Early pregnancy depressive symptoms and severe maternal morbidity

Maternal mental health conditions are common in pregnancy; suboptimal maternal mental health is associated with numerous adverse pregnancy outcomes, including preterm birth, hypertensive disorders of pregnancy, and maternal mortality.

The relationship between maternal mental health during early pregnancy and subsequent severe maternal morbidity (SMM) remains to be investigated. We examined whether depressive symptoms in early pregnancy were associated with SMM at delivery hospitalization.

This was a secondary analysis of data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be study. In this prospective cohort, nulliparous individuals were followed from the first trimester through delivery at eight centers in the United States. The Edinburgh Postnatal Depression Scales (EPDS) was administered at 6-13 weeks' gestation and assessed categorically at thresholds (≥10 and ≥13) that are commonly used in clinical practice. The primary outcome was SMM at delivery hospitalization, and secondarily, SMM without transfusion. Relative risk regression using a modified Poisson model with robust error variance was used and adjusted for baseline age, insurance status, tobacco use, and residential Area Deprivation Index. In secondary analyses, we further adjusted for preexisting psychiatric diagnosis and psychotropic medication exposure in early pregnancy.

Among 8,784 nulliparas enrolled in early pregnancy (median gestational age: 12.0 weeks; interquartile range [IQR] 11.0, 13.0), 17.2% and 7.1% of individuals had an EPDS score ≥10 and ≥13, respectively. 2.3% experienced SMM and 0.5% experienced non-transfusion SMM. Having an EPDS ≥10 was associated with a greater frequency of SMM in comparison to having an EPDS <10 (3.0% vs 2.1%; relative risk [RR] 1.42; 95% confidence interval [CI] 1.02, 1.96). However, the relative risk was not significant after adjustment (adjusted relative risk [aRR] 1.17; 95% CI: 0.77, 1.77). Individuals who met the higher EPDS threshold of ≥13 had an increased risk of SMM without transfusion in unadjusted (1.1% vs 0.4%, RR 2.53, 95% CI: 1.13, 5.67) and adjusted analyses (1.1% vs 0.4%, aRR: 3.12; 95% CI: 1.11, 8.81). The above associations were similar after further adjustment for a psychiatric diagnosis and psychotropic medication exposure in early pregnancy.

In a prospective US cohort of nulliparous individuals, severe early pregnancy depressive symptoms were associated with an increased risk of SMM without transfusion. Further data about whether intervention for depression in early pregnancy can affect SMM are needed.