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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, University Central Hospital of Helsinki, and the Research and Development Centre, the Social Insurance Institution, Helsinki, Finland.
Address reprint requests to: Tapio Kurki, MD, Department of Obstetrics and Gynecology, University Central Hospital of Helsinki, PO Box 140 00029 HUCS, Finland E-mail: tapio.kurki{at}huch.fi
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Abstract |
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Methods: In this prospective population-based study during pregnancy at outpatient maternity clinics in the Helsinki metropolitan area, depression was assessed by a Finnish modification of the short form of the Beck Depression Inventory and anxiety by one established question. Preeclampsia was defined as elevated blood pressure (BP) (more than 140/100 mmHg) and proteinuria (0.3 g during 24 hours or more). Age, smoking, alcohol consumption, marital status, socioeconomic status, and bacterial vaginosis were analyzed as potentially confounding factors in a multiple logistic regression analysis.
Results: Six hundred twenty-three consecutive nulliparous women with singleton pregnancies were studied at ten to 17 (median 12) weeks’ gestation and at delivery. Of them, 28 (4.5%) women developed preeclampsia. Depression (mean Beck score 4.5, range 3–17) was observed in 185 (30%), women and anxiety was observed in 99 (16%) in early pregnancy. In multivariate analysis, after adjustment for potentially confounding factors, depression was associated with increased risk (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.1, 5.4) for preeclampsia, as was anxiety (OR 3.2; 95% CI 1.4, 7.4). Either depression or anxiety, or both, were associated with increased risk (OR 3.1; 95% CI 1.4, 6.9) for preeclampsia. Bacterial vaginosis together with depression was associated with increased risk (OR 5.3; 95% CI 1.8, 15.0) for preeclampsia.
Conclusion: Depression and anxiety in early pregnancy are associated with risk for subsequent preeclampsia, a risk further increased by bacterial vaginosis.
Preeclampsia is a major complication in pregnancy.1 As the etiology of this complication is largely unknown,2 psychological aspects or aspects related to the nervous system also have to be considered.3 Preeclampsia has been regarded as a pregnancy-specific disease, but recent data on overall sympathetic overactivity in preeclampsia may imply that the autonomic nervous system and perhaps central nervous system also may contribute to the risk for this disorder.4
Little is known about the impact of psychosocial factors on subsequent preeclampsia. Strenuous work may increase the risk of preeclampsia,5,6 but the general stress of living may not.7
Therefore, we conducted a prospective study to assess the impact of depression and anxiety in early pregnancy on the subsequent risk for preeclampsia.
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Materials and Methods |
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Of the 652 women, 15 were excluded because of a prior elevated risk for preeclampsia; five of them had essential hypertension, five had gestational diabetes, and five had twins. In addition, 14 women were excluded from the final analysis, nine because of spontaneous abortion, three because of termination of pregnancy, and two because of second-trimester fetal death; none of these had preeclampsia. The remaining 623 patients at low risk for preeclampsia comprised the study population, with the outcome of pregnancy known in all cases.
Of the 623, 23 (3.7%) women delivered before 37 weeks’ gestation, and of these, 18 experienced spontaneous preterm delivery. In the remaining five, cause of prematurity was induction of labor due to severe preeclampsia (n = 3), cholestasis of pregnancy (n = 1), or fetal hydrops (n = 1).
Depression was measured by a Finnish modification for population studies8,9 of the shortened version of the Beck Depression Inventory,10,11 a widely used self-rating scale for depression with established reliability and validity.12,13 Results with the shortened 13-item Beck Depression Inventory have a high correlation with those in the original long Beck Depression Inventory. Both introductory questions and one positive choice answer were added for each item to the Finnish modification.8 Because these additional positive choices measure self-confidence and do not affect the scoring of depression, they are therefore more suitable for population screening than is the original Beck Depression Inventory, which was developed for psychiatric patients.14 As the majority of the subjects with depressive disorders may not be diagnosed by the primary and occupational health services, and therefore may not receive appropriate treatment, the Social Insurance Institution in Finland developed a 14-item questionnaire (13 items for depression and one for anxiety) for population screening.8,9 An example of the Finnish modification of the shortened 13-item Beck Depression Inventory is the following item of the questionnaire: "How do you feel?" "I am feeling quite optimistic and good" (4); "I do not feel sad" (0); "I feel sad or blue" (1); "I am blue or sad all the time and I cannot snap out of it" (2); "I am so sad or unhappy that I cannot stand it" (3). The first choice (4) measures self-confidence (only in the Finnish version), and the remaining three are from the original shortened Beck Depression Inventory.10 This Finnish modification has good reliability and validity and is used widely for screening of Finnish populations.8,9 We defined depression as a score of 3 or more, with lower scores considered as normal.
It is known that the majority of depressed persons also have anxiety.15 There are, however, no questions for perceived anxiety in the original or shortened version of Beck Depression Inventory. That is why one question regarding anxiety was developed. Anxiety was assessed as a dichotomous variable (0 for normal and 1–3 indicating presence of anxiety) with the following question: "Are you tense or distressed?" The choices were "I believe I have good nerves and do not become distressed easily" (0); "I do not feel tense or distressed" (0); "I become distressed quite easily" (1); "I become very easily anxious, tense and distressed" (2); "I feel myself all the time anxious and tense as if I had lost my nerves" (3). Positive answers (1–3) to this question were associated with an increased risk of anxiety among Finnish farmers.16
Gestational age was determined by the last menstrual period and by ultrasound at 16 to 20 weeks. Preeclampsia was defined as elevated blood pressure (BP) (more than 140/100 mmHg) and proteinuria (0.3 g during 24 hours or more) after 20 weeks’ gestation. The potentially confounding variables studied were age, smoking, alcohol consumption, marital status, and social class based on the woman’s profession (five categories include academic white-collar (9%), nonacademic white-collar (34%), skilled laborer (40%), nonskilled laborer (7%), and unclassified (10%). Bacterial vaginosis was assessed at the first prenatal visit by Gram stain as described previously.17
With a prevalence of 30% of mild depression among pregnant Finnish women, it was calculated that about 200 women with depression and 400 without were needed for the study for it to have an 80% power to detect a difference of 6% (10% compared with 4%) in incidence of preeclampsia between the groups at P < .05. All variables were treated as categoric. The 
2 test was used for testing differences, with P < .05 considered statistically significant. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated with SAS (SAS Institute, Inc., Cary, NC) including multiple logistic regression analysis. All statistical tests were two sided.
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Results |
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The mean Beck score for the whole study population was 2.0 (range 0–17). Depression (mean Beck score 4.5, range 3–17) was detected in 185 (30%) women and anxiety in 99 (16%) (Table 1
).
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When multiple logistic regression analysis was applied, depression was still associated with 2.5-fold (95% CI 1.1, 5.4) and anxiety 3.2-fold (95% CI 1.4, 7.4) risk for preeclampsia when the data were adjusted for the six potentially confounding factors. Either depression or anxiety or both were associated with a 3.1-fold (95% CI 1.4, 6.9) risk for preeclampsia. Depression together with bacterial vaginosis (n = 44) was associated with a 5.3-fold risk (95% CI 1.8, 15.0) for preeclampsia (n = 7) as compared with the group of women who had neither depression nor bacterial vaginosis. The remaining variables showed no such synergistic effect.
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Discussion |
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Vasoconstriction in preeclampsia may develop early in pregnancy.2,22 Indeed, increased uterine artery resistance in maternal anxiety23 could be a primary manifestation or even the cause of preeclampsia. The synergistic association of depression with bacterial vaginosis for subsequent risk of preeclampsia was an unexpected finding. It has, however, been shown that inflammatory changes may enhance the risk for subsequent preeclampsia.24,25 Furthermore, it is known that black pregnant women often have bacterial vaginosis26 as well as preeclampsia27 when compared with white women. Another explanation may be that bacterial vaginosis serves as a marker of low socioeconomic status, at least in the United States,26 but this is not necessarily the case in our population. Furthermore, it is known that depressive symptoms are more common in pregnant women of low economic status.28
Depression and anxiety during pregnancy could prove harmful through altered excretion of vasoactive hormones or other neuroendocrine transmitters,4,29–32 which in turn may increase the risk for hypertension.33 It is also possible that depression may trigger such vascular changes and eventually induce preeclampsia. However, the precise biochemical mechanism(s) remain unknown.
The limitations of this study may be that mood was assessed only once in early pregnancy, and that no information was available on family history or on biochemical parameters. Furthermore, the size of our series was not sufficient to assess whether the degree of depression was associated with the magnitude of the risk for preeclampsia. However, we consider that the strengths of this study are its prospective nature, enrollment of only nulliparous women, and early assessment (before any signs of preeclampsia) of depression and anxiety.
Our results indicate that women showing depression are at increased risk for subsequent preeclampsia and need extra social and psychological support and close follow-up for symptoms of preeclampsia.
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Footnotes |
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Received July 19, 1999. Received in revised form September 22, 1999. Accepted October 1, 1999.
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References |
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2. O’Brien W. Predicting preeclampsia. Obstet Gynecol 1990;76: 731–2.
3. Schobel H, Fischer T, Heuszer K, Geiger H, Schmieder R. Preeclampsia - A state of sympathetic overactivity. N Engl J Med 1996;335:1480–5.
4. Lewinsky R, Riskin-Mashiah S. Autonomic imbalance in preeclampsia: Evidence for increased sympathetic tone in response to the supine-pressor test. Obstet Gynecol 1998;91:935–9.[Abstract]
5. Klonoff-Cohen H, Cross J, Pieper C. Job stress and preeclampsia. Epidemiology 1996;7:245–9.[Medline]
6. Wergeland E, Strand K. Working conditions and prevalence of preeclampsia. Int J Gynaecol Obstet 1997;58:189–96.[Medline]
7. Nisell H, Larsson G, Wager J. The relation between life stress and hypertensive complications during pregnancy. Acta Obstet Gynecol Scand 1989;68:423–7.[Medline]
8. The Social Insurance Institution. Coping as the target of social policy. Studies in Social Security and Health, Helsinki, Finland, 1995.
9. Hänninen V, Aro H. Sex differences in coping and depression among young adults. Soc Sci Med 1996;43:1453–60.
10. Beck A, Beck R. Screening depressed patients in family practice. A rapid technic. Postgrad Med 1972;52:81–5.
11. Beck A, Rial W, Rickels K. Short form of depression inventory: Crossvalidation. Psychol Rep 1974;34:1184–6.[Medline]
12. Beck A, Steer R, Garbin M. Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clin Psychol Rev 1988;8:77–100.
13. Holcomb W Jr, Stone L, Lustman P, Gavard J, Mostello D. Screening for depression in pregnancy: Characteristics of the Beck Depression Inventory. Obstet Gynecol 1996;88:1021–5.[Abstract]
14. Beck A, Ward C, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561–71.
15. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. (DSM-IV). Washington DC: American Psychiatric Association, 1994.
16. Raitasalo R, Notkola V. Screening of mental health disorders among farmers and occupational health care. J Soc Med 1987;24: 232–41.
17. Kurki T, Sivonen A, Renkonen O-V, Savia E, Ylikorkala O. Bacterial vaginosis in early pregnancy and pregnancy outcome. Obstet Gynecol 1992;80:173–7.
18. Jarrahi-Zadeh A, Kane F Jr, Van de Castle R, Lachenbruch P, Ewing J. Emotional and cognitive changes in pregnancy and early puerperium. Br J Psychiatry 1969;115:797–805.
19. Cox J. Psychiatric morbidity and pregnancy: A controlled study of 263 semi-rural Ugandan women. Br J Psychiatry 1979;134:401–5.
20. Piyasil V. Anxiety and depression in teenage mothers: A comparative study. J Med Assoc Thai 1998;81:125–9.[Medline]
21. Raskin V, Richman J, Gaines C. Patterns of depressive symptoms in expectant and new parents. Am J Psychiatry 1990;147:658–60.
22. Orpana K, Avela K, Ranta V, Viinikka L, Ylikorkala O. The calcium-dependent oxide production of human vascular endothelial cells in preeclampsia. Am J Obstet Gynecol 1996;174:1056–60.[Medline]
23. Teixeira J, Fisk N, Glover V. Association between maternal anxiety in pregnancy and increased uterine artery resistence index: cohort based study. BMJ 1999;318:153–7.
24. Sacks G, Studena K, Sargent K, Redman C. Normal pregnancy and preeclampsia both produce inflammatory changes in peripheral blood leukocytes akin to those of sepsis. Am J Obstet Gynecol 1998;179:80–6.[Medline]
25. Walker J. Antioxidants and inflammatory cell response in preeclampsia. Semin Reprod Endocrinol 1998;16:47–55.[Medline]
26. Hillier S, Nugent R, Eschenbach D, Krohn M, Gibbs R, Martin D, et al. Association between bacterial vaginosis and preterm delivery of low-birth-weight infant. The vaginal infections and prematurity study group. N Engl J Med 1995;333:1737–42.
27. Knuist M, Bonsel G, Zondervan H, Treffers P. Risk factors for preeclampsia in nulliparous women in distinct ethnic groups: A prospective cohort study. Obstet Gynecol 1998;92:174–8.[Abstract]
28. Séguin L, Potvin L, St.-Denis M, Loiselle J. Chronic stressors, social support, and depression during pregnancy. Obstet Gynecol 1995; 85:583–9.[Abstract]
29. Paarlberg K, Vingerhoets A, Passchier J, Dekker G, Van Geijn H. Psychosocial factors and pregnancy outcome: A review with emphasis on methodological issues. J Psychosom Res 1995;39:563–95.[Medline]
30. Wadhwa P, Dunkel-Schetter C, Chicz-DeMet A, Porto M, Sandman C. Prenatal psychosocial factors and the neuroendocrine axis in human pregnancy. Psychosom Med 1996;58:432–46.
31. Sandman C, Wadhwa P, Chicz-DeMet A, Dunkel-Schetter C, Porto M. Maternal stress, HPA activity, and fetal/infant outcome. Ann NY Acad Sci 1997;814:266–75.
32. Potter W, Manji H. Catecholamines in depression: An update. Clin Chem 1994;40:279–87.
33. Sullivan P, Schoentgen S, DeQuattro V, Procci W, Levine D, Van-der-Meulen J, et al. Anxiety, anger, and neurogenic tone at rest and in stress in patients with primary hypertension. Hypertension 1981;3:119–23.
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