Abstract

This study is based on the hypothesis that women with a history of depression and/or women who experience depressive symptoms for the first time during pregnancy have a higher risk of developing preeclampsia (PE) as a pregnancy complication.

 

Little research documents the relationship between emotional well being and PE outcomes.  While it has been suggested that altered excretion of vasoactive hormones in women with depression may increase the risk for PE (Bonari, et al., 2004), there are no data specifically addressing this issue.  Furthermore, the mechanisms that may link depression, specifically a history of Major Depressive Disorder (MDD) prior to pregnancy, with an increased PE risk are unknown. 

The total sample size consisted of 960 previously pregnant women:  438 participants with preeclampsia outcomes (46%) and 522 participants without preeclampsia outcomes (54%).  All 960 participants completed the 30 question online survey within a 60 day interval.


To investigate this possible association, 960 women participated in this online survey designed to assess the impact that depressive symptoms prior to and throughout pregnancy may have on subsequent PE outcomes.

 

Results indicate that a history of depression is associated with a 2.2-fold increased risk (OR 2.2, 95% CI 1.1, 5.4) for subsequent PE outcomes.  Furthermore, results demonstrate that women presenting depressive symptoms during pregnancy, specifically women reporting daily psychological stress are associated with a 3.5 fold increase risk (OR 3.5, 95% CI .45, .69) for PE outcomes, followed by women who endure anxiety on a frequently or daily basis, associated with a 1.7 fold increased risk (OR 1.7, 95% CI .43, .73) for subsequent PE outcomes.

Major Depressive Disorder

Annually, 15 to 25 percent of adults in the United States are affected by Major Depressive Disorder.  Women are twice as likely as men to be diagnosed with MDD (Epperson, 1999).  An estimated 20 percent of women in the United States develop MDD in their lifetimes (Bhatia, 1999).  The peak age of Major Depressive Disorder in women is 18 to 44 years which coincides with the prime childbearing years (Epperson, 1999).  The prevalence of MDD among pregnant women is significant, affecting 4 to 16 percent of all pregnancies in the United States (Misri, 2007).  Approximately 25 to 35 percent of pregnant women experience depressive symptoms that peak during the first trimester (Zinga, Phillips, & Born, 2005).  Elevated levels of depression during pregnancy are shown to be associated with preterm labor (Alder, Fink, Bitzer, Hösli, & Holzgreve, 2007).

 

Because depressive symptoms mimic pregnancy related disturbances, distinguishing whether a woman is experiencing depression versus symptoms of pregnancy can be challenging (Misri, 2007).  Obstetricians may be especially challenged in distinguishing depressive symptoms from those of pregnancy among patients with no history of depression.

Risk factors for developing depression during pregnancy include:  previous history of mood disorders, postpartum depression, and/or family psychiatric illness, as well as limited psychosocial support, marital instability, and/or the recent loss of a loved one (Luskin, 2001).  Negative life events may trigger depressive symptoms such as a divorce or loss of a loved one (Davison, & Neale, 2001).  Single or separated mothers with financial problems and/or minimal parental support are all considered high risk for developing depression during pregnancy (Berle et. al., 2005).  Pregnant women in cultures providing inadequate support and high expectations of new mothers have also been found to be at increased risk (Fitch, 2002).

 

Untreated depression during pregnancy is associated with poor maternal nutrition, as well as increased consumption of alcohol and poor attendance at prenatal visits, placing both mother and fetus at risk (Austin, 2006).  Several studies have shown that depression during pregnancy may be a risk factor for spontaneous abortion (Arck, 2001). Considering that a history of depression is the strongest indicator for depression during pregnancy (Bhatia, 1999), the abrupt discontinuation of antidepressants during pregnancy may lead to the recurrence of the disorder (Misri, 2007).


Preeclampsia

Preeclampsia (PE) is a potentially life threatening disease that only occurs during pregnancy, typically after the 20th week of gestation (Sibai, 2008).  Affecting over four million women worldwide, preeclampsia is responsible for approximately 76,000 deaths each year (Lyall & Belfort, 2007).  Currently, PE can only be detected far into the pregnancy, with the appearance of the following clinical signs: hypertension, proteinuria, and edema (Sibai & Dekker, 2005).  Currently, no predictive test exists to identify women who will subsequently develop preeclampsia (Huppertz, 2008).

 

Annually, preeclampsia affects five to eight percent of all pregnancies (Lyall & Belfort, 2007).  The disease is associated with significant prematurity and all of its associated complications, including admission to the Neonatal Intensive Care Unit (NICU).  Proper prenatal care is essential to diagnose and manage preeclampsia.  Substandard prenatal care, including failure to diagnose the condition may lead to death (Ceron-Mireles, Harlow, Sánchez-Carrillo, & Nunez, 2001).  Symptoms associated with the pregnancy induced disease include swelling, sudden weight gain, headaches and changes in vision (Lyall & Belfort, 2007).  However, some women with rapidly advancing disease experience few symptoms (Sibai, & Dekker, 2005).  To date, there is no available cure for the disease apart from timely delivery of the baby and more importantly, of the placenta (Huppertz, 2008).

Rationale for the Present Study

This study examines both a history of depression and depressive symptoms during pregnancy with subsequent preeclampsia outcomes.  This study extends those cited above by specifically examining a history of MDD pre-pregnancy versus the wide range of all maternal mood disorders.

 

Furthermore, if results show that women with a history of MDD prior to pregnancy are also at a higher risk of developing preeclampsia, these may be implications for treating depression in the months before conception and/or for closely monitoring women with a history of MDD during pregnancy.

 

This thesis intends to determine if pregnant women with a history of MDD prior to pregnancy are more prone to develop PE than women without a history of MDD; in order to clarify the nature of the preeclampsia/depression link.  Additionally, this retrospective study investigates whether women with prenatal history of MDD are at greater risk of developing PE than women who report depressive symptoms for the first time during their pregnancy.  Finally, this study evaluates the impact of both the prenatal history of MDD as well as the depressive symptoms experienced during pregnancy with preeclampsia outcomes, such as preterm delivery, future incidence of PE, and maternal morbidity.

 

The operant hypothesis is that women with a history of MDD are more likely to develop PE than women without a history of MDD.  Furthermore, this analysis will evaluate if women with a history of MDD prior to pregnancy will have the same risk level for developing PE as women who develop depressive symptoms for the first time during pregnancy.  Thus, history of depression anytime up to and during gestation in women should be associated with increased preeclampsia risk.  

Acknowledgements

First of all, an enormous thank you to Eleni Tsigas, (Executive Director of the Preeclampsia Foundation). Without her 100% support and approval, this project may have never existed.  Eleni, thank you for not only permitting me to place the study on your website but also for helping me to come up with the 30 question survey in the first place.

 

Miguel E. Basañez, PhD, (in 2010 Deputy Director of the Cultural Change Institute, The Fletcher School, Tufts University and in 2016 Ambassador of Mexico in the USA, Washington D.C.).  His encouraging words, patience, and guidance have strengthened me enormously.

 

Thomas F. McElrath, MD, PhD, (Division of Maternal-Fetal Medicine, Brigham & Women’s Hospital).  His immense wisdom and insightful comments have inspired me to dedicate all of my strength and energy to this study.  Thank you for being my thesis director!

 

Professor Dante Spetter, PhD, (Research Advisor in Behavioral Science in the Master of Liberal Arts Program).  Her guidance and encouragement has permitted this project to shine from the very beginning.  Thank you for being my thesis advisor!

 

Last but not least, I would like to thank Peter O’Malley, (Assistant Director, Master of Liberal Arts Program), who has been the best guidance counselor a student could possibly have.  Peter, your advice has always made the difference between night and day, thanks so much for everything!