Postpartum

Depression in Pregnancy and Postpartum: A Review of Critical Issues

Stanley A et al., 2026

Continuities in Maternal Depression

Zafman KB et al., 2026

The New Technologies of Birth

Zhu B et al., 2026

Validating At-Home Urinary Hormone Measurements in Postpartum and Perimenopause Fertility Transitions

Bouchard TP et al., 2025·Womens Health Rep (New Rochelle)

Measuring quantitative menstrual cycle hormones at home may help women better understand their postpartum and perimenopause fertility transitions, but these quantitative fertility monitors require validation. This study included 16 North American women, aged 28-51, during either the postpartum (n = 8, cycles = 18) or perimenopause (n = 8, cycles = 35) fertility transitions testing daily first-morning urine testing with both the Mira Monitor and ClearBlue Fertility Monitor (CBFM) along with menstrual cycle parameter tracking. The main outcome measures were a rise in estrone-3-glucuronide (E13G) and luteinizing hormone (LH) urine hormone values from the Mira monitor correlated to low, high, or peak values on the CBFM. Both in the postpartum and perimenopause transitions, the identification of the day of ovulation based on the LH surge on the Mira and CBFM monitors was highly correlated (R = 0.94 and 0.83, p < 0.001). The E13G levels on the Mira monitor were significantly higher for a CBFM reading of "High" compared with "Low" for both the postpartum and perimenopausal cycles (all p < 0.001). Similarly, the LH levels on the Mira monitor were significantly higher for a CBFM reading of "Peak" (LH surge) compared with "High" for both the postpartum and perimenopausal cycles (all p < 0.001). The LH surge and levels of E13G in urine identified on the quantitative Mira fertility monitor strongly correlate to the LH surge and the shift from low to high on the CBFM during the postpartum and perimenopause transitions.

Condoms, IUDs, counseling and natural family planning

Upadhye JJ et al., 2025·Am Fam Physician

Prevalence and risk factors for postpartum depression 2 months after a vaginal delivery: a prospective multicenter study

Froeliger A et al., 2024·Am J Obstet Gynecol

Very little is known about the prevalence and risk factors of postpartum depression among women with vaginal births without major pregnancy complications. This study aimed to assess the prevalence of postpartum depression and identify its characteristics 2 months after singleton vaginal delivery at or near term. This was an ancillary cohort study of the TRanexamic Acid for Preventing Postpartum Hemorrhage After Vaginal Delivery randomized controlled trial, which was conducted in 15 French hospitals in 2015-2016 and enrolled women with singleton vaginal deliveries after 35 weeks of gestation. After randomization, the characteristics of labor, delivery, and the immediate postpartum experience, including the experience of childbirth, were prospectively collected. Medical records provided women's other characteristics, particularly any psychiatric history. Of note, 2 months after childbirth, provisional postpartum depression diagnosis was defined as a score of ≥13 on the Edinburgh Postnatal Depression Scale, a validated self-administered questionnaire. The corrected prevalence of postpartum depression was calculated with the inverse probability weighting method to take nonrespondents into account. Associations between potential risk factors and postpartum depression were analyzed by multivariate logistic regression. Moreover, an Edinburgh Postnatal Depression Scale cutoff value of ≥11 was selected to perform a sensitivity analysis. The questionnaire was returned by 2811 of 3891 women (72.2% response rate). The prevalence rates of the provisional diagnosis were 9.9% (95% confidence interval, 8.6%-11.3%) defined by an Edinburgh Postnatal Depression Scale score of ≥13 and 15.5% (95% confidence interval, 14.0%-17.1%) with a cutoff value of ≥11. The characteristics associated with higher risks of postpartum depression in multivariate analysis were mostly related to prepregnancy characteristics, specifically age of <25 years (adjusted odds ratio, 1.8; 95% confidence interval, 1.1-2.9) and advanced age (adjusted odds ratio, 1.8; 95% confidence interval, 1.2-2.6), migration from North Africa (adjusted odds ratio, 2.9; 95% confidence interval, 1.9-4.4), previous abortion (adjusted odds ratio, 1.4; 95% confidence interval, 1.0-2.0), and psychiatric history (adjusted odds ratio, 2.9; 95% confidence interval, 1.8-4.8). Some characteristics of labor and delivery, such as induced labor (adjusted odds ratio, 1.5; 95% confidence interval, 1.1-2.0) and operative vaginal delivery (adjusted odds ratio, 1.4; 95% confidence interval, 1.0-2.0), seemed to be associated with postpartum depression. In addition, bad memories of childbirth in the immediate postpartum were strongly associated with postpartum depression symptoms at 2 months after giving birth (adjusted odds ratio, 2.4; 95% confidence interval, 1.3-4.2). Approximately 10% of women with vaginal deliveries have postpartum depression symptoms, assessed by a score of ≥13 on the depression scale that was used at 2 months. Prepregnancy vulnerability factors; obstetrical characteristics, such as induced labor and operative vaginal delivery; and bad memories of childbirth 2 days after delivery were the main factors associated with this provisional diagnosis. A screening approach that targets risk factors may help to identify women at risk of postpartum depression who could benefit from early intervention.

Effectiveness of a Postpartum Breastfeeding Protocol for Avoiding Pregnancy

Schneider MM et al., 2023·Linacre Q

The uses of cervical mucus and basal body temperature as indicators of return to fertility postpartum have resulted in high unintended pregnancy rates. In 2013, a study found that when women used urine hormone signs in a postpartum/breastfeeding protocol this resulted in fewer pregnancies. To improve the original protocol's effectiveness, (1) women were to increase the number of days tested with the Clearblue Fertility Monitor, (2) an optional second luteinizing hormone test could be done in the evening, and (3) instructions were given to manage the beginning of the fertile window for the first six cycles postpartum. The purpose of this study was to determine the correct and typical use effectiveness rates to avoid pregnancy in women who used a revised postpartum/breastfeeding protocol. A cohort review of an established data set from 207 postpartum breastfeeding women who used the protocol to avoid pregnancy was completed using Kaplan-Meier survival analysis. Total pregnancy rates that included correct and incorrect use pregnancies were eighteen per one hundred women over twelve cycles of use. For the pregnancies that met a priori criteria, the correct use pregnancy rates were two per one hundred over twelve months and twelve cycles of use and typical use rates were four per one hundred women at twelve cycles of use. The protocol had fewer unplanned pregnancies than the original, however, the cost of the method increased.

Depression Associated With Hormonal Contraceptive Use as a Risk Indicator for Postpartum Depression

Larsen SV et al., 2023·JAMA Psychiatry

Hormonal sensitivity may contribute to the risk of depression in some women, as observed during the premenstrual, postpartum, and perimenopausal phases, and when initiating hormonal contraception (HC). However, little evidence exists to support that such depressive episodes are linked across the reproductive life span. To determine whether prior depression associated with HC initiation is coupled with a higher risk of postpartum depression (PPD) than prior depression not associated with HC initiation. DESIGN, SETTING, This cohort study used Danish health registry data collected from January 1, 1995, through December 31, 2017, and analyzed from March 1, 2021, through January 1, 2023. All women living in Denmark born after 1978 with their first delivery between January 1, 1996, and June 30, 2017, were eligible for inclusion; 269 354 met these criteria. Women were then excluded if they had never used HC or if they had a depressive episode before 1996 or within 12 months prior to delivery. Prior depression associated with vs not associated with HC initiation, ie, if developed within 6 months after start of an HC exposure or not. Depression was defined as a hospital diagnosis of depression or filling a prescription for antidepressant medication. Crude and adjusted odds ratios (ORs) were calculated for the incidence of PPD defined as the development of depression within 6 months after first delivery. Of 188 648 first-time mothers, 5722 (3.0%) (mean [SD] age, 26.7 [3.9] years) had a history of depression associated with initiation of HC use, and 18 431 (9.8%) (mean [SD] age, 27.1 [3.8] years) had a history of depression not associated with the initiation of HC. Women with HC-associated depression had a higher risk of PPD than women with prior non-HC-associated depression (crude OR, 1.42 [95% CI, 1.24-1.64]; adjusted OR, 1.35 [95% CI, 1.17-1.56]). These findings suggest that a history of HC-associated depression may be associated with a higher risk of PPD, supporting that HC-associated depression may indicate PPD susceptibility. This finding offers a novel strategy in clinical PPD risk stratification and points to the existence of a hormone-sensitive subgroup of women.

Time to Resumption of Menses, Spatial Distribution, and Predictors Among Post-partum Period Women in Ethiopia, Evidence From Ethiopian Demographic and Health Survey 2016 Data: Gompertz Inverse Gaussian Shared Frailty Model

Belay DG et al., 2022·Front Reprod Health

The timing of the resumption of post-partum menses is important for a woman who intends to avoid subsequent unintended pregnancy, and it has key implications on maternal, neonatal, and child health outcomes. Despite this, information is scant about the time to resumption of post-partum menses and predictors in Ethiopia. Therefore, this study aimed to determine the time it takes to start menses and spatial distribution among post-partum period women in Ethiopia and identify its predictors. A secondary data analysis was conducted based on 2016 Ethiopian Demographic and Health Survey (EDHS). A total weighted sample of 6,489 post-partum women was included in the analysis. STATA 14 was used to weigh, clean, and analyze the data. The shared frailty model was applied since the EDHS data have a hierarchical nature. For checking the proportional hazard assumption, the Schenefold residual test, Log-Log plot, Kaplan-Meier, and predicted survival plot were applied. Akakie Information Criteria (AIC), Cox-Snell residual test, and deviance were used for checking model adequacy and for model comparison. Based on these, the Gompertz inverse Gaussian shared frailty model was the best-fitted model for this data. Variables with a p < 0.2 were considered for the multivariable Gompertz inverse Gaussian shared frailty model. Finally, the adjusted hazard ratio (AHR) with a 95% confidence interval (CI), and a p < 0.05 was reported to identify the significant predictors of time to the resumption of post-partum menses. The median survival time to post-partum menses resumption was 14.6 months. In this study, 51.90% [95% CI: 50.03, 53.76] of post-partum period women had resumed, and the risk of menses resumption was 1.17 times [AHR: 1.17; 95% CI: 1.03-1.33] higher among urban resident, 1.14 times [AHR: 1.14; 95% CI: 1.0-1.24] in women who had attended formal education, and 1.63 times [AHR: 1.63; 95% CI: 1.4-1.7] higher among women who used hormonal contraceptives. However, the risk of post-partum menses resumption was lower among 7-24 months breastfeeding women by 36% [AHR: 0.64; 95% CI: 0.5-0.76], women with child alive by 26% [AHR: 0.74; 95% CI: 0.6-0.85], and multiparous women by 27% [AHR: 0.73; 95% CI: 0.6-0.80]. Almost half of the participants had resumed post-partum menses, with the median survival timing of menses resumption at 14.5 months. Women residing in urban areas, who attended formal education, and using hormonal contraceptives have a shorter time to resume post-partum menses, whereas a woman with an alive child, breastfeeding practice, and multiple parity has a longer time to resume post-partum menses. Therefore, the healthcare providers and program managers should act on the resumption of post-partum menses through health education and promotion to cultivate the 14 months lag period identified by considering the significant factors.

Polycystic ovary syndrome and postpartum depression among Hispanics and non-Hispanics: a population-based study

Fugal AD et al., 2022·AJOG Glob Rep

Women with polycystic ovary syndrome experience increased health complications during and after pregnancy, including a higher prevalence of postpartum depression. Although previous research has found that Hispanic women with polycystic ovary syndrome experience heightened hyperandrogenism and metabolic effects compared with non-Hispanic women, it is unknown whether they experience other polycystic ovary syndrome-related comorbidities, such as postpartum depression, to a greater degree than their non-Hispanic counterparts. This study aimed to determine the associations among a self-reported prepregnancy diagnosis of polycystic ovary syndrome, polycystic ovary syndrome symptoms (irregular menstruation, hirsutism, and acne), and postpartum depression among a national sample of at-risk women and evaluated the potential effect modification by Hispanic ethnicity. The study population included 52,267 postpartum (2-6 months) women who completed the US Pregnancy Risk Assessment Monitoring System Phase 8 questionnaire (2016-2018). Data from US states that captured self-reported polycystic ovary syndrome symptoms in the 3 months before pregnancy (n=17 states) were used. Moreover, we performed a subanalysis restricted to data from the Utah Pregnancy Risk Assessment Monitoring System Phase 8 questionnaire (2016-2019; n=5814), as it was the only state that considered self-reported polycystic ovary syndrome symptoms during this period. Postpartum depressed mood and anhedonia, the postpartum depression outcome measurements, were assessed via the following questions, (1) "Since your new baby was born, how often have you felt down, depressed, or hopeless?" and (2) "Since your new baby was born, how often have you had little interest or little pleasure in doing things you usually enjoyed?" In addition, postpartum depressed mood and anhedonia were assessed separately and as a combined variable. Here, weighted adjusted prevalence ratios and 95% confidence intervals were used to assess the association between polycystic ovary syndrome and postpartum depressed mood and anhedonia among Hispanic women and non-Hispanic women while taking into account preconception sociodemographics, lifestyle, and health history confounding factors. The national study population was composed of 16.8% of Hispanic ethnicity, with 11.4% Hispanic women and 17.1% non-Hispanic women reporting prepregnancy polycystic ovary syndrome symptoms. The study found no association between women reporting prepregnancy polycystic ovary syndrome vs women without polycystic ovary syndrome and the prevalence of postpartum depressed mood and/or anhedonia. Moreover, the results were null when we stratified by Hispanic ethnicity. The Utah study population was composed of 15.5% of women of Hispanic ethnicity, with 5.8% of Hispanic women and 7.4% of non-Hispanic women reporting prepregnancy polycystic ovary syndrome. Symptom-based polycystic ovary syndrome (having irregular menstruation with hirsutism or irregular menstruation with acne), compared with having regular menstruation in the Utah sample, was associated with a 1.54 higher adjusted prevalence ratio (95% confidence interval, 1.14-2.09) for postpartum depressed mood and anhedonia. Stratified analyses by ethnicity indicated a 2to 5-fold higher prevalence of postpartum depression with symptom-based polycystic ovary syndrome for Hispanic women and a 1.5-fold higher prevalence for non-Hispanic women. In this US population-based study, a self-reported prepregnancy diagnosis of polycystic ovary syndrome was not associated with postpartum depression. However, self-reported polycystic ovary syndrome symptoms, including irregular menstruation and acne and/or hirsutism, were associated with a higher probability of postpartum depression, most prominently for Hispanic women. Our findings suggested that capturing polycystic ovary syndrome symptoms among at-risk women may be important for identifying associations with postpartum depression and potentially other comorbidities.

Effectiveness of fertility awareness-based methods for pregnancy prevention during the postpartum period

Redmond JJ et al., 2022·Contraception

To summarize the evidence on typical and perfect-use effectiveness of fertility awareness-based methods for avoiding pregnancy during the postpartum period, whether breastfeeding or not. We conducted a systematic review of studies published in English, Spanish, French, or German by November 2021 in MEDLINE, EMBASE, CINAHL, Web of Science, and ClinicalTrials.gov. Abstract and full text reviews were completed by 2 independent reviewers. at least 50 subjects who enrolled prior to experiencing 3 cycles after childbirth and were using a specific fertility awareness-based method to avoid pregnancy; unintended pregnancy rate or probability calculated; postpartum amenorrheic and postpartum cycling individuals analyzed separately; and prospectively measured pregnancy intentions and outcomes. Outcomes were abstracted and study quality was systematically assessed by 2 independent investigators. Four studies provided effectiveness data for 1 specific fertility awareness-based method among postpartum individuals. Of these, there were zero high quality, 1 moderate quality, and 3 low quality for our question of interest. Typical-use pregnancy probability for the first 6 cycles postpartum for Marquette Method users was 12.0 per 100 women years (standard error [SE] not reported) and for Billings Ovulation Method users ranged from 9.1 (SE 3.9) for non-lactating women <30 years old to 26.8 (SE 4.6) for lactating women <30 years old. Typical-use pregnancy probabilities for the first 6 months post-first menses for the Postpartum Bridge to Standard Days Method users was 11.8 (95% confidence interval 6.01-17.16) and for Billings Ovulation Method users was 8.5 per 100 women (SE 1.7). The current evidence on the effectiveness of each fertility awareness-based method for postpartum persons is very limited and of mostly low quality. More high quality studies on the effectiveness of fertility awareness-based method in postpartum persons are needed to inform clinical counseling and patient-centered decision-making. Although postpartum individuals may desire to use fertility awareness-based methods to avoid pregnancy, the evidence of the effectiveness of fertility awareness-based methods in this population is limited. More high-quality studies are needed to inform shared decision-making.

Polycystic ovary syndrome and postpartum depression symptoms: a population-based cohort study

Koric A et al., 2021·Am J Obstet Gynecol

Women with polycystic ovary syndrome are more likely to experience several pregnancy complications including hypertensive disorders, gestational diabetes mellitus, and preterm births than women without polycystic ovary syndrome. However, at present, there is limited research on whether polycystic ovary syndrome is associated with both anxiety and depression during pregnancy and whether this augments a woman's risk of postpartum depression, particularly among high-risk populations who have limited access to care. Our primary objective was to assess the association between prepregnancy polycystic ovary syndrome and postpartum depression, considering important baseline confounding factors. Our secondary objective was to evaluate the mediating role of prenatal depression and anxiety on the association between polycystic ovary syndrome and postpartum depression. This study involved a population-based sample of 3906 postpartum (2-6 months) women who completed the Utah Pregnancy Risk Assessment Monitoring System Phase 8 questionnaire (2016-2018). Weighted adjusted prevalence ratios were used to assess the association between polycystic ovary syndrome and postpartum depression, considering potential confounding factors and assessing mediating effects of depression and anxiety experienced during pregnancy. Following the exclusion criteria, 8.2% of women reported clinical polycystic ovary syndrome and 19.1%, 6.2%, and 4.4% reported irregular periods and acne, irregular periods and hirsutism, and all 3 symptoms, respectively. Moreover, 17.7% and 23.5% reported experiencing prenatal depression and anxiety and 9.5% and 10.2% reported experiencing postpartum depressed mood and anhedonia, respectively. Clinical polycystic ovary syndrome was associated with a 1.76 higher adjusted prevalence ratio (95% confidence interval, 1.03-3.00) for postpartum depressed mood or anhedonia after taking into consideration age, prepregnancy body mass index, race/ethnicity, education, and marital status. A similar higher prevalence was seen for irregular periods and acne (adjusted prevalence ratio, 1.65; 95% confidence interval, 1.13-2.41), irregular periods and hirsutism (adjusted prevalence ratio, 1.40; 95% confidence interval, 0.82-2.40), and all 3 symptoms (adjusted prevalence ratio, 1.75; 95% confidence interval, 0.96-3.19) and postpartum depressed mood or anhedonia. Prenatal depression and anxiety mediated 20% and 32% of the effect of clinical polycystic ovary syndrome on postpartum depressed mood and anhedonia, respectively. Clinical polycystic ovary syndrome is associated with postpartum depressed mood and symptoms among this population-based sample inclusive of high-risk mothers. Prenatal depression and anxiety mediate this association, emphasizing the importance of prenatal psychological screening among women with polycystic ovary syndrome. An additional important clinical and public health implication of this study lies in the finding that nearly 20% of women in this population-based sample who reported at least 2 polycystic ovary syndrome symptoms (including at-risk women who may not have access to care) had not received a clinical diagnosis for polycystic ovary syndrome.

Pregnancy-induced long-term uterine vascular remodeling in the rat

Camilleri C et al., 2020·Reprod Biol

Despite the available research investigating uterine physiology during and immediately following pregnancy, including at the vascular and muscular levels, knowledge of the potential long-term timeline of such changes is limited. Thus, our study sought to investigate the potential long-term changes in uterine vasculature and horn length in the postpartum rat, following delivery and weaning. Female Long-Evans rats (n = 9-11 rats/group/timepoint) a pregnant group and an age-matched virgin control group. Rat weight, food consumption and vaginal impedance measurements were recorded throughout the experiment. Rats in the pregnant group were bred and pregnancy was confirmed using ultrasound imaging. The uterus and its vasculature were collected at various 3 (week of weaning), 8-9 and 13 weeks postpartum, and at age-equivalent timepoints in the virgin group, and the diameters of the main uterine artery and vein, and lengths of the mesometrial segmental vessels (MSV) and uterine horns were recorded. The results indicated a significant difference between the previously-pregnant and virgin rats in both internal and external arterial diameters (but not arterial wall thickness), as well as the uterine horn length, 3 weeks postpartum, but not 8-9 and 13 weeks postpartum. Significant differences were observed in both venous diameter and MSV length at all timepoints measured. Placental scars were also observed in previously-pregnant rats at all timepoints measured. Our study highlights the long-term impact of pregnancy on the uterine vasculature and the necessity for consideration of such changes on subsequent pregnancies, as well as pregnancy-related vascular pathologies.

The Baby-Friendly Hospital Initiative (BFHI): An Early Cross-Sectional Analysis of PRAMS Phase 8 Data on Hospital Practices and Breastfeeding Outcomes in Utah and Wyoming

Bliss JC et al., 2020·Utah Womens Health Rev

Breastfeeding has immediate and long-term benefits for both maternal and child health. This study examines the association between Baby-Friendly Hospital Initiative (BFHI) experiences and breastfeeding outcomes in the Mountain West region. A cross-sectional (retrospective secondary data analysis) was performed using the 2016 Pregnancy Risk Assessment Monitoring System (PRAMS) data. The participants were derived from a stratified random sample of 2,013 women living in Utah and Wyoming who recently had a live birth and who were surveyed on BFHI practices. The association between BFHI experiences and breastfeeding duration were assessed using crude and adjusted Poisson regression models, controlling for other BHFI experiences and maternal age, pre-pregnancy BMI, household income, smoking, alcohol, delivery method, and number of days spent in the hospital post delivery. 82.4% and 82.3% of women from Utah and Wyoming, respectively, reported breastfeeding for 2 months or longer. After controlling for other BFHI experiences and potential confounders, the one shared BFHI experience that was associated with breastfeeding for 2 months or longer vs less than 2 months was starting breastfeeding in the hospital (adjusted prevalence ratio [aPR]=1.49, 95% CI (1.12, 1.98) in Utah and aPR=2.03, 95% CI (1.13, 3.64) in Wyoming. Among women in Utah and Wyoming, only 5 of 7 BFHI steps were significant for breastfeeding duration in at least one state. There is substantial epidemiological support for health benefits to both mother and infant for exclusive breastfeeding to 6 months and prolonged breastfeeding until at least 1-year. Our findings suggest that women who initiate breastfeeding in the hospital may be more likely to breastfeed for a longer duration.

Progesterone - Friend or foe?

Sundström-Poromaa I et al., 2020·Front Neuroendocrinol

Estradiol is the "prototypic" sex hormone of women. Yet, women have another sex hormone, Progesterone. The goal of this article is to provide a comprehensive review on progesterone, and its metabolite allopregnanolone, biological properties, main functions, and effects on mood in women. Recent years of intensive research on progesterone and allopregnanolone have paved the way for new treatment of postpartum depression. However, treatment for premenstrual syndrome and premenstrual dysphoric disorder as well as contraception that women can use without risking mental health problems are still needed. As far as progesterone is concerned, we might be while its metabolite allopregnanolone has been proven useful for treatment of PPD, it may trigger negative symptoms in women with PMS and PMDD. Overall, our current knowledge on the beneficial and harmful effects of progesterone is limited and further research is imperative.

Postpartum Lactational Amenorrhea and Recovery of Reproductive Function and Normal Ovulatory Menstruation

Prior JC, 2020·Maternal-Fetal and Neonatal Endocrinology

The association between hormones and antipsychotic use: a focus on postpartum and menopausal women

González-Rodríguez A et al., 2019·Ther Adv Psychopharmacol

During the postpartum and menopausal periods of women's lives, there is a well-established and significant drop of circulating estrogens. This may be the reason why both these periods are associated with an increased risk for onset or exacerbation of psychiatric disorders. Whether symptoms are mainly affective or mainly psychotic, these disorders are frequently treated with antipsychotic medications, which calls for an examination of the relationship between hormone replacement and antipsychotic agents at these time periods. The aim of this narrative review is to summarize what is known about the association of hormones and antipsychotics in the postnatal period and at menopause. In the review, we focus on estrogen and oxytocin hormones and include, for the most part, only papers published within the last 10 years. Both estradiol and oxytocin have at various times been implicated in the etiology of postpartum disorders, and estrogens, sometimes combined with progesterone, have been tested as potential treatments for these conditions. The role of estradiol as an adjunct to antipsychotics in the prevention of postpartum relapses is currently controversial. With respect to oxytocin, studies are lacking. Psychosis in menopausal and postmenopausal women has been successfully treated with estrogens and selective estrogen-receptor modulators, mainly raloxifene, in addition to antipsychotics. Some symptoms appear to respond better than others. No oxytocin study has specifically targeted postmenopausal women. Because of feedback mechanisms, there is a theoretical danger of therapy with exogenous hormones interfering with endogenous secretion and disturbing the balance among inter-related hormones. When used with antipsychotics, hormones may also affect the metabolism and, hence, the brain level of specific antipsychotics. This makes treatment with antipsychotics plus hormones complicated. Dose, timing and route of intervention may all prove critical to efficacy. While much remains unknown, this literature review indicates that, within standard dose ranges, the combination of hormones and antipsychotics for postnatal and menopausal women suffering severe mental distress can be beneficial, and is safe.

Factors in the Hospital Experience Associated with Postpartum Breastfeeding Success

Schliep KC et al., 2019·Breastfeed Med

Hospitals are in a unique position to promote, protect, and support breastfeeding. However, the association between in-hospital events and breastfeeding success within population-based samples has not been well studied. A stratified (by education and birth weight) systematic sample of 5,770 mothers taking part in the Utah Pregnancy Risk Assessment Monitoring System, 2012-2015, were included. Mothers, 2-4 months postpartum, completed the 82-item questionnaire, including if they had ever breastfed their new baby, and if so, current breastfeeding status. Relationships between in-hospital experiences and breastfeeding termination and duration were evaluated via Poisson and Cox proportional hazard regression models, respectively, adjusting for other in-hospital experiences, maternal age, race/ethnicity, maternal education, marital status, smoking, physical activity, delivery method, pregnancy complications, and length of hospital stay. Of all, 94.4% of mothers self-reported breastfeeding initiation, of whom 18.8% had breastfed <2 months, having breastfed on average 3.2 weeks (standard 0.07). In fully adjusted models, mothers who reported receiving a pacifier, receiving formula, or had staff help them learn how to breastfeed had a higher prevalence of terminating breastfeeding before 2 months (adjusted prevalence ratio [aPR] = 1.13, 95% confidence interval [CI]: 0.97-1.32; aPR = 1.20, 95% CI: 1.07-1.36; and aPR = 1.25, 95% CI: 1.08-1.34). Conversely, mothers who reported starting and feeding only breast milk in the hospital and receiving a phone number to call for help with breastfeeding had a lower prevalence of breastfeeding termination before 2 months (aPR = 0.72, 95% CI: 0.61-0.86; aPR = 0.57, 95% CI: 0.51-0.64; and aPR = 0.91, 95% CI: 0.80-1.03). Adjusted Cox models showed similar direction of associations. Encouraging mothers to exclusively breastfeed in the hospital, and reducing gift packs containing pacifiers and formula, may be key areas United States hospitals can focus on to increase breastfeeding success. Prospective assessment in other geographical regions is needed to corroborate these findings.

Parity and lactation are not associated with incident fragility fractures or radiographic vertebral fractures over 16 years of follow-up: Canadian Multicentre Osteoporosis Study (CaMos)

Cooke-Hubley S et al., 2019·Arch Osteoporos

Parity and lactation showed no associations with incident clinical fragility fractures or radiographic vertebral compression fractures in the 16-year CaMos prospective study. Parity was associated with slightly greater decline in femoral neck but not hip or spine areal bone mineral density (aBMD), while lactation showed no associations with aBMD change. Pregnancy and especially lactation cause loss of bone mass and microarchitectural changes, which temporarily increase fracture risk. After weaning, aBMD increases but skeletal microarchitecture may be incompletely restored. Most retrospective clinical studies found neutral or even protective associations of parity and lactation with fragility fractures, but prospective data are sparse. CaMos is a randomly selected observational cohort that includes ~ 6500 women followed prospectively for over 16 years. We determined whether parity or lactation were related to incident clinical fragility fractures over 16 years, radiographic (morphometric and morphologic) vertebral fractures over 10 years, and aBMD change (spine, total hip, and femoral neck) over 10 years. Parity and lactation duration were analyzed as continuous variables in predicting these outcomes using univariate and multivariate regression analyses. Three thousand four hundred thirty-seven women completed 16 years of follow-up for incident clinical fractures, 3839 completed 10 years of morphometric vertebral fracture assessment, 3788 completed 10 years of morphologic vertebral fracture assessment, and 4464 completed 10 years of follow-up for change in aBMD. In the multivariate analyses, parity and lactation duration showed no associations with clinical fragility fractures, radiographic vertebral fractures, or change in aBMD, except that parity associated with a probable chance finding of a slightly greater decline in femoral neck aBMD. Parity and lactation have no adverse associations with clinical fragility or radiographic vertebral fractures, or the rate of BMD decline over 10 years, in this prospective, multicenter study of a randomly selected, population-based cohort of women.

Dissociation between Cervical Mucus and Urinary Hormones during the Postpartum Return of Fertility in Breastfeeding Women

Bouchard T et al., 2018·Linacre Q

Identifying the return of fertility with cervical mucus observations is challenging during the postpartum period. Use of urinary measurements of estrogen and progesterone can assist in understanding the return to fertility during this period. The purposes of this study were to describe the postpartum return of fertility by an analysis of total estrogen (TE) and pregnanediol glucuronide (PDG) profiles and to correlate these profiles with cervical mucus observations. Twenty-six participants collected urine samples during the postpartum period and recorded mucus scores. TE and PDG hormones were analyzed and compared with mucus scores. During amenorrhea, mucus reflected TE changes in only 35 percent of women; after amenorrhea, typical mucus patterns were seen in 33 percent of cycles. We concluded that postpartum mucus and hormone profiles are significantly dissociated but that monitoring urinary hormones may assist in identifying the return of fertility. We also identified different hormonal patterns in the return to fertility. The postpartum period is a challenging time for identifying the return of fertility. The purposes of this study were to describe the hormonal patterns during the return of fertility and to correlate these patterns with cervical mucus observations. Twenty-six postpartum women collected urine samples and recorded mucus scores. Urinary estrogen and progesterone hormones were analyzed and compared with mucus scores. Before the return of menses, mucus reflected hormonal changes in only 35 percent women and after first menses in 33 percent of cycles. We found that hormone profiles do not correlate well with mucus observations during the postpartum return of fertility.

Current Medical Research: Summer/Fall 2017

Fehring RJ et al., 2018·Linacre Q

This issue of Current Medical Research (CMR) includes studies that provide evidence that use of natural family planning (NFP) can be helpful for subfertile couples wishing to achieve a pregnancy, the effectiveness of a method of NFP during breastfeeding, and the effects of using NFP on marital relationships. This review also includes evidence on predicting the sex of a baby by timing intercourse, evidence that brain injuries can be reflected in changes in the menstrual cycle, and that women prefer methods of family planning that have no side effects. The issue ends with an in-depth review of new technologies that aid in the use of NFP. Topics covered include subfertile couples, breastfeeding, marriage, predicting the sex of a baby, brain injuries, and new technologies.

Effect of Lactobacillus rhamnosus HN001 in Pregnancy on Postpartum Symptoms of Depression and Anxiety: A Randomised Double-blind Placebo-controlled Trial

Slykerman RF et al., 2017·EBioMedicine

Probiotics may help to prevent symptoms of anxiety and depression through several putative mechanisms. The aim of this study was to evaluate the effect of Lactobacillus rhamnosus HN001 (HN001) given in pregnancy and postpartum on symptoms of maternal depression and anxiety in the postpartum period. This was a secondary outcome, the primary outcome being eczema in the offspring at 12 months of age. Design, Setting, A randomised, double-blind, placebo-controlled trial of the effect of HN001 on postnatal mood was conducted in 423 women in Auckland and Wellington, New Zealand. Women were recruited at 14–16 weeks gestation. Women were randomised to receive either placebo or HN001 daily from enrolment until 6 months postpartum if breastfeeding. Modified versions of the Edinburgh Postnatal Depression Scale and State Trait Anxiety Inventory were used to assess symptoms of depression and anxiety postpartum. Australia ACTRN12612000196842. 423 women were recruited between December 2012 and November 2014. 212 women were randomised to HN001 and 211 to placebo. 380 women (89.8%) completed the questionnaire on psychological outcomes, 193 (91.0%) in the treatment group and 187 (88.6%) in the placebo group. Mothers in the probiotic treatment group reported significantly lower depression scores (HN001 mean = 7·7 (SD = 5·4), placebo 9·0 (6·0); effect size -1·2, (95% CI -2·3, -0·1), p = 0·037) and anxiety scores (HN001 12·0 (4·0), placebo 13·0 (4·0); effect size -1·0 (-1·9, -0·2), p = 0·014) than those in the placebo group. Rates of clinically relevant anxiety on screening (score > 15) were significantly lower in the HN001 treated mothers (OR = 0·44 (0·26, 0·73), p = 0·002). Women who received HN001 had significantly lower depression and anxiety scores in the postpartum period. This probiotic may be useful for the prevention or treatment of symptoms of depression and anxiety postpartum.

Association of Hormonal Contraception with depression in the postpartum period

Roberts TA et al., 2017·Contraception

Studies have demonstrated an association between hormonal contraception use with subsequent depression and antidepressant use. This association has not been assessed among postpartum women. This study is a secondary analysis of insurance records from 75,528 postpartum women enrolled in the US military medical system, who delivered between October 2012 and September 2014. Our analyses excluded women who used antidepressants or had a diagnosis of depression in the 24months prior to delivery. We assessed the relationship of hormonal contraception use with subsequent antidepressant use or diagnosis with depression in the first 12months postpartum using Cox proportional hazards regression, with a time dependent covariate measuring exposure to hormonal contraception. Antidepressants were prescribed to 7.8% of women and 5.0% were diagnosed with depression. In multivariable analysis adjusting for demographics, both antidepressant use and diagnosis with depression younger age, lower socioeconomic status, and a history of military service. Compared to women with no hormonal contraceptive use, use of etonogestrel containing contraception was associated with a higher risk of antidepressant use (Implant: 1.22(95%CI:1.06-1.41), p<0.001; 1.45(1.16-1.80), p=0.001). Use of norethindrone-only pills was associated with a lower risk of antidepressant use (0.58(0.52-0.64), p<0.001) and depression diagnosis (0.56(0.49-0.64), p<0.001). Use of a levonorgestrel intrauterine system was associated with a lower risk of depression diagnoses (0.65(0.52-0.82), p<0.001). The risk of major depression diagnosis and antidepressant use in the postpartum period varies with the type of hormonal contraception used. Further research is required to describe the mechanisms of these relationships.

Breastfeeding and Breast Cancer Risk Reduction: Implications for Black Mothers

Anstey EH et al., 2017·Am J Prev Med

Breast cancer is the most commonly diagnosed cancer and a leading cause of death from cancer among U.S. women. Studies have suggested that breastfeeding reduces breast cancer risk among parous women, and there is mounting evidence that this association may differ by subtype such that breastfeeding may be more protective of some invasive breast cancer types. The purpose of this review is to discuss breast cancer disparities in the context of breastfeeding and the implications for black mothers. Black women in the U.S. have lower rates of breastfeeding and nearly twice the rates of triple-negative breast cancer (an aggressive subtype) compared with white women. In addition to individual challenges to breastfeeding, black women may also differentially face contextual barriers such as a lack of social and cultural acceptance in their communities, inadequate support from the healthcare community, and unsupportive work environments. More work is needed to improve the social factors and policies that influence breastfeeding rates at a population level. Such efforts should give special consideration to the needs of black mothers to adequately address disparities in breastfeeding among this group and possibly help reduce breast cancer risk. Interventions such as peer counseling, hospital policy changes, breastfeeding-specific clinic appointments, group prenatal education, and enhanced breastfeeding programs have been shown to be effective in communities of color. A comprehensive approach that integrates interventions across multiple levels and settings may be most successful in helping mothers reach their breastfeeding goals and reducing disparities in breastfeeding and potentially breast cancer incidence.

Effectiveness of an Online Natural Family Planning Program for Breastfeeding Women

Fehring RJ et al., 2017·J Obstet Gynecol Neonatal Nurs

To analyze the effectiveness of an online, nurse-managed natural family planning (NFP) program among breastfeeding women and subgroups of these women. Longitudinal comparative cohort study. A university-based online NFP education program and menstrual cycle charting system. Women (N = 816) with a mean age of 30.3 years (standard deviation = 4.5) who registered to use the online NFP system and indicated they were breastfeeding. Participants tracked their fertile times with an electronic hormone fertility monitor (EHFM), cervical mucus monitoring, or both. All unintended pregnancies were evaluated by professional nurses. The correct use pregnancy rates were 3 per 100 users over 12 cycles of use, and typical rates were 14 per 100 at 12 cycles of use. At 12 cycles of use, total pregnancy rates were 16 per 100 for electronic hormone fertility monitor users (n = 380), 81 per 100 among mucus-only users (n = 45), and 14 per 100 for electronic hormone fertility monitor plus mucus users (n = 391). Use of a nurse-managed online NFP program for women can be effective to help women avoid pregnancy while breastfeeding, especially with correct and consistent use.

The effect of depot medroxyprogesterone acetate on postnatal depression: a randomised controlled trial

Singata-Madliki M et al., 2016·J Fam Plann Reprod Health Care

Depot medroxyprogesterone acetate (DMPA) is the most commonly used hormonal contraceptive method in South Africa. It is frequently administered in the immediate postnatal period, yet it is unclear whether it affects the risk of postnatal depression (PND). To determine whether DMPA increases the risk of PND compared with the copper-containing intrauterine device (IUD) when administered after delivery. A single-blind randomised controlled trial conducted at two teaching hospitals in East London, South Africa. Eligible, consenting women (N=242) requiring postnatal contraception were randomised to receive DMPA or an IUD within 48 hours of childbirth and interviewed at 1 and 3 months postpartum. Depression was measured using the Beck Depression Inventory (BDI-II) and the Edinburgh Postnatal Depression Scale (EPDS). Resumption of sexual intercourse, menstrual symptoms and breastfeeding rates were also assessed. One-month EPDS depression scores were statistically significantly higher in the DMPA arm compared with IUD arm (p=0.04). Three-month BDI-II scores were significantly higher in the DMPA arm than in the IUD arm (p=0.002) and, according to the BDI-II but not the EPDS, more women in the DMPA arm had major depression at this time-point (8 vs 2; p=0.05). There were no statistically significant differences in other outcome measures except that fewer women had resumed sexual activity by 1 month postpartum in the DMPA arm (13% vs 26%; p=0.02). The possibility that immediate postnatal DMPA use is associated with depression cannot be excluded. These findings justify further research with longer follow-up. PACTR201209000419241.

Efficacy of a new postpartum transition protocol for avoiding pregnancy

Bouchard T et al., 2013·J Am Board Fam Med

The postpartum period is a challenging time for family planning, especially for women who breastfeed. Breastfeeding delays the return of menses (lactational amenorrhea), but ovulation often occurs before first menses. For this reason, a protocol was developed to assist women in identifying their return of fertility postpartum to avoid pregnancy. In this prospective, 12-month, longitudinal cohort study, 198 postpartum women aged 20 to 45 years (mean age, 30.2 years) were taught a protocol for avoiding pregnancy with either online or in-person instruction. A hand-held fertility monitor was used to identify the fertile period by testing for urinary changes in estrogen and luteinizing hormone, and the results were tracked on a web site. During lactational amenorrhea, urine testing was done in 20-day intervals. When menses returned, the monitor was reset at the onset of each new menstrual cycle. Participants were instructed to avoid intercourse during the identified fertile period. Kaplan-Meier survival analysis was used to calculate unintentional pregnancy rates through the first 12 months postpartum. There were 8 unintended pregnancies per 100 women at 12 months postpartum. With correct use, there were 2 unintended pregnancies per 100 women at 12 months. The online postpartum protocol may effectively assist a select group of women in avoiding pregnancy during the transition to regular menstrual cycles.

Effect of depot medroxyprogesterone acetate on postpartum depression

Tsai R et al., 2010·Contraception

Depot medroxyprogesterone acetate (DMPA) is commonly prescribed to women immediately postpartum due to its efficacy, convenience and lack of estrogen. It is unclear whether administering a progestin injection can affect the course of postpartum depression (PPD), which some suspect to be influenced by hormonal changes. In this retrospective study, the objective was to determine whether DMPA administered immediately postpartum influences the development of PPD. A retrospective review of a total of 404 charts was conducted of clinic patients who were scheduled for 6-week postpartum visits at a major medical center, where all patients are routinely asked to complete the Edinburgh Postnatal Depression Scale (EPDS). The average scores on the EPDS at these visits were compared between patients who had received DMPA prior to postpartum discharge from the hospital and patients who had not received any hormonal contraception by using an unpaired t test. In addition, the proportions of women diagnosed with PPD via the scale were compared via contingency tables. Fifty-five women who had received immediate DMPA were compared with 192 women with no hormonal contraception after delivery. The groups were similar in parity, race, mode of delivery and weight, but women receiving DMPA were significantly younger (24.2 vs. 26.2 years, p=.03). Mean EPDS scores at 6 weeks postpartum were not statistically significant between the groups (5.02 vs. 6.17, p=.16). Six patients (10.9%) who received immediate DMPA were diagnosed with PPD based on EPDS scores greater than or equal to 13, while 27 (14.1%) in the comparison group had PPD (p=.88). Administration of DMPA in the immediate postpartum period does not appear to predispose women to PPD.

Protocol for determining fertility while breastfeeding and not in cycles

Fehring RJ et al., 2005·Fertil Steril

A protocol was developed and evaluated for nonovulating breastfeeding women to determine potential fertility with an electronic hormonal fertility monitor. The amount of required abstinence (i.e., days of potential fertility) through the first menstrual cycle indicated by the fertility monitor was significantly lower (17% of the total days) compared with the amount of abstinence (50% of the total days) indicated by the self-observation of cervical mucus.

Recent use of oral contraceptives and the risk of multiple sclerosis

Alonso A et al., 2005·Arch Neurol

Exogenous estrogens affect the onset and clinical course of experimental allergic encephalomyelitis. Oral contraceptives, a frequent source of exogenous estrogens in humans, could have a role in the development of multiple sclerosis (MS). To examine whether recent oral contraceptive use and pregnancy history are associated with the risk of MS. A case-control study nested in the General Practice Research Database. This database contains prospective health information (drug prescriptions and clinical diagnoses) on more than 3 million Britons who are enrolled with selected general practitioners. One hundred six female incident cases of MS, younger than 50 years, with at least 3 years of continuous recording in the General Practice Research Database before the date of first symptoms (index date), identified between January 1, 1993, and December 31, 2000, and 1001 controls matched on age, practice, and date of joining the practice. Main Outcome Measure Incidence of first symptoms of MS, confirmed through medical records. The incidence of MS was 40% lower (odds ratio, 0.6; 95% confidence interval, 0.4-1.0) in oral contraceptive users compared with nonusers during the previous 3 years. The risk of MS increased in the 6 months after pregnancy (odds ratio, 2.9, 95% confidence interval, 1.2-6.6), but it was not otherwise related to parity. The hormonal changes that occur during oral contraceptive use and pregnancy may be associated with a short-term reduction in the risk of MS, and the postpartum period may be associated with a short-term increase in the risk of MS.

Clinical trial: Progesterone reduces postpartum depression in Naprotechnology patients

Hilgers TW et al., 2004

Diagnosing postpartum depression: can we do better?

Fergerson SS et al., 2002·Am J Obstet Gynecol

The purpose of this study was to evaluate the efficacy of the Edinburgh Postnatal Depression Scale versus routine clinical evaluation to detect postpartum depression among a low-income inner-city population and to evaluate risk factors associated with a positive score on the Edinburgh Postnatal Depression Scale. On the basis of the day of the month, all English-speaking patients who were seen for their postpartum visit were assigned either to routine clinical evaluation for postpartum depression or routine clinical evaluation plus the use of the 10-question Edinburgh Postnatal Depression Scale. During the 7-week study period, 72 women 35 women in the routine evaluation group and 37 women in the Edinburgh Postnatal Depression Scale group. Women who completed the Edinburgh Postnatal Depression Scale were significantly more likely than those in the routine evaluation group to be identified as 11 of 37 women (30%) versus 0 of 35 women (P <.001). A failed attempt at breast-feeding was associated with an increased risk of a score of > or =10 on the Edinburgh Postnatal Depression Scale (relative risk, 3.78; 95% CI, 1.03-13.89). The Edinburgh Postnatal Depression Scale appears to be a valuable and efficient tool for the identification of patients who are at risk for postpartum depression.

The treatment of postpartum depression: minimizing infant exposures

Newport DJ et al., 2002·J Clin Psychiatry

The first 3 postpartum months represent a high-risk period for psychiatric illnesses. This article reviews the prevalence and diagnostic criteria for postpartum illnesses, including the "maternal blues," postpartum depression, and postpartum psychosis. Pharmacologic treatment of these disorders is often complicated by a patient's desire to breast-feed, yet there are no controlled trials of antidepressant treatment during lactation. Infant exposure and limitations to monitoring infant sera are reviewed. Lastly, a model and guide for reducing fetal and infant exposures is presented.

Randomised trial of thyroxine to prevent postnatal depression in thyroid-antibody-positive women

Harris B et al., 2002·Br J Psychiatry

Women who are positive for thyroid antibodies in early gestation are prone to post-partum depression, apparently independent of thyroid dysfunction, as measured by serum levels of free thyroxine, free triodothyroxine and thyroid-stimulating hormone. This finding may be due to infrequent monitoring of thyroid function, because hyperthyroidism, hypothyroidism and combinations of both may occur post-partum. To test the hypothesis that stabilising thyroid function post-partum by administering daily thyroxine reduces the rate of occurrence and severity of associated depression. In a randomised double-blind placebo-controlled trial, 100 microg of thyroxine or placebo was given daily to 446 thyroid-antibody-positive women (342 of whom were compliant) from 6 weeks to 6 months post-partum, assessing their psychiatric and thyroid status at 4-weekly intervals. There was no evidence that thyroxine had any effect on the occurrence of depression. The 6-month period prevalence of depression was similar to that reported previously. The excess of depression in thyroid-antibody-positive women in the post-partum period is not corrected by daily administration of thyroxine.

Obstetric, somatic, and demographic risk factors for postpartum depressive symptoms

Josefsson A et al., 2002·Obstet Gynecol

To identify and test the predictive power of potential independent risk factors of postpartum depressive symptoms during pregnancy and the perinatal period. We conducted a case-control study where 132 women with postpartum depressive symptoms were selected as an index group and 264 women without depressive symptoms as a control group. Data related to sociodemographic status, medical, gynecologic, and obstetric history, pregnancy, and perinatal events were collected from standardized medical records. The strongest risk factors for postpartum depressive symptoms were sick leave during pregnancy and a high number of visits to the antenatal care clinic. Complications during pregnancy, such as hyperemesis, premature contractions, and psychiatric disorder were more common in the postpartum depressed group of women. No association was found between parity, sociodemographic data, or mode of delivery and postpartum depressive symptoms. Women at risk for postpartum depression can be identified during pregnancy. The strongest risk factors, sick leave during pregnancy and many visits to the antenatal care clinic, are not etiologic and might be of either behavioral or biologic origin. The possibilities of genetic vulnerability and hormonal changes warrant further investigation to reach a more thorough understanding.

Review of validation studies of the Edinburgh Postnatal Depression Scale

Eberhard-Gran M et al., 2001·Acta Psychiatr Scand

To review validation studies of the Edinburgh Postnatal Depression Scale (EPDS). A systematic search was performed in Medline and the Science Citation Index Expanded (ISI) from the period 1987-2000. For sensitivity and specificity of the EPDS presented in each study, 95% confidence intervals were estimated. Positive and negative predictive values were estimated assuming prevalences of postpartum depression ranging from 5% to 20%. Eighteen validation studies were identified. The study design varied between studies. The sensitivity and specificity 65-100% and 49-100%, respectively. The confidence intervals were estimated to be wide. Our estimates suggest a lower positive predictive value in a normal population than in the validation study samples. Most studies show a high sensitivity of the EPDS. Because of the differences in study design and large confidence intervals, uncertainty remains regarding the comparability between the sensitivity and specificity estimates of the different EPDS versions.

Treating mental illness in lactating women

Buist A, 2001·Medscape Womens Health

A high prevalence of psychiatric illness has been noted in the postpartum period. Recent research looks to the potential effects of maternal illness during this period on child development. With the promotion of breast feeding for well-documented medical benefits, there has been increasing attention to the potential effects on the infant of exposure to medication via breast milk. This article reviews the current literature on the secretion of psychotropic medication into breast milk, and any known negative effects. The shortcomings of these studies are highlighted, and recommendations to the clinician are given within the limitations of the current state of knowledge. The World Health Organization (WHO) has estimated that depression will be 1 of the 2 major illness burdens confronting the world by 2020. The incidence of depression is 2-fold higher in women than in men, and the average age at onset is 25 years. These facts combined with the noted risk of a marked increase in psychiatric illness postpartum have serious implications. Depression occurring at this time can present with depressed mood, anxiety, and difficulties coping with the infant. Suicide, although not more common in depression, is at the severe end of the spectrum in those with puerperal psychosis and bipolar disorder. The morbidity associated with depression is not confined to women suffering from it; there are also potential negative effects of maternal depression on child development, on older children, and on the woman's partner. These effects include impaired bonding and cognitive and behavioral delays in the infant and difficulties in childhood. Moreover, the increased use of antidepressants in the Western world in combination with the strong promotion of breast feeding also has implications for the dependent infant. What do we know? And, what are the risks?

Estrogen deficiency in severe postpartum depression: successful treatment with sublingual physiologic 17beta-estradiol: a preliminary study

Ahokas A et al., 2001·J Clin Psychiatry

The postpartum period is a time when women are vulnerable to depressive disorders, which can be severe and have long-lasting adverse sequelae. In spite of multiple contacts with health care providers, women with postpartum depression often remain unrecognized and untreated. To evaluate the association between estradiol and postpartum depression, we measured serum estradiol concentration and performed an open-label study of physiologic 17beta-estradiol. Twenty-three women fulfilling ICD-10 criteria for major depression with postpartum onset were consecutively recruited from a psychiatric emergency unit. Serum estradiol concentrations were measured at baseline and weekly during sublingual 17beta-estradiol treatment for 8 weeks. The treatment effect was assessed using a clinician-rated depression symptom scale, the Montgomery-Asberg Depression Rating Scale (MADRS). At baseline, all patients were severely depressed (mean MADRS total score = 40.7; range, 35-45) and had a low serum estradiol concentration (mean = 79.8 pmol/L; range, 23-140 pmol/L); in 16/23 patients, the concentration was even lower than the threshold value for gonadal failure. During the first week of estradiol treatment, depressive symptoms diminished significantly, resulting in a mean MADRS score of 11.0 (Z = -4.20, p < .001), and serum estradiol concentrations approached those of the follicular phase (mean +/- SD = 342 +/- 141 pmol/L). At the end of the second week of treatment, the MADRS scores were compatible with clinical recovery in 19/23 patients. This preliminary study shows that depression symptoms may be rapidly reduced in patients with postpartum depression who have documented estradiol deficiency by treatment with 17beta-estradiol and suggests that estradiol can have significance in the pathophysiology of this condition and may be an option in the treatment of women vulnerable to postpartum depression.

Influence of parity and lactation on hip fracture risk

Michaëlsson K et al., 2001·Am J Epidemiol

Several studies indicate that parity and lactation are associated with modest, short-term bone loss, but the long-term effect on osteoporotic fracture risk is uncertain. The authors therefore analyzed data from a population-based case-control study among Swedish postmenopausal women aged 50-81 years between October 1993 and February 1995. Mailed questionnaires and telephone interviews were used to collect data on 1,328 incident cases with hip fracture and 3,312 randomly selected controls. In age-adjusted analyses, the risk of hip fracture among all women was reduced by 10% per child (95% confidence interval (CI): 5, 14). After multivariate adjustment including body mass index as a covariate, the risk reduction was 5% per child (95% CI: 0, 10). Oral contraceptive use modified the association of parity with hip fracture risk. Among never users of oral contraceptives, the risk of hip fracture was reduced by 8% per child (95% CI: 2, 13), whereas among ever users of oral contraceptives, the risk was in the opposite direction, with an increase in risk by 19% per child (95% CI: 0, 41). After parity was considered, there was no association of duration of lactation period with fracture risk. The authors conclude that parity is modestly associated with a reduced hip fracture risk among women who had not used oral contraceptives previously.

Nurse-midwives' knowledge and promotion of lactational amenorrhea and other natural family-planning methods for child spacing

Fehring RJ et al., 2001·J Midwifery Womens Health

The purpose of this study was to describe and assess certified nurse-midwives' (CNMs) knowledge and promotion of two modalities for child spacing, natural family-planning (NFP) and the lactational amenorrhea method (LAM). One thousand two hundred CNMs were randomly selected from a national membership list and mailed a 24-item questionnaire on NFP and LAM. Of the 514 respondents (42.8% return rate), 450 (87.5%) were currently practicing as CNMs. Respondents had an average age of 46 years, with an average of 10 years of practice. CNMs ranked NFP as the ninth most used and the eighth most effective family-planning method in their practice, with an average perceived method-effectiveness of 88% and use-effectiveness of 70%. Although most respondents felt somewhat prepared during their education program to provide NFP, only 22% would offer NFP as a family-planning option for child spacing.

Prevalence of depressive symptoms in late pregnancy and postpartum

Josefsson A et al., 2001·Acta Obstet Gynecol Scand

Postnatal depression refers to a non-psychotic depressive episode that begins in or extends into the postpartum period. The aims of this study were to examine the prevalence of depressive symptoms in a pregnant and later postnatal population, to determine the natural course of these symptoms and whether there is an association between antenatal and postnatal depressive symptomatology. A longitudinal study with a total population of 1,558 consecutively registered pregnant women in the southeast region of Sweden. Presence of depressive symptoms was measured with the Edinburgh Postnatal Depression Scale on four occasions namely in gestational week 35-36, in the maternity ward, 6-8 weeks and 6 months postpartum. The prevalence of depressive symptoms during late pregnancy was 17%; in the maternity ward 18%; 6-8 weeks postnatally 13%; and 6 months postnatally, 13%. A correlation between antenatal and postnatal depressive symptoms was found (r=0.50, p<0.0001). Detection of women at risk for developing postnatal depressive symptoms can be done during late pregnancy. Antenatal care clinics constitute a natural and useful environment for recognition of women with depressive symptoms.

Multicenter study of the lactational amenorrhea method (LAM) III: effectiveness, duration, and satisfaction with reduced client-provider contact

Peterson AE et al., 2001·Contraception

The objective of this effort was to assess the use and efficacy of the Lactational Amenorrhea Method (LAM) with reduced numbers of client-provider contacts. A co-sponsored multicenter study of LAM was performed to test the efficacy and acceptability of the method under "post-marketing" conditions, with investigator-initiated at the time of intake and then again at month 7 of postpartum. These data are assumed to provide an assessment of LAM's use, efficacy, and performance that more closely reflects the prevailing conditions of these populations during normal use. Three hundred and sixty-two subjects were recruited through centers that had participated in the previous, more contact-intensive studies. Using a cooperatively developed protocol, data were gathered prospectively on at least 10 and up to 50 LAM acceptors at nine sites, and entered and cleaned on site. Data were further cleaned and analyzed at the Georgetown University Institute for Reproductive Health (IRH) and the Department of Nutrition at the University of Connecticut. Using country-level and pooled data, descriptive statistics and life tables were produced. LAM efficacy in this sample is 100% because there were no pregnancies at any of the participating sites. Satisfaction with the method was high, and the rate of continuation on to another method after LAM was 66.7% at 7 months postpartum. Of the women who had never used family planning prior to LAM, 63.0% went on to use another method of family planning in a timely manner. LAM can be highly effective as an introductory postpartum family planning method when offered in a variety of cultures, health care settings, and industrial and developing country locales. Under conditions of limited client-provider contact, LAM remains effective and leads to acceptance of another method by about two-thirds of the acceptors. Women are able to use LAM effectively without extensive counseling or follow-up, with a high level of user satisfaction.

Serum allopregnanolone in women with postpartum "blues"

Nappi RE et al., 2001·Obstet Gynecol

To relate serum allopregnanolone and progesterone levels postpartum to maternity "blues." Forty primiparous, healthy, married women (24-39 years of age; at least 13 years of education) who delivered healthy neonates in the Department of Obstetrics at the University of Pavia entered the present study. Blood samples were drawn at 8:30 AM on postpartum day 3 for measurements of serum allopregnanolone, progesterone, cortisol, prolactin, and estradiol. On the same day, every woman was interviewed using the Hamilton Rating Scale for Depression for psychometric testing and completed a self-administered version of the Stein Questionnaire for symptoms of the "blues." Eighteen of 40 women (45%) experienced maternity "blues" (12 who delivered vaginally and six who delivered by cesarean). Serum allopregnanolone levels were significantly lower in those women experiencing postpartum "blues" with respect to euthymic women (1.1 +/- 0.4 versus 2.3 +/- 1.0 nmol/L; P <.001), whereas progesterone levels did not differ significantly (11.6 +/- 5.6 versus 19.1 +/- 15.6 nmol/L; P >.058). Allopregnanolone and progesterone levels correlated significantly in euthymic women (r =.648; P =.001) but not in those with postpartum "blues" (r =.317; P =.199). There was a significant negative correlation between the Hamilton score and levels of serum allopregnanolone (r = -.62; P =.001) and progesterone (r = -.36; P =.024). Serum allopregnanolone levels were detectable postpartum and were significantly decreased in women with maternity "blues."

Population-based screening for postpartum depression

Georgiopoulos AM et al., 2000·Obstet Gynecol

To estimate the community prevalence in Olmsted County, Minnesota of elevated scores on the Edinburgh Postnatal Depression Scale, a self-report screening tool for postpartum depression. At the 6-week postpartum visit, the Edinburgh Postnatal Depression Scale was administered to women who gave birth in Olmsted County between July 28, 1997 and March 28, 1998. Study sites included all ambulatory clinics that provide pregnancy care in the county, and women who missed postpartum visits were contacted by mail. A threshold of 12 or more points on the scale was selected for clinical use; data for scores of ten and above were also examined. Of the 909 Olmsted County women studied (response rate 83.2%), 11.4% (n = 104) had scores of 12 or greater, with a 95% confidence interval (CI) of 9.4%, 13.5%. The percentage of women with a positive screen increased to 19.8% (n = 180; 95% CI 17.2%, 22.4%) when scores of 10 or higher were included, as has been recommended for screening in primary care settings. Forty-eight or 5.3% of the subjects (95% CI 3.8%, 6.7%) indicated experiencing suicidal ideation during the previous week. More than 11% of women had elevated scores on the Edinburgh Postnatal Depression Scale, indicating a high likelihood of postpartum depression and the need for further assessment. The screening process required little extra time and was acceptable to the subjects and clinicians. Screening for postpartum depression is appropriate and feasible for clinical practice and increases the identification of women suffering from this serious, common, and highly treatable disorder.

Effects of gonadal steroids in women with a history of postpartum depression

Bloch M et al., 2000·Am J Psychiatry

Endocrine factors are purported to play a role in the etiology of postpartum depression, but direct evidence for this role is lacking. The authors investigated the possible role of changes in gonadal steroid levels in postpartum depression by simulating two hormonal conditions related to pregnancy and parturition in euthymic women with and without a history of postpartum depression. The supraphysiologic gonadal steroid levels of pregnancy and withdrawal from these high levels to a hypogonadal state were simulated by inducing hypogonadism in euthymic women-eight with and eight without a history of postpartum depression-with the gonadotropin-releasing hormone agonist leuprolide acetate, adding back supraphysiologic doses of estradiol and progesterone for 8 weeks, and then withdrawing both steroids under double-blind conditions. Outcome measures were daily symptom self-ratings and standardized subjective and objective cross-sectional mood rating scales. Five of the eight women with a history of postpartum depression (62.5%) and none of the eight women in the comparison group developed significant mood symptoms during the withdrawal period. Analysis of variance with repeated measures of daily and cross-sectional ratings of mood showed significant phase-by-group effects. These effects reflected significant increases in depressive symptoms in women with a history of postpartum depression but not in the comparison group after hormone withdrawal (and during the end of the hormone replacement phase), compared with baseline. The data provide direct evidence in support of the involvement of the reproductive hormones estrogen and progesterone in the development of postpartum depression in a subgroup of women. Further, they suggest that women with a history of postpartum depression are differentially sensitive to mood-destabilizing effects of gonadal steroids.

Postpartum anxiety and depression: onset and comorbidity in a community sample

Stuart S et al., 1998·J Nerv Ment Dis

A community-based sample of 107 women completed the Beck Anxiety Inventory, Beck Depression Inventory, State-Trait Anxiety Inventory, and Edinburgh Postnatal Depression Scale at 14 weeks postpartum and at 30 weeks postpartum. The point prevalence of anxiety was 8.7% at 14 weeks and 16.8% at 30 weeks postpartum. The point prevalence of depression was 23.3% at 14 weeks and 18.7% at 30 weeks postpartum. The incidence of anxiety during this time period was 10.28%, and the incidence of depression was 7.48%, indicating high incidences of both postpartum anxiety and depression later in the postpartum period. The Edinburgh Postnatal Depression Scale was found to have a strong correlation with the State Anxiety Scale of the State-Trait Anxiety Inventory (r = .73 at 14 weeks, r = .82 at 30 weeks), suggesting that the Edinburgh Postnatal Depression Scale may be a good screening instrument for anxiety as well as depression.

Risk factors and predictive signs of postpartum depression

Righetti-Veltema M et al., 1998·J Affect Disord

Depressed new mothers usually do not seek and therefore do not receive any psychiatric help. In order to assess predictive signs of postpartum depression (PPD), an unselected sample of 570 women were seen by midwives during their pregnancy, using a questionnaire elaborated by ourselves and Derogatis' Hopkins Symptom Checklist. Three months after delivery each new mother was examined again by the same midwife using Cox' Edinburgh Postnatal Depression Scale. The medical files were also examined. Of the new mothers, 58 (10.2%) suffered from PPD. Most significant factors were socio-professional difficulties, multiparity, deleterious life events, depressive mood prior to delivery, early mother-child separation and negative birth experience. The coping abilities of the depressed mother were decreased and her vulnerability to new stress factors increased. It is possible to detect women at risk for PPD already during pregnancy. We therefore elaborated a very simple, short predictive scale which is in the process of validation. Protective factors still have to be studied. Knowledge of these factors should help all caregivers to recognize, during pregnancy, women at risk for PPD, in order to initiate preventive and/or therapeutic measures.

Hormonal changes in the postpartum and implications for postpartum depression

Hendrick V et al., 1998·Psychosomatics

The months following childbirth are a time of heightened vulnerability to depressive mood changes. Because of the abrupt and dramatic changes occurring in hormone levels after delivery, many studies have examined the role of hormonal factors in postpartum depression. The authors review the literature on potential hormonal etiologies in postpartum depression, in particular for progesterone, estrogen, prolactin, cortisol, oxytocin, thyroid, and vasopressin. While evidence for an etiologic role is lacking for most hormones, changes in certain hormonal axes may contribute to depressive mood changes in some women following childbirth.

Course of mood and anxiety disorders during pregnancy and the postpartum period

Altshuler LL et al., 1998·J Clin Psychiatry

Because the onset of mood and anxiety disorders often occurs during the childbearing years, many women may be taking psychotropic medications for these disorders when they conceive. These medications easily diffuse across the placenta, and their impact on the fetus is of concern. But discontinuation may lead to relapse, in which case psychiatric symptoms may affect the fetus. Thoughtful treatment planning presents a dilemma to the clinician. Limited data suggest heightened vulnerability to relapse of mood and anxiety disorders in women during the postpartum period. Pregnancy appears to exacerbate symptoms of obsessive-compulsive disorder, while panic disorder patients may remain well after discontinuing medication. Future studies should address the prevalence and relapse rates of mood and anxiety disorders, particularly after medication discontinuation, among pregnant women.

Psychosocial predictors of depressive symptomatology level in postpartum women

Bernazzani O et al., 1997·J Affect Disord

This study explored a multifactorial model for the prediction of the intensity of depressive symptoms in postpartum women. Data were gathered from 213 pregnant women during the second trimester of pregnancy and at 6 months postpartum. Participants were assessed according to a number of psychosocial variables. A path analysis indicated that four variables had a direct effect on postpartum depressive lower occupational status, prenatal depression level, more distal stressors and a personal psychiatric history. Eight variables, which reflected past and present experiences, showed an indirect effect. The implications of these findings are discussed.

Postpartum mood disorders: clinical perspectives

Pariser SF et al., 1997·J Womens Health

Mood disorders are common in women. A prepregnancy personal history of mood disorder (bipolar or major depression), premenstrual syndrome, or (possibly) postpartum blues places a woman at high risk for a postpartum exacerbation of symptoms. Untreated or unrecognized postpartum mood disorders can lead to serious psychologic and social consequences, in some cases even leading to suicide or infanticide. Women at risk for postpartum mood disorders need to be referred for psychiatric consultation before pregnancy and parturition. Informed, professional collaboration offers the best opportunities for prevention, as well as the earliest recognition and treatment of emergent symptoms.

Screening for postpartum depression. An antepartum questionnaire

Posner NA et al., 1997·J Reprod Med

To develop and evaluate a questionnaire used antepartum to screen for postpartum depression. Demographic and clinical data, based on previously identified variables, were obtained from 106 second-trimester gravidas (sample I) by interview, self-administered questionnaire and medical record review. The Beck Depression Inventory (BDI) was administered at 1, 6 and 12 weeks postpartum (PP). Statistical analysis, including stepwise linear regression with maximum r-squared improvement, identified a subset of the 24 most predictive variables. This antepartum questionnaire (APQ) was validated retrospectively in the original sample and prospectively in a second group of 99 women (sample II). In both sample populations the APQ had acceptable sensitivity (80-82%) and specificity (78-82%). The incidence of postpartum depressive symptoms (PPDS) rose from 10% to 17% by six weeks without an appreciable decline at 12 weeks (15%). The percentage of women showing more than mild depressive symptoms increased with PP time from 30% at 1 week to 47% at 12. The APQ is now available for screening and evaluating early therapeutic intervention in PPDS.

Psychobiology of postpartum mood disorders

Wisner KL et al., 1997·Semin Reprod Endocrinol

Postpartum mood disorders are common. The clustering of mood-disorder episodes after birth compels a search for factors particularly potent during childbearing. In this article, the complex relationships between the dynamic postbirth physiological environment and mood disorder are discussed. Available studies show a lack of evidence that serum levels of gonadal hormones account for mood disturbance in women. However, substantial amounts of data demonstrate their ability to modulate other neuroendocrine systems. Alterations in hypothalamic-pituitary-adrenal (HPA) axis function attributable to childbearing show remarkable similarity to those observed in depressed women. Postpartum women are also at increased risk for hypothalamic-pituitary-thyroidal (HPT) axis dysfunction that may increase affective-disorder vulnerability. A decreased rate

Serum cholesterol concentration and postpartum depression. Oestrogen may have been a confounder

Leopold KA et al., 1997·BMJ

Depression during pregnancy and the puerperium

Llewellyn AM et al., 1997·J Clin Psychiatry

Epidemiologic studies demonstrate a twofold higher rate of depression in women than in men. The childbearing years are a time of increased risk for onset of depression in women. Pregnancy, miscarriage or pregnancy loss, infertility, and the postpartum period may challenge a woman's mental health. Virtually no life event rivals the neuroendocrine and psychosocial changes associated with pregnancy and childbirth. This paper provides a brief overview of depression during pregnancy and the postpartum period. Incidence, risk factors, and complications of depression during pregnancy and the puerperium are discussed to aid the clinician in early identification of at-risk patients. Treatment recommendations are also provided based on the available literature, clinical experience, and consideration of the possible special circumstances (i.e., breast-feeding) of this population of women.

Postpartum depressive disorders

Susman JL, 1996·J Fam Pract

Despite the high prevalence of postpartum depressive disorders, many signs and symptoms of this illness are dismissed as normal physiologic changes associated with childbirth. Prompt recognition and treatment are imperative in order to limit the negative impact on both the mother and infant. Mood disturbances may have a minor functional impact that respond well to social support (eg. postpartum blues) or cause significant functional compromise requiring more aggressive therapy (eg. postpartum depression). The most extreme case of postpartum depressive disorder, postpartum psychosis, occurs when patients develop psychosis, mania, or thoughts of infanticide. Depression during pregnancy or the presence of risk factors suggests the need for careful follow-up. If postpartum depression develops, psychotherapy is the first-line treatment. Antidepressant treatment may be warranted for some patients, and the risks and benefits to both the mother and infant should be considered in the decision to institute pharmacotherapy.

Hypothalamic corticotropin-releasing hormone suppression during the postpartum period: implications for the increase in psychiatric manifestations at this time

Magiakou MA et al., 1996·J Clin Endocrinol Metab

The third trimester of human pregnancy is characterized by a hyperactive hypothalamic-pituitary-adrenal axis, possibly driven by progressively increasing circulating levels of placental CRH and gradually decreasing levels of CRH-binding protein. The postpartum period, on the other hand, is characterized by an increased vulnerability to psychiatric manifestations (postpartum "blues," depression, and psychosis), a phenomenon compatible with suppressed hypothalamic CRH secretion. To investigate the hypothesis that the postpartum period is associated with suppression of hypothalamic CRH secretion, we studied prospectively 17 healthy euthymic women (mean +/- SE age, 32.0 +/- 1.1 yr) with no prior history of depression, starting at the 20th week of gestation. Psychometric testing was performed monthly during pregnancy and postpartum on day 2 and weeks 2, 3, 6, 8, 12, 16, and 20, whereas serial ovine (o) CRH tests were performed postpartum at 3, 6, and 12 weeks. While pregnant, all 17 subjects remained euthymic; in the postpartum period, 7 women developed the "blues," and 1 developed depression. Overall, the mean plasma ACTH response to an iv bolus of 1 microgram/kg oCRH was markedly blunted at 3 and 6 weeks, but normal at 12 weeks postpartum, whereas the mean plasma cortisol response was at the upper limit of normal at all 3 times. These data are compatible with a suppressed hypothalamic CRH neuron that gradually returns to normal while hypertropic adrenal cortexes are progressively down-sizing. When the postpartum ACTH responses to oCRH were analyzed separately for the euthymic women and the women who had the "blues" or depression, the blunting of ACTH was significantly more severe and long lasting in the latter group; this was observed at all 3 times of testing. We conclude that there is central suppression of hypothalamic CRH secretion in the postpartum, which might explain the increased vulnerability to the affective disorders observed during this period. The suppressed ACTH response to oCRH might serve as a biochemical marker of the postpartum "blues" or depression.

Transdermal oestrogen for treatment of severe postnatal depression

Gregoire AJ et al., 1996·Lancet

Postnatal depression can have long-term adverse consequences for the mother, for the marital relationship, and for the infant's psychological development. Such depressions can be severe and resistant to both support and counselling and to therapy with antidepressant drugs. We investigated the antidepressant efficacy of oestrogen given transdermally. In a double-blind, placebo-controlled study, 61 women with major depression, which began within 3 months of childbirth and persisted for up to 18 months postnatally, were allocated randomly active treatment (n=34; 3 months of transdermal 17 beta-oestradiol 200 micrograms daily alone, then 3 months with added cyclical dydrogesterone 10mg daily for 12 days each month) or placebo (n=27; placebo patches and tablets according to the same regimen). The women were assessed monthly by self-ratings of depressive symptoms on the Edinburgh postnatal depression scale (EPDS) and by clinical psychiatric interview (schedule for affective disorders and schizophrenia [SADS]-change scale). On pretreatment assessments the women in both groups were severely depressed (mean EPDS score 21.8 [SD 3.0] active group, 21.3 [2.9] placebo group; SADS scores, 66.3 [11.4] and 64.3 [10.7]). During the first month of therapy the women receiving oestrogen improved rapidly, and to a significantly greater extent than controls (mean EPDS scores 13.3 [SD 5.7] vs 16.5 [5.3]. Patients receiving placebo also improved over time but, on average, their scores did not fall below the screening threshold for major depression for at least 4 months. The estimated overall treatment effect of oestrogen on the EPDS was 4.38 points (95% Cl 1.89-6.87). None of a range of other factors (age, psychiatric, obstetric and gynaecological history, severity and duration of current episode of depression, and concurrent antidepressant medication), influenced the response to oestrogen. This study has shown that transdermal oestrogen is an effective treatment for postnatal depression. Further studies are required to establish the minimum effective dose and shortest necessary duration of treatment as well as the mechanism of antidepressant action of oestrogen.

Prophylactic estrogen in recurrent postpartum affective disorder

Sichel DA et al., 1995·Biol Psychiatry

Seven women with histories of puerperal psychosis and four with histories of puerperal major depression were consecutively treated with high-dose oral estrogen immediately following delivery. None of the women had histories of nonpuerperal affective disorder, and all women were affectively well throughout the current pregnancy and at delivery. Despite the high risk for recurrent illness in this population, only one woman developed relapse of postpartum affective disorder. All others remained entirely well and required no treatment with psychotropic medications during the 1 year follow-up period. This low rate of relapse, 9% compared to an expected 35-60% without prophylaxis, suggests that oral estrogen may stem the rapid rate of change in estrogen following delivery, thereby preventing the potential impact on dopaminergic and serotonergic neuroreceptors. It is hypothesized that the rapid rate of change of estrogen after delivery creates an "estrogen withdrawal state." This may be a critical factor in driving acute puerperal affective psychosis and early-onset puerperal major depression.

Natural family planning

Geerling JH, 1995·Am Fam Physician

A better understanding of reproductive anatomy and physiology has led to newer methods of natural family planning, including the ovulation method and the symptothermal method. Studies have shown that 1 percent of couples who consistently and correctly use either of these methods conceives during one year of use. However, in the absence of standardized interpretation of study results, use-effectiveness data of these methods vary widely. The lactational amenorrhea method may be used in selected patients during the first six months postpartum, and its effectiveness in avoiding pregnancy is reported to be as high as 98 percent. Advocates of natural family planning promote these methods as inexpensive and safe ways to determine periods of peak fertility and point to the potential benefit of increased communication in a relationship.

Women at risk for postpartum-onset major depression

Stowe ZN et al., 1995·Am J Obstet Gynecol

There is considerable evidence that the childbearing years represent a time when women are highly vulnerable to developing mood disorders. Prospective, cross-sectional, and retrospective studies have demonstrated that more than 10% of new adult mothers will experience a major depressive episode during the first postpartum year. Changes in the health care delivery system will result in increased pressure on the obstetrician/gynecologist to identify and treat women with postpartum-onset depression. Despite shortcomings in the available literature, prospective studies have identified risk factors for developing postpartum depression. Furthermore, the clear overlap between the normal sequelae of childbirth and the symptoms of major depression, including alterations in sleep, energy, libido, appetite, and body weight, underscores the need to develop guidelines for early identification. We furnish a brief overview of postpartum mood disorders with a primary focus on the antenatal and postnatal risk factors for developing postpartum depression. Based on the extent literature and our clinical experience, a set of recommendations for early identification and treatment is provided.

Sperm binding to the human zona pellucida after migration through human cervical mucus

Vigil P et al., 1995·Int J Androl

During lactational amenorrhea a special type of cervical mucus, similar to that found during the luteal phase, is produced. This mucus, however, is able to support sperm migration. In the study described, the ability of spermatozoa to bind to the human zona pellucida (hZP) after migration through periovulatory and post-partum mucus was studied. Mucus was obtained from exclusively breastfeeding women in amenorrhea at 30, 60, 120 and 180 days post-partum. Periovulatory mucus samples from normally cycling women were used as a control. Flat capillary tubes were filled with BWW culture medium at the top and cervical mucus at the bottom. The tubes were immersed in a semen reservoir and the spermatozoa allowed to migrate through the mucus for 3 h into the culture media. Then the spermatozoa were coincubated with 3-4 hZP for 30 min and the number of bound spermatozoa per zona was counted. Periovulatory cervical mucus had an average Insler score of 14 +/- 0.5 as compared to 4.6 +/- 0.4 for post-partum mucus. Spermatozoa recovered from periovulatory mucus were always able to bind to the hZP in only 68 +/- 7% of the cases. Moreover, spermatozoa recovered from post-partum mucus bound to the ZP in lower numbers than did spermatozoa recovered fro periovulatory mucus (p < 0.03). These results suggest a greater ability of sperm-hZP binding after migration through periovulatory mucus and they also indicate that sperm binding to the ZP is possible even after sperm migration through a low quality mucus.

First admission with puerperal psychosis: 7-14 years of follow-up

Videbech P et al., 1995·Acta Psychiatr Scand

The aim of this study was to investigate women who had first-episode psychosis within 1 year after parturition. The Danish Psychiatric Central Register and the Danish Medical Birth Register were linked to identify all women admitted for the first time to a psychiatric department in Arhus County with a psychotic episode. Fifty cases were found, giving a frequency of first-episode psychosis within 1 year after delivery of 1 per 1000. First-episode psychotic disease within the first month postpartum occurred in 1 case per 2000 deliveries. The age distribution corresponded to that of the background population, but the cases were primiparous more often than expected. The socioeconomic status was equal to that of a matched control group of obstetric patients. Birth complications did not occur more frequently than expected, but the probands had a higher risk of preterm delivery than the controls. The clinical picture of the index episode was that of manic-depressive psychosis in nearly half of the cases, but no cases of schizophrenia were found. Sixty percent of the patients had a picture of severe depression, and 20% suffered from manic disorder. The follow-up, 7 to 14 years later, was carried out by interviewing the general practitioners. Forty percent of the women had not preserved full working capacity due to mental disorder. Moreover, the follow-up pointed to schizophreniform symptoms at the index episode as a predictor of incapacity to work. Recurrences were very common (60%), especially of the nonpuerperal type, and half of the recurrences belonged to the manic-depressive disorders.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum lactogens possessed normal bioactivity in patients with lactation insufficiency

Livingstone VH et al., 1994·Clin Endocrinol (Oxf)

Insufficient breast milk is the most common reason for premature termination of breast-feeding. The causes of lactation insufficiency are usually multifactorial; in a small percentage of cases it is due to primary lactation failure of unknown origin. The aim of this study was to investigate whether lactation insufficiency of unknown origin could be caused by serum lactogens that had reduced biological activity. Women with lactation insufficiency of unknown origin and normal lactating controls were subjected to a standardized breast-feeding test for assessment of milk production. Thirty minutes later, serum samples were obtained for determination of total lactogen bioactivity, using an in-vitro bioassay, and levels of prolactin (PRL) and growth hormone (GH) using radioimmunoassay (RIA). Twelve lactating mothers with a clinical diagnosis of lactation insufficiency of unknown origin were compared with 12 matched mothers with normal lactation. The Nb2 lymphoma cell bioassay was used to measure total lactogen bioactivity in sera. Conventional RIA kits were used to estimate serum PRL and GH concentrations. Mean milk yield on standardized test feed was 21.6 ml for patients and 146.5 ml for controls. In both patient and control groups the total serum lactogen bioactivity ranged from about 150 to 5000 mIU/l, while the serum RIA (PRL+GH) levels ranged from about 350 to over 7000 mIU/l. There was no evidence of lactogens with reduced bioactivity in the patients' sera. Lactation insufficiency in the women studied cannot be explained by serum lactogens that possess unusually low bioactivity.

Maternity blues and major endocrine changes: Cardiff puerperal mood and hormone study II

Harris B et al., 1994·BMJ

To define relation between mood and concentrations of progesterone and cortisol during perinatal period to test hypothesis that rapid physiological withdrawal of steroid hormones after delivery is associated with depression. Prospective study of primiparous women from two weeks before expected date of delivery to 35 days postpartum. Antenatal clinic in university hospital, obstetric inpatient unit, patients' homes. 120 of 156 primiparous women interviewed. Remainder excluded because of major marital, socioeconomic, or medical problems or because caesarean section required. Concentrations of progesterone and cortisol in saliva samples; women's moods assessed by various scores for depression. Changes in salivary progesterone and cortisol concentrations were similar to those already characterised for plasma. Peak mean score for maternity blues (5.3 on Stein scale) was on day five postpartum (P < 0.02 compared with mean scores on other postpartum days). High postpartum scores for maternity blues were associated with high antenatal progesterone concentrations on day before delivery (P < 0.05), with high rate of rise of antenatal progesterone concentrations (P < 0.05), with decreasing progesterone concentrations from day of delivery to day of peak blues score (P > or = 0.01), and with low progesterone concentrations on day of peak blues score (P < 0.01). Seventy eight women were designated as having maternity blues (peak score > or = 8 on Stein scale) while 39 had no blues. Women with blues had significantly higher antenatal progesterone concentrations and lower postnatal concentrations than women without blues (geometric mean one day before delivery 3860 pmol/l v 3210 pmol/l respectively, P = 0.03; ten days postpartum 88 pmol/l v 114 pmol/l, P = 0.048). Cortisol concentrations were not significantly associated with mood. Maternal mood in the days immediately after delivery is related to withdrawal of naturally occurring progesterone.

Natural family planning

Foxwell M, 1994·Mod Midwife

Natural family planning (NFP) methods can be effective if taught well and practised by well-motivated couples. Midwives should be able to give couples an understanding of the basic principles of the methods. The observable signs of the fertile cycle are changes in basal body temperature, in the consistency of cervical mucus and in the texture and position of the cervix. Practised properly the ovulation method can have a failure rate of as little as 2.2 pregnancies per 100 woman-years. The ovulation method is a suitable method for mothers who have breastfed to detect the onset of ovulation.

[Puerperium after threatened premature labor--positive effects of infection screening by determination of CRP in pregnancy]

Winkler M et al., 1994·Zentralbl Gynakol

Silent intrauterine infection as cause of preterm labour should be recognised early by measuring C-reactive protein (CRP) levels in the maternal serum. Ensuing antibiotic therapy may not only cause gestational prolongation, but also has a positive effect on pathology during the puerperal period. Consequently, we examined the rate of infectious puerperal complications of 181 patients who suffered from so-called idiopathic preterm labour. 84 patients showed normal CRP-levels at the onset of tocolysis (< 5 mg/l); an elevated level was found in 97 patients (> 5 mg/l). Patients with elevated CRP-levels and supplemented antibiotic therapy during pregnancy (n = 51) showed significantly fewer symptoms of postpartal endometritis than women with similarly elevated CRP-levels but without antibiotics (n = 46). This effect was not produced when preterm labour was associated with normal CRP-levels. Patients with premature contractions and elevated CRP-values at the onset of tocolysis seem to benefit from the antibiotic therapy during pregnancy because they show reduced infectious complications throughout the puerperal period.

Follow-up and family study of postpartum psychoses. Part I: Overview

Schöpf J et al., 1994·Eur Arch Psychiatry Clin Neurosci

A group of 119 patients suffering from a severe psychiatric postpartum disorder who were admitted for the first time in their life to a psychiatric hospital has been investigated. The onset of illness occurred within 3 months following delivery. The patients represented 92% of the total sample fulfilling the inclusion criteria. A follow-up investigation was performed after a mean of 21 years (range 2-35 years). Of the patients 66% had nonpuerperal psychotic episodes in later life. The diagnosis, taking into account the long-term course, was affective psychosis in 57%, schizoaffective psychosis in 18%, schizophreniform psychosis in 12%, brief reactive psychosis in 4% and schizophrenia in 9%. A bipolar psychosis was found in 31%. The relation of unipolar to bipolar psychoses corresponded to that in a control group of affectively ill women without puerperal onset. The frequency of a manic syndrome in bipolar psychoses at the index episode was the same as in nonpuerperal episodes, which does not suggest a mania-provoking pathoplastic effect of the puerperium. The comparison with female nonpuerperal controls matched for age and diagnosis revealed evidence of a better long-term course in the index patients. The risk of a puerperal relapse for further pregnancies was 35%. The global morbidity risk for functional psychoses in first-degree relatives was 11%, with affective psychoses representing the majority of secondary cases (6.8%). The index patients showed a nonsignificant lower morbidity risk in relatives than a control group of psychotically ill women without puerperal onset. The major aetiological factor found for postpartum psychoses is the relation of these disorders to functional psychoses. There is strong evidence that the postpartum period tends to provoke affective psychoses and other nonschizophrenic psychoses, but not, or only to a lesser degree, narrowly defined schizophrenias. The liability to puerperal decompensations suggests some common pathophysiological mechanism, the nature of which remains unknown.

Postpartum mood disorders. A startling contrast to the joy of birth

Knops GG, 1993·Postgrad Med

More than half of new mothers may be affected by mood disorders after childbirth. Possible causes and recommended management depend on the type of disorder and its severity. In this article, Dr Knops discusses recognition, prevention, and management of three types of postpartum mood disorders as well as the need for support for a woman and her family at this vulnerable time.

Human cervical mucus: relationship between biochemical characteristics and ability to allow migration of spermatozoa

Morales P et al., 1993·Hum Reprod

Cervical mucus is produced throughout the menstrual cycle. Sperm migration, however, is possible only during the periovulatory period of the cycle. Cervical mucus is also produced during the amenorrhoeic post-partum period. Post-partum mucus is very similar to luteal phase mucus except that it can allow sperm migration. In this study, mucus samples obtained from all these periods were classified according to their capacity to allow sperm migration. The biochemical characteristics of mucus samples that did (peri-ovulatory and 40% of post-partum samples) and did not (luteal and 60% of post-partum samples) allow sperm migration were then compared. Mucus samples with positive sperm migration showed the highest percentage of water and lowest protein and glycoprotein concentration (per ml of mucus). In addition, post-partum mucus samples with positive sperm migration showed lower concentrations of proteins and glycoproteins than post-partum mucus samples that did not allow sperm migration. However, the amount of glycoproteins per mg of protein was similar between post-partum samples that were positive and negative for sperm migration. These data suggest that the carbohydrate composition of the glycoproteins is playing a key role in the ability of cervical mucus to accept spermatozoa.

Puerperal psychoses: a clinical case study with follow-up

Benvenuti P et al., 1992·J Affect Disord

Thirty cases of post-partum psychotic disorders occurred between 1973 and 1987 and hospitalized at the Psychiatric Ward of Florence University were studied and followed up. A structured diagnostic interview was used, which explored DSM Ill-R diagnosis both for mood disorders and for psychotic features. The psychotic symptoms had started within 8 weeks of parturition in all cases. Only 36.7% of the patients showed no subsequent pathology after the puerperal symptoms. The diagnoses, both at the index episode and at the follow-up, revealed a great predominance of mood disorders and the absence of schizophrenia. The follow-up survey showed a greater proportion of bipolar disorders than it appeared at the puerperal onset of the disease. A high frequency of puerperal psychotic relapses has also occurred after subsequent deliveries during the follow-up period.

Folates and post partum depression

Rouillon F et al., 1992·J Affect Disord

Hypofolatemia can cause psychiatric disturbances of a depressive nature. Pregnancy and delivery are often associated with hypofolatemia. This study was conducted to determine if hypofolatemia at day 3 post partum is a risk factor for baby blues or post partum depression. To study this hypothesis, 131 post partum women were followed prospectively for the 3 months immediately following delivery. 19% were found to have 'baby blues', as defined by a score greater than 20 on Pitt's scale (Pitt, 1968, J. Psychiatry 114, 1325-1335) and 12% had post partum depression as defined by a score greater than 7 on QD2A scale (Pichot et al., 1984, Rev. Psycholog. App. 34, 229-250, 323-340), within the three months post partum. No relationship was observed between the serum or erythrocyte folate levels on the third day following delivery and the maternal post partum depression scores. A statistically significant correlation between post partum depression and previous psychiatric disturbance was, however, observed.

Post-partum cervical mucus: biological and rheological properties

Vigil P et al., 1991·Hum Reprod

In this study we have evaluated the score, sperm migration and ultrastructural characteristics of cervical mucus present in amenorrhoeic women under exclusive breastfeeding at 30, 60, 90, 120, 150 and 180 days post-partum. Periovulatory mucus samples from seven normally cycling women were used as a control. The average scores of post-partum and periovulatory mucus were 4.6 +/- 0.4 and 14.1 +/- 0.5 respectively. Twenty-one (39%) of the 54 post-partum cervical mucus samples and all (100%) periovulatory mucus samples allowed sperm migration. Positive sperm migration into post-partum mucus was observed at all time intervals studied. The only parameter that correlated with sperm migration into post-partum mucus was ferning formation. Sperm migration was obtained in all post-partum mucus samples with a score greater than 8, but samples with scores between 2 and 7 also showed sperm penetration. Scanning electron microscopic studies showed the characteristic spongy appearance of periovulatory mucus. Post-partum mucus was formed by a dense mesh (rocky appearance), when samples were generally unable to sustain sperm migration, but samples where sperm migration occurred showed small areas of spongy mucus mixed with areas in which a dense mesh and high cellularity was observed.

The nosology and prognosis of puerperal psychosis: a review

McGorry P et al., 1990·Compr Psychiatry

Functional psychosis in the puerperal period is a dramatic phenomenon that presents a unique set of diagnostic and therapeutic challenges. Despite its omission from modern classificatory systems such as DSM-III and DSM-III-R, the concept of puerperal psychosis continues to receive support from clinicians on the basis of the apparently distinctive clinical picture that characterizes psychoses occurring at this time. The range of possible nosological models is considered in light of relevant studies of puerperal illness, and the evidence for and against each model is presented. The question of the prognosis of puerperal psychosis is reviewed and guidelines for its estimation in the individual case proposed. The heuristic importance of puerperal psychosis in terms of basic research and preventive psychiatry is also stressed.

Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale

Cox JL et al., 1987·Br J Psychiatry

The development of a 10-item self-report scale (EPDS) to screen for Postnatal Depression in the community is described. After extensive pilot interviews a validation study was carried out on 84 mothers using the Research Diagnostic Criteria for depressive illness obtained from Goldberg's Standardised Psychiatric Interview. The EPDS was found to have satisfactory sensitivity and specificity, and was also sensitive to change in the severity of depression over time. The scale can be completed in about 5 minutes and has a simple method of scoring. The use of the EPDS in the secondary prevention of Postnatal Depression is discussed.

Lactation and postpartum infertility: the use-effectiveness of natural family planning (NFP) after term pregnancy

Hatherley LI, 1985·Clin Reprod Fertil

The use-effectiveness of natural methods of family planning in lactation is evaluated by comparing the incidence of unplanned pregnancies in a group of nursing mothers practising these methods with the incidences reported previously in surveys of breastfeeding women using no contraception. The complexity of the physiological processes involved in the resumption of ovulation after term pregnancy is discussed in relation to NFP and the problems encountered by its users in the context of normal family life. The serum prolactin and gonadotrophin levels are correlated with the postpartum interval and nursing status of the participants and discussed in relation to NFP after childbirth.

Natural family planning after pregnancy. A problem for women with previously irregular menstrual cycles

Hatherley LI, 1985·Clin Reprod Fertil

A prospective six-year study (1975-1980) of 273 patients, monitored in the use of natural family planning (NFP), has shown that those with previously irregular menstrual cycles are disadvantaged in the subsequent use of the ovulation method after pregnancy in that they have fewer recognizable safe days and/or are more likely to have unplanned pregnancies than women who had regular cycles prior to pregnancy. Eight patients, seven nursing and one non-nursing mother, conceived during postpartum amenorrhoea. The reliability of memory in the recall of previous menstrual histories is discussed in relation to the results of an international study of menstrual cycles by the World Health Organization (WHO 1983). The relevance of prediction of menstrual events in natural family planning is also considered.

Late infertile days in early postpartum cycles

Hatherley LI, 1985·Clin Reprod Fertil

Luteal phase abnormalities in early menstrual cycles after pregnancy have been shown to cause confusion in the practice of natural family planning (NFP) for some patients and to restrict severely the number of late infertile days available to others. The cause of the abnormalities is uncertain but appears to be related to the nursing status of the patient.

Psychiatric disorder in pregnancy and the first postnatal year

Watson JP et al., 1984·Br J Psychiatry

We interviewed 128 women regularly during pregnancy and the first postnatal year. Psychiatric interviews identified eight 'cases' of psychiatric disorder (6 per cent) in early pregnancy and twenty 'cases' (16 per cent) at six weeks after birth. Postnatal affective disorder, which accounted for 15 of these cases, was significantly associated with dissatisfaction with the marital relationship and also with previous psychiatric history. The implications of the term 'postnatal depression' are considered in terms of the course of the disorder in the 29 women (23 per cent) who had episodes of affective disorder at some time during pregnancy and the postnatal year. We found that the majority of episodes of affective disorder could be understood in terms of previous psychiatric history and/or reaction to life-events, including the stress of childbirth itself.

Puerperal Psychosis. Phenomena and diagnosis

Brockington IF et al., 1981·Arch Gen Psychiatry

Fifty-eight psychoses beginning within two weeks of childbirth are compared with 52 episodes of nonpuerperal psychotic illness occurring in young women. A clinical approach based on the use of multiple information sources and integrated assessment was used. Statistically significant differences between the two groups of patients were found in 52 of 214 psychopathological variables. Postpartum patients had more manic symptoms and "confusion," while nonpuerperal patients had more schizophrenic symptoms. The Research Diagnostic Criteria (RDC) showed an excess of schizoaffective (manic) puerperal patients and schizoaffective (depressed) or schizophrenic nonpuerperal patients. Only five of 58 puerperal episodes met RDC for schizophrenia. The relative lack of schizophrenic symptoms in the puerperal group was confirmed by self-ratings. The results are interpreted as supporting a link between puerperal psychosis and manic-depressive disease.

Plasma progesterone levels in normal pregnancy, labor, and the puerperium. II. Clinical data

Yannone ME et al., 1968·Am J Obstet Gynecol

One hundred and seventy-two plasma progesterone determinations were performed in normal pregnancy, labor, and the puerperium. One hundred and nineteen of the assays were done on isolated samples; 53 of the assays were done in 11 serial studies. While the concentration of progresterone in peripheral blood increased progressively with advancing pregnancy, no apparent decrease in the hormone level occurred at or near the onset of labor or during its progress. A significant decrease in plasma progesterone one hour after the delivery of the placenta continued to decline to menstrual cycle levels by 72 hours post partum.