Friday, January 22, 2010

Stress, Anxiety Can Up Risk of Depression in Pregnancy

Stress, history of depression, lack of social support and unintended pregnancy are among the major factors that contribute to increased risk of depression in pregnant women, a new study shows.

Other important factors are maternal anxiety, domestic violence and having public insurance coverage, said the University of Michigan researchers, who reviewed 159 studies conducted between 1980 and 2008.

The study appears in the January issue of the American Journal of Obstetrics & Gynecology.

Depression, which occurs in about 12.7 percent of pregnant women, can cause problems for mothers and babies, including pre-term delivery, preeclampsia, sleep disturbances and disrupted mother-infant bonding.

It's important for physicians to know how to identify depression in pregnant women, said the study authors, who noted that not all women who test positive on depression screening tests have or will develop clinical depression.

"We are hoping that [health-care] providers can use the presence or absence of risk factors such as those identified in our study to enhance their assessments for depression in addition to the information they obtain from the screening test," study author Dr. Christie A. Lancaster, a clinical lecturer in the obstetrics and gynecology department at U-M, said in a news release.


Pot smoking during pregnancy may stunt fetal growth

Women who smoke marijuana during pregnancy may impair their baby's growth and development in the womb, a new study suggests.

Poor fetal growth and reduced head circumference at birth are linked to an increased risk of problems with thinking, memory and behavior in childhood. Cigarette smoking during pregnancy is known to impair fetal growth, but studies on the potential effects of marijuana have been inconclusive.

For the new study, researchers in the Netherlands followed more than 7,000 pregnant women, 3 percent of whom acknowledged smoking marijuana at least during early pregnancy. They found that babies born to marijuana users tended to weigh less and have smaller heads than other infants.

What's more, the study found, the longer a woman had used marijuana during pregnancy, the stronger the impact on birth size - suggesting that the drug itself was to blame.

And while most marijuana users in the study also smoked cigarettes, the drug appeared to have effects over and above those of tobacco. In fact, marijuana showed stronger effects on birth size than tobacco, the investigators report in the Journal of the American Academy of Child and Adolescent Psychiatry.

The findings suggest that marijuana use, even restricted to early pregnancy, may have irreversible effects on fetal growth, write the researchers, led by Hannan El Marroun of Erasmus University Medical Center in Rotterdam.

The study included almost 7,500 pregnant women who were surveyed on their use of alcohol, tobacco and drugs, and had ultrasounds to chart fetal growth during the first, second and third trimesters.

Overall, 214 women said they had used marijuana before and during early pregnancy; 81 percent quit after learning they were pregnant, but 41 women continued to smoke marijuana throughout pregnancy.

The researchers found that, on average, marijuana users gave birth to smaller babies, particularly those who had used throughout pregnancy.

Women who had smoked only during early pregnancy had babies who were 156 grams -- about 5.5 ounces -- lighter than infants born to women who had not used the drug. Women who had continued to smoke past early pregnancy had babies who were 277 grams, or nearly 10 ounces, smaller.

Based on ultrasound, marijuana use only in early pregnancy impaired fetal growth by about 11 grams per week, while use throughout pregnancy slowed fetal growth by roughly 14 grams per week. That compared with a deficit of 4 grams per week with tobacco use, the researchers found.

Similar patterns were seen when the researchers looked at fetal head circumference.

According to El Marroun's team, mothers' marijuana use could stunt fetal growth for several reasons. Like tobacco smoking, it may deprive the fetus of oxygen. It is also possible that the byproducts of marijuana directly affect the developing nervous and hormonal systems of the fetus.

Finally, the researchers note, pregnant women who use marijuana may have other factors in their lives - such as a less-than-healthy diet or chronic stress -- that could contribute to poor fetal growth.


Untreated Gum Disease During Pregnancy Risks Life of Baby

Pregnant women with untreated gum disease may have more at stake than just their teeth. They may also be risking the lives of their babies, a new study shows.

Expectant mothers have long been warned that gum disease can cause a baby to be born prematurely or too small. But for the first time scientists have linked bacteria from a mother's gums to an infection in a baby that was full-term but stillborn, according to the study which was published Thursday in Obstetrics and Gynecology.

Scientists from Case Western University made the discovery after a 35-year-old California woman contacted them to help investigate the death of her baby. Earlier studies by the same researchers showed that an oral bacteria called Fusobacterium nucleatum could spread from the bloodstream to the placenta in mice. The woman wanted to know if it was possible in humans.

Bacteria from the mouth can easily get into the bloodstream once a woman's gums are bleeding, explains the study’s lead author Yiping Han, an associate professor of periodontics and pathology at Case Western University. Generally, this type of bacteria can be easily combated by the immune system of the mom-to-be, whether mouse or human. But because of special conditions that exist in the womb, the fetus can be more susceptible, Han suspects.

“Once the bacteria are in the blood, they can go almost anywhere,” Han says. “The placenta is an immuno-suppressed organ, compared to other organs like the liver and the spleen. And that makes it easy for the bacteria to colonize the placenta.”

The California woman told researchers that she had experienced heavy bleeding from her gums — a sign of gum disease — during her pregnancy. Bleeding gums aren’t unusual in pregnant women, with about 75 percent developing the condition due to normal hormonal changes. Mild gum disease can be treated simply by brushing and flossing more often. Pregnant women with more serious cases may need dental surgery.

Usually women’s uterine infections, which can harm a fetus, are caused by bacteria that work their way up from the vaginal canal, says Han. But the researchers detected a bacteria in the baby not typically found in the vaginal region. Plaque samples from the woman’s teeth were found to be positive for the exact same strain of the oral bacteria found in the dead baby’s stomach and lungs.

Women shouldn’t be overly alarmed by the new study, says Dr. Richard H. Beigi, an obstetric infectious disease specialist and an assistant professor of reproductive science at the University of Pittsburgh Medical Center.

“This is just one case,” he explained. “Most pregnant women have bleeding gums and most don’t have dead babies. This can happen, but it’s rare. And this finding doesn’t mean that it’s increasing.”

Still, Beigi says, it should serve as a reminder that pregnant women with bleeding gums should see a dentist to treat their gingivitis. Gingivitis can increase the risk of preterm birth anywhere from twice to seven times, studies indicate.

The new study underscores the importance of oral hygiene not only for pregnant women, but also for those contemplating pregnancy, says Dr. Michael Lu, an associate professor of obstetrics, gynecology and public health at the University of California Los Angeles Medical Center.

“We know that gingivitis doesn’t happen overnight and that it’s important for women to enter pregnancy in good health,” Lu says. “I would love to see every woman who is contemplating pregnancy get pre-conception care that includes an oral-health check-up.”


Thursday, January 21, 2010

Birth Weights Are Falling in U.S.

Mothers are giving birth to lighter babies in the U.S., and no one is quite sure why.

This finding, published Thursday in the Journal of Obstetrics and Gynecology, has potentially troubling public-health implications, if the trend continues. Low-birth-weight babies are at higher risk for a host of health problems.

Between 1990 and 2005, the birth weight of full-term babies in the U.S. declined nearly two ounces to an average of seven pounds and 7.54 ounces, a reversal of a trend that had seen birth weights climb steadily since the 1950s, according to the study. They were also born 2.5 days earlier on average in 2005 than in 1990, the study said.

The decrease in weight—based on an analysis of nearly 37 million non-multiple births from a national database—isn't likely to affect the health of the average baby in the study, according to researchers. But the data showed a 1% increase in the number of the lowest-weight babies and suggested the birth-weight decline didn't stop in 2005.

These data suggest that it may be important for medical professionals to pay attention to the weight of babies born around 37 weeks and 38 weeks, as well as those considered pre-term, or less than 37 weeks, according to Joann Petrini, senior adviser at the March of Dimes and assistant research director at Danbury Hospital in Connecticut, who wasn't involved in the study.

Researchers also found a 2% decrease in the number of babies considered large—those over the 90th percentile of weight for gestational age—which is a positive, according to Dr. Oken. Large babies can experience more birth trauma and cause more birth injury to the mother.

The lower-birth-weight trend could not be explained by common factors like how much weight mothers gained during pregnancy, whether the delivery was induced or by cesarean section, prenatal care, or common maternal-health issues such as smoking and hypertension, researchers said.

Researchers also repeated their analysis in a sample of low-risk women—healthy, educated Caucasians in their mid-to-late 20s—and found that the decrease in birth weight was even more pronounced, suggesting that the trend isn't the result of changes in the population of mothers.

Other investigators also have begun to note the same trend. "There's no question" about the change in birth-weight pattern, said Michael Kramer, scientific director of the Institute for Human Development and Child and Youth Health at the Canadian Institutes of Health Research, who wasn't involved in the study.

"It is a new trend," he said. "We really don't know why the birth weight has decreased." A similar pattern has been observed in Canada, he said.

Some potential factors that weren't examined in this study include better control of gestational diabetes—when a mother develops diabetes during pregnancy—and more physical activity during pregnancy, said Dr. Kramer.

Babies considered too large, as well as too small, tend to have more health problems in the long run. The optimal size for a newborn is around 4,000 grams, or roughly 8.8 pounds, according to Dr. Kramer. The average baby in the study was found to be smaller than optimal. In 1990, the average birth weight was 3,441 grams, and in 2005 it fell to 3,389 grams, according to the study.

Babies born too small tend to have higher blood pressure and a greater risk of diabetes in the long run, said Dr. Oken.

From the 1950s until the 1980s, birth weights had increased as a result of increases in mothers' weight and how many pounds they gained during the pregnancy, as well as reduced smoking and older maternal age, according to Dr. Kramer.


Drugs for depression, anxiety tied to preterm birth

Pregnant women who take certain drugs for depression or anxiety may have heightened risks of preterm delivery or other birth complications, according to a new study.

Researchers found that among nearly 3,000 women who gave birth in Washington State, those who started taking antidepressants known as selective serotonin reuptake inhibitors (SSRIs) in the second or third trimester had a higher risk of preterm birth.

Compared with their counterparts not on the medications, these women were nearly five times more likely to deliver prematurely.

The same risk was not seen, however, among women who started on an SSRI before pregnancy or during the first trimester. SSRIs include drugs like sertraline (Zoloft), paroxetine (Paxil) and fluoxetine (Prozac).

The researchers also found a higher risk of preterm delivery among women who took anti-anxiety drugs known as benzodiazepines, regardless of when they began treatment.

Those drugs, which include medications like lorazepam (Ativan) and alprazolam (Xanax), were linked to higher risks of other complications as well - including low birth weight, newborn respiratory distress and a low Apgar score, a standard measure of newborn health.

The findings of the study are published in the American Journal of Obstetrics & Gynecology.

Exactly what the study means for women on SSRIs or benzodiazepines is not entirely clear. A major limitation is that it could not estimate the benefits of treatment, lead researcher Dr. Ronit Calderon-Margalit, of the Hebrew University-Hadassah School of Public Health in Jerusalem, noted in an email to Reuters Health.

Any risks of using the medications during pregnancy need to be balanced against the risks of leaving depression and anxiety disorders untreated.

"It is very important to have other studies of the risks associated with (these) drugs, but also of benefits associated with treating mothers," said Calderon-Margalit, who was at the University of Washington in Seattle at the time of the study.

In addition, SSRIs did not appear to present equal risks for all women. Calderon-Margalit described the antidepressant findings as "mostly reassuring" for women who start the drugs before pregnancy or in the first trimester -- as most SSRI users in the study had.

The study included 2,793 pregnant women, 11 percent of whom used a psychiatric medication during pregnancy. Of these, 138 were on an SSRI, while 85 used a benzodiazepine.

Among women who were not on any medication, 9 percent gave birth prematurely, versus nearly half of women on benzodiazepines.

Meanwhile, 14 percent of women on SSRIs had a preterm birth, but the elevated risk turned out to be concentrated among those who started an antidepressant after the first trimester. Of those 21 women, 16 delivered prematurely.

Several other birth complications, often related to preterm birth, were also higher-than-average among women on benzodiazepines.

Seventeen percent of their newborns suffered respiratory distress syndrome and one-third ended up in the neonatal intensive care unit. Those figures were 3 percent and 6 percent, respectively, among newborns whose mothers had not used psychiatric medications during pregnancy.

Calderon-Margalit pointed out that most women on benzodiazepines used lorazepam (Ativan), so it is possible that the risks are associated mainly with that drug. However, further research is needed to determine whether any particular medications carry particular risks.


Wednesday, January 20, 2010

No need for pregnant women to fast during labor

There is no reason why pregnant women at low risk for complications during delivery should be denied fluids and food during labor, a new Cochrane research review concludes.

"Women should be free to eat and drink in labor, or not, as they wish," the authors of the review wrote in the Cochrane Library, a publication of the Cochrane Collaboration, an international organization that evaluates medical research.

Dr. Jennifer Milosavljevic, a specialist in obstetrics and gynecology at Henry Ford Health System, Detroit, who was not involved in the Cochrane Review, agrees that pregnant women should be allowed to eat and/or drink during labor.

"In my experience," she told Reuters Health in an email, "most pregnant patients at Henry Ford are placed on a clear liquid diet during labor which includes water, apple juice, cranberry juice, broth, and jello. If a patient is brought in for a prolonged induction of labor, she will typically be permitted to eat a regular diet and order anything off the menu in between different induction modalities."

Milosavlievic has "not seen any adverse outcomes by allowing women the option of liquids and/or a regular diet in labor."

Standard hospital policy for many decades has been to allow only tiny sips of water or ice chips for pregnant women in labor if they were thirsty. Why? It was feared, and some studies in the 1940s showed, that if a woman needed to undergo general anesthesia for a cesarean delivery, she might inhale regurgitated liquids or food particles that could lead to pneumonia and other lung damage.

But anesthesia practices have changed and improved since the 1940s, with more use of regional anesthesia and safer general anesthesia.

And recently, attitudes on food and drink during labor have begun to relax. Last September, the American College of Obstetricians and Gynecologists (ACOG) released a "Committee Opinion" advising doctors that women with a normal, uncomplicated labor may drink modest amounts of clear liquids such as water, fruit juice without pulp, carbonated beverages, clear tea, black coffee, and sports drinks. They fell short of saying food was okay, however, advising that women should avoid fluids with solid particles, such as soup.

"As for the continued restriction on food, the reality is that eating is the last thing most women are going to want to do since nausea and vomiting during labor is quite common," Dr. William H. Barth, Jr., chair of ACOGs Committee on Obstetric Practice, noted in a written statement at the time.

But based on the evidence, Mandisa Singata of the East London Hospital Complex in East London, South Africa, an author on the new Cochrane Review, says "women should be able to make their own decisions about whether they want to eat or drink during labor, or not."

Singata and colleagues systematically reviewed five studies involving more than 3100 pregnant that looked at the evidence for restricting food and drink in women who were considered unlikely to need anesthesia. One study looked at complete restriction versus giving women the freedom to eat and drink at will; two studies looked at water only versus giving women specific fluids and foods and two studies looked at water only versus giving women carbohydrate drinks.

The evidence showed no benefits or harms of restricting foods and fluids during labor in women at low risk of needing anesthesia.

Poor nutritional balance may be associated with longer and more painful labors. Drinking clear liquids in limited quantities has been found to bring comfort to women in labor and does not increase labor complications.


Tuesday, January 19, 2010

Blood test tells fetal sex in early pregnancy

Normally, parents who want to know the sex of their baby before it's born find out through ultrasound done in the second trimester. A blood test that can be done early in pregnancy is highly accurate at determining the sex of the fetus, however, a new study finds.

The test is important, write the authors of the study, because in some cases, there are medical reasons to determine fetal sex earlier. That has traditionally meant invasive tests, like amniocentesis, which carry a small risk of miscarriage.

Consequently, maternal blood tests that pick up certain markers of fetal sex have been developed and put into use in recent years. So far, research has shown the accuracy of these tests to vary widely, depending on the methods used.

In this latest study, published in the journal Obstetrics & Gynecology, researchers in the Netherlands found that the testing method used at their center was 100 percent accurate in determining fetal sex among nearly 200 pregnant women.

Part of what's new about the findings is that they show the effectiveness of blood testing as it is done in routine practice -- and not just in the research setting, Dr. Ellen van der Schoot, of Sanquin Research Amsterdam, told Reuters Health in an email. The study does not discuss costs, nor when the test might be available to the general public.

Still, the findings, according to van der Schoot and her colleagues, support using the tests in cases where fetal sex is important in detecting or managing certain inherited medical conditions.

For example, congenital adrenal hyperplasia (CAH) is a genetic disorder that causes girls to develop abnormal external genitalia and male-like characteristics like a deep voice and excessive body hair.

It is possible, however, to treat the disorder with the steroid dexamethasone as soon as pregnancy is established, so knowing the fetal sex sooner is better than later.

Similarly, fetal sex is key in genetic disorders linked to abnormalities in the X chromosome. These disorders -- such as hemophilia and Duchenne/Becker muscular dystrophy -- are almost always seen in boys rather than girls, because boys inherit only one X chromosome, from the mother. (Girls inherit an X chromosome from each parent.)

In cases where a mother is known to carry an X-linked genetic defect, blood testing for fetal sex tells doctors whether further, invasive testing for the particular genetic disorder should be done. If the fetus is female, invasive tests can be avoided.

In the current study, van der Schoot and her colleagues looked at 201 pregnant women who had blood testing at their lab between 2003 and 2009. The test, done as early as the seventh week of pregnancy, determines fetal sex by looking for two genes found on the Y sex chromosome.

Only men carry the Y chromosome, so when these genes were found in a pregnant woman's blood sample, the fetus was assumed to be male. When the test did not detect the genes, the mother's blood was analyzed further to confirm that certain other fetal DNA was present; with that confirmation, the researchers concluded that the fetus was female.

Of the 201 women in this study, blood tests gave conclusive results to 189. In each case, that result turned out to be correct.