Women’s Mental Health
Journal Article Annotations
2021, 3rd Quarter
Women's Mental Health
Annotations by Mary Burke, MD and Liliya Gershengoren, MD, MPH
September, 2021
- Suicidal Risk in Women with Premenstrual Syndrome and Premenstrual Dysphoric Disorder: A Systematic Review and Meta-Analysis.
- Racial Disparities in the Risk of Complications After Nonobstetric Surgery in Pregnancy.
- Maternal Antibody Response, Neutralizing Potency, and Placental Antibody Transfer After Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection.
PUBLICATION #1 — Women's Mental Health
Suicidal Risk in Women with Premenstrual Syndrome and Premenstrual Dysphoric Disorder: A Systematic Review and Meta-Analysis.
Divya Prasad, Bianca Wollenhaupt-Aguiar, Katrina N Kidd, Taiane de Azevedo Cardoso, Benicio N Frey
Abstract: J Womens Health (Larchmt). 2021 Aug 20. doi: 10.1089/jwh.2021.0185. Online ahead of print.
Purpose:
Women with premenstrual dysphoric disorder (PMDD) and premenstrual syndrome (PMS) experience substantial functional impairment and decreased quality of life. While previous research has highlighted a relationship between premenstrual disturbances and suicide risk, no meta-analysis has been conducted to quantitatively assess the findings.
Methods:
A systematic review and meta-analysis was conducted by searching the literature in three databases (Pubmed, PsycINFO, and EMBASE) on July 15, 2020. Studies that assessed the relationship between suicidality (attempt, ideation, and/or plan) and premenstrual disturbance (PMDD, PMS, and/or premenstrual symptoms) were included.
Results:
Thirteen studies were included in the qualitative review (n = 10 included in meta-analysis). Results revealed that women with PMDD are almost seven times at higher risk of suicide attempt (OR: 6.97; 95% CI: 2.98-16.29, p < 0.001) and almost four times as likely to exhibit suicidal ideation (OR: 3.95; 95% CI: 2.97-5.24, p < 0.001). Similarly, women with PMS are also at increased risk of suicidal ideation (OR: 10.06; 95% CI: 1.32 to -76.67, p = 0.03), but not for suicide attempt (OR: 1.85; 95% CI: 0.77 to -4.46, p = 0.17).
Conclusions:
Women with PMDD and PMS are at higher risk of suicidality compared with women without premenstrual disturbances. These findings support routine suicidal risk assessments for women who suffer from moderate-to-severe premenstrual disturbance. Furthermore, psychosocial treatments for women diagnosed with PMS/PMDD should consider and target suicidality to minimize risk and improve well-being.
Annotation
The finding:
Results from this meta-analysis demonstrate an association between PMDD and suicidality. Women with PMDD are at higher risk of suicide attempts and ideation by almost seven- and fourfold, respectively. Furthermore, PMS and premenstrual symptoms are risk factors for suicidal ideation but not suicide attempts.
Strength and weaknesses:
There is a paucity of research on PMDD and suicidality. This meta-analysis attempts to quantitatively confirm results of prior studies describing an association of PMDD with suicidal thoughts, ideation, plans, and attempts. The limitation of this study includes its inclusion of studies written in English and Spanish only. In addition, most studies described a cross-sectional design that limits the ability to draw causal relationships between PMDD, PMS, and suicidality.
Relevance:
C-L psychiatrists working in OB/GYN or general hospital settings often encounter patients with suicidal ideation or a recent suicide attempt. Increased awareness of premenstrual disturbances in these patients will further help to tailor treatment from a multidisciplinary perspective.
PUBLICATION #2 — Women's Mental Health
Racial Disparities in the Risk of Complications After Nonobstetric Surgery in Pregnancy.
Monique McKiever, Courtney D Lynch, Olubukola O Nafiu, Christian Mpody, David M O'Malley, Mark B Landon, Maged M Costantine, Timothy M Pawlik, Kartik K Venkatesh
Abstract: Obstet Gynecol. 2021 Aug 1;138(2):236-245.
Objective:
To examine whether there are racial and ethnic differences in postoperative complications after nonobstetric surgery during pregnancy in the United
States.
Methods:
We conducted a secondary analysis of the prospective ACS NSQIP (American College of Surgeons National Surgical Quality Improvement) program from 2005 to 2012. We assessed pregnant women 18–50 years without prior surgery in the preceding 30 days who underwent a nonobstetric surgery. Race and ethnicity were categorized as non-Hispanic Black, Hispanic, and non-Hispanic White (reference). The primary outcome was a composite of 30-day major postoperative complications inclusive of cardiovascular, pulmonary, and infectious complications, reoperation, unplanned readmission, blood transfusion, and death. We used modified Poisson regression to estimate the relative risk of complications.
Results:
Among 3,093 pregnant women, 18% were non-Hispanic Black, 20% Hispanic, and 62% non- Hispanic White. The most common surgeries were appendectomy (36%) and cholecystectomy (19%). Black women (18%) were more likely to be assigned American Society of Anesthesiologists (ASA) physical status class III or higher than their White (12%) or Hispanic (9%) peers. Non-Hispanic Black pregnant women had a higher risk of 30-day major postoperative complications compared with their White peers (9% vs 6%; adjusted relative risk [aRR] 1.41, 95% CI 1.11–1.99). This difference persisted when limiting the analysis to apparently healthy women (ASA class I or II) (7% vs 4%; aRR 1.64, 95% CI 1.08–2.50), those who underwent appendectomy (10% vs 3%; aRR 2.36, 95% CI 1.13–4.96), and when appendectomy and cholecystectomy were performed by laparoscopy (7% vs 3%; aRR 2.62, 95% CI 1.22–5.58). Hispanic pregnant women were not at an increased risk of complications compared with non-Hispanic pregnant White women.
Conclusions:
Pregnant non-Hispanic Black women were at higher risk of major postoperative complications after nonobstetric surgery compared with their White counterparts.
Annotation
The finding:
Compared to White and Hispanic women, non-Hispanic Black women were more likely to have major post-operative consequences of surgeries that occur during pregnancy. Cholecystectomy and appendicitis were the most common surgeries. Among major complications, Black women had higher rates of transfusion and experienced longer surgeries. The adjusted RR was significant higher overall (1.41), among healthier subjects (1.64 among women with American Society of Anesthesiology (ASA) risk classification I-II), and in score-matched control analyses (1.50). Black women were more likely to be rated in ASA class III, indicating the presence of severe, systemic disease (18%), compared to White and Hispanic pregnant women (12%, 9% respectively). Overall, Hispanic women had better surgical outcomes.
Strength and weaknesses:
This was a large (3,093 subjects) longitudinal prospective study of a national database. Researchers had access to multiple sources of information for their analyses that included premorbid conditions, Current Procedural Terminology codes and surgical specialty, operative time, type of anesthesia, work relative value units, and case urgency. Composite scores of adverse outcomes were derived using a previously validated tool. Tables of data were easy to read. There were no reported conflicts of interest. Weaknesses included the authors’ inability to examine outcomes among other ethnic groups (Asian, Native American) due to the limits of the database or study disaggregated information.
Relevance:
Surgical complications of pregnancy impact the health of the developing fetus, the overall health of the pregnancy, and the mental well-being of the expectant mothers. This study bolsters prior research demonstrating significant health disparities in this country, in particular between non-Hispanic Black and White women. While the authors do not make causal conclusions, they set this study squarely in the context of ongoing investigations of serious health disparities in the US. They deepen the discussion of systemic bias in the US health system, with information that can generate better health care for Black women, as well as preparation for higher likelihood of adversity during pregnancy for Black women in the US.
PUBLICATION #3 — Women's Mental Health
Maternal Antibody Response, Neutralizing Potency, and Placental Antibody Transfer After Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection.
Naima T Joseph, Carolynn M Dude, Hans P Verkerke, Les'Shon S Irby, Anne L Dunlop, Ravi M Patel, Kirk A Easley, Alicia K Smith, Sean R Stowell, Denise J Jamieson, Vijayakumar Velu, Martina L Badell
Abstract: Obstet Gynecol. 2021 Aug 1;138(2):189-197. doi: 10.1097/AOG.0000000000004440.
Objective:
To characterize maternal immune response after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy and quantify the efficiency of transplacental antibody transfer.
Methods:
We conducted a prospective cohort study of pregnant patients who tested positive for SARS CoV-2 infection at any point in pregnancy and collected paired maternal and cord blood samples at the time of delivery. An enzyme-linked immunosorbent assay (ELISA) and neutralization assays were performed to measure maternal plasma and cord blood concentrations and neutralizing potency of immunoglobulin (Ig)G, IgA, and IgMantibodies directed against the SARS-CoV-2 spike protein. Differences in concentrations according to symptoms compared with asymptomatic infection and time from positive polymerase chain reaction (PCR) test result to delivery were analyzed using nonparametric tests of significance. The ratio of cord to maternal anti–receptor binding domain IgG titers was analyzed to assess transplacental transfer efficiency.
Results:
Thirty-two paired samples were analyzed. Detectable anti–receptor-binding domain IgG was detected in 100% (n532) of maternal and 91% (n529) of cord blood samples. Functional neutralizing antibody was present in 94% (n530) of the maternal and 25% (n58) of cord blood samples. Symptomatic infection was associated with a significant difference in median (interquartile range) maternal anti–receptor-binding domain IgG titers compared with asymptomatic infection (log 3.2 [3.5–2.4] vs log 2.7 [2.9–1.4], P5.03). Median (interquartile range) maternal anti–receptor-binding domain IgG titers were not significantly higher in patients who delivered more than 14 days after a positive PCR test result compared with those who delivered within 14 days (log 3.3 [3.5–2.4] vs log 2.67 [2.8–1.6], P5.05). Median (range) cord/maternal antibody ratio was 0.81 (0.67–0.88).
Conclusions:
These results demonstrate robust maternal neutralizing and anti–receptor-binding domain IgG response after SARS-CoV-2 infection, yet a lower-than-expected efficiency of transplacental antibody transfer and a significant reduction in neutralization between maternal blood and cord blood. Maternal infection does confer some degree of neonatal antibody protection, but the robustness and durability of protection require further study.
Annotation
The finding:
The investigators found that pregnancy does not suppress the immune response to the SARS-CoV-2 virus: maternal IgG was present in 100% of maternal blood samples after infection. However, there is a low transplacental passage of maternal neutralizing antibodies to the spike receptor protein (the mechanism of immunity relevant to vaccinations). Only 25% of cord blood samples had such antibodies. Time from maternal infection to delivery did not affect potency of neutralizing antibodies.
Strength and weaknesses:
This was a methodical, prospective study of maternal and cord blood samples, and infection was confirmed by PCR testing. COVID-19 remains a public health crisis, and its impact on pregnancy and fetal development remains of major importance for all involved in women’s health care. The patient population was predominantly African American, a demographic group that has been hit especially hard by the pandemic and that has traditionally been under-represented in medical literature. The findings were cleanly presented and easy to follow. The article also reviews information about the SARS-CoV-2 virus that has been elucidated in the past 18 months, including viral replication patterns and what we understand about immune response.
Relevance:
C-L psychiatrists working in obstetrical and perinatal services should be familiar with the impact of the SARS-CoV-2 virus on their patients. In particular, psychiatrists should continue to recommend vaccination and thoughtful decisions regarding avoidable exposure risk. Further research is needed on fetal outcomes of maternal SARS-CoV-2 infection.
