Mamas on Bedrest: How pregnancy triggers physiologic and emotional responses in women

May 9th, 2014

Hey Mamas!

PregnantwomanonballI’m bringing you Part II of Kathy Morelli’s series on physical and hormonal influences on women’s mental health. In Part II she focuses on the changes that occur during pregnancy. Kathy breaks down the emotional responses to pregnancy this way:

Emotional. What if the pregnancy was unplanned? What if this pregnancy follows a stillbirth or miscarriage? What if her primary relationship with the baby’s father is not going well? There is also job stress, financial factors and a whole host of other life stressors that combined can make the news of a pregnancy hard to take and All of these emotional considerations require attention and adjustment. We clinicians and birth workers must be aware of these potential life stressors and be sure that we are as vigilant in addressing these emotional needs of the women that we serve as we are addressing their physical needs.

Physiologic/Hormonal. By the first six weeks of pregnancy, estrogen levels rise to three times more than during the menstrual cycle! Progesterone levels also rise quickly and Progesterone is also implicated in depressive moods. As the pregnancy progresses through the second and third trimester, along with elevated estrogen and progesterone levels, the hormones cortisol, prolactin and oxytocin rise. Cortisol is a strong player in the HPA feedback loop. High levels of cortisol are also associated with depression. And prolactin is also associated with anxiety, anger and irritability. Oxytocin is known as the bonding and happiness hormone. Natural oxytocin causes nutrition absorption, uterine contractions, pair-bonding, mother-infant bonding, pain amnesia, calmness and feelings of belonging and happiness. Now add in bed rest! Mamas on Bedrest are at increased risk of developing perinatal mood disorders because in addition to the normal hormonal fluctuations of pregnancy, the stress of being on bed rest and the unsurety of the pregnancy stimulate the “fight or flight” response, releasing additional cortisol and neurotransmitters that will affect Mamas’ mood.

During an uninterrupted birth, there is a surge of oxytocin, beta-endorphin, adrenaline, noradrenaline and prolactin. These hormones all combine to orchestrate the event of birth and positive emotional outcome. Oxytocin for uterine contractions, calmness, love.  Beta-endorphins for a protective emotional high during a peak physical activity.  Adrenaline rush for energy and the final push of the fetal ejection reflex.  And high prolactin levels to consolidate breast milk production and breastfeeding. However, if there is medical intervention of any sort during labor and delivery; an epidural, episiotiomy, forceps/vacuum extraction or cesarean section, this natural hormonal protection and mood enhancement is disrupted and often lost resulting in birth trauma, post tramautic stress disorder and post partum depression. The extent of the trauma is different for every woman and typically correlates to the level of intervention. Researchers are just beginning to understand the delicate interaction between hormones, labor and deliver and a women’s mental health, and as more research is done, we will have better understanding of this complex interaction and how best to care for women during pregnancy labor and delivery to protect their mental and as much as possible, minimize negative emotional effects.

In Part III, Kathy looks at hormones and post partum! 

 

Mamas on Bedrest: Biological Aspects of Post Partum Depression-Part II

December 17th, 2012

In our last post, we learned that there are specific physical changes that occur in pregnancy that put women at risk for Post Partum Depression (PPD). In most women, these changes self correct in the post partum period. However, for many women, re-regulation does not take place. And in women with susceptible anatomy, these changes put them at increased risk of developing Post Partum Depression. Below, we share information from a recent publication that discusses how the changes that occur as a natural course of pregnancy can contribute to a woman developing PPD.

Changes in Post Partum Depression

Endocrine

Low levels of estrogen and progesterone have been shown to be associated with PPD, but cannot be said to be causative as there have been studies in which participants had elevated levels of estrogen and/or progesterone and had PPD. However, estrogen therapy-in relatively large doses-does seem to improve PPD.

PPD being linked to suppression of the HPA has been substantiated in several studies. Women with PPD have markedly suppressed HPA and their HPA’s don’t return to their baseline regulation as does those of women not subject to PPD.

Oxytocin, the milk let down hormone, seems to have a positive mood altering effect. However, when women have difficulty with breastfeeding or stop breastfeeding, they often are at increased risk for developing PPD. This point remains controversial as some women, it seems, stop breastfeeding because they are depressed. Oxytocin does seem to have a suppressive effect on the HPA

As previously stated, Serotonin seems to play a prominent role in PPD.  Low levels of serotonin are indicative of depression and medications that increase serotonin levels (SSRI’s) successfully treat PPD. Other neurochemicals and neurogenetic predispositions that influence the serotonin levels, typically suppression of serotonin production and release, further put women with these chemical anomalies or genetic predispositions are at increased risk for developing PPD.

Seasonal/circadian Changes

Newer research in PPD shows that there are seasonal effects, i.e. PPD may in fact be more prevalent in the fall and winter months, as SAD.

High morning levels of Melatonin are associated with PPD. Melatonin is made from serotonin but when secreted in the morning, when one is to awaken instead of at night when one is trying to sleep, increases sleep deprivation and sleep deprivation is a hallmark of PPD. Unfortunately, sleep disturbances are also a hallmark of the early post partum period, so it is often hard to discern if the Melatonin levels are abnormal due to depression or due to post partum sleep disturbances. For now, studies suggest that high am blood levels of Melatonin are present in women with PPD. More work in this area is forthcoming.

Immunologic Changes

Inflammation plays a roll in PPD. As previously stated, cortisol levels are increased during pregnancy (due to the maternal/fetal interaction) and the feedback loop telling the adrenals that there is enough cortisol is shut down. Without the adrenals functioning, at delivery, cortisol levels drop and the inflammatory response is left unchecked. Increases in inflammation is the result of a prolonged inflammatory response which has been shown to be a way for PPD to develop.

Thyroid Disease

Abnormal thyroid function appears to be associated with increased psychiatric symptoms, with hyperthyroidism being related to anxiety, mania, restlessness, depression and cognitive deficits and hypothyroidism is associated with memory deficits, lack of concentration, psychomotor slowing and depression.

Pregnancy in and of itself challenges normal thyroid function, often resulting in the presence of thyroid antibodies. During pregnancy TSH levels fluctuate depending on the stage of pregnancy while levels of T3 and T4 remain relatively stable within normal limits. In the early post partum, TSH levels are decreased. Of note, thyroid hormone replacement in the post partum doesn’t seem to prevent or reduce PPD symptoms in the presence of thyroid antibodies.  Currently, these authors are only able to report that

Women with maternity blues have higher TSH levels  and women with higher, albeit still normal, TSH levels (measured 4 weeks after delivery) tended to have higher depression scores at 4-weeks postpartum.  In addition, the authors reported a positive association between subclinical hypothyroidism at delivery and the development of self-reported depressive symptoms at 6 months post partum.

Given this information, the best thing to do in a woman with PPD symptoms would be to test for thyroid function and treat accordingly.

Other Potential Factors in PPD

Vitamin D. It seems that Vitamin D is being found to affect everything from our moods to our weights and everything in between, so it’s no surprise that it has an effect on PPD. What is surprising is that fact that recent studies have reported associations between vitamin D deficiency, inflammatory response and mood disorders.

As it relates to PPD, the authors note that Vitamin D levels have been found in postpartum women compared with pregnant women, but there is  so far only one study in the literature, examining serum 25(OH)D levels postpartum in relation to Edinburgh Postpartum Depression Scale scores. That particular study shows a significant association over time between low 25(OH)D levels and high depression scores postpartum. Thus far, only one randomized clinical trial has evaluated treatment with high doses of vitamin D in depressed subjects with promising results.

Leptin

Although Leptin is most closely associated with satiety and obesity research, recent research has linked leptin with depression and reproductive function in women. Leptin is reported to rise during pregnancy, fall after delivery and subsequently increase during the first 6-months postpartum. A study by these authors showed that higher leptin levels at delivery provided protection against depressive symptoms at 5-days, 6-weeks and 6-months post partum. Several theories are suggested for the protection, but to date, there is no definitive explanation.

This is a very interesting and important article. This level of indepth research is much needed if we are ever to be able to effectively treat (and perhaps even prevent) PPD. As these authors showed, there are multiple mechanisms potentially responsible for post partum depression. It is no longer enough to “poo poo” it away as mood, fatigue, being a new mommy or to ignore the signs and symptoms all together. Each and every pregnant and post partum patient should be routinely asked if they have any signs or symptoms of mood changes, and prompt and aggressive evaluation and treatment should be undertaken to ensure that mamas in need, receive the help and care necessary.

Reference

Alkistis Skalkidou, Charlotte Hellgren, Erika Comasco, Sara Sylvén & Inger Sundström Poromaa. Biological aspects of postpartum depression. Women’s Health, November 2012, Vol. 8, No. 6, Pages 659-671.  DOI 10.2217/whe.12.55 (doi:10.2217/whe.12.55)

Mamas on Bedrest: Post Partum Depression-The Physiologic Reasons it Occurs, Part I

December 14th, 2012

Postpartum depression (PPD) affects nearly 1 million American women annually, and most women don’t realize that there are significant physical reasons for the disorder. No, you’re not just crazy, tired and “hormonal” The truth is that there are significant biochemical changes going on in the post partum woman’s body such that coupled with their normal physiology, many women are prime candidates for post partum depression. If you don’t believe me, please head on over to my colleague Katherine Stone’s website, PostPartum Progress. Katherine, who has been blogging about post partum depression for nearly a decade, presents the statistics on just how many women are affected by post partum depression annually and then goes on to apply the statistics to actual numbers which we can all understand. She’s done a wonderful job illustrating how widespread and potentially devastating post partum depression can be for women.

In case you don’t know, here are some of the Signs and Symptoms of Post Partum Depression, as outline on Post Partum Progress.

The Research

Alkistis Skalkidou and colleagues from the Department of Women’s & Children’s Health and the Department of Neuroscience, Uppsala University, Uppsala, Sweden recently published Biological Aspects of Post Partum Depression in Women’s Health.  (2012;8(6):659-671) In this article, the researchers give very specific biologic reasons for the occurence of post partum depression in women by comparing the neurological and endocrine (hormonal) changes that occur in “normal” pregnant women and those that occur in women at risk for developing post partum depression. There are real physical changes that occur that are often the underlying reason post partum depression occurs.

Neuropsychoendocrine Changes in Normal Pregnancy and Post Partum

The chemical and hormonal changes necessary for a normal pregnancy to occur are usually offset by other changes that balance them out. Estrogens, progesterone, testosterone, corticotropin-releasing hormone (CRH) and cortisol all rise dramatically during pregnancy and drop just as dramatically at delivery and in the early post partum period. These hormones are typically regulated by a complex feedback system, the Hypothalamic Pituitary Axis (HPA), that is temporarily suspended during pregnancy to allow for the necessary hormonal increases needed to sustain fetal growth and development.

The adrenal glands are upregulated to produce more cortisol, necessary for fetal growth and development. But this additional adrenal output allows for cortisol levels to reach 3 times their non-pregnant levels, while at the same time depressing the fight or flight response. Prolactin levels steadily increase during pregnancy and at delivery are some 10 fold greater than in non pregnant women. Prolactin allows for milk production, yet prolactin, which crosses the blood brain barrier, contributes to the sustained inhibition of the HPA in the post partum of breastfeeding women.  Thus, hormone levels that were previously high as the HPA was shut down, drop dramatically and the normal regulation systems don’t detect the decreased levels and restart hormone production.

The nervous system has a similar down regulation resulting in a lowered response to stress in pregnant women versus non-pregnant women, and this persist while women breastfeed. Startle responses are diminished and women have been found to have a decreased reaction to emotional stimuli in the post partum versus in the latter stages of pregnancy.

Finally, neurotransmitter (brain chemical) levels are decreased in pregnant and newly post partum women. Increased activity of the enzyme Monoamine Oxidase reduce the levels of the brain chemicals serotonin, norepinephrine and dopamine-all responsible for stabilizing mood. GABA (another mood stabilizer) levels are also decreased in pregnant and post partum women, leading to serotonin deficiency. Combined with other neurochemical changes, to date it has been noted that post partum depression is primarily a state of serotonin deficiency.

So as you can see there are real, physical reasons that post partum depression occurs. Many complex changes occur during pregnancy and while they most often re-regulate themselves after delivery, some women’s bodies will not as readily re-regulate, sometimes due to the stress of pregnancy, sometimes due to genetic predispositions. Regardless of the reason it is occuring, PPD is a serious medical condition that is the result of physical, biological changes.

The major problem with post partum depression is underdiagnosis. Mental health disorders continue to be a source of shame in this country. Many women have the mistaken belief that if they are not euphoric after the birth of their blessed children, then there is something wrong with them of which they should be ashamed and it should be hidden at all costs. Nothing could be further from the truth! Post partum depression is an actual physical disorder in which the body’s chemicals are significantly imbalanced leading to impairments in thoughts, judgements and reasoning. The good news is that there is treatment for post partum depression. The bad news is that women are seldom forthcoming with (or are even familiar with) the signs and symptoms of post partum depression to raise the issues with their health care providers.  Health care providers should, at regular intervals during the later phases of pregnancy and throughout the post partum period, ask targeted questions of their patients to screen them for post partum depression as well as other mood disorders.

In the next installment of this discussion, we’ll look at how the physical changes contribute to PPD in women and how treatments help women’s bodies re-regulate.

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