Awareness and management of obstetrical complications of depression

IUGR infants are at increased risk of iat­rogenic prematurity and stillbirth. Fetuses that weigh <10th percentile for their ges­tational age are delivered no later than 40 weeks; delivery can be indicated as early as 32 weeks, depending on the results of other antenatal tests. Women who have a growth-restricted infant have a higher risk of cesarean delivery because growth-restricted infants often have less reserve and poorer tolerance of labor.

Preeclampsia and eclampsia
Preeclampsia is defined as blood pressure >140/90 mm HG on at least 2 occasions, with proteinuria, that occurs later than the twentieth week of pregnancy in women who did not have hypertension or renal dysfunction at baseline. Preeclampsia is a progressive disease that can cause severe maternal morbidity, including renal failure, stroke, hepatic rupture, pulmonary edema, and heart failure.

Eclampsia refers to onset of seizures in the setting of preeclampsia. These 2 hyperten­sive disorders are the third leading world wide cause of maternal mortality.²⁸

Depressed women have an elevated risk of preeclampsia. The association between preeclampsia and depression might be caused by the presence of increased levels of inflammatory mediators^29,30; other comorbidities, such as increased body mass index, also might be involved, but the risk for preeclampsia in depressed women still is increased after controlling for obesity.³¹

The presence of preeclampsia is respon­sible for a high percentage of iatrogenic pre­term births, because the cure for the disorder is delivery—even at early or previable gesta­tional age. Complication rates for mother and infant are high.

The presence of preeclampsia is a sig­nificant risk factor for intrauterine fetal demise. Treating the mother after delivery involves administration of IV magnesium for 24 hours; often, the mother is separated from her infant for a day after birth.

Impact on prenatal care
Depression increases odds that women will have fewer prenatal visits.³² During pregnancy, women typically initiate pre­natal care during the first trimester, when pregnancy-dating ultrasonography and early screening tests for chromosomal abnormalities are performed. Prenatal vis­its occur monthly until the third trimes­ter, then every 2 weeks between 32 and 36 weeks’ gestation, increasing to weekly after 36 weeks’ gestation.

The increased number of visits in late pregnancy allows for early detection and treatment of hypertensive disorders; assesses fetal well-being; and decreases the risks of morbidity and mortality for mother and fetus.³³ Because women who suffer from depression are at increased risk of an array of adverse pregnancy outcomes, the impor­tance of regular and timely prenatal care cannot be understated.

In addition, the prenatal visit gives the obstetrician the opportunity to connect women with other specialists for manage­ment of any unmet medical needs. One study showed that, when women have adequate prenatal care (measured by the number of visits), the association between preterm birth and self-reported maternal depression was eliminated.³⁴

Substance use
Substance use and depression often co-exist.^35,36 Unlike screening for depression, screening for substance use is universal dur­ing prenatal care. Studies have shown that women who screen positive for depression are at higher risk of a number of comorbidi­ties, including substance use.^37,38 Conversely, women who use substances are more likely to screen positive for depression.

Evidence suggests that best practice might be to screen for depression in any woman who has a positive drug screen, if a provider is not routinely screening their general patient population.³⁹ Substance use in pregnancy is associated with a number of poor outcomes, including placental abrup­tion (cocaine use); dysmorphic facies and congenital anomalies (alcohol); and neonatal abstinence syndrome (heroin).

Antidepressants in pregnancy
A full discussion of the risks and ben­efits associated with pharmacotherapy for depression in pregnancy is beyond the scope of this article. Generally, antidepressant use is fraught with concerns over teratogenic­ity and adverse fetal outcomes. Although ACOG states that (1) pharmacotherapy for depression should be individualized and (2) most selective serotonin reuptake inhibi­tors (SSRIs) are not considered major terato­genic agents, many obstetricians and patients feel uncomfortable using these medications in pregnancy.⁴⁰ Often, pre-pregnancy antide­pressants are discontinued in the first trimes­ter; one large population-based study found that only 0.9% of women who had depres­sion filled their antidepressant prescription consistently throughout their pregnancy.⁴¹

It is unclear whether antidepressant use in pregnancy contributes to the risk of preterm birth seen in women who have depression. In a large population-based study, use of antidepressants in the second trimester was associated with preterm delivery but severe depression was not.¹⁸ A recent meta-analysis revealed an increased risk of preterm birth in women who used an antidepressant, com­pared with healthy women and untreated depressed women.⁴²

Research limits, unanswered questions. Regrettably, it is difficult to untangle risk factors for preterm birth among depressed women without randomized controlled studies that are not ethically feasible. It can­not be said with certainty whether antide­pressant pharmacotherapy is associated with a higher risk of preterm birth than depression alone.