Brain development after intrauterine exposure to lithium: A magnetic resonance imaging study in school-age children.

OBJECTIVE: Lithium is often continued during pregnancy to reduce the risk of perinatal mood episodes for women with bipolar disorder. However, little is known about the effect of intrauterine lithium exposure on brain development. The aim of this study was to investigate brain structure in children after intrauterine exposure to lithium. METHODS: Participants were offspring, aged 8-14 years, of women with a diagnosis of bipolar spectrum disorder. In total, 63 children participated in the study: 30 with and 33 without intrauterine exposure to lithium. Global brain volume outcomes and white matter integrity were assessed using structural MRI and diffusion tensor imaging, respectively. Primary outcomes were total brain, cortical and subcortical gray matter, cortical white matter, lateral ventricles, cerebellum, hippocampus and amygdala volumes, cortical thickness, cortical surface area and global fractional anisotropy, and mean diffusivity. To assess how our data compared to the general population, global brain volumes were compared to data from the Generation R study (N = 3243). RESULTS: In our primary analyses, we found no statistically significant associations between intrauterine exposure to lithium and structural brain measures. There was a non-significant trend toward reduced subcortical gray matter volume. Compared to the general population, lithium-exposed children showed reduced subcortical gray and cortical white matter volumes. CONCLUSION: We found no differences in brain structure between lithium-exposed and non-lithium-exposed children aged 8-14 years following correction for multiple testing. While a rare population to study, future and likely multi-site studies with larger datasets are required to validate and extend these initial findings.

Clustering of characteristics associated with unplanned pregnancies: the generation R study.

BACKGROUND: Unplanned or unintended pregnancies form a major public health concern because they are associated with unfavorable birth outcomes as well as social adversity, stress and depression among parents-to-be. Several risk factors for unplanned pregnancies in women have previously been identified, but studies usually take a unidimensional approach by focusing on only one or few factors, disregarding the possibility that predictors might cluster. Furthermore, data on predictors in men are largely overlooked. The purpose of this study is to determine predictors of unplanned versus planned pregnancy, to determine predictors of ambivalent feelings regarding pregnancy, and to investigate how characteristics of men and women with an unplanned pregnancy cluster together. METHODS: This study was embedded in Generation R, a multiethnic population-based prospective cohort from fetal life onwards. Pregnancy intention was reported by 7702 women and 5367 partners. Information on demographic, mental, physical, social, and sexual characteristics was obtained. Logistic regression, multinomial regression and cluster analyses were performed to determine characteristics that were associated with an unplanned pregnancy, with ambivalent feelings regarding the unplanned pregnancy and the co-occurrence of characteristics in women and men with unplanned pregnancy. RESULTS: Twenty nine percent of the pregnancies were unplanned. Logistic regression analyses showed that 42 of 44 studied predictors were significantly associated with unplanned pregnancy. The most important predictors were young age, migration background, lower educational level, lower household income, financial difficulties, being single, lower cognitive ability, drug use prior to pregnancy, having multiple sexual partners in the year prior to the pregnancy, younger age of first sexual contact and a history of abortion. Multinomial regression analyses showed that a Turkish or Moroccan background, Islamic religion, little financial opportunities, being married, having ≥3 children, high educational level, more mental health and social problems and older age of first sexual contact were associated with prolonged ambivalent feelings regarding pregnancy. Different combinations of characteristics were observed in the four clusters of women and men with unplanned pregnancy. CONCLUSIONS: Many predictors are related with unplanned pregnancies, ambivalent feelings toward the pregnancy, and we identified very heterogeneous groups of women and men with unplanned pregnancies. This calls for heterogeneous measures to prevent unplanned pregnancies.

"Who am I to say?" Dutch care providers' evaluation of psychosocial vulnerability in pregnant women.

Maternity care increasingly focuses on evaluating psychosocial vulnerability during pregnancy. Research and nationwide (public health) programs, both in the USA and Europe, led to the development of new protocols and screening instruments for care providers to systematically screen for psychosocial vulnerability in pregnant women. However, standardised screening for vulnerability is complex since it requires discussion of sensitive issues. Women may fear stigmatisation and may have limited trust in their care providers or the health system. Our study contributes to the growing field of client-facing risk work by exploring care providers' interpretations and evaluation of psychosocial vulnerability in pregnant women. Drawing on semi-structured interviews with Dutch maternity care providers, we explore how they conceptualise risk and vulnerability and identify 'vulnerable pregnant women' in their practices. We find that care providers conceptualise 'vulnerability' as primarily based on risk, which contributes to an imbalanced focus on individual mothers, rather than on both parents and the social context. Our findings highlight care providers' concerns around 'care avoidance', seen as a risk factor affecting 'vulnerability' during pregnancy and as a possible consequence of risk screening. The care providers we interviewed employ "in between-strategies" based on intuition, emotion, and trust to skillfully attend to the risk that comes with risk work, in terms of its potential impact on relationships of trust and open communication. We conclude that 'vulnerability' should be understood as a multi-layered, situated and relational concept rather than simply as an epidemiological category. Since a trusting relationship between pregnant women and care providers is crucial for the evaluation of vulnerability, we reflect critically on the risk of standardised perinatal psychosocial risk evaluations. Policy should recognise providers' "in between-strategies" to embed epidemiological understandings of risk in the context of everyday risk work.

The Impact of Maternal Prenatal Stress Related to the COVID-19 Pandemic during the First 1000 Days: A Historical Perspective.

The COVID-19 pandemic has a major impact on society, particularly affecting its vulnerable members, including pregnant women and their unborn children. Pregnant mothers reported fear of infection, fear of vertical transmission, fear of poor birth and child outcomes, social isolation, uncertainty about their partner's presence during medical appointments and delivery, increased domestic abuse, and other collateral damage, including vaccine hesitancy. Accordingly, pregnant women's known vulnerability for mental health problems has become a concern during the COVID-19 pandemic, also because of the known effects of prenatal stress for the unborn child. The current narrative review provides a historical overview of transgenerational effects of exposure to disasters during pregnancy, and the role of maternal prenatal stress. We place these effects into the perspective of the COVID-19 pandemic. Hereby, we aim to draw attention to the psychological impact of the COVID-19 pandemic on women of reproductive age (15-49 year) and its potential associated short-term and long-term consequences for the health of children who are conceived, carried, and born during this pandemic. Timely detection and intervention during the first 1000 days is essential to reduce the burden of transgenerational effects of the COVID-19 pandemic.

Objective assessment of alcohol consumption in early pregnancy using phosphatidylethanol: a cross-sectional study.

BACKGROUND: Alcohol consumption during pregnancy is associated with major birth defects and developmental disabilities. Questionnaires concerning alcohol consumption during pregnancy underestimate alcohol use while the use of a reliable and objective biomarker for alcohol consumption enables more accurate screening. Phosphatidylethanol can detect low levels of alcohol consumption in the previous two weeks. In this study we aimed to biochemically assess the prevalence of alcohol consumption during early pregnancy using phosphatidylethanol in blood and compare this with self-reported alcohol consumption. METHODS: To evaluate biochemically assessed prevalence of alcohol consumption during early pregnancy using phosphatidylethanol levels, we conducted a prospective, cross-sectional, single center study in the largest tertiary hospital of the Netherlands. All adult pregnant women who were under the care of the obstetric department of the Erasmus MC and who underwent routine blood testing at a gestational age of less than 15 weeks were eligible. No specified informed consent was needed. RESULTS: The study was conducted between September 2016 and October 2017. In total, we received 1,002 residual samples of 992 women. After applying in- and exclusion criteria we analyzed 684 samples. Mean gestational age of all included women was 10.3 weeks (SD 1.9). Of these women, 36 (5.3 %) tested positive for phosphatidylethanol, indicating alcohol consumption in the previous two weeks. Of women with a positive phosphatidylethanol test, 89 % (n = 32) did not express alcohol consumption to their obstetric care provider. CONCLUSIONS: One in nineteen women consumed alcohol during early pregnancy with a high percentage not reporting this use to their obstetric care provider. Questioning alcohol consumption by an obstetric care provider did not successfully identify (hazardous) alcohol consumption. Routine screening with phosphatidylethanol in maternal blood can be of added value to identify women who consume alcohol during pregnancy.

Implementing an Eye Movement and Desensitization Reprocessing Treatment-Program for Women With Posttraumatic Stress Disorder After Childbirth.

PURPOSE: The purpose of this study is to describe the implementation and outcomes of an Eye Movement and Desensitization Reprocessing (EMDR) treatment-program for women with posttraumatic stress disorder (PTSD) after childbirth. METHODS: A prospective cohort-study with pre- and post-measurements was carried out in the setting of an academic hospital in the Netherland. Included were women who gave birth to a living child at least 4 weeks ago, with a diagnosis of PTSD, or severe symptoms of PTSD combined with another psychiatric diagnosis. All received up to 8 sessions of EMDR-therapy. The posttraumatic stress disorder Checklist for DSM-5 was administered before and after treatment. Trauma history was assessed before treatment with the Life Events Checklist for the DSM-5, the Childhood Trauma Questionnaire and the Childbirth Perception Scale. Descriptive statistics were used. RESULTS: Forty-four women were referred, 26 met the inclusion criteria. After treatment, none of the women met the criteria for diagnosis of PTSD after on average 5 weekly sessions of EMDR- therapy. These outcomes are promising, as they were achieved in women with relatively high levels of psychiatric comorbidity (64%) and high rates of previous mental health treatment (80%). CONCLUSION: Implementing an EMDR-treatment program for women with PTSD after childbirth in the setting of an academic hospital is feasible and effective. Key factors for success include a close collaboration between the relevant hospital departments and a thorough case conceptualization addressing the etiology of the PTSD.

Lithium exposure during pregnancy increases fetal growth.

BACKGROUND: Lithium is an effective treatment in pregnancy and postpartum for the prevention of relapse in bipolar disorder, but there is a lack of knowledge about the potential adverse impact on fetal development. AIMS: To investigate the impact of lithium exposure on early fetal growth. METHODS: In this retrospective observational cohort study, we included all singleton pregnancies of women using lithium and referred for advanced fetal ultrasound scanning between 1994 and 2018 to the University Medical Centers in Leiden and Rotterdam, the Netherlands (n=119). The Generation R study, a population-based cohort, served as a non-exposed control population from the same geographic region (n=8184). Fetal head circumference, abdominal circumference, femur length, and transcerebellar diameter were measured by ultrasound at 18-22 weeks of gestation. RESULTS: Lithium use during pregnancy was associated with an average increase in head circumference of 1.77 mm (95% confidence interval: 0.53, 3.01), in abdominal circumference of 5.54 mm (95% confidence interval: 3.95, 7.12) and in femur length of 0.59 mm (95% confidence interval: 0.22, 0.96) at 18-22 weeks gestation. Furthermore, lithium use during pregnancy was associated with an average increase in birth weight of 142.43 grams (95% confidence interval: 58.01, 226.89), whereas it was associated with an average decrease of 1.41 weeks in gestational duration (95% confidence interval: -1.78, -1.05). CONCLUSIONS: Lithium use during pregnancy was associated with increased fetal growth parameters at 18-22 weeks gestational age and increased birth weight. Further research is needed to evaluate both short- and long-term implications, as well as the mechanisms driving this difference in growth.

Growth trajectories of the human fetal brain in healthy and complicated pregnancies and associations with neurodevelopmental outcome in the early life course.

BACKGROUND: There is a need for non-invasive prenatal markers of the brain to assess fetuses at risk for poor postnatal neurodevelopmental outcome. Periconceptional maternal conditions and pregnancy complications impact prenatal brain development. AIMS: To investigate associations between growth trajectories of fetal brain structures and neurodevelopmental outcome in children in the early life course. STUDY DESIGN: Periconceptional prospective observational cohort. SUBJECTS: Singleton pregnancies were included in the Rotterdam periconception cohort. Two- and three-dimensional ultrasound scans at 22, 26 and 32 weeks gestational age were analysed. OUTCOME MEASURES: Head circumference (HC), cerebellum, corpus callosum (CC), Sylvian fissure, insula and parieto-occipital fissure (POF) were measured. Neurodevelopment was evaluated using the Age-and-Stages-questionnaire-3 (ASQ-3) and the Child-Behaviour-Checklist (CBCL) at 2 years of age. Linear mixed models, used to estimate the prenatal brain growth trajectories, and linear regression models, used to evaluate the associations between prenatal brain structures and neurodevelopmental outcomes, were applied in the total study population, and in subgroups: fetal growth restriction (FGR), preterm birth (PTB), fetal congenital heart disease (CHD), and uncomplicated controls. RESULTS: Consent for participation was received from parents on behalf of their child 138/203 (68%). ASQ-3 was completed in 128/203 children (63%) and CBCL in 93/203 children (46%). Significant smaller subject-specific growth trajectories (growth rate of CC, HC, left insula, left POF and right POF and the baseline size of CC, HC, left POF and right POF) were found in the FGR subgroup, compared to the other subgroups (all p-values <0.05). In the total group (n = 138), the growth rate of the left insula was associated with poorer ASQ-3 score (ß = -869.51; p < 0.05). Healthy controls (n = 106) showed a comparable association (ß = -1209.87; p < 0.01). FGR (n = 10) showed a larger baseline size of the right Sylvian fissure in association with poorer CBCL-score (ß = 4.13; p < 0.01). In CHD (n = 12) the baseline size of the left Sylvian fissure and its growth rate were associated with respectively poorer and better CBCL-scores (ß = 3.11; p < 0.01); (ß = -171.99; p < 0.01). In PTB (n = 10) no associations were found. CONCLUSIONS: This explorative study suggests associations between ultrasound measurements of fetal brain growth and neurodevelopmental outcome at 2 years of age. In future, this non-invasive technique may improve early identification of fetuses at risk for neurodevelopmental outcome and follow-up postnatal clinical care.

Effects of bright light therapy for depression during pregnancy: a randomised, double-blind controlled trial.

OBJECTIVES: Approximately 11%-13% of pregnant women suffer from depression. Bright light therapy (BLT) is a promising treatment, combining direct availability, sufficient efficacy, low costs and high safety for both mother and child. Here, we examined the effects of BLT on depression during pregnancy. DESIGN: Randomised, double-blind controlled trial. SETTING: Primary and secondary care in The Netherlands, from November 2016 to March 2019. PARTICIPANTS: 67 pregnant women (12-32 weeks gestational age) with a DSM-5 diagnosis of depressive disorder (Diagnostic and Statistical Manual of Mental Disorders). INTERVENTIONS: Participants were randomly allocated to treatment with either BLT (9000 lux, 5000 K) or dim red light therapy (DRLT, 100 lux, 2700 K), which is considered placebo. For 6 weeks, both groups were treated daily at home for 30 min on awakening. Follow-up took place weekly during the intervention, after 6 weeks of therapy, 3 and 10 weeks after treatment and 2 months postpartum. PRIMARY AND SECONDARY OUTCOME MEASURES: Depressive symptoms were measured primarily with the Structured Interview Guide for the Hamilton Depression Scale-Seasonal Affective Disorder. Secondary measures were the Hamilton Rating Scale for Depression and the Edinburgh Postnatal Depression Scale. Changes in rating scale scores of these questionnaires over time were analysed using generalised linear mixed models. RESULTS: Median depression scores decreased by 40.6%-53.1% in the BLT group and by 50.9%-66.7% in the DRLT group. We found no statistically significant difference in symptom change scores between BLT and DRLT. Sensitivity and post-hoc analyses did not change our findings. CONCLUSIONS: Depressive symptoms of pregnant women with depression improved in both treatment arms. More research is necessary to determine whether these responses represent true treatment effects, non-specific treatment responses, placebo effects or a combination hereof. TRIAL REGISTRATION NUMBER: NTR5476.

Acute psychiatric illness and drug addiction during pregnancy and the puerperium.

Pregnancy and the puerperium do not protect against acute psychiatric illness. During puerperium, the chance of acute psychiatric illness, such as a psychotic episode or relapse of bipolar disorder, is greatly increased. Suicide is a leading cause of maternal death. Both psychiatric disease and ongoing drug addiction impact not only the pregnant woman's somatic and mental health but also impact short-term and long-term health of the child. Indeed, prompt recognition and expeditious treatment of acute psychiatric illness during pregnancy and the puerperium optimize health outcomes for two patients. Pregnancy and puerperium represent a stage of life of great physiologic adaptations, as well as emotional and social changes. This conjunction of changes in somatic, emotional health and social health may mitigate the occurrence, clinical presentation, and clinical course of acute psychiatric illness and call for a multidisciplinary approach, taking into account both the medical and social domains. This chapter describes acute psychiatric illnesses during pregnancy and the puerperium and illicit substance abuse, from a clinical perspective, while also describing general principles of diagnosis and clinical management during this stage of life, which is an important window of opportunity for both the pregnant woman and the child.

Prevalence of benzodiazepines and benzodiazepine-related drugs exposure before, during and after pregnancy: A systematic review and meta-analysis.

BACKGROUND: Maternal use of benzodiazepines during pregnancy is common and has increased over the last decades. In this systematic review and meta-analysis, we studied the literature to estimate the worldwide use of benzodiazepines before, during and after pregnancy, which could help to estimate benzodiazepine exposure and to prioritize and guide future investigations. METHODS: We systematically searched Embase, Medline Ovid, Web of Science and Cochrane Central up until July 2019 for studies reporting on benzodiazepine use before (12 months), during and after pregnancy (12 months). Random effects meta-analysis was conducted to calculate pooled prevalence estimates, as well as stratified according to substantive variables. RESULTS: We identified 32 studies reporting on 28 countries, together reporting on 7,343,571 pregnancies. The worldwide prevalence of benzodiazepine use/prescriptions during pregnancy was 1.9% (95%CI 1.6%-2.2%; I2 97.48%). Highest prevalence was found in the third trimester (3.1%; 95%CI 1.8%-4.5%; I2 99.83%). Lorazepam was the most frequently used/prescribed benzodiazepine (1.5%; 95%CI 0.5%-2.5%; I2 99.87%). Highest prevalence was found in Eastern Europe (14.0%; 95%CI 12.1%-15.9%; I2 0.00%). LIMITATIONS: All analyses revealed considerable heterogeneity. CONCLUSIONS: Our meta-analysis confirmed that benzodiazepine use before, during and after pregnancy is prevalent. The relatively common use of benzodiazepines with possible risks for both mother and (unborn) child is worrying and calls for prescription guidelines for women, starting in the preconception period. Given the substantial proportion of children exposed to benzodiazepines in utero, future research should continue to study the short- and long-term safety of maternal benzodiazepine use during pregnancy and to explore non-pharmacological alternative treatments.

Dose-effect of maternal serotonin reuptake inhibitor use during pregnancy on birth outcomes: A prospective cohort study.

BACKGROUND: While antidepressant use during pregnancy is increasingly common, there is concern about the possible effects of in-utero antidepressant exposure on the child. Our objective was to examine whether there is a dose-effect of maternal serotonin reuptake inhibitors (SRI) during pregnancy on birth outcomes. METHODS: Women between 12 and 16 weeks of gestation, who were using an SRI, were eligible for participation in this nation-wide prospective observational cohort study. Recruitment took place between April 2015 and February 2018 (n = 145). SRI exposure and psychopathology symptoms were assessed throughout pregnancy. Exposure was defined as SRI standardized dose at 36 weeks of gestation and mean SRI standardized dose over total pregnancy. Multivariable linear and logistic regression were used to examine the associations with birth weight, gestational age at birth, and being small for gestational age. RESULTS: Maternal SRI dose at 36 weeks of gestation was significantly associated with birth weight (adjusted ß = -180.7, 95%CI -301.1;-60.2, p-value < 0.01) as was mean SRI standardized dose during total pregnancy (adjusted ß = -187.3, 95%CI -322.0;-52.6, p-value < 0.01). No significant associations between maternal SRI dose and gestational age or being small for gestational age were observed. LIMITATIONS: Although prospective, we cannot make full causal inferences given that we did not randomize women to different dosages. CONCLUSION: These findings suggest that careful dosing of SRI use during pregnancy may prevent a negative impact on birth weight and indicate the need for further investigation of causality.

Lithium during pregnancy and after delivery: a review.

Lithium is an effective treatment in pregnancy and postpartum for the prevention of relapse in bipolar disorder. However, lithium has also been associated with risks during pregnancy for both the mother and the unborn child. Recent large studies have confirmed the association between first trimester lithium exposure and an increased risk of congenital malformations. Importantly, the risk estimates from these studies are lower than previously reported. Tapering of lithium during the first trimester could be considered but should be weighed against the risks of relapse. There seems to be no association between lithium use and pregnancy or delivery related outcomes, but more research is needed to be more conclusive. When lithium is prescribed during pregnancy, lithium blood levels should be monitored more frequently than outside of pregnancy and preferably weekly in the third trimester. We recommend a high-resolution ultrasound with fetal anomaly scanning at 20 weeks. Ideally, delivery should take place in a specialised hospital where psychiatric and obstetric care for the mother is provided and neonatal evaluation and monitoring of the child can take place immediately after birth. When lithium is discontinued during pregnancy, lithium could be restarted immediately after delivery as strategy for relapse prevention postpartum. Given the very high risk of relapse in the postpartum period, a high target therapeutic lithium level is recommended. Most clinical guidelines discourage breastfeeding in women treated with lithium. It is highly important that clinicians inform and advise women about the risks and benefits of remaining on lithium in pregnancy, if possible preconceptionally. In this narrative review we provide an up-to-date overview of the literature on lithium use during pregnancy and after delivery leading to clinical recommendations.

The role of structured Antenatal Risk Management (sARM) on experiences with antenatal care by vulnerable clients.

INTRODUCTION: Vulnerable clients (i.e. clients reporting psychopathology, psychosocial problems, or substance use, and/or features of deprivation) represent a challenge in perinatal care, both in term of care process and outcome. Adhering to a structured care process (i.e. structured Antenatal Risk Management [sARM]) has shown to benefit professionals in supporting vulnerable clients, but its effect on client experiences is yet to be determined. As better processes are assumed to benefit outcome, we investigated the relationship between vulnerable clients' experiences with antenatal care in perinatal units adhering to differing degrees of sARM. METHODS: We combined data from two sources: on the client level antenatal collected survey data from which vulnerability status (Mind2Care instrument) and client experiences (ReproQ questionnaire) were derived, and on the unit level interview data from healthcare providers from which the unit degree of sARM was ascertained. RESULTS: A total of N = 1.176 clients from N = 38 units were included in the study. Vulnerable clients with psychosocial problems reported more negative experiences than non-vulnerable clients. In high sARM units, vulnerable clients, regardless of type of problems, reported more negative experiences than non-vulnerable clients. In multiple regression analysis this effect disappeared and only vulnerability defined as psychosocial problems remained predictive for negative experiences. CONCLUSIONS: Vulnerable clients, specifically those with psychosocial problems, present a challenge in perinatal healthcare. Negative appraisal of care might be an unavoidable drawback of adhering to sARM. It also stresses the need for improving caregiver-client expectations and system side improvements.

Seasonality of depressive symptoms during pregnancy.

Various risk factors have been identified for antepartum depression. This study evaluated seasonal influences on antepartum depressive symptoms. Data of 2,438 pregnant women on current depressive symptoms was obtained from a large-scale cross-sectional study in The Netherlands. Most women were screened during the first trimester. Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS) and dichotomized using ≥ 9 as cut-off score. The seasonal relationship between antepartum depressive symptoms and the month of assessment was estimated by fitting a sinusoidal curve to the data. A total of 323 women (13.2%) scored above cut-off. In the full sample, we found no significant evidence for seasonal influences on depressive symptoms after adjusting for confounders. Additionally, we found that the seasonal influence was obscured by the modification of the effect by current treatment status. In women untreated for psychiatric complaints, we found a minimum of depressive symptomatology in September and a maximum in March. In women treated for psychiatric complaints we found a minimum of depressive symptomatology in December and a maximum in June. Thus, the effects of seasonality are apparent, but opposite in treated and untreated women. However, health professionals should be aware of depressive symptoms the whole year through.

Bright light therapy in pregnant women with major depressive disorder: study protocol for a randomized, double-blind, controlled clinical trial.

BACKGROUND: Depression during pregnancy is a common and high impact disease. Generally, 5-10 % of pregnant women suffer from depression. Children who have been exposed to maternal depression during pregnancy have a higher risk of adverse birth outcomes and more often show cognitive, emotional and behavioural problems. Therefore, early detection and treatment of antepartum depression is necessary. Both psychotherapy and antidepressant medication, first choice treatments in a non-pregnant population, have limitations in treating depression during pregnancy. Therefore, it is urgent and relevant to investigate alternative treatments for antepartum depression. Bright light therapy (BLT) is a promising treatment for pregnant women with depressive disorder, for it combines direct availability, sufficient efficacy, low costs and high safety, taking the safety for the unborn child into account as well. METHODS: In this study, 150 pregnant women (12-18 weeks pregnant) with a DSM-V diagnosis of depressive disorder will be randomly allocated in a 1:1 ratio to one of the two treatment arms: treatment with BLT (9.000 lux) or treatment with dim red light therapy (100 lux). Both groups will be treated for 6 weeks at home on a daily basis for 30 min, within 30 min of habitual wake-up time. Follow-up will take place after 6 weeks of therapy, 3 and 10 weeks after end of therapy, at birth and 2, 6 and 18 months postpartum. Primary outcome will be the average change in depressive symptoms between the two groups, as measured by the Structured Interview Guide for the Hamilton Depression Scale - Seasonal Affective Disorder version and the Edinburg Postnatal Depression Scale. Changes in rating scale scores of these questionnaires over time will be analysed using generalized linear mixed models. Secondary outcomes will be the changes in maternal cortisol and melatonin levels, in maternal sleep quality and gestational age, birth weight, infant behaviour, infant cortisol exposure and infant cortisol stress response. DISCUSSION: If BLT reduces depressive symptoms in pregnant women, it will provide a safe, cheap, non-pharmacological and efficacious alternative treatment for psychotherapy and antidepressant medication in treating antepartum depression, without any expected adverse reactions for the unborn child. TRIAL REGISTRATION: Netherlands Trial Register NTR5476 . Registered 5 November 2015.

Decision-making after ultrasound diagnosis of fetal abnormality.

During the last few decades, the use of ultrasonography for the detection of fetal abnormalities has become widespread in many industrialised countries. This resulted in a shift in timing of the diagnosis of congenital abnormalities in infants from the neonatal period to the prenatal period. This has major implications for both clinicians and the couples involved. In case of ultrasound diagnosis of fetal anomaly there are several options for the obstetric management, ranging from standard care to non-aggressive care to termination of pregnancy. This essay explores the context of both clinical and parental decision-making after ultrasound diagnosis of fetal abnormality, with emphasis on the Dutch situation. While normal findings at ultrasound examination have strong beneficial psychological effects on the pregnant woman and her partner, the couple are often ill-prepared for bad news about the health of their unborn child in the case of abnormal findings. When parents consider end-of-life decisions, they experience both ambivalent and emotional feelings. On the one hand, they are committed to their pregnancy; on the other hand, they want to protect their child, themselves and the family from the burden of severe disability. These complex parental reactions have implications for the counselling strategy.

Impact of decision-making in a multidisciplinary perinatal team.

OBJECTIVES: (1) To describe the characteristics of decision-making about management of unborn infants with serious anomalies by a multidisciplinary perinatal team. (2) To evaluate the impact of multidisciplinary team discussions on the degree to which decisions about the management of unborn infants with serious anomalies are supported. (3) To evaluate the impact of the team discussions on the arguments used by physicians for their preferences concerning management. METHODS: Prospective analysis of 78 cases discussed within the multidisciplinary perinatal team of a tertiary centre by means of an anonymous one-page questionnaire with structured questions pertaining to the opinion of the responder on medical management of each case. RESULTS: We did not find systematic differences between specialties prior to the discussion of cases. However, discussion with the multidisciplinary perinatal team improved decision-making about management of unborn infants with serious anomalies by enhancing the degree of support for the decisions taken. The discussions of the team did not change the physicians' arguments mentioned for their preferences. CONCLUSION: Multidisciplinary team discussions improve decision-making about management of unborn infants with serious congenital anomalies.

Survival after non-aggressive obstetric management in cases of severe fetal anomalies: a retrospective study.

OBJECTIVE: Obstetricians may choose to refrain from interventions aimed at sustaining fetal life (i.e., non-aggressive obstetric management) when the fetus has an extremely poor prognosis. However, if the infant is then born alive, crucial neonatal management decisions then have to be made. We sought empirical data concerning such perinatal end-of-life decisions. Firstly, to describe survival during delivery and after birth following non-aggressive obstetric management, and secondly, to describe neonatal management in infants born alive after non-aggressive obstetric management. DESIGN: Retrospective descriptive study. SETTING: Tertiary centre. POPULATION: Eighty-one infants born to women who opted for a non-aggressive obstetric management policy because of sonographically diagnosed severe fetal anomaly. METHODS: Data were collected from obstetric and neonatal records, as well as ultrasound reports. MAIN OUTCOME MEASURES: Survival, neonatal management and health status after birth. RESULTS: Relevant data were available for 78/80 (98%) infants. Six (8%) infants died in utero, 16 (21%) died during delivery (11 from cephalocentesis) and 56 (72%) were born alive. Life-sustaining neonatal treatment was initiated in 29 (52%) of the live-born infants. Twenty-three of these 29 (79%) infants died within six months of birth. Of the 27 live-born infants who did not receive neonatal life-sustaining treatment, 25 (93%) died. Eight infants survived; all with severe health problems. CONCLUSION: Life-sustaining neonatal support after non-aggressive obstetric management in the presence of severe fetal malformation has little impact on survival.

Parental decision-making after ultrasound diagnosis of a serious foetal abnormality.

OBJECTIVE: The purpose of this article is to provide clinicians who are involved in the field of foetal medicine with a comprehensive overview of theories that are relevant for the parental decision-making process after ultrasound diagnosis of a serious foetal abnormality. METHODS: Since little data are available of parental decision-making after ultrasound diagnosis of foetal abnormality, we reviewed the literature on parental decision-making in genetic counselling of couples at increased genetic risk together with the literature on general decision-making theories. The findings were linked to the specific situation of parental decision-making after an ultrasound diagnosis of foetal abnormality. RESULTS: Based on genetic counselling studies, several cognitive mechanisms play a role in parental decision-making regarding future pregnancies. Parents often have a binary perception of risk. Probabilistic information is translated into two options: the child will or will not be affected. The graduality of chance seems to be of little importance in this process. Instead, the focus shifts to the possible consequences for future family life. General decision-making theories often focus on rationality and coherence of the decision-making process. However, studies of both the influence of framing and the influence of stress indicate that emotional mechanisms can have an important and beneficial function in the decision-making process. CONCLUSION: Cognitive mechanisms that are elicited by emotions and that are not necessarily rational can have an important and beneficial function in parental decision-making after ultrasound diagnosis of a foetal abnormality. Consequently, the process of parental decision-making should not solely be assessed on the basis of its rationality, but also on the basis of the parental emotional outcome.