Posts Tagged ‘depression’

Pregnancy, Holiday Stress and You!

Wednesday, December 15th, 2010
The season of joy can indeed be joyous, but for most people it also means cramming enormous amounts of activity into a tiny amount of time. While Holiday gift shopping and business and social celebrations are fun, they arrive with the need to prepare large meals, deal with relatives and in-laws, worry about the cost of new clothes and extra food, end of year taxes, finances in general, bonus anxiety and even job security. This kind of pressure can  bring on enormous amounts of stress and will drive you nuts (not the warm chestnut kind) very quickly if you let it.
For mothers-to-be, how does all of this stress affect her pregnancy? Can maternal psychiatric conditions such as depression, anxiety, and stress adversely affect the baby when pregnant during the holiday season? This particular area of concern has always been debatable but review of recent scientific literature has shown some surprising results regarding the relationship between psychiatric conditions and the possibility of affecting the uteroplacental environment… and consequently the fetus.

Is there evidence that psychiatric conditions can effect pregnancy outcome?

A recent article from the Journal of Affective Disorders, in 2010 by Nicole Paz found that the risk of placental abruption is increased in pregnant women with mood or anxiety disorders. Placental abruption is an obstetrical emergency when the placenta prematurely separates from the wall of the uterus. This occurs in about 1 to 2% of all pregnancies. It is often associated with an “ischemia of the placenta” or a lack of perfusion to the placenta causing parts of the placenta to be infarcted (deadened) and consequently separate from the wall of the uterus. The placenta is the lifeline to the baby and having substantial areas that no longer function can dramatically effect the safety and well-being of the baby. Many other medical situations can be associated with this event such as hypertension, uterine infections, trauma to the uterus, premature rupture of membranes, maternal smoking, and maternal clotting disorders. Now there might be evidence that psychiatric conditions can also effect the placenta.

Previous studies by Qiu in 2009 have shown that there is a higher risk of preeclampsia (hypertension, protein in the urine , and marked swelling) and preterm delivery with maternal depressive, anxiety and stress symptoms. The authors Alder in 2007, and Halbreich in 2005 confirmed that anxiety during pregnancy and psychological distress have been reported to be associated with preterm delivery, low birth weight, and obstetrical complications. Another scientist Cohen in 1989 described placental abruption associated with panic attacks.

What is the mechanism by which this occurs?

Activation of the sympathetic nervous system with elevated chemicals in the body such as cortisol, corticotrophin releasing hormone, and serotonin levels, associated with anxiety and stress is believed to cause some of these observations. Stress causes increased hypothalamic—pituitary-adrenal activity. These elevated chemicals can result in systemic inflammation and damage to vessel lining (endothelial dysfunction) which can lead to abruption of the placenta. Other investigators have found changes in clotting and platelet activity in women with major depression which can then affect coagulation pathways resulting in preeclampsia and abruption. Much evidence has mounted to show a relationship between depression and cardiovascular disease later in life through similar mechanisms.

More studies need to be done to investigate all the hormonal, vascular, and hemodynamic effects of maternal mood and anxiety on pregnancy and its outcome.

Is there evidence that psychiatric conditions occurring during pregnancy can effect mothers after they deliver?

Research has shown that anxiety, depression, and prenatal stress is also associated with maternal mental disorders after birth. There is a higher incidence of postpartum depression in women that have prenatal anxiety.

Is there evidence that psychiatric conditions during pregnancy can effect the emotional state of children after they are born?

Behavioral and emotional problems in children such as attention deficit disorders, hyperactivity, oppositional defiant disorder and childhood anxiety are more prevalent in mothers that have anxiety and psychological distress during their pregnancies.

Summary

Maternal anxiety and stress during pregnancy can negatively affect both mom and baby both during the pregnancy and afterward. Screening women that have some of these disorders, and providing treatment, could be found to alter some of the adverse pregnancy outcomes associated with some of these well known psychiatric illnesses.

In the meantime, try to chill out during THIS holiday season. Allow yourself to sit back, and let everyone else worry about the seasonal details. No gift, meal, or gathering should ever be allowed to get under your skin because you don’t want stress to get the better of your baby’s health.

Get some relaxation tapes, try a little yoga and/or meditation and treat yourself to a massage—DOCTORS ORDERS!!

Please accept our best wishes for a happy, healthy and stress-free Holiday Season.

Dr. Michele Brown & the Beauté de Maman Team

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Posted in Infant & Pregnancy Safety | 1 Comment »

The Sly Masquerader: Thyroid Disease During Pregnancy

Wednesday, June 30th, 2010

A 26 year old, newly-pregnant woman sits on the exam table in her obstetrician’s office. She is excited about her pregnancy and does not want to complain about her nausea, vomiting, weight loss, anxiety, difficulty sleeping, and fatigue. The obstetrician can tell just by looking at her that she seems to be suffering the normal symptoms of pregnancy and is not overly worried. After all, nausea and vomiting occur in 50–80% of all pregnant women, especially between the 5th and 13th week. The doctor reassures the patient that this is normal, and encourages her to hydrate and rest. Sometimes the physician will suggest a medication, or a supplement, to reduce the symptoms of nausea and vomiting.

Is it possible that this woman is experiencing something more severe than the normal, early pregnancy symptoms?

One of the great masqueraders for pregnant women is thyroid disease. Many of the symptoms that women experience in the early stages of pregnancy are the exact symptoms that occur with thyroid problems. Women will commonly experience fatigue, weight gain, constipation, insomnia, and lethargy. Health care providers will often reassure patients that this is normal and these symptoms are due to the hormonal and physiological changes that one expects with the early stages of a healthy pregnancy. However, one must be on the alert that these same symptoms could be representative of a much more serious underlying problem; one that could have major, negative ramifications on the pregnancy and the newborn infant. Left undiagnosed and untreated, hypothyroidism (low thyroid hormone) could result in serious, high-risk conditions during the pregnancy. Prematurity, preeclampsia, placental separation (abruption), and/or serious consequences in the child such as congenital cretinism (mental retardation, deafness, muteness).

This weeks blog will focus only on hy-PER-thyroidism (when you have too much thyroid hormone.)

Next week we will review hyp-O-thyroidism. (when you have too little thyroid hormone) and its effects on pregnancy.

Who should get screened for thyroid disease in pregnancy?

The current American College of Obstetrics and Gynecology guidelines state that thyroid functions should be checked only in women with a personal history of thyroid disease or symptoms of thyroid disease. It is NOT universally recommended to test all pregnant women even though there are cases of women who have disease that do not have symptoms (subclinical cases).

How does maternal thyroid hormone effect the fetus?

The fetal brain is completely dependent on maternal thyroid hormone until about 12 weeks gestation. At that time, the fetus is able to manufacture its own thyroid hormone in conjunction with the maternal hormone that crosses the placenta. Diminished levels of thyroid hormone in the mother impair fetal brain development. Elevated levels can also cross the placenta and cause excessive production in the fetus. (Graves disease.)

What is hyperthyroidism?

The thyroid is an endocrine gland located in the neck that controls metabolism. It receives a message (TSH) from an area in the brain called the pituitary which releases thyroid hormone (T4).

When the gland produces more hormone than it is supposed to, hyperthyroidism is diagnosed (elevated thyroid hormone T4 and low TSH.) This can occur in about .2% of all pregnancies. The most common form of the disease is Graves disease where certain antibodies are made by the body that stimulate thyroid hormone production. Other causes can be multinodular goiter, subacute thyroiditis, an extra thyroid source of hormone production (certain tumors of the ovary or pituitary), thyroid adenoma.

What are the symptoms of hyperthyroidism?

  • nervousness
  • tremors
  • tachycardia
  • frequent stool
  • excessive sweating
  • heat intolerance
  • weight loss
  • goiter
  • insomnia
  • palpitations
  • hypertension
  • eye changes-lagging of the eyelid and retraction of the eye lid

What are the risks to the mother and the fetus if hyperthyroidism is left untreated?

If left untreated, hyperthyroid can cause:

  • preterm delivery
  • severe preeclampsia
  • heart failure
  • fetal loss
  • low birth weight infants
  • stillbirth
  • fetal hyperthyroidism

How do you treat hyperthyroidism in the mother?

A classification of drugs called thioamides are used to treat hyperthyroidism.

  • PTU
  • methimazole

These drugs prevent the manufacture of the thyroid hormone by preventing a needed substrate iodine from attaching to the thyroid molecule and it also blocks the the manufacture of of another active form of the hormone T3.

These drugs do cross the placenta and can effect the fetal thyroid, although it is generally transient. Generally, these drugs are safe to use in pregnancy but rare side effects of the drug can include fever, sore throat, hepatitis, rash, nausea, loss of taste and smell, loss of appetite and a very serious and rare side effect called agranulocytosis (less than 1%) which is an abnormal condition of the blood characterized by a severe reduction of white blood cells (fever, prostration and bleeding ulcers of rectum, mouth, and vagina.)

Infants must be observed carefully after birth with mothers on antithyroid medication since newborns have been known to have neonatal hypothyroidism and goiter in mothers who have been treated. Babies are ultrasounded during pregnancy looking for fetal goiter and growth problems which can present problems at delivery due to the hyperextension of the neck.

It is generally considered safe to breast feed on these medications.

Other drugs used to treat hyperthyroidism are beta-blockers (propranolol) which act to reduce the rapid heart rate that can occur. Side effects from this drug can include growth retardation in the fetus, fetal bradycardia (slowed heart rate) and hypoglycemia in the infant (low blood sugar).

Radioactive iodine is never used in pregnancy since it can ablate the fetal thyroid. A patient was treated with radioactive iodine prior to becoming pregnant, should avoid becoming pregnant for at least 4 months. If all medications fail, or allergy to the medications exist, thyroidectomy, or surgical excision of the thyroid is recommended.

What is subclinical hyperthyroidism?

In about 1.7% of women there are asymptomatic women with normal thyroid hormone but a low TSH. This condition generally has been found to have no effect on the pregnancy since it is the maternal T4 level that is critical for fetal brain development, regardless of what the TSH level is. However, these women should be observed for osteoporosis, cardiovascular morbidity and progression to overt disease or thyroid failure in the future.

What is thyroid storm?

Thyroid storm is an acute obstetrical emergency that occurs in about 10% of women with hyperthyroidism. Symptoms include a change in mental status, seizures, nausea, diarrhea, and cardiac arrythmias. Patients are placed in the intensive care unit for constant monitoring and observation since there is a high risk of maternal heart failure. Thyroid storm can be precipitated by an acute surgical emergency, infection, diabetes. anesthesia, and noncompliance with thyroid medications. In addition to the usual treatment of hyperthyroidism as described above, steroids are commonly given.

Can thyroid disease present itself right after delivery?

About 6 to 9% of women with no history of thyroid disease can present with disease after delivery, generally within the first year postpartum. This is common in women that have previously known thyroid antibodies that are not activated until after the delivery, or women with a strong family history of diabetes or other autoimmune disorders. Most women have transient hyperthyroidism which then converts to hypothyroidism requiring treatment. About 77% of women will completely recover but 30% will continue with thyroid disease permanently. Many women that recover will develop this disorder again with subsequent pregnancies.

Summary:

Because of the close similarity of symptoms that occur with a normal early pregnancy, be sure to ask your health care providers if you should be screened for thyroid disease. Discovery and correction of this condition can have beneficial ramifications to ensure a happy, healthy mother and baby. As stated in many previous blogs, pregnancy can be the crystal ball of future medical conditions and by being vigilant, pregnancy can help a woman avoid diseases and conditions from surfacing later in life.

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Don’t Let Your Happy Pregnancy be Spoiled by Depression

Monday, October 19th, 2009

Depression in PregnancyDepression occurs in about 14–23% of all pregnant women. It is essential that we know how to make the diagnoses, when to treat, and the safety profile of the various drugs in managing this disorder. A recent landmark review was published by The American College of Obstetrics and Gynecology and the American Psychiatric Association that reviews the current guidelines.

Should I take an antidepressants if I am thinking of becoming pregnant?

Women with minimal or no symptoms for 6 months prior to conception, should contemplate tapering and discontinuing medication before conception. Behavioral therapy treatments can be used instead of medication.
Women with moderate to severe symptoms on medication should have their psychiatrist continue and optimize their medication prior to conception. The safety profile of the medications used should be carefully evaluated. Newer medications for depression and psychosis should be avoided if safety profile is not available.
Other conditions such as substance abuse, anxiety disorders, and eating disorders should be addressed at the same time.

What is the relationship between maternal depression and pregnancy outcomes?

Results from studies on miscarriage, growth effects, preterm births, and developmental delay with depression and use of antidepressant medication is severely limited due to poor studies and lack of consistency in conclusions. However, there was some evidence of an association of maternal depression and increased irritability, less attentiveness and activity, and fewer facial expressions in the newborn infant.

What is the safety profile of some of the commonly used antidepressant medication?

Tricyclic antidepressants-(Elavil, Norpramin, Pamelor, Aventyl, Anafranil, Tofranil, Evadyne)

Most studies have shown no association between the use of the tricyclic antidepressants and structural malformations. There was an increased association with newborn complications such as jitteriness, irritability, and occasionally convulsions.

Serotonin reuptake inhibitors (examples include Prozac, Celexa, Paxil, and Zoloft)

Some studies have shown a higher risk of cardiac malformations when SSRI’s were used during the first trimester, although the risk is considered very low and does not yet warrant the recommendations that women should not take these drugs. Combinations of different SSRI’s seem to have an even greater risk profile. However, other factors might be contributing to the results including obesity, diabetes, alcohol, and tobacco use. Some studies have shown evidence of rapid breathing, low sugar, temperature instability, irritability, weak cry, lower Apgar scores, and seizures in infants exposed to SSRI’s, especially in late pregnancy. Especially concerning were some reports of persistent pulmonary hypertension and respiratory distress. This can result in right heart failure.

Other antidepressants (Wellbutrin and Zyban, Effexor, Cymbalta, Remeron)

Fewer studies have been done on these agents but no increased risk of congenital anomalies or stillbirths have been found. There was a higher rate of newborn symptoms such as respiratory problems, low Apgar scores,hypoglycemia, and neonatal convulsions compared to women on no medications.

Electroconvulsive therapy

Severe depression that is unresponsive to medication can be treat with electroconvulsive therapy and does not harm the mother or the fetus.

Summary:

In conclusion, treatment of depression in pregnancy is based upon the risk of untreated mental illness in the mother versus risk factors to the fetus with the use of medication. The approach to decision making should be based on multiple factors including the severity of the disease, risk of relapse by stopping medications, response to therapy, social support, and recommendations on the part of the psychiatrist.

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