Abstract
Objectives
This study aims to determine the rates of clinically-significant anxiety and depressive symptoms during the immediate postpartum in a sample of women referred to a university maternity department, as well as the associated risk factors and the relations with the level of maternal bonding.

Patients and methods
During the third national lockdown for the COVID-19 pandemic (February-April 2021), on days 2–3 after delivery 127 mothers were administrated the Edinburgh postnatal depression scale (EPDS), the state-trait anxiety inventory (STAI-YA), the mother-to-infant bonding scale (MIBS) and questions issued from the coronavirus health impact survey questionnaire (CRISIS).

Results
The rate of perinatal clinically-significant symptoms were 17% for depression (EPDS cut-off ≥ 12) and 15% for anxiety (STAI-YA cut-off ≥ 40). In the multivariate analysis, being a single mother, risk of being infected by the SARS-CoV2, risk that a close relative might be infected by the SARS-CoV2 and the length of stay in maternity were associated with an increased EPDS total score, while breastfeeding was associated with a lower EPDS total score. Six variables remained positively associated with the STAI-YA total score in the multivariate model: the maternal level of academic achievement, a hospitalization during the pregnancy, peripartum medical complications, risk of being infected by the SARS-CoV2, risk of a close relative being infected by the SARS-CoV2 and physical fatigue. Low but statistically significant correlations were found between the MIBS total score and the EPDS total score (rs = 0.26) and with the STAI-YA total score (rs = 0.26).

Discussion
The observed rates of anxiety and depressive symptoms were in the same range as those reported in observational studies conducted in high-resource countries during the COVID-19 pandemic. Risk of being infected by the SARS-CoV2 was both an independent risk factor for anxiety and depressive symptoms. The relations between the measure of maternal bonding and the severity of maternal emotional symptoms call for a better consideration of the long-term consequences of the pandemic on children’s socio-emotional development.

Introduction
     Cumulative evidence supports an increased risk of maternal peripartum psychological difficulties since the beginning of the COVID-19 pandemic [1], [2], [3], [4], [5], [6]. The meta-analysis conducted by Zhang and Yu [3] found an average prevalence of 43% for anxiety and of 32% for depression among pregnant women exposed to the context of the pandemic. These figures conceal although significant disparity across countries, with in particular a more substantial increase of postpartum depressive symptoms in low-resource compared to high-resource countries [7]. The capacity of the healthcare professionals providing adapted mental health interventions and care continuity during the pandemic appears a key moderator factor of maternal psychopathology risk [8], [9]. In line with this, Chmielewska and Barratt [7] found that the estimated efficiency of the national health care system was a stronger predictor of the observed between-study heterogeneity for maternal health outcomes than factors-related to the stringency of mitigation measures for the COVID-19 epidemic (e.g. the duration of lockdown).

     Alongside, several concerns have been raised that the application of social distancing measures in maternity wards led to lower social and professional support, ultimately contributing to increase the risk of maternal psychological difficulties [9], [10], [11]. The application of social distancing measures in maternity led to a strict restriction of partner and family visits while pregnant women faced additional sources of stress related to COVID-19 pandemic [11]. It has also been raised that a reduction of the length of stay in maternity and a constriction of paramedical team linked to the reorganization of workforce during the pandemic complicate the recognition of psychological needs of women during the perinatal period. An underestimation of maternal psychological difficulties could also be reinforced by a lower access to face-to-face supportive care (including social worker, psychologist and psychiatrist) and subsequently decreased opportunity to receive professional help [12].

Conclusion
     The rates of clinically-significant depressive and anxiety symptoms in the immediate postpartum among women referred to a university hospital center was roughly comparable to the range observed in previous observational studies prior the context of the COVID-19 pandemic. This report stresses the possible contribution of maternal worries about SARS-CoV2 infection in maternal anxiety and depressive symptoms, as long as other well-recognized risk factors. In a modern hospital where digital technologies and telehealth interventions were available the effect of social distancing measures in the maternity care was not clear. The relationships reported between the severity of maternal emotional symptoms and maternal bonding in the days following childbirth are worth considering to discuss the possible long-term impact of the pandemic on children socioemotional development.

Abstract

     Despite widespread acceptance that prenatal symptoms of depression in mothers are detrimental to infants’ long-term emotional and cognitive development, little is known about the mechanisms that may integrate outcomes across these domains. Rooted in the integrative perspective that emotional development is grounded in developing cognitive processes, we hypothesized that prenatal symptoms of depression in mothers would be associated with delays in neural maturation that support sociocognitive function in infants, leading to more problematic behaviors. We used a prospective longitudinal study of mothers (N = 92) and their infants to test whether self-reported symptoms of depression in mothers during the second and third trimesters were associated with neural development and infant outcomes at 4 months of age. While controlling for postpartum symptoms of depression, more prenatal symptoms of depression in mothers predicted less neural maturation in the parietal region of 4-month-old infants. Less neural maturation, in turn, was associated with greater infant negativity, suggesting neural maturation as a putative mechanism linking maternal symptoms of depression with infant outcomes. Differences in neural regions and developmental timing are also discussed.

1- Introduction

     Early environmental characteristics play a significant role in infant cognition-emotion interactions, ultimately leading to both short- and long-term infant outcomes. The prenatal environment is particularly salient, as prenatal stress in the form of maternal depressive symptoms positively predicts negative emotional reactivity (Davis et al., 2007, Diego et al., 2005) and negatively predicts cognitive function in infants (Barker et al., 2013), effects which can persist well into adolescence (de Bruijn et al., 2009, Luoma et al., 2001, Luoma et al., 2004). Research aimed at understanding the effects of maternal depression on infant outcomes have traditionally tested emotion and cognition as separate effects in streams of development. Yet, contemporary theory and mounting empirical work underscore both the overlap and the interplay between putatively cognitive and emotional trajectories of development, particularly early infancy (Bell and Wolfe, 2004, Calkins and Bell, 2010). Nonetheless, the mechanisms for such overlap remain largely unknown. During infancy, the maturation of neural architecture that supports cognitive and emotional processing may provide insight into their integration during a sensitive period of development (Deave et al., 2008, Luoma et al., 2001). Thus, the current study was designed to test an integrative pathway, infant neural maturation, by which maternal symptoms of prenatal depression may impact infant development.

3- Results

3-1 Preliminary analyses

     Descriptive statistics and correlations among study variables are reported in Table 1. Symptoms of maternal depression showed moderate stability over time, with the greatest stability observed across the two prenatal assessments. At the bivariate level, greater numbers of maternal depressive symptoms in the second trimester of pregnancy were associated with smaller frontal alpha-delta ratio scores at age 4 months but were unrelated to parietal alpha-delta ratio scores. Maternal depressive symptoms in the third trimester did not show bivariate associations with infant alpha-delta ratios at frontal or parietal sites. Greater negative affect in infants at 4 months of age was associated with greater numbers of maternal depressive symptoms in the second trimester and at the postpartum assessment. Maternal symptoms of depression were not associated with mother-reported infant behaviors or observed positivity in infants at the bivariate level.

Abstract

     Ultrasound is an imaging modality that is highly operator dependent. This article reviews the challenges in learning how to perform obstetric sonography, as well as the processes necessary to acquire expert performance skills in sonography. Simulation-based education and learning, and the value of medical simulation are also discussed. Ultrasound simulators are an effective means of teaching obstetric sonography, because it provides training, deliberate practice, and performance evaluation/feedback which allows continuous and critical self-evaluation. We review evidence that simulation can improve performance in obstetric ultrasound examination, review current simulators, and discuss the current problems/gaps in ultrasound simulation. Optical positioning ultrasound simulation is a novel high-fidelity simulation learning system, which addresses many of these problems/gaps and is introduced for the first time here.

Introduction

     Ultrasound imaging is integral to the practice of obstetrics, as it allows comprehensive anatomic and physiologic evaluation of the fetus and maternal pelvic organs [1]. Therefore, ultrasound examinations are recommended for all pregnant women [2–4]. Over the years, there has been an overall increase in the utilization of obstetric ultrasound in the U.S., with women receiving on average 4–5 sonographic examinations per pregnancy [5]. Yet, there is substantial variability in the sensitivity of routine sonography to detect fetal anomalies [6–8]. In a review of 36 studies that included more than 900,000 fetuses, an overall sensitivity of only approximately 40% for detecting fetal anomalies was noted [9]. Although the sensitivity of obstetric sonography depends upon gestational age at screening, type of congenital anomaly, selection of pregnant women, etc. the level of training and expertise of the sonologist is crucial to examination performance [10].

Conclusions

     Ultrasound examinations are recommended for all pregnant women. Yet, sonography is a highly operator-dependent modality that is challenging to master. Simulator training is a reliable tool to assess learners, and improves healthcare education and practice, as well as patient safety. There is broad consensus on the value of integrating simulation into ultrasound education and training programs. Ultrasound simulators are an innovative and effective means of teaching obstetric sonography, because it provides training, deliberate practice, and performance evaluation/feedback which allows continuous and critical self-evaluation. Moreover, teaching occurs in a controlled and safe environment, where skills can be practiced repetitively, and without patient anxiety and medicolegal concerns. Simulation-based training also allows trainees to practice a systematic approach to ultrasonography before the start of clinical training. Optical positioning ultrasound simulation is a high-fidelity simulation learning system which can address many of the current problems/gaps in ultrasound simulation, due to its unique characteristics.

Objective: To investigate the relationship between prenatal maternal alcohol consumption and the risk of attention deficit hyperactivity disorder (ADHD), the strengths and difficulties questionnaire (SDQ) score and abnormal hyperactivity score in seven-year-old children. Methods: This study is a retrospective analysis of the Millennium Cohort Study (MCS). Questionnaires were used to gather data on gestational alcohol consumption when children were 9 months old and neurodevelopmental outcomes in offspring at 7 years of age (N = 13,004). Alcohol consumption was classified into never, light, moderate and heavy. Crude and adjusted logistic regression models were used for data analysis. Results: The total number of women who reported drinking alcohol in pregnancy (the light, moderate and heavy drinking group) was 3916 (30.1%). No significant association was found between light, moderate or heavy gestational alcohol consumption and ADHD (adjusted odds ratio [aOR] for light = 0.80, 95% confidence interval [CI] = [0.53,1.22], aOR for moderate = 0.83, [0.40, 1.74]; aOR for heavy = 1.27, [0.54, 2.98]); for abnormal SDQ score (aOR for light = 0.94, [0.78,1.13], aOR for moderate = 0.70, [0.49,1.00]; aOR for heavy = 1.08, [0.70, 1.66]); for abnormal Hyperactivity score (aOR for light = 1.02, [0.89,1.17]; aOR for moderate = 1.05, [0.82, 1.34]; aOR for heavy = 0.90, [0.62, 1.32]), in offspring. Conclusion: Light, moderate or heavy antenatal alcohol consumption was not associated with an increased susceptibility to ADHD or behavioural outcomes in this study. However, due to the limited number of cases we cannot rule out an increased risk of ADHD in relation to heavy alcohol consumption.

Introduction

Existing literature links prenatal alcohol exposure to numerous adverse neurodevelopmental outcomes in offspring (Carmichael Olson et al., 1997; Banerjee et al., 2007; Jones et al., 1973). Long-term neurobehavioral deficits, including hyperactivity, even at low doses of prenatal alcohol exposure have been demonstrated in animal literature (Riley, 1990; Sood et al., 2001). Conversely, there is conflicting evidence cited in the literature suggesting that low levels of maternal alcohol consumption in pregnancy (MACP) may not be associated with adverse neurodevelopmental and health outcomes in early childhood (Kelly et al., 2009; Kelly et al., 2012; Robinson et al., 2010; O’Leary et al., 2010; Alati et al., 2008; Eriksen et al., 2012; Testa et al., 2003; Gallagher et al., 2018). Attention deficit hyperactivity disorder (ADHD) is a childhood-onset neurodevelopmental disorder characterised by developmentally inappropriate and impairing inattention, impulsivity and/or overactivity (Thapar and Cooper, 2016). ADHD is the most common cognitive and behavioural disorder diagnosed among school children, with an estimated worldwide prevalence of 3.4% (Polanczyk et al., 2015) ADHD incurs a significant economic burden and is associated with subpar social, academic, adaptive and occupational functioning (Barkley, 2002; Banerjee et al., 2007; Gupte-Singh et al., 2017; Polanczyk et al. 2015).

The aim of this systematic review was to report pregnancy and perinatal outcomes of coronavirus spectrum infections, and particularly coronavirus 2019 (COVID-19) disease because of severe acute respiratory syndromeecoronavirus-2 infection during pregnancy. DATA SOURCES: Medline, Embase, Cinahl, and Clinicaltrials.gov databases were searched electronically utilizing combinations of word variants for coronavirus or severe acute respiratory syndrome or SARS or Middle East respiratory syndrome or MERS or COVID-19 and pregnancy. The search and selection criteria were restricted to English language. STUDY ELIGIBILITY CRITERIA: Inclusion criteria were hospitalized pregnant women with a confirmed coronavirus relatedeillness, defined as severe acute respiratory syndrome, Middle East respiratory syndrome, or COVID-19. STUDY APPRAISAL AND SYNTHESIS METHODS: We used meta-analyses of proportions to combine data and reported pooled proportions. The pregnancy outcomes observed included miscarriage, preterm birth, preeclampsia, preterm prelabor rupture of membranes, fetal growth restriction, and mode of delivery. The perinatal outcomes observed were fetal distress, Apgar score <7 at 5 minutes, neonatal asphyxia, admission to a neonatal intensive care unit, perinatal death, and evidence of vertical transmission. RESULTS: Nineteen studies including 79 hospitalized women were eligible for this systematic review: 41 pregnancies (51.9%) affected by COVID-19, 12 (15.2%) by Middle East respiratory syndrome, and 26 (32.9%) by severe acute respiratory syndrome. An overt diagnosis of pneumonia was made in 91.8%, and the most common symptoms were fever (82.6%), cough (57.1%), and dyspnea (27.0%). For all coronavirus infections, the rate of miscarriage was 39.1% (95% confidence interval, 20.2e59.8); the rate of preterm birth <37 weeks was 24.3% (95% confidence interval, 12.5e38.6); premature prelabor rupture of membranes occurred in 20.7% (95% confidence interval, 9.5e34.9), preeclampsia in 16.2% (95% confidence interval, 4.2e34.1), and fetal growth restriction in 11.7% (95% confidence interval, 3.2e24.4); 84% were delivered by cesarean; the rate of perinatal death was 11.1% (95% confidence interval, 84.8e19.6), and 57.2% of newborns (95% confidence interval, 3.6e99.8) were admitted to the neonatal intensive care unit. When focusing on COVID-19, the most common adverse pregnancy outcome was preterm birth <37 weeks, occurring in 41.1% of cases (95% confidence interval, 25.6e57.6), while the rate of perinatal death was 7.0% (95% confidence interval, 1.4e16.3). None of the 41 newborns assessed showed clinical signs of vertical transmission. CONCLUSION: In hospitalized mothers infected with coronavirus infections, including COVID-19, >90% of whom also had pneumonia, preterm birth is the most common adverse pregnancy outcome. COVID-19 infection was associated with a relatively higher rate of preterm birth, preeclampsia, cesarean, and perinatal death.

Background: Insomnia is common during pregnancy but the prevalence and risk factors of insomnia in Chinese women during pregnancy is not well studied. This study aimed to examine the prevalence of insomnia and its risk factors in Chinese women during pregnancy. Methods: In this cross sectional study, 436 Chinese pregnant women with Insomnia Severity Index (ISI) ≥ 8 were clinically assessed using the insomnia criteria based on the combination of DSM-IV (Diagnostic and Statistical Manual-4th Edition) and ICD-10 (International Classification of Dieases, 10th Edition). Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS), Pregnancy Pressure Scale (PPS), Perceived physical discomfort level and number, Epworth Sleepiness Scale (ESS), and a general socio-demographic questionnaire were administered. Results: The results showed that about 20% of the pregnant women met the strict diagnosis criteria of insomnia. Independent-samples t-test revealed that several risk factors were correlated with the group with insomnia (N = 84) compared to the group without insomnia (N = 352). Binary Logistic regression analysis found that more significant bed partner influence (OR = 1.92, 95% CI: 1.03–3.60), depressive symptoms (OR = 1.07, 95% CI: 1.00–1.14), daytime sleepiness (OR = 1.07, 95% CI: 1.01–1.14), subjective somatic discomfort (OR = 2.27, 95% CI: 1.11–4.65), kinds of somatic discomfort (OR = 1.14, 95% CI: 1.03–1.27) and later gestation (OR = 1.05, 95% CI: 1.01–1.09) were significantly associated with insomnia. Conclusion: In this cohort of Chinese pregnant women, about a fifth of women suffered from clinically significant insomnia. Measures to prevent the adverse effects of insomnia should be provided to pregnant women with depressive symptoms, Sleep disturbance of the bed partner, excessive daytime sleepiness and somatic discomfort, especially late in gestation.

Introduction

Insomnia is the most prevalent sleep disturbance experienced in women during pregnancy, affecting 52%–61% of pregnant women [1]. The prevalence of insomnia during pregnancy is high from the start and two thirds of pregnant women suffer from insomnia in the later period of pregnancy [2]. One previous study found that 97% of the women at the end of pregnancy reported middle-of-the-night awakenings, but only less than a third of the women considered sleep disruption as a problem [3]. It has been shown that insomnia is related to a number of potential maternal and infant health risks, such as adverse pregnancy outcomes (hypertension, gestational diabetes mellitus (GDM)) [4–7]. Disturbed sleep in early and late pregnancy may also augment the risk for cardio-metabolic risk factors, which is associated with maternal and infant morbidity [4]. In addition, insomnia is frequently related to a variety of psychiatric disorders, such as depression and anxiety during pregnancy [8,9] and during the postpartum period [9–11]. Insomnia symptoms are also related to BMI increase in post-pregnancy [12]. In addition, sleep loss during pregnancy is related to fetal intrauterine growth retardation, longer duration of delivery, and unplanned cesarean section [13,14]. Pregnant women who slept b6 h per night appear to have longer labor and 4.5 times higher likelihood of a cesarean section [13,15,16].

1- Introduction

2- Material and methods

3- Results

4- Discussion

5- Conclusion

References

Abstract

Background
Although many perinatal women are affected by anxiety, few studies have focused on perinatal anxiety and its potential triggers. The primary aim of this study was to examine concurrent and prospective associations between mid-pregnancy insomnia and perinatal anxiety. Furthermore, we compared psychosocial and reproductive characteristics between participants with and without mid-pregnancy insomnia and explored changes in the prevalence of obsessive-compulsive disorder (OCD) symptoms from mid-pregnancy to 8 weeks postpartum.
Methods
This study was part of the Norwegian Depression and Anxiety in the Perinatal Period (DAPP) prospective, population-based, cohort study. We analyzed hospital birth records and questionnaire responses from pregnancy week 17 and postpartum week 8 (n = 530). The Bergen Insomnia Scale was used to measure insomnia and the Hopkins Symptom Checklist to measure anxiety. OCD symptoms were measured based on questions from the Mini-International Neuropsychiatric Interview. Results Mid-pregnancy insomnia was significantly associated with both concurrent and postpartum anxiety in a linear mixed model adjusted for several potential confounders. Participants with mid-pregnancy insomnia had significantly higher levels of perinatal anxiety and postpartum OCD symptoms than participants with normal mid-pregnancy sleep. OCD symptoms affected more women after delivery than before (6.4% vs. 3.8% p = 0.034).
Limitations Immigrants were underrepresented in our sample.
Conclusion
Our results suggest that mid-pregnancy insomnia is a marker for concurrent anxiety and predictor of postpartum anxiety. Future research should examine whether insomnia treatment starting in mid-pregnancy reduces both perinatal insomnia and anxiety. Health providers should also be aware that postpartum women have an increased risk of developing OCD symptoms.

Introduction

Most research on perinatal mental disorders has focused on depression (Fisher et al., 2016), whereas anxiety, despite being prevalent (Fairbrother et al., 2016), has often been overlooked (Howard et al., 2014) and under-treated (Smith et al., 2009). Perinatal anxiety has been acknowledged as an essential topic, and a growing number of studies have addressed it (Field, 2018; Furtado et al., 2018), with an ongoing discussion regarding which instruments should be used for detection (Matthey, 2016; Sinesi et al., 2019). Anxiety can be defined as specific anxiety and related disorders (ADs), including obsessive-compulsive disorder (OCD) (Fairbrother et al., 2019), as well as less specific symptoms of excessive worry, restlessness, and malaise. Maternal anxiety may have negative implications not only for the obstetric outcome (Schetter and Tanner, 2012) and the child’s health and development (Glasheen et al., 2010; Hoffman et al., 2017), but also for the mother’s relationship with both the infant (Dawson et al., 2000) and the other parent (Wenzel et al., 2005), but more research on perinatal anxiety is needed (Ali, 2018; Goodman et al., 2016; McGuinness et al., 2011). Insomnia, a syndrome characterized by difficulties in sleep onset or continuity, poor sleep quality, and impaired daytime functioning (Reichner, 2015), is twice as frequent among women as men (Bei et al., 2015). During pregnancy, the prevalence of insomnia ranges from 13% early in the first trimester (Okun et al., 2015) up to 74% late in the third trimester (Fernández-Alonso et al., 2012). Insomnia can occur independently or in comorbidity with other psychiatric disorders (Morin and Benca, 2012) and is a risk factor for the development of anxiety in non-perinatal populations (Hertenstein et al., 2018). Thus, antenatal insomnia may be associated with perinatal anxiety. The few previous studies on the relationship between perinatal insomnia and anxiety are subject to limited access to covariates, small sample sizes, and the use of only antenatal measurements (Polo-Kantola et al., 2017); cross-sectional design and recruitment from psychiatric settings (Swanson et al., 2011); or assessments late in pregnancy (Osnes et al., 2019).

Methods

Results

Discussion

References

Abstract

Purpose: Young women face numerous obstacles to accessing contraception, including lack of money, time, or transportation to visit a doctor. In addition, concerns about confidentiality deter many adolescents from seeking contraceptive care. Pharmacists in Washington, D.C. will soon be able to prescribe hormonal birth control, which can potentially increase contraceptive access for adolescents. This study explores the needs and concerns of teens and young women residing in Washington, D.C. to inform implementation of this service.
Methods: In this community-based participatory research study, four focus group discussions were conducted in February 2017, two with teen females aged 14e17 years and two with young women aged 18e24 years. A youth advisory council, comprising 13 women aged 16e22 years living in Washington, D.C., helped develop the discussion guide and interpret findings. Data were analyzed thematically by age group using inductive and deductive codes.
Results: Young people viewed pharmacies as convenientlocations to access contraceptives but expressed concerns about privacy, affordability, and pharmacist approachability. Younger participants viewed these concerns as significant barriers for their peers. Participants suggested pharmacies protect privacy and confidentiality by offering private consultation spaces and clear information about what insurance plans can disclose to parents. Participants also recommended pharmacies create a youth-friendly, nonjudgmental environment and offer pharmacists training on contraceptive counseling for young women.
Conclusions: Addressing concerns about privacy, costs, and pharmacist approachability can help ensure thatyouthseekingcontraceptivescaneasilyaccess theirpreferredmethod.Pharmaciesshouldcontinuously incorporateyoungpeople’s feedback toensure thisservice remainsaccessibleandacceptable toadolescents.

Methods

This study takes a community-based participatory research approach to understanding the viewpoints of young people by incorporating youth leadership into the study’s design and implementation. A youth advisory council was assembled to guide the development of study questions, assist with focus group recruitment, and help interpret findings. To be eligible for the youth advisory council, participants had to be female; aged 16e22 years; interested in improving access to birth control; and residing, attending school, or working in Washington, D.C. Women were recruited through outreach to local youth-serving organizations, which were identified through an Internet search and recommendations by authors’ colleagues. Study staff interviewed women on a first-come, first-served basis until the desired number of participants was reached. The youth advisory council met once a week for five weeks to learn about contraceptive methods and barriers young people face in accessing them; understand pharmacist provision of contraceptive methods; identify issues and questions important to young people interested in accessing this service; provide guidance on the creation of a focus group discussion guide; and advise study staff on effective means of recruiting young people to participate in focus group discussions. The council met again after all focus group discussions had been conducted to review the data and provide input in the interpretation of findings. Four focus group discussions were conducted in Washington, D.C. in February of 2017, two with female teens aged 14e17 years and two with young women aged 18e24 years. Participants were recruited through outreach to local school counselors and the same local organizations used to recruit members of the youth advisory council; word-of-mouth by youth advisory council members; and by flyers posted around George Washington University, the Columbia Heights shopping area, and other public locations frequented by young people. To be eligible, participants had to be female; aged 14e24 years; living, working, or attending school in Washington, D.C.; and interested in participating in a study about access to birth control.

Intensive care unit (ICU)-acquired weakness is a devastating complication of critical illness. With time in ICU, the incidence increases and its presence is associated with increased short-term and long-term mortality.1,2 In ICU survivors, ICU-acquired weakness often does not recover completely, even years after ICU admission.3 Persistent ICU-acquired weakness is considered to be part of the postintensive care syndrome, which encompasses a spectrum of persistent physical, mental, and cognitive impairment seen in survivors of critical illness, especially after prolonged and/or severe critical illnesses.4 The mechanisms underlying ICU-acquired weakness are complex and involve structural and functional alterations in both muscles and nerves.5 Attained myofibers show signs of atrophy, which may be triggered by inflammation, immobilization, endocrine and metabolic alterations, impaired microcirculation, denervation, and certain drugs.5 Apart from that, relative starvation may also play a role. Indeed, a considerable number of patients have a nutritional deficit on ICU admission and/or cannot receive normal feeding. In healthy volunteers, prolonged underfeeding mimics the severe muscle atrophy as typically observed in prolonged critically ill patients. In these otherwise healthy people, this condition obviously can be reversed by giving nutrition.

TO FEED OR NOT TO FEED?

Several observational studies have associated the accumulation of a caloric and/or protein deficit in critically ill patients with an increased risk of ICU-acquired weakness and mortality. Hence, for a long time, early full nutritional support has been recommended for critically ill patients.7 However, whether the relationship between feeding deprivation and ICU-acquired weakness and decreased survival is causal or not cannot be deducted from observational studies. Indeed, because tolerance of feeding, especially of enteral nutrition (EN), is affected by the severity of illness, the association of enhanced feeding with improved outcome could be explained by a better feeding tolerance in less sick patients.8 Establishing a causal relationship can only be done by a randomized controlled trial (RCT). Because of the long-lasting dogma of starvation harming critically ill patients and the resultant ethical constraints, RCTs randomizing patients to artificial feeding or no feeding have not been performed. Instead, in the last years, several large RCTs have investigated the impact of different doses (and routes) of artificial feeding.9–17 These studies have substantially changed the insights in the effects of nutritional support in critical illness (Table 1). Indeed, recent RCTs have not confirmed the hypothesized benefit of early, enhanced artificial feeding of critically ill patients and several trials have indicated potential harm.9,10,15 This article reviews the evidence obtained from these studies, the underlying mechanisms potentially explaining the results, and the remaining questions.

Because more women are waiting to have children until later in life, cancer diagnoses in pregnancy are becoming more common. Gestational cancer is defined as a new cancer diagnosis during pregnancy or in the first year postpartum.1 The most common cancers in reproductive aged women are breast, melanoma, thyroid, cervical, and lymphomas, listed in order of decreasing frequency.2 The diagnosis of cancer in the gestational period poses many difficult decisions for which multiple clinical, personal, and ethical factors need to be considered for treatment planning. We review the pertinent information for some of the more common gestational cancers, as well as some less common, but with increasing prevalence in the United States.

BREAST CANCER

Gestational breast cancer is considered any breast cancer occurring either during pregnancy, in the year after delivery, or anytime during lactation. Breast cancer is one of the most common pregnancy-associated cancers. Pregnancy-associated breast cancer occurs in 20% of breast cancer patients younger than 30 years of age.3 The incidence is only 0.4% of all breast cancers diagnosed in women aged 16 to 49, however the rate is increasing.1 This increase is most likely secondary to delaying the age at which women begin childbearing. The majority of gestational breast cancer is infiltrating ductal carcinoma. Gestational breast cancer is more likely to be poorly differentiated and have metastases at the time of diagnosis when compared with nonpregnant women.4 There is typically a lower incidence of estrogen receptor–positive, progesterone receptor–positive breast cancer diagnosed during pregnancy and the postpartum period, whereas human epidermal growth factor 2–positive tumors seem to be equal in incidence to that of nonpregnant women.5 A diagnosis of breast cancer during pregnancy or lactation is often more challenging given the normal physiologic changes in the breast during these periods.6 For example, rapid enlargement and hypertrophy during pregnancy and the postpartum period can distort the anatomy of the breast. Often the diagnosis is delayed by pregnancy and lactation; hence, the diagnosis is made at more advanced stages during pregnancy.7 Interestingly, a breast cancer diagnosis during lactation can be detected by the milk rejection sign, in which the nursing infant will refuse to nurse from the cancerous side.2 Any breast mass persisting for more than 2 weeks during pregnancy or lactation needs to be evaluated. Even though 80% of breast biopsies during pregnancy are benign, delayed diagnosis because of pregnancy or lactation is critical to prognosis.

In pregnancy, potential effects of infections on both mother and fetus must be considered. Pregnant women are at increased risk of some infections due to physiologic changes of pregnancy. Infections may cause complications with the pregnancy, and some maternal infections are transmissible to the fetus. When determining treatment, potential effects on the fetus and the pregnancy must be taken into consideration including different effects by trimester. In this article, the authors discuss common infections that require special considerations in pregnancy, infections that can be vertically transmitted, and infections that can cause in utero and perinatal infection leading to birth defects (including the classic TORCH infections).

PREGNANCY CONSIDERATIONS WITH COMMON INFECTIONS

Urinary Tract Infections

Recurrent bacteriuria and pyelonephritis are more common in pregnancy. Smooth muscle relaxation and dilation of ureters with pregnancy increases the propensity for ascending infection. Screening and treatment of urinary tract infections (UTIs) are more intensive in pregnancy than in the general population. Infectious Disease Society of America guidelines recommend universal screening of pregnant women for asymptomatic bacteriuria with urine culture in early pregnancy and periodic rescreening in women with positive culture during pregnancy.1 Diagnosis is made if greater than or equal to 105 colony-forming units of uropathogen or greater than or equal to 104 of Group B Streptococcus (GBS) is present in urine culture.2,3 Pyelonephritis in pregnancy typically requires inpatient empirical intravenous antibiotics, with the patient switched to an oral regimen once improving and afebrile for 24 to 48 hours.4 Appropriate antibiotics are given for 10 to 14 days followed by suppressive therapy for the remainder of pregnancy to prevent recurrence.4 GBS growing in any amount in urine culture during pregnancy indicates significant anogenital colonization and therefore qualifies the woman for intrapartum antibiotics to prevent neonatal GBS disease.5 The pregnancy and trimester need to be considered when prescribing antibiotics. Penicillins, cephalosporins, and aztreonam are considered safe in pregnancy. Antibiotics with high protein binding, such as ceftriaxone, may cause hyperbilirubinemia in newborns if used within a day of delivery. Nitrofurantoin is associated with birth defects6,7 and hemolytic anemia8 and, therefore, is avoided in the first trimester and at term. Trimethoprim-sulfamethoxazole should be avoided in the first trimester and at term because trimethoprim is a folic acid antagonist and sulfonamides can displace plasma binding of bilirubin in newborns. Tetracyclines are avoided in pregnancy due to fetal bone and teeth developmental defects9,10 and fluoroquinolones are avoided due to developmental defects of cartilage in animal experiments.

Objective: We examined whether the experience of a “pregnancy scare” is related to subsequent changes in contraceptive use that increase the risk of unintended pregnancy. Methods: We used data from the Relationship Dynamics and Social Life (RDSL) study, which interviewed a random, population-based sample of 1003 young women weekly for 2.5 years. We used multivariate regression models to predict the effect of experiencing a pregnancy scare on change in contraceptive use. Results: We found pregnancy scares are associated with changes in contraceptive use that increase the risk of pregnancy. Experiencing a pregnancy scare is related to discontinued contraceptive use, change from consistent to inconsistent use of contraception, and change from a more effective to a less effective method of contraception. We also found pregnancy scares are associated with continued inconsistent use of contraception. Conclusions: Our findings suggest that the experience of a pregnancy scare does not serve as a “wake-up call” to start using contraception, to start using it consistently, or to switch to a more effective method to reduce the risk of unintended pregnancy. Instead, contraceptive use after a pregnancy scare typically remains the same or worsens. Implications: Clinicians should be aware that young women who have experienced pregnancy scares may be at increased risk of unintended pregnancy, relative to young women who did not experience a pregnancy scare.

Introduction

The rate of unintended pregnancy in the United States remains persistently high [1], and is unlikely to decrease without new policy or interventions. In particular, a more comprehensive understanding of the precursors of unintended pregnancy is essential to formulate new approaches that reduce the unintended pregnancy rate [2]. This study explores one possible pathway — the relationship between experiencing a pregnancy scare and subsequent changes in contraceptive use. The term “pregnancy scare” describes when a woman who wants to avoid pregnancy believes she is pregnant, but later learns that she is not. According to national surveys, more than half of young women experience a pregnancy scare [3,4]. Women from less advantaged backgrounds are more likely to experience a pregnancy scare than those from more advantaged backgrounds [5], and the demographic correlates of pregnancy scares are similar to the demographic correlates of unintended pregnancy [5,6]. Furthermore, experiencing a pregnancy scare is strongly associated with subsequent unintended pregnancy, independent of background factors [5,7]. Although it seems possible that a pregnancy scare would be a “wakeup call” to start using contraception or to switch to a more effective method, the positive association between a pregnancy scare and later unintended pregnancy does not support this theory. Or, if a pregnancy scare is in fact a “wake-up call”, any improvement in contraceptive use is only temporary. It could even be that experiencing a pregnancy scare increases pregnancy desire, or increases tolerance of an undesired pregnancy, so that women become less likely to use contraception or more likely to switch to a less-effective method. That is, even women who wanted to avoid pregnancy quickly adjust their feelings to be more positive about pregnancy when they think they are probably pregnant, and those feelings remain positive to some degree even after they realize they are not actually pregnant. Of course, there is also the possibility that experiencing a pregnancy scare is not related to any change in contraceptive use at all. In this study we estimate the effect of experiencing a pregnancy scare on subsequent changes in: (1) contraceptive use; (2) consistency of contraceptive use; and (3) effectiveness of the contraceptive method used.

Seizures are the most common major neurologic complication encountered in pregnancy with a prevalence of in the United States of 1.2%.1 Nearly one-half million women with epilepsy are of reproductive age and between 0.5% and 1.0% of all pregnancies occur among women with epilepsy.2,3 The etiology of seizures covers a wide range of diseases, vascular insults, infectious sequelae, malignant processes, metabolic derangements, toxic insults, primary central nervous system dysfunction, and more.4,5 In pregnancy, eclampsia represents a unique consideration among possible causes of seizure. Although epileptic seizures are the most common, it is crucial to accurately determine the underlying cause of seizures in pregnancy to provide appropriate therapy.

Epilepsy

Women with epilepsy who become pregnant are at a substantially increased risk of adverse outcomes, including preeclampsia, preterm labor, stillbirth, cesarean delivery, and a more than 10-fold increased risk of death.6 The majority of maternal deaths are related to poor seizure control. As such, achieving control of maternal epilepsy is the primary concern in the management of pregnant women with an underlying seizure disorder.3 This goal is complicated by the risk of potential congenital malformations owing to the use of antiepileptic therapy.