ANTENATAL DEPRESSION; ITS PREVALENCE OF POSITIVE SCREEN AND THE ASSOCIATING RISK FACTORS INCLUDING LABOUR AND NEONATAL OUTCOME Dr Nurezwana Elias MD (UKM), MOG (UM) Clinical Lecturer Department of Obstetric and Gynaecology University of Malaya
INTRODUCTION • Worldwide about 10% of pregnant women and 13% of women who have just given birth experience a mental disorder, primarily depression. The percentage is higher in the developing countries (WHO) • Antenatal depression is often neglected and unrecognized . • Associated with various unwanted outcomes for both mothers and neonates. • Detection of early symptoms of antenatal depression may protect against the onset of depression in postnatal period • Although antenatal depression often resolves with the birth of baby, in 30-50% of cases, they continue to have postnatal depression Austin and Lumley 2003, Bronwyn and Jeanette 2008, Gavin AR et al. 2011
EPDS • Edinburgh Postnatal Depression Scale (EPDS) • designed to identify postpartum depression • Useful in screening for antenatal depression. • was found to have satisfactory sensitivity and specificity, and was also sensitive to change in the severity of depression over time. • The scale can be completed in about 5 minutes and has a simple method of scoring Cox et al. 1987
OBJECTIVE • This study aims to investigate the prevalence of antenatal depressive disorder among obstetric patients that delivered in University Malaya Medical Centre, Malaysia. • In addition, the relationship between socio-demographic, obstetric risks factor, labour outcomes and neonatal outcomes with antenatal depressive disorder are assessed.
METHODOLOGY • This is a prospective observational study conducted in the maternity centre of University Malaya Medical Centre (UMMC) from 1st of April to 31st of August 2014. • All pregnant women in the third trimester (32-41weeks) were invited to participate in this study • A total of 265 women were recruited and written consent was obtained
• Participants were asked to fill the EPDS on two occasion; first, during the third trimester and second, after delivery • There are ten (10) statements specific for depressive symptoms. Each statement has four possible responses, which are scored from 0 to 3 depending on the severity of the response. Higher scores indicate more severe depressive symptoms with a maximum total score of 30.
• The Malay version of EPDS was validated by Rushdi, W.M.W.M. & Mohamed, M.N. (2003), based on a study of Malay population in Malaysia. • A score of 12 or higher is an indication that depressive symptoms have been reported and that a psychiatric clinical assessment interview is required. It has sensitivity of 72.6% and specificity of 92.7%. Rushdi, W.M.W.M. & Mohamed, M.N. (2003)
• The association between risk factors, labour and neonatal outcome with positive screen group on EPDS score were analysed
RESULT • Positive screen Positive Screen of Antenatal Depression for depression was found in 40 women (17%); whilst 190 (83%) 17% women scored <12. 83% EPDS score >/= 12
ASSOCIATION BETWEEN SOCIO-DEMOGRAPHIC WITH POSITIVE SCREEN FOR ANTENATAL DEPRESSION Variables EPDS >=12 EPDS <12 Chi Square sig (2- tailed) *Age (with ± 29.6 ± 5.27 31.1 ± 4.64 0.71 standard dev) Nationality Malaysian 39 (95.1%) 181 (93.3%) 0.66 Non Malaysian 2(4.9%) 13 (6.7%) Ethnicity Malay 27 (65.9%) 136 (70.1%) 0.47 Chinese 5 (12.2%) 21 (10.85) Indian 7 (17.1%) 19 (9.8 %) Others 2 (4.9%) 18 (9.35) Marital status Married 40 (97.6 %) 188 (96.9%) 0.82 Single/divorced 1 (2.4%) 6 (3.1%)
Variables EPDS >=12 EPDS <12 Chi Square sig (2- tailed) Education Primary 0 90.0%) 14 (7.2%) 0.89 Secondary 15 (36.6%) 48 (24.7%) Tertiary 25 (63.45) 26 (63.4%) Household income (RM) <1500 7 (17.1%) 16 (8.3%) 0.38 1500-3000 11 (26.8%) 62(32.1%) 3000-4500 15(36.5%) 74 (38.8%) >4500 8 (19.5%) 41 (21.2%) Smoking Yes 2 (4.9%) 16 (8.2%) 0.46 No 39 (95.1%) 178 (91.8%) Alcohol Yes 2 (4.9%) 5 (2.6 %) 0.43 No 39 (95.1%) 189 (97.4%)
ASSOCIATION BETWEEN OBSTETRIC RISK FACTORS WITH POSITIVE SCREEN FOR ANTENATAL DEPRESSION Variables EPDS >=12 EPDS <12 Chi Square sig (2-tailed) *Parity (mean with ± 0.74 ± 0.87 1.07 ± 1.2 0.9 standard dev) h/o non-viable pregnancy (1 st trimester) Yes 4 (9.8%) 37 (19.1%) 0.15 No 37 (90.2%) 157 (80.9 %) Pre-existing medical illness 16 (39.0%) 44 (22/7%) Yes 25 (61.0%) 150 (77.3 %) 0.03 No Antenatal risks Low 12 (29.3%) 60 (30.9%) 0.83 Moderate-high 29 (70.7%) 134 (69.1%) Hypertensive in pregnancy Yes 6 (146%) 26(13.4%) 0.83 No 35 (85.4%) 168 (86.6%) Diabetes in pregnancy Yes 7 (17.1%) 28 (14.4%) 0.66 No 34 (82.9 %) 166 (85.6 %)
Variables EPDS >=12 EPDS <12 Chi Square sig (2- tailed) Antepartum haemorrhage 0(0.0%) 7 (3.6%) Yes 41(100%) 186 (96.4%) 0.22 No Threatened preterm labour 1 (2.4%) 12(6.25) Yes 40 (97.6%) 182 (93.8%) 0.34 No Placenta praevia Yes 0 (0.0%) 7 (3.6%) 0.22 No 41 (100%) 186 (96.4%) History of admission Yes 3 (7.3%) 27 (13.9%) 0.25 No 38 (92.7%) 167 (86.1 %)
ASSOCIATION BETWEEN LABOUR AND NEONATAL OUTCOMES WITH POSITIVE SCREEN OF ANTENATAL DEPRESSION Variables EPDS >=12 EPDS <12 Chi square; sig (2-tailed) Mode of delivery V agina birth 24 (58.5) 126(66.0%) 0.65 Instrumental 4 (9.8%) 14 (7.3%) Caesarean 13(31.7%) 53 (26.7%) Type of caesarean Elective 4 (30.8%) 18 (34.0%) 0.82 Emergency 9 (69.2%) 35 (66.0%) Induced labour Y es 17 (50%) 33 (22.8%) 0.01 No 17 (50%) 122 (77.2%) Analgesic in labour Epidural 5 (19.2%) 10 (7.4%) 0.06 Opiod 12 (46.2%) 59 (43.3%) Entonox 3 (11.5%) 45 (33.1%) None 6 (23.1%) 2 (16.2%) Gender Boy 19 (46.3%) 92 (48.2%) 0.457 Girl 22 (53.7%) 99 (51.8%) Immediate NICU admission Y es 15(36.6%) 20 (10.5%) 0.00 No 26 (63.4%) 170 (89.4%)
CORRELATION BETWEEN LABOUR AND NEONATAL OUTCOMES WITH SIGNIFICANT ANTENATAL DEPRESSION ON EPDS SCORES. Variables R p value N R2 Gestational weeks -.100 0.125 235 0.01 of delivery Second stage of .306 0.002 166 0.093 labour Blood loss .201 0.002 232 0.041 Birth weight -.321 0.000 232 0.103 Apgar score in 5 -.214 0.001 233 0.046 min Cord Ph -.285 0.000 224 0.082
A POSITIVE CORRELATION BETWEEN ANTENATAL EPDS SCORE AND POSTNATAL EPDS SCORE(R=.919, P<0.01)
FINAL LOGISTIC REGRESSION MODEL OF ANTENATAL EPDS SCORE ON RISK FACTORS, LABOUR & NEONATAL OUTCOMES Variables OR SE 95% CI Wald Pre-existing 3.066 0.518 1.11-8.46 4.678 medical illness Blood loss 1.005 0.002 1.001-1.009 5.456 Birth weight 0.998 0.001 0.997-0.999 8.009 Cord pH 0.000 3.090 0.00-0.202 6.137
DISCUSSION • Edinburgh Postnatal Depression Scale (EPDS) is a reliable tool for screening depressive symptoms during antenatal period and it is sensitive to changes of severity of depression overtime • It can detect depressive symptoms as early as first trimester and its progression until postpartum periods
• This study demonstrate that antenatal depression is a strong predictor of postnatal depression • This finding support the evolution of antenatal depressive symptoms from third trimester to postpartum period
• It is known that antenatal /postnatal depression commonly to occur in lower social economic class and lower education level group. • However in this population sample, there was no significant difference in socio-economic backgrounds • It shows that ANY women during pregnancy are vulnerable for ANTENATAL DEPRESSION. • Therefore universal screening for antenatal depression should be incorporated in standard antenatal care.
• Antenatal depression was found to be associated with adverse labour and neonatal outcomes • Therefore early detection and intervention may help in reducing the risks of unwanted pregnancy outcomes. • Health policy makers can contribute by giving more attention to mental health status of pregnant mother. • A guideline specific for management of mental health disorder during pregnancy should be establish to help physician managing cases on daily basis.
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