Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.

Objective  To develop a practical evidence based list of clinical risk factors that can be assessed by a clinician at ≤16 weeks’ gestation to estimate a woman’s risk of pre-eclampsia. Design  Systematic review and meta-analysis of cohort studies. Data sources  PubMed and Embase databases, 2000-15. Eligibility criteria for selecting studies  Cohort studies with ≥1000 participants that evaluated the risk of pre-eclampsia in relation to a common and generally accepted clinical risk factor assessed at ≤16 weeks’ gestation. Data extraction  Two independent reviewers extracted data from included studies. A pooled event rate and pooled relative risk for pre-eclampsia were calculated for each of 14 risk factors. Results  There were 25 356 688 pregnancies among 92 studies. The pooled relative risk for each risk factor significantly exceeded 1.0, except for prior intrauterine growth restriction. Women with antiphospholipid antibody syndrome had the highest pooled rate of pre-eclampsia (17.3%, 95% confidence interval 6.8% to 31.4%). Those with prior pre-eclampsia had the greatest pooled relative risk (8.4, 7.1 to 9.9). Chronic hypertension ranked second, both in terms of its pooled rate (16.0%, 12.6% to 19.7%) and pooled relative risk (5.1, 4.0 to 6.5) of pre-eclampsia. Pregestational diabetes (pooled rate 11.0%, 8.4% to 13.8%; pooled relative risk 3.7, 3.1 to 4.3), prepregnancy body mass index (BMI) >30 (7.1%, 6.1% to 8.2%; 2.8, 2.6 to 3.1), and use of assisted reproductive technology (6.2%, 4.7% to 7.9%; 1.8, 1.6 to 2.1) were other prominent risk factors. Conclusions  There are several practical clinical risk factors that, either alone or in combination, might identify women in early pregnancy who are at “high risk” of pre-eclampsia. These data can inform the generation of a clinical prediction model for pre-eclampsia and the use of aspirin prophylaxis in pregnancy.

https://www.bmj.com/content/bmj/353/bmj.i1753.full.pdf

Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies

Magnitude and risk factors for postpartum symptoms: a literature review.

Background: Postpartum depression (PPD) poses a major global public health challenge. PPD is the most common complication associated with childbirth and exerts harmful effects on children. Although hundreds of PPD studies have been published, we lack accurate global or national PPD prevalence estimates, and have no clear account of why PPD appears to vary so dramatically between nations. Accordingly, we conducted a meta-analysis to estimate the global and national prevalence of PPD, and a meta-regression to identify economic, health, social or policy factors associated with national PPD prevalence. Methods: We conducted a systematic review of all papers reporting PPD prevalence using the Edinburgh Postnatal Depression Scale. PPD prevalence and methods were extracted from each study. Random effects meta-analysis was used to estimate global and national PPD prevalence. To test for country level predictors, we drew on data from UNICEF, WHO, and the World Bank. Random effects meta-regression was used to test national predictors of PPD prevalence. Findings: 308 studies of 304,449 women from 56 countries were identified. The global pooled prevalence of PPD was 17.5% (95% CI: 16.4% - 18.6%), with significant heterogeneity across nations (Q = 17,192, p = .000, I2 = 98%), ranging from 3.10% (0.01% - 10.87%) in Singapore to 37.78% (30.95% - 44.83%) in Chile. Nations with significantly higher rates of income inequality (R2=42.78%), maternal mortality (R2=25.54%) infant mortality (R2=12.23%), total fertility rates (R2=17.14%), or women of childbearing age working > 40 hours a week (R2=24.14%) have higher rates of PPD. Together, these factors explain 77.26%% of the national variation in PPD prevalence. Interpretation: The global prevalence of PPD is greater than previously thought and varies dramatically by nation. Disparities in wealth inequality and maternal-child-health factors explain much of the national variation in PPD prevalence.

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Economic and Health Predictors of National Postpartum Depression Prevalence: A Systematic Review, Meta-analysis, and Meta-Regression of 291 Studies from 56 Countries.

Objectives Depression and depressive symptoms are common mental disorders that have a considerable effect on patients’ health-related quality of life and satisfaction with medical care, but the prevalence of these conditions varies substantially between published studies. The aim of this study is to conduct a systematic review and meta-analysis to provide a precise estimate of the prevalence of depression or depressive symptoms among outpatients in different clinical specialties. Design Systematic review and meta-analysis. Data sources and eligibility criteria The PubMed and PsycINFO, EMBASE and Cochrane Library databases were searched to identify observational studies that contained information on the prevalence of depression and depressive symptoms in outpatients. All studies included were published before January 2016. Data characteristics were extracted independently by two investigators. The point prevalence of depression or depressive symptoms was measured using validated self-report questionnaires or structured interviews. Assessments were pooled using a random-effects model. Differences in study-level characteristics were estimated by meta-regression analysis. Heterogeneity was assessed using standard χ2 tests and the I2 statistic. The study protocol has been registered with PROSPERO under number CRD42017054738. Results Eighty-three cross-sectional studies involving 41 344 individuals were included in this study. The overall pooled prevalence of depression or depressive symptoms was 27.0% (10 943/41 344 individuals; 95% CI 24.0% to 29.0%), with significant heterogeneity between studies (p Conclusion Our study provides evidence that a significant proportion of outpatients experience depression or depressive symptoms, highlighting the importance of developing effective management strategies for the early identification and treatment of these conditions among outpatients in clinical practice. The substantial heterogeneity between studies was not fully explained by the variables examined.

https://bmjopen.bmj.com/content/bmjopen/7/8/e017173.full.pdf

Prevalence of depression and depressive symptoms among outpatients: a systematic review and meta-analysis

The prevalence of postpartum depression is approximately 13%. Postpartum depression is associated with a higher maternal morbidity and mortality, and also with pervasive effects on the emotional, cognitive and behavioral development of the child. The aim of our study was to identify socio-demographic, psychosocial and obstetrical risk factors of postpartum depression in a middle class community sample, using a prospective design. We enrolled consecutively 312 pregnant outpatients in a single maternity unit. The first assessment was conducted between 32 and 41 weeks gestation, and a second time between 6 and 8 weeks after delivery. Depressive symptoms were measured using the French version of the Edinburgh Postnatal Depression Scale (EPDS). A cut-off score of 12/30 or above was considered as indicative of Major Depression. Of the initial sample of 312 women, 264 (84.6%) were followed-up between 6 and 8 weeks after delivery and considered for analysis. Depression during pregnancy, migrant status, and physical abuse by the partner were independently associated with postpartum depression when considered together, whereas physical complications were significantly associated with postpartum depression only when adjusting for antenatal depression. Depression during pregnancy, history of physical abuse, migrant status and postpartum physical complications are four major risk factors for postpartum depression.

Predictors of postpartum depression: prospective study of 264 women followed during pregnancy and postpartum.

The prevalence of OCS and OCD is higher in schizophrenic patients than in the general population. These disorders are sometimes induced by AAPs. There is higher frequency of OCS and greater severity in patients treated with antipsychotics with predominant anti-serotoninergic profiles opposed to those with predominant dopaminergic blockade. Induced OCS may be due to complex neuromodulation involving many serotonin, dopamine and glutamate receptors and several subtypes. Concerning connectivity, AAPs differentially influence the BOLD signal, depending on the intensity of D2 receptor blockade. The OFC could play a significant role, on account of its involvement in inhibitory control. There is a paradox: AAPs are efficient as augmentation to SSRI in treatment resistant OCD, some of them such as risperidone or aripiprazole have favourable effects in schizoptypic OCD, but AAPs cause induced OCS in schizophrenic patients. When prescribing AAPs, we should inform patients about this potential side effect and assess systematically OCS with Y-BOCS assessment after 1 month of treatment. Afterwards there are different strategies: Aripiprazole in combination can reduce OCS induced by clozapine, SSRI are slightly effective and CBT shows a few encouraging results. OCS are sometimes dose-dependent, so we also recommend prescribing the minimum effective dose and gradual introduction.

Adeline Gaillard

Papers

Predictors of postpartum depression: prospective study of 264 women followed during pregnancy and postpartum.

Induced Obsessive Compulsive Symptoms (OCS) in schizophrenia patients under Atypical 2 Antipsychotics (AAPs): review and hypotheses