S., studies have shown that flu related hospitalizations may exceed 200,000 per year and that over the past 30 years deaths may range from 3,000-49,000 per year. People who have a greater chance of serious flu complications include children younger than 2 years old, adults 65 years and older, pregnant and postpartum women, people with chronic medical conditions or weak immune systems, and people younger than 19 years of age on long-term aspirin.
In 2009, only 1% of the population was pregnant, but pregnant women accounted for 5-6% of H1N1 flu-related deaths. Pregnant women have physiologic changes in their bodies with include an altered immune system as well as changes to their circulatory (heart) and respiratory (lungs) systems which results in a decrease in functional residual capacity, an increase in cardiac output, and an increase in oxygen demand. These changes make them more susceptible to severe illness, complications, hospitalization, and even death from the flu. Some of these complications include dehydration, pneumonia, acute respiratory distress syndrome (ARDS ) requiring mechanical ventilation, miscarriage , preterm labor, preterm delivery and birth. An estimated 25 of 10,000 pregnant women in the third trimester will require hospitalization due to flu related problems. During pregnancy, women have a four to fivefold increased rate of serious illness and hospitalization with influenza.
The influenza vaccination is the best way to prevent the flu. Studies have shown the flu shot can reduce your chances of catching the flu by 70-90% in healthy individuals and reduce the risk of hospitalization or death by 50%-80% in high-risk individuals. Studies also show that currently only 15-25% of pregnant women receive the flu shot annually. Flu vaccination of pregnant women can reduce febrile flu illness by more than 30% in mothers and their young infants as well as reduce influenza infections in 0-6 month old infants by 63%. Use of the influenza vaccine reduces costs overall and can result in a savings of $50 per immunized pregnant woman.
On September 15, 2010, The CDC along with the American College of Obstetricians and Gynecologists (ACOG) and nine other medical organizations (AAFP, AAP, ACNM, AMA, ANA, AOA, APhA, AWHONN, and March of Dimes) released a statement recommending that ALL pregnant and postpartum (including after pregnancy loss) women receive the seasonal influenza vaccine for 2010-2011. The key points from this statement are as follows:
On September 21, 2010, ACOG released a statement encouraging healthcare providers to educate and offer influenza vaccination to all their patients and especially pregnant patients. They stated that ALL pregnant women should get the flu vaccine in any trimester and that flu prevention is an essential part of prenatal care. The CDC also supports that getting the flu shot is the first and most important step in protecting pregnant women and their infants against the flu.
The October 2010 Committee Opinion – Influenza Vaccination During Pregnancy by ACOG, addresses the use of thimerosal , a mercury containing preservative in flu shots, and indicates that it does not cause any adverse effects except for occasional local skin reactions. Numerous studies do not show an association with autism or other problems in infants to immunized mothers. However, for those mothers that remain concerned, a thimerosal –free flu shot is also available.
Symptoms of the flu include fever, cough, sore throat, runny nose, congestion, muscle and body aches, headaches, fatigue, and in some cases vomiting and diarrhea. Sick individuals may be able to infect others and shed the virus starting 1 day before symptoms and up to 5-7 days after becoming ill. In pregnant women, the flu can rapidly progress and worsen. Treatment is typically, supportive care with rest and fluids. Pregnant women are encouraged to treat any fevers with Tylenol, especially because in the first trimester hyperthermia can lead to birth defects and in labor maternal fever can lead to neonatal seizures, encephalopathy or cerebral palsy. Treatment with antivirals may be recommended and ideally work best if started within the first 48 hours of symptoms, but may still provide some benefit if started later. The two FDA approved antivirals are Tamiflu and Relenza. Tamiflu is preferred for pregnant women as it is absorbed systemically. Pregnant women who think they may have the flu should also see their doctor immediately if they experience:
In summary, the CDC outlines “Take 3” key actions to fight the flu:
The flu vaccine should not be given to children younger than 6 months of age, individuals with a severe egg allergy, anyone with a prior severe reaction or a history of Guillian-Barre Syndrome (GBS) after vaccination, or someone with a current fever should wait for immunization until the fever resolves.
The flu vaccination is recommended for everyone over 6 months of age and an important measure for public health prevention. As pregnant women are particularly vulnerable to the flu and more susceptible to increased morbidity and mortality, it is essential for all pregnant women, women planning to be pregnant during flu season, postpartum women, and women breastfeeding to get the flu vaccination. Please get your flu shot for your overall health and wellness and to help prevent this epidemic.
By Shawn A. Tassone, M.D.
Author of “Hands Off My Belly! The Pregnant Woman’s Guide to Surviving Myths, Mothers, and Moods” – Mom’s Choice Gold Recipient and Arizona Book Publisher’s Glyph Award Winner.
So much mysticism and mythology surrounds the pregnancy due date. Much of the mysticism is held by physicians who hold on to the old ways of determining when a pregnant woman will deliver. Believe me, most physicians would love a way to determine the due date so we could plan our lives around the deliveries of our patients, but the truth is only 1-2% of women will actually deliver on their due date. So what determines a due date, and what is the difference between EDC (estimated date of confinement) and EDD (estimated date of delivery) and what the heck is Naegele’s Rule. This post will help show the origins of the due date and how we are currently using a system that is about 250 years old.
Franz Karl Naegele (1778-1851) was the German obstetrician who initially came up with the rule to determine a woman’s due date based on her last menstrual period (LMP). There are many ways to calculate Naegele’s Rule. I use the system where you take the LMP, add 7 days, and subtract three months. So if your LMP was April 1, 2009 then your due date would be January 8, 2010. You can impress your friends at parties with this maneuver. There are problems with Naegele’s Rule and many people have pointed out that this 250 year old method is no longer appropriate for our advanced age. What are some of the potential errors with calculating the EDC in this method?
It assumes that you are having a regular period and that you ovulate on day 14 of your cycle. I am a gynecologist and there are many women out there that have irregular cycles that ovulate on day 20, 25, 12, 15….you get my point. This obviously would add potential error to the EDC determination and could change things by days to weeks.
There is another assumption that the routine pregnancy is 280 days long and that is based on our current calendar system. The problem with this is that there are many months that contain 30 days or 31 days and what happens in a leap year, or if you are not pregnant over the shorter month of February. The point is that there is a movement out there that is trying to say that the number should be 288 days and that we are inducing women that have premature babies. A study done in 1990 stated that the proper method for determining a due date was to take the LMP, count back three months and add fifteen days for a primiparous (first pregnancy) woman or 10 days for a multiparous (subsequent births) woman. This was published in the journal Obstetrics and Gynecology.
There are many that argue this method of calculating the EDC is as archaic as the term EDC itself. Lending to the agrarian societies from whence it came, the EDC literally came from the fact that a woman was confined to her bed for the last part of her pregnancy to prevent preterm labor. While we still prescribe bedrest today as a possible therapy for preterm labor it does seem odd that the medical establishment uses terminology from the 1700’s.
The due date is as individual as the pregnant mother. While the EDC is currently calculated by Naegele’s Rule this does seem a bit archaic and inefficient; especially if we are using this dating method to determine inductions and postdatism. There have been other methods with increased accuracy but they require a woman to measure body temperatures and be move involved in her own self-care. Many reading this article are very involved with birth and feel as though self-care is very important, but there are many women out there that simply choose not to be observant of their own cycle. So, what do we “do” with the “due”. Unfortunately, I think we will keep going with the current system and back it up with ultrasounds which are accurate within 5 days if done in the first trimester.
Approximately 3% of so-called term births (occurring after 37 weeks) are completed with fetal lung immaturity and this could be because the baby may have been between 35-37 weeks and not term.
Are we too involved in the birthing process? Are there better ways to determine the pregnant due date or should we not worry about and just let man/woman be born in his own time. The latin word natura gives rise to the word natural and means “to be born”. Maybe we should just leave well enough alone.
Hands Off My Belly! The Pregnant Woman’s Survival Guide to Myths, Mothers, and Moods is for sale on Amazon and Barnes and Noble and at most brick and mortar stores.