1. Prynhaun da

3. Psychological challenges in Obstetrics and Gynaecology:
The Clinical Management
Editors Jayne Cockburn & Michael Pawson
Amazon.com

5. Stress in Pregnancy Miss Jayne Cockburn FRCOG
Consultant Obstetrician and Gynaecologist Frimley Park Hospital
National treasurer: BSPOGA
(British Society for Psychosomatic Obstetrics and Gynaecology and Andrology)

6. The effects of antenatal stress and anxiety on the fetus and the child

8. Public health implications of reducing stress/anxiety/depression in pregnancy
More than one million children in UK suffer from neurodevelopmental disorders
Attributable load of neurodevelopmental problems due to prenatal stress 10-15%
Potential to reduce number of affected children in the UK by 100, ,000

9. Distress caused by 6 day war in Israel, 1967
Antenatal stressor
Distress caused by 6 day war in Israel, 1967
Experience of acute disasters: freezing ice storm, 9/11
Problem
Anxiety and Depression
Schizophrenia
Autism
Behavioural problems-ADHD, conduct disorder
Impaired cognitive development, especially of language
Sleep problems in infants

10. National Institute of Child Health: Pregnancy and Perinatology Board
Strategic Plan 2005–2010
‘ The programming hypothesis brings a new perspective to public health. Diseases that were once thought to arise near the time of their manifestation in adult life are now known to have roots in pre– and early post–natal life….’

11. 17 4
20 week fetus
birth
5 years

12. Long term effects of prenatal stress on offspring of non human primate
More anxiety
Lower attention span
HPA axis hyperactivity
(greater cortisol responses)
Mimicked by giving ACTH to the mother-blocked by adrenalectomy
Schneider, Coe et al

13. ALSPAC Study. Does antenatal stress affect child behaviour in humans?
Aim of our study:
To determine the long term effects of antenatal stress or anxiety on the behavioural development of the child
O’Connor et al 2002, 2003

14. ALSPAC study Maternal anxiety-at 18 and 32 weeks of pregnancy
Compared 15% most anxious mothers
with the rest
Child behaviour
–maternal report at 4 and 7 years old.
Strengths and Difficulties questionnaire.
Attention deficit/hyperactivity;
anxiety and depression;
conduct disorder
O’Connor et al 2002, 2003

15. Multivariate Analysis Cohort with complete data n = 7, 363
Maternal age
Birthweight
Gestational age
Smoking
Alcohol
Psychosocial factors: crowding
Maternal education
Postnatal depression and anxiety

16. Multivariate analysis-boys- 7 years Behavioural/emotional problems and maternal antenatal anxiety at 32 weeks
*** ** ** **
O’Connor et al 2003

17. Multivariate analysis-girls – 7 years Behavioural/emotional problems and maternal antenatal anxiety at 32 weeks ** * ** *

18. Links are similar with antenatal anxiety at 18 weeks gestation but less marked than at 32 weeks It is not just first trimester

19. Multivariate analysis: MDI
Predictor variables B SE
Beta
Maternal education
1.37
0.63
0.19*
Smoking during pregnancy
-2.84
2.21
-.12
Alcohol during pregnancy
0.23
0.55
0.04
Child sex (Female=1; Male=2)
-2.67
1.65
-0.13
Child age
-1.22
0.59
-0.17*
Maternal age
-0.12
0.21
-0.05
Trait anxiety at follow-up
-0.03
0.12
Depressive symptoms at follow-up
.06
.27
.03
Social support at follow-up
.04
.12
Prenatal stressful life events
-3.04
0.58
-0.47**
Postnatal stressful life events
0.65
0.47
0.14

20. ALSPAC study
Effects of antenatal anxiety are additive with postnatal anxiety and depression
O’Connor et al 2002b

21. For top 15% of most anxious women in pregnancy, SDQ symptom rate
(ADHD, anxiety, conduct disorder)
in 4 and 7 year old children
doubled from 5 to 10%.
Attributable load of behavioural/emotional problems in whole population due to antenatal anxiety/stress ~10-15%
O’Connor et al 2002, 2003

22. Bayley Scales of Infant Development (BSID-II)
Study child’s cognitive (MDI)
development at
17 months
Saliva cortisol

23. Antenatal life events and Bayley’s Mental Development score at 18 months
***

24. Significant correlation coefficients between antenatal life event scores and child’s MDI
You were separated/divorced
-0.33**
You had a serious argument with your partner
-0.28*
Your partner was emotionally cruel to you
-0.37**
You suffered from mental illness
-0.24*
A friend or relative suffered from mental illness

25. Domestic abuse during pregnancy Low income Hispanic population
The prevalence of abuse during pregnancy:
verbal abuse %
physical abuse 7.6%
sexual abuse %
Coonrod et al Am J Obstet and Gynecol 2007.

26. Mental Developmental Index in child of those with and without relationship problems in pregnancy

27. Fear reactivity in child of those with and without relationship problems in pregnancy

28. Predictive adaptive value of changes due to prenatal stress in a stressful environment in the wild?
ADHD- shifting attention helps if predators about
Anxiety/fear reactivity-
beneficial effects
of more vigilance

29. The placenta

30. Correlation between maternal anxiety and plasma cortisol during pregnancy
After 17 weeks ga r= 0.09 ns

31. Maternal stress/anxiety/mental illness
cortisol
11 b-HSD 2

32. Correlation between maternal plasma and amniotic fluid cortisol with increasing maternal anxiety
***
*** *
Submitted for publication

33. 11-βHSD2 stress Maternal Placenta Fetal cortisol cortisone 11-βHSD2

34. Effect of prenatal stress on placental 11b-HSD2 in rat placenta Mairesse et al (2007)

35. Correlation between amniotic fluid cortisol and cognitive development r= - 0.245 n=125 p=0.006

36. Summary
Maternal antenatal stress is associated with impaired child neurodevelopment
Effects of antenatal stress are different with each child-most are not affected
Probably depends on genetic vulnerability and gene environment interaction
Can be modified by early postnatal care

37. Antenatal Interventions
To medicate or not?
Dugas et al 2003: Excellent forms of psychological treatment – brief time limited
Stress reduction
CBT,
Relationship support

38. Olds USA
Nurse visited 6.5 antenatally and 21 visits to second birthday, health behaviours and emotional support
6 months less emotional distress of infants
21 months less likely to exhibit language delay
24 months superior mental development
At 17 years had half the the level of probation and offending.

39. Maternal antenatal stress predicts problem behaviour for children – lifelong
Mediated via cortisol and placental metabolism
Antenatal intervention urgently needed by all health care professionals

40. Educational Poster for Expectant Mothers National Child Welfare
Association
1919