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Trauma is highly prevalent, and women are twice as likely as men to develop posttraumatic stress disorder following a traumatic exposure. Consequently, many women entering the perinatal period have trauma histories. In the perinatal period, a trauma history can negatively impact treatment engagement and adversely affect the experience of pregnancy, postpartum, and parenting. A trauma-informed care approach can mitigate these effects.This review aims to summarize literature that can aid psychiatrists in (1) identifying signs and symptoms of trauma in perinatal women, (2) integrating elements of trauma-informed care into perinatal mental health care, and (3) offering interventions that can minimize adverse outcomes for perinatal women and their children.A PubMed search was conducted with keywords including trauma, pregnancy, perinatal, posttraumatic stress disorder, postpartum posttraumatic stress disorder, and trauma informed care.Perinatal care, given its somewhat invasive nature, has the potential to traumatize or cause retraumatization. Trauma-related disorders are common and can present or worsen in the perinatal period. Trauma can manifest in multiple forms in this population, including exacerbation of preexisting posttraumatic stress disorder, new onset acute stress disorder in the perinatal period, or postpartum posttraumatic stress disorder secondary to traumatic childbirth. Unaddressed trauma can adversely affect the experience of pregnancy, postpartum, and parenting. Psychiatrists caring for women in the perinatal period are in an ideal position to screen for trauma and offer appropriate intervention. A trauma-informed approach to obstetric care can help clinical teams respond to the unique trauma-related challenges that can arise during obstetric care. Trauma-informed care, with its emphasis on establishing a culture of safety, transparency, trustworthiness, collaboration, and mutuality, can empower health care providers and systems with powerful tools to respond to trauma and its myriad effects in a strengths-based manner. By applying a trauma-informed lens, psychiatrists can help their obstetric colleagues provide patient-centered compassionate care and treatment.Applying a trauma-informed approach to evaluation and treatment of perinatal populations could decrease the toll trauma has on affected women and their children.

Perinatal Psychiatry Access Programs ("Access Programs") are system-level interventions that aim to build the capacity of perinatal healthcare professionals to address mental health, and thereby improve access to perinatal mental healthcare. Access Programs are widely implemented and positioned to promote health equity in perinatal mental healthcare, but little is known about the adaptations being made to the model in response to calls to promote health equity.One respondent from each of the 14 Access Programs (n = 14) completed an online survey that queried on adaptations made to promote perinatal mental healthcare equity.Twelve of the 14 Access Program team members (86%) indicated implementation of at least one new equity initiative. The average number of initiatives that a single Access Program implemented was 3.5 (range 0-10). Two Access Programs (14%) implemented 8.5 initiatives (range: 7-10), indicating that a small cohort is leading promotion of equity among Access Programs.Efforts to further expand the capacity and services of Access Programs to address perinatal mental healthcare inequities are needed. These adaptations may provide a robust opportunity for implementation initiatives to promote health equity through a system-level intervention.

Introduction Despite increased attention on severe maternal morbidity and maternal mortality, scant research exists on adverse maternal outcomes in women with disabilities. This study compares the rates of severe maternal morbidity and maternal mortality in women with and without intellectual and developmental disabilities. Methods This study used 2004–2017 Healthcare Cost and Utilization Project Nationwide Inpatient Sample data. Analyses were conducted in 2019‒2020. The risk of severe maternal morbidity with and without blood transfusion and maternal mortality during delivery among women with and without intellectual and developmental disabilities were compared using modified Poisson regression analysis. Results This study identified 32,324 deliveries to women with intellectual and developmental disabilities. Per 10,000 deliveries, 566 deliveries with severe maternal morbidity occurred in women with intellectual and developmental disabilities compared with 239 in women without intellectual and developmental disabilities. Women with intellectual and developmental disabilities had greater risk of both severe maternal morbidity (risk ratio=2.36, 95% CI=2.06, 2.69) and nontransfusion severe maternal morbidity (risk ratio=2.95, 95% CI=2.42, 3.61) in unadjusted analyses, which was mitigated in adjusted analyses for sociodemographic characteristics (risk ratio=1.74, 95% CI=1.47, 2.06; risk ratio=1.85, 95% CI=1.42, 2.41) and the expanded obstetric comorbidity index (risk ratio=1.23, 95% CI=1.04, 1.44; risk ratio=1.31, 95% CI=1.02, 1.68). The unadjusted incidence of maternal mortality in women with intellectual and developmental disabilities was 284 per 100,000 deliveries, nearly 4-fold higher than in women without intellectual and developmental disabilities (69 per 100,000 deliveries; risk ratio=4.07, 95% CI=2.04, 8.12), and the risk remained almost 3-fold higher after adjustment for sociodemographic characteristics (risk ratio=2.86, 95% CI=1.30, 6.29) and the expanded obstetric comorbidity index (risk ratio=2.30, 95% CI=1.05, 5.29). Conclusions Women with intellectual and developmental disabilities are at increased risk of severe maternal morbidity and maternal mortality. These findings underscore the need for enhanced monitoring of the needs and maternal outcomes of women with intellectual and developmental disabilities in efforts to improve maternal health.

Background The COVID-19 pandemic has affected mental health and created barriers to healthcare. In this study, we sought to elucidate the pandemic's effects on mental health and access to care for perinatal individuals. Methods This cross-sectional study of individuals in Massachusetts who were pregnant or up to three months postpartum with a history of depressive symptoms examined associations between demographics and psychiatric symptoms (via validated mental health screening instruments) and the COVID-19 pandemic's effects on mental health and access to care. Chi-square associations and multivariate regression models were used. Results Of 163 participants, 80.8% perceived increased symptoms of depression and 88.8% of anxiety due to the pandemic. Positive screens for depression, anxiety, and/or PTSD at time of interview, higher education, and income were associated with increased symptoms of depression and anxiety due to the pandemic. Positive screens for depression, anxiety, and/or PTSD were also associated with perceived changes in access to mental healthcare. Compared to non-Hispanic White participants, participants of color (Black, Asian, Multiracial, and/or Hispanic/Latinx) were more likely to report that the pandemic changed their mental healthcare access (aOR:3.25, 95%CI:1.23, 8.59). Limitations Limitations included study generalizability, given that participants have a history of depressive symptoms, and cross-sectional design. Conclusions The pandemic has increased symptoms of perinatal depression and anxiety and impacted perceived access to care. Self-reported increases in depression and anxiety and changes to healthcare access varied by education, race/ethnicity, income, and positive screens. Understanding these differences is important to address perinatal mental health and provide equitable care.

Background Depression is the most commonly diagnosed medical condition among women veterans ages 18 to 44; however, depression symptoms occurring during pregnancy have not been well-studied in this population. Methods Pregnant veterans were recruited from 15 Veterans Health Administration sites across the United States; our sample included 501 participants. Sociodemographic characteristics, military service, health status, and pregnancy related factors, as well as the Edinburgh Postnatal Depression Scale (EPDS), were collected as part of a telephone survey. Additional data were obtained from electronic health record data. We used multivariable logistic regression models to examine factors associated with an EPDS score suggestive of clinically significant depressive symptoms (≥10). Findings Prenatal EPDS scores of 10 or greater were calculated for 28% of our sample. Our final model indicated that factors associated with decreased odds of an EPDS score of 10 or greater included spousal or partner support during pregnancy (adjusted odds ratio [aOR], 0.35; 95% confidence interval [CI], 0.16–0.77) and employment (aOR, 0.40; 95% CI, 0.24–0.67). A past diagnosis of anxiety (aOR, 2.54; 95% CI, 1.43–4.50), past antidepressant use (aOR, 3.27; 95% CI, 1.71–6.24), and active duty service (aOR, 1.91; 95% CI, 1.08–3.37) were associated with increased odds of having an EPDS score of 10 or greater. Conclusions This is the first quantitative estimate of depression symptoms in pregnant veterans across multiple Veterans Affairs facilities. The prevalence of depression symptomology was greater than the high end of prevalence estimates in the general pregnant population. Given that the risk of depression increases during the postpartum period, women who can be identified with depressive symptomatology during pregnancy can be offered critical resources and support before giving birth.

BACKGROUND: Women with intellectual and developmental disabilities (IDD) experience disparities in obstetric care access and quality, in addition to communication gaps with healthcare providers. Many obstetric providers are untrained and uneducated about critical aspects of providing care to persons with IDD. OBJECTIVE: The study was conducted to describe obstetric clinicians’ training experiences related to providing obstetric care to women with IDD, to assess the perceived need for formalized training, and to identify recommendations for training content. METHODS: This study involved qualitative individual interviews (n=9) and one focus group (n=8) with obstetric clinicians who self-reported experience caring for women with IDD during pregnancy. Descriptive coding and content analysis techniques were used to develop an iterative codebook related to education and training; codes were applied to the data. Coded data were analyzed for larger themes and relationships. RESULTS: Analysis revealed three main themes: 1. Need for obstetric training and education: No participant reported receiving any training in caring for pregnant women with IDD. Participants expressed a need for formal education. 2. Recommendations for formal training: Participants noted the need for training during residency and beyond, and all healthcare staff should be included in training. 3. Training outcomes should increase knowledge, enhance attitudes, and develop practical skills related to care for pregnant women with IDD. CONCLUSION: Results indicate a need for systematic training efforts regarding obstetric care for women with IDD. Improved training and education may decrease health inequities and improve the quality of care, and thus pregnancy outcomes, for women with IDD. LEVEL OF EVIDENCE: VI

Background: There is a lack of nationally representative estimates for the consequences of early child undernutrition on pre-adolescent outcomes in India. Understanding this relationship is helpful to develop interventions that not only prevent child undernutrition but also mitigate its consequences. Methods: Data from two waves of India Human Development, a nationally representative panel survey dataset was used to identify 7,868 children who were assessed for undernutrition during early childhood (0-5 years) in 2004-05 and later re-interviewed during their pre-adolescent (8-11 years) years in 2011-12. Early childhood undernutrition was assessed using the Composite Index of Anthropometric Failure (CIAF). Short stature (height-for-age z

Study Objective To determine whether complications during pregnancy or at delivery influence postpartum contraception choices and rapid repeat pregnancy rates in adolescent women. Design, Setting, Participants, Interventions, and Main Outcome Measures This retrospective cohort study included 321 adolescents delivering at UMASS Memorial Healthcare. Complications during pregnancy and delivery along with subsequent contraception use were investigated. Postpartum contraception choice (long-acting reversible contraception [LARC] vs non-LARC) at either delivery, hospitalization discharge, or at postpartum outpatient appointment, and rapid repeat pregnancy rate (pregnancy confirmed within 12 months of index delivery), were analyzed according to pregnancy complications. Comparisons were made with χ 2 and Fisher exact tests for categorical variables, and with Wilcoxon rank sum test for continuous variables. Results Of the study population, 27.7% (n = 89/321) used LARC in the postpartum period. The LARC and non-LARC patient populations differed significantly regarding history of abortion ( P = .029), with no differences in obstetric complications between the groups. Of the population, 16.6% (n = 53/320) became pregnant again within 1 year of their index delivery. Those with a rapid repeat pregnancy had significantly increased gravidity ( P = .002), parity ( P = .003), number of previous spontaneous or therapeutic abortions ( P = .026); they were also more like to have nonlive birth as a complication ( P = .028), compared with those without repeat pregnancy. No other obstetrical complications were statistically significantly different between the compared groups. Conclusion Obstetrical complications seem to have little effect on postpartum contraception choice or repeat pregnancy rate with the notable exception of nonlive birth being associated with rapid repeat pregnancy.

Background Care during pregnancy is multifaceted and often goes beyond traditional prenatal care from an obstetrical care provider. Coordinating care between multiple providers can be challenging, but is beneficial for providers and patients. Care coordination is associated with decreased costs, greater patient satisfaction, and a reduction in medical errors. To our knowledge, no previous review has examined maternity care coordination (MCC) programs and their association with pregnancy outcomes. Methods Using a search algorithm comprised of relevant MCC terminology, studies were identified through a systematic search of PubMed, Scopus, ClinicalTrials.gov , and Google Scholar. Studies meeting eligibility criteria (e.g., defining the care coordination components and examining at least one quantitative outcome) were fully abstracted and quality rated using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. Main Findings Thirty-three observational studies of MCC were included in this review. Quality scores ranged from 27% to 100%. Most studies included strategies with a team approach to decision making and/or individual case management. Social service referrals to outside organizations were also common. Twenty-seven studies reported infant birth weight as a main outcome; 12 found a significant improvement in birth weights among care coordination participants. Conclusions Roughly one-third of the included studies reported improved birth weights among care coordination participants. However, it remains unknown what effect care coordination strategies have on patient and provider satisfaction in the prenatal care setting, two aspects of maternity care that may advance the quality and utilization of prenatal health services.

Hispanic women are at increased risk of gestational diabetes mellitus (GDM) as compared to non-Hispanic white women. While smoking has been associated with increased risk of type 2 diabetes, studies of smoking and GDM are sparse and conflicting. Therefore, we evaluated the relationship between cigarette smoking and GDM in Hispanic women.We conducted a pooled analysis of two Hispanic datasets based in Massachusetts: the UMass Medical Health Care dataset and the Proyecto Buena Salud dataset. A total of 3029 Hispanic prenatal care patients with singleton gestations were included. Cigarette smoking prior to and during pregnancy was collected via self-report. Diagnosis of GDM was abstracted from medical records and confirmed by study obstetricians.One-fifth of participants (20.4%) reported smoking prior to pregnancy, and 11.0% reported smoking in pregnancy. A total of 143 women (4.7%) were diagnosed with GDM. We did not observe an association between pre-pregnancy cigarette smoking and odds of GDM (multivariable OR=0.77, 95% CI 0.47, 1.25). In contrast, smoking during pregnancy was associated with a 54% reduction in odds of GDM (OR=0.46, 95% CI 0.22, 0.95). However, this association was no longer statistically significant after adjustment for age, parity, and study site (OR=0.47, 95% CI 0.23, 1.00).In this population of Hispanic pregnant women, we did not observe statistically significant associations between pre-pregnancy smoking and odds of GDM. A reduction in odds of GDM among those who smoked during pregnancy was no longer apparent after adjustment for important diabetes risk factors.

Some evidence suggests that phytoestrogens, such as soy-derived isoflavones, may have beneficial effects on cardiovascular health and glycemic control. These data are mainly limited to postmenopausal women or individuals at elevated cardiometabolic risk. There is a lack of data for pregnant women who have elevated estrogen levels and physiologically altered glucose and lipid metabolism. We analyzed data from 299 pregnant women who participated in the NHANES 2001–2008 surveys. Multivariable linear regression analyses were used to examine the association between urinary concentrations of isoflavonoids and cardiometabolic risk markers, adjusted for body mass index, pregnancy trimester, total energy intake, dietary intake of protein, fiber, and cholesterol, and demographic and lifestyle factors. Cardiometabolic risk markers were log-transformed, and geometric means were calculated by quartiles of urinary concentrations of isoflavonoids. Comparing women in the highest vs. lowest quartiles of urine total isoflavone concentrations, we observed significant, inverse associations with circulating concentrations of fasting glucose (79 vs. 88 mg/dL, P-trend = 0.0009), insulin (8.2 vs. 12.8 μU/mL, P-trend = 0.03), and triglyceride (156 vs. 185 mg/dL, P-trend = 0.02), and the homeostasis model assessment of insulin resistance (1.6 vs. 2.8, P-trend = 0.01), but not for total, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol. The concentrations of individual isoflavonoids, daidzein, equol, and O-desmethylangolensin were inversely associated with some cardiometabolic risk markers, although no clear pattern emerged. These data suggest that there may be a relation between isoflavone intake and cardiometabolic risk markers in pregnant women.

Feeding intolerance is a common occurrence in preterm infants, yet there are no precise measures for clinically assessing this potentially serious manifestation. This article reports the results of a study designed to evaluate neonatal intensive care (NICU) nurses’ precision in abdominal and emesis assessments, considered the most objective, observable signs of feeding intolerance. Forty-six NICU nurses participated in the study by observing pictures of preterm infant abdomens and pictures of “staged” emesis. There was little agreement among the participants regarding the infant abdomen pictures or the amount of emesis observed in the pictures. There was no relationship between years of NICU experience nurses’ assessments. The ability of nurses to assess clinical signs of potentially serious complications in preterm infants is critically important. Standardized education and training as well as precise assessment tools are needed.

Healthcare workers exposed to ionizing radiation in the workplace are at increased risk for cancer. The exact mechanism is complex; however, DNA damage, immunosuppression, and oxidative stress triggered by ionizing radiation appear to play a central role. In the present study, we investigated the influence of occupational radiation exposure on DNA oxidation, antioxidants and cytokine levels in healthcare personnel. A total of 60 volunteers of which 20 were occupationally exposed to ionizing radiation and 40 were non-exposed control subjects participated in this research study. Plasma levels of DNA oxidation, cytokines, percentage of glutathione disulfide (%GSSG), and extracellular superoxide dismutase (EcSOD) activity were measured. A significant increase was observed in the levels of interleukin (IL)-6 (0.6±0.08 pg/mL), IL-1α (0.36±0.1 pg/mL) and macrophage inflammatory protein (MIP)-1α (16.2±1.4 pg/mL) in radiation-exposed workers compared to control subjects (0.44±0.08 pg/mL; 0.24±0.07 pg/mL; 12±1.6 pg/mL; respectively, p

Objective to examine whether, among parous women, adherence to gestational weight gain (GWG) recommendations in the most recent previous pregnancy is associated with adherence to GWG recommendations in the current pregnancy. Design retrospective cohort study. Setting review of labour and delivery records from a Massachusetts tertiary-care centre. Participants 1,325 women who delivered two consecutive singletons from April 2006 to March 2010. Measurements pre-pregnancy weight status and adherence to GWG recommendations were categorised using 1990 Institute of Medicine (IOM) guidelines. Analyses were stratified by weight status before the second pregnancy. Findings 56% and 46% of women gained more than 1990 IOM recommendations during the first and second of consecutive pregnancies; 57% gained within the same adherence category in both pregnancies. Excessive GWG during the first pregnancy was strongly associated with excessive gain during the second pregnancy (adjusted odds ratio [AOR]=5.4 [95% CI: 1.7–16.4] for underweight, 3.7 [95% CI: 2.4–5.5] for normal weight, 3.0 [95% CI: 1.2–7.6] for overweight, and 5.3 [95% CI: 2.4–11.7] for obese women). Inadequate gain in the first of consecutive pregnancies was strongly associated with subsequent inadequate GWG for underweight women (AOR=13.7; 95% CI: 3.9–48.0), normal weight women (AOR=2.9; 95% CI: 1.7–5.1), and obese women (AOR=3.6; 95% CI: 1.4–9.3). Results were similar in sensitivity analyses using IOM 2009 guidelines. Key conclusions adherence to GWG recommendations in consecutive pregnancies is highly concordant. Implications for practice consideration of GWG during previous pregnancies may facilitate discussions about GWG during prenatal care.

cluded: death, RDS, grades 3 or 4 IVH, sepsis, NEC, or retinopathy of prematurity. The primary composite maternal outcome included: death, pulmonary edema, blood transfusion, ARDS, CVA, ATN, DIC, or liver rupture. RESULTS: Of 9960 evaluated pregnancies, 114 delivered 20 weeks and 101 had major fetal birth defects. Overall 28.2% had PAH 19.2% mild GTHN, 2.0% severe GHTN, 3.8% mild PrE, and 3.1% severe PrE. Outcome risks by PAH type (all p-values 0.001) and adjusted ORs (with no PAH as referent) are given (Table). Maternal and perinatal outcomes were elevated the most for severe PrE (2.6 to 9-fold) and least for mild GHTN (0.7 to 2.4-fold). CONCLUSION: The risks of adverse outcomes increase with severity of PAH sub-type. Mild PrE has similar perinatal risks to severe GHTN but maternal risks are greater.

Objective Several conditions are associated with increased preeclampsia (PE) risk. Whether altered maternal angiogenic factor levels contribute to risk in these conditions is unknown. Our objective was to compare angiogenic biomarker patterns in high-risk pregnancies and low-risk controls. Study Design We conducted a planned secondary analysis of a 2-center observational study of angiogenic biomarkers in high-risk women. A total of 156 pregnant women with a PE risk factor and 59 low-risk controls were studied. Serial maternal serum samples were collected during 3 gestational windows: 23-27 weeks, 28-31 weeks, and 32-35 weeks. Soluble fms-like tyrosine kinase 1 (sFlt1), soluble endoglin (sEng), and placental growth factor (PlGF) were measured by enzyme-linked immunosorbent assay. Geometric mean angiogenic biomarker levels and angiogenic ratio (sFlt1 + sEng):PlGF were compared with low-risk controls for each risk group, at each gestational window. Results Gestational biomarker patterns differed in PE risk groups as compared with low-risk controls. Women with multiple gestations had markedly higher sFlt1 and sEng at all gestational windows. Women with prior PE had higher sFlt1 and angiogenic ratio, and lower PlGF, from 28 weeks onward. Women with chronic hypertension had significantly higher angiogenic ratio for all 3 gestational windows, but differences disappeared when women with PE were excluded. Obese and nulliparous women had significantly lower PlGF, but no differences in the angiogenic ratio. Conclusion High-risk groups have altered angiogenic biomarker patterns compared with controls, suggesting that altered production or metabolism of these factors may contribute to PE risk, particularly in women with multiple gestations and prior PE.

Objective Placental soluble fms-like tyrosine kinase-1 may contribute to the pathogenesis of preeclampsia. Here we describe alterations in serum angiogenic factor levels in women with multiple gestation pregnancies, a major preeclampsia risk factor. Study Design We collected serial serum specimens from 101 pregnant women at high preeclampsia risk between 22 and 36 weeks' gestation. Soluble fms-like tyrosine kinase-1 and placental growth factor were measured by enzyme-linked immunosorbent assay. Women who had preeclampsia or gestational hypertension develop were excluded. Results Maternal soluble fms-like tyrosine kinase-1 was higher in multiple gestation (n = 20) compared with high-risk singleton (n = 81) pregnancies for each gestational age range examined. Maternal placental growth factor was significantly higher in multiple vs high-risk singletons before 31 weeks' gestation, whereas the soluble fms-like tyrosine kinase-1/placental growth factor ratio was higher in multiple vs high-risk singletons after 27 weeks. Conclusion Alterations in circulating angiogenic factors are present in women with multiple gestations and may contribute to higher preeclampsia risk in this population.

Objective The objective of the study was to evaluate angiogenic factors for the prediction of preeclampsia in high-risk women. Study Design We collected serial serum specimens from 94 women at high preeclampsia risk between 22 and 36 weeks' gestation. Soluble fms-like tyrosine kinase-1 (sFlt1) and placental growth factor (PlGF) were measured by enzyme-linked immunosorbent assay. Results Mean serum sFlt1 and the sFlt1/PlGF ratio were higher in subjects who developed early-onset (less than 34 weeks) preeclampsia, as compared with subjects without preeclampsia, from 22 weeks gestation onward. In subjects who developed late-onset (34 weeks or later) preeclampsia, sFlt1 was significantly increased after 31 weeks' gestation. The sFlt1/PlGF ratio at 22-26 weeks was highly predictive of early-onset preeclampsia. The within-woman rate of change of the sFlt1/PlGF ratio was predictive of overall preeclampsia risk. Conclusions In high-risk women, serum sFlt1 and the sFlt1:PlGF ratio are altered prior to preeclampsia onset and may be predictive of preeclampsia. Larger studies are needed to confirm these findings.